Cluster Network Action Plan 2016-17 Monmouthshire North ... · Public Health Wales (2016) Child Measurement Programme for Wales 2014/2015 1.2 Engagement 1.2.1 To be a central source

Cluster Network Action Plan 2016-17

Monmouthshire North - Neighbourhood Care Network (NCN)

2

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

Objective For completion

by: -

Outcome for patients Action/Progress to Date RAG

Rating

1.1 Obesity

1.1.1

To tackle obesity and work

towards a reduction in the

number of ante-natal women

& children aged 0-4 years old

in defined geographical areas,

who are overweight/obese

Aligned to Monmouthshire SIP-Nobody Is Left Behind Healthcare Standard 1.1/3.1 Links SCP2 Adopted as population need priority

On-going

Local Authority

Public Health

NCN

Housing

Adult Weight

Management

Service

NERS

Midwifery

Flying Start

Families First

Community

Based initiatives

Families have access to

children and young

people’s services,

initiatives and projects

addressing obesity issues

‘Place Based Working’

Principles underpin work-

streams

Action:

To establish a task & finish group to support delivery of

key actions:

Establish baseline position to measure progress

To map level 2 services for weight management &

refer/recommend following brief intervention

To increase awareness & access to level 2 services for

target groups

Raise issue of weight & health routinely with brief

advice/intervention & refer to level 2 (community) /

3 ABUHB Adult Weight Management Service (AWMS)

Attend a Childhood Obesity Strategy (COS) event &

support implementation / delivery of local action plan

To monitor progress of NCN funded Community

Dietician

Progress:

- NCN Management Team themed meetings focus on clear

action for NCN/MT delivery

- Joint COS workshop held to inform 3 year action plan

- Making Every Contact Count (MECC) training undertaken

with GPs, Practice & District Nurses & planned for Health

Visitors & School Health Nurses

- NCN funding considered for ante-natal & junior referral

scheme with NERS

- Linked to NUTRITION SKILLS FOR LIFE™ training

- 2015-16: 105 referrals to the AWMS (highest ranking out of

12 NCNs) with a projection of 220 in 2016/7 (Red)

A

3

Public Health exercise - Childhood obesity

Children aged 4-5 years who are overweight or obese -

Monmouthshire wide: 21% Source:

Public Health Wales (2016) Child Measurement Programme for Wales

2014/2015

1.2 Engagement

1.2.1

To be a central source of

information, identifying gaps

in service locally and sharing

its work programme with

stakeholders

Aligned with SIP-People are confident, capable and involved/Nobody Is Left Behind Healthcare Standard 1.1 Links to SCP2

On-going

NCN

ABUHB

Practices

Third Sector

Public Health

Severnside Trust

Mechanisms are in place

to ensure patients,

services and partners are

informed of the work of

the NCN

Shared learning &

communication leads to

improved services & local

knowledge

Action:

To respond to findings from ABUHB Engagement Team

events relating to accessing Healthcare

To publish a monthly NCN newsletter

Progress:

- GAVO Rep attends NCN meetings representing the Third

Sector

- NCN newsletter developed to share new developments and

current issues across ABUHB & partners

A

1.3 Learning Disabilities

1.3.1

New: Increase up-take of LD

Enhanced Service Annual

Reviews

Aligned with SIP-People are confident, capable and involved (Approximately 2,396 people have a learning disability in Monmouthshire of these approximately 753 are children between the ages of 0-17) Healthcare Standard 1.1/2.7/3.1/3.2 Links to SCP1/2/8

31.03.17

Practices

ABUHB

Local Authority

NCN

90% of patients with a

LD, who are eligible,

have access to Annual

Health Reviews via

Primary Care Services

Increased access for

assessment to identify

healthcare needs

Action:

Liaise with Monmouthshire County Borough Council LD

lead to assess barriers against meeting the 90% target

Review number of claims made against number of

eligible patients assessed

Progress:

- Meeting needed to agree action

- 2014/15: 160 people (2.3455%) received GP Practice health

checks (Source CMWEB)

A

4

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

reasonable needs of local patients


by: -


Rating

2.1 Access

2.1.1

New: To identify

opportunities for shared

working & Good Practise

across Practices

Links to SCP2 Healthcare Standard 1.1

31.03.17

Practice

Managers

NCN Lead &

team

Patients benefit from

increased collaboration,

standardised and

streamlined processes;

Increased GP capacity

Action:

NCN lead attends Practice Manager meetings to address

NCN related issues

Undertake NCN lead annual Practice visit

Progress:

- Practice Manager Forum discussions, NCN leads attend on

rotational basis

- NCN lead Practice visit undertaken early 2016

A

2.1.2

New pilot: To enable

implementation of the NHS

England Constitution for

patients resident in England

Aligned with Monmouthshire SIP-People are confident, capable and involved Healthcare Standard 3.1 Links to SCP10

31.01.17

Practices

NCN lead

NHS England

NHS Wales

ABUHB

National guidelines are

adhered to

Patients in England,

registered with a GP in

Wales, access healthcare

in a Hospital of their

choice

Action:

To overcome barriers impacting on cross border flow

changes

Referral pathways are tested and lessons learned prior to

full implementation

Progress:

- 6 month test phase with 5 North & South GP Practices

(starting July 2016)

- Training for Practice staff within the WCCG test facility

- Test phase to be evaluated before wider roll-out

A

2.1.3

New: To support the

development of a ‘Care Closer

To Home’ (CC2H) strategy

On-going

NCN

ABUHB Divisions

Local Authority

Patients benefit from a

clear strategy, which

underpins partnership

working, allowing for the

Action:

To facilitate a multi-agency workshop in each NCN

locality/borough

NCN to contribute to the development of joint local action

A

5

and action plan

Aligned with SIP-Nobody Is Left Behind Healthcare Standard 1.1/3.1/5.1 Links to SCP4

ISPB

Third Sector

sharing of local skills,

expertise and resources,

leading to appropriate

care being provided

either at home or close to

it

plans

Progress:

- CC2H team presentation at NCN meeting

- Scoping/planning workshop held August 2016

- Resource maps provided by all stakeholders during

workshop to understand what agencies can bring and

identify duplication of resources/skills

- Draft strategy in development

2.2 Estates

2.2.1

New: To enable wider

delivery of services in primary

care


On-going

NCN

Practices

ABUHB Facilities

ABUHB

Housing

Patients are able to

access local services in

premises which are fit for

purpose

Action:

To engage with Practices via Practice visits, NCN

meetings and Practice Development Plans to understand

accommodation issues

Progress:

- Practice visits undertaken

- Assessing impact of new housing developments

- Practices engaged in development of the ABUHB Estates

Plan

- Analysis of PDPs undertaken

- Melin Homes presentation July 2016:

- Monmouthshire has largest population boom, with

increase in populate of 1.7 people per house built

- Significantly higher house prices

- Population is predicted to shrink, however trend has

been 15% increase since 1991

A

2.3 Workforce

2.3.1

New: To enable local access

to a Direct Access

Physiotherapy (DAP) service

Aligned with SIP- People are

31.03.17

NCN

Practices

ABUHB

Physiotherapy

Improved GP access

Improved quality of

referrals to Physiotherapy

service

Action:

To support the work programme of the DAP

Progress against expected outcomes presented at NCN

meetings

A

6

confident, capable and involved Healthcare Standard 1.1 Links with SCP10 NCN Funding Priority

Service Progress:

- NCN agreement to allocate funding to support band 6 level

service function

- DAP recruited October 2016

- Service specification presented to the NCN

- On-going reports expected when in post

2.3.2

Early warning for Practices

anticipating difficulty with

recruitment / filling vacancies

Healthcare Standard 7.1 Links to SCP7

On-going

Practices

Primary Care

Team

NCN Clinical

Team

NCN

Continuity of services;

Support against potential

Practice fragility

Action:

Practices inform NCN if anticipating difficulty

Practices meet with NCN clinical team to discuss action

Progress:

- Practices reporting increased pressures & difficulties in

retaining and finding new partners/salaried GPs via PDPs

- ABUHB website developed to allow vacancies to be shared

A

2.3.3

New: To enable wider

delivery of services in primary

care


On-going

NCN

Primary Care

ABUHB Facilities

ABUHB

Housing

Patients are able to

access local services in

premises which are fit for

purpose

Action:

To consider accommodation requirements identified via

Practice visits, NCN meetings and Practice Development

Plans

Progress:

- Practice visits undertaken

- Assessing impact of new housing developments

- Practices engaged in development of the ABUHB Estates

Plan

- Analysis of PDPs undertaken

- Melin Homes presentation July 2016:

- Monmouthshire has largest population boom, with

increase in populate of 1.7 people per house built

- Significantly higher house prices

- Population is predicted to shrink, however trend has

been 15% increase since 1991

A

2.4 Performance

2.4.1 On-going Patients benefit from Action: A

7

New: To reinforce links

between the NCN & NCN

Management Team

Healthcare Standard 5.1 Links to All SCPs (excluding 6)

NCN

Public Health

Service Leads

ABUHB Finance

Team

increased collaboration,

standardised and

streamlined processes

Management Team to agrees priorities & clear action to

support delivery of the NCN Plan

To monitor spend against NCN budget and agreed

processes

Progress:

- Agreement that Management Team meetings focus on lead

priorities from NCN Plans with themed meetings

- Action logs linked to NCN Plan Strategic Aims

- Quarterly (CORE) performance reports considered at

Management Team

- Key Performance Indicators reviewed to ensure links with

the NCN action plan are in place

- Small Grant Scheme implemented

- Monthly combined finance/NCN meetings implemented

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


by: -


Rating

3.1 Planned Care

3.1.1

New: To explore the potential

for a local Cardiology Service

Healthcare Standard 3.1 Aligned with SIP- People are confident, capable and involved Links to SCP3/7/10 Source: PDPs

31.03.17

NCN

Secondary Care

GP with Special

Interest

Practices

Patients have access to

local care provided in

partnership between

Primary and Secondary

Care

Improved local access to

relevant diagnostics &

assessments

Action:

To be informed of progress via the Chepstow Hospital

Development Group

NCN to liaise with Cardiology Directorate colleagues to

support development & address barriers

Progress:

- Chepstow Hospital Development Group considering PFI

implications

- On-going work with directorate to establish local service

- Directorate visit to site held

A

8

- Progress reported at NCN meeting

3.1.2


for an extra-ordinary local

counselling service for young

people

Healthcare Standard 2.7/3.1 Aligned with SIP-People are confident, capable and involved Links to SCP3/10 Source: PDPs

31.03.17

NCN

Practices

MH Division

Third Sector

Young people have

access to professionals

trained in counselling

during school holidays

Action:

To respond to identified gap in counselling for young

people

Progress:

- Identified via analysis of Practice Development Plans

- Discussed with wider NCN and agreed as a priority in

principle, depending on available funding and competing

proposals

- NCN funding proposal from Young People’s Mental Health

Counselling service being considered

A

3.1.3


for a Practice based Complex

Wound Care service

Aligned with SIP - People are confident, capable and involved Links to SCP3/10 Source: PDPs Healthcare Standard 3.1 Adopted as local priority

31.03.17

NCN

Tissue Viability

Nurses

Practices


increased Practice Nurse

knowledge & skills

through dedicated

sessions and training

Action:

To understand demand levels across Practices in relation

to available capacity

To explore an option to develop a Practice Nurse led CWS

from NCN funding

Progress:

- Known high number of patients needing regular post-

discharge wound care

- Discussion held at NCN meeting with Secondary Care Tissue

Viability Nurses – to agree action around a proposal for

Practice based service & training

A

3.1.4

Pilot: To enable a direct

referral pathway for people

with Faecal Calprotectin

(FCAL)

Aligned with SIP- People are confident, capable and involved Links to SCP10 Healthcare Standard 3.1

On-going

Secondary Care

NCN lead

Practices

Patients with

Inflammatory Bowel

Disease who require a

Secondary Care referral,

follow an agreed pathway

Improved quality of

referrals

Action:

Practices support the FCAL pilot by using the agreed

referral pathway

Referral data is presented to the NCN

Progress:

- Pilot phase extended to Autumn 2016 with outcomes to be

reported at NCN

A

9

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


by: -


Rating

4.1 Frailty

4.1.1

New: To scope potential for

urgent diagnostics, refuge

beds & Hot-Clinics across 3

sites

Aligned with SIP-Nobody Is Left Behind Healthcare Standard 2.5/3.1 Links to SCP9 Source: PDPs

On-going

NCN lead

ABUHB

Integrated

Services

Partnership

Board (ISPB)

NCN

Supported management

of patients in primary

care setting;

Reduced admissions to

secondary care;

Improved access to

relevant diagnostics &

assessments

Action:

To support the development of a 12 month ‘proof of

concept’ proposal for Consultant led service

Progress:

- Action monitored via the Chepstow Hospital Development

Group

- Issues with Single Point of Access noted (Source: PDPs)

- Status and finance monitoring considered at Integrated

Services Partnership Board meetings

A

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


by: -


Rating

5.1 End of Life Care

5.1.1

Review the delivery of End of

Life Care using the Individual

Case Review Audit

Aligned with SIP- People are confident, capable and involved Healthcare Standard 3.1/4.1 Links to SCP3/10

31.03.17

NCN Lead

Practices

Palliative Care

Team

NCN

Improved care processes

for individuals and

families / carers

regarding End of Life

Care provision

Action:

Summarise case review data, identify arising issues and

actions

Establish a review cycle, to monitor progress

Progress:

- Audit findings shared with the NCN on an annual basis &

informs NCN lead year-end report

A

10

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


by: -


Rating

6.1 Suspected Cancer

6.1.1

Review the care of all

patients newly diagnosed

between 1 January 2016 to

31 December 2017 with lung,

gastrointestinal and ovarian

cancer

Aligned with SIP- People are confident, capable and involved Healthcare Standard 3.1 Links to SCP3/9/10

31.03.17

NCN

GP Macmillan

Lead

NCN Lead

Practices

St David’s

Foundation

All lung, gastrointestinal

and ovarian cancer

patients will have their

referral information

reviewed and outpatient

appointments/results

followed up

Action:

Summarise case review data, identify arising issues and

actions

Establish a review cycle, to monitor progress

Progress:



- GP Macmillan lead attended NCN meeting & will facilitate

outcomes being shared with Secondary Care

- Gwent-wide Community Health Champions Project (funded

via Wellbeing Activity Grant in partnership with PHW)

awareness training module designed to help increase

knowledge and understanding of:

- The different screening services available

- Who is eligible for screening and when

- How to signpost to appropriate services

A

Strategic Aim 7: Minimising the risk of polypharmacy


by: -


Rating

7.1 Polypharmacy

7.1.1

Identify and record numbers

and rates for patients aged

85 years or more receiving 6

31.03.17

NCN Lead

Pharmacist

Practices

Patients at high risk or

harm, of over or under

medicating, are identified

and reviewed

Action:

Undertake a review of practice clinical systems to

identify patients over the age of 85yrs in receipt of 6 or

more medicines

A

11

or more medications

Aligned with SIP- People are confident, capable and involved Healthcare Standard 2.6/3.1 Links to SCP3/4/7

NCN

Undertake face to face medication reviews

Progress:



7.1.2

Continue to support the roles

and integration of GP Practice

based Pharmacists

Aligned with SIP- People are confident, capable and involved Healthcare Standard 3.1/7.1 Links to SCP3/4/7

On-going

NCN

Pharmacy

Practices

Patients have local access

to, and benefit from

evidence based

interventions;


reduced waiting times;

Increased GP capacity

Action:

Pharmacist to present progress against expected

outcomes at two NCN meetings

Pharmacist provides quarterly performance data

presented at NCN leads meeting

Quarterly report to be shared with Community Nursing

Leads

Undertake annual evaluation of performance

Progress:

- Presentation given at NCN meeting 2

- Quarter 1 report submitted

A

7.2 Medicines Management

7.2.1

To monitor the NCN

prescribing budget and

delivery of the Medicines

Management plan

Healthcare Standard 2.6 Links to SCP3/4/7

31.03.17

Prescribing

Advisors

Practices

NCN Support

Efficient use of resources

that can be re-invested

more appropriately into

patient care

Action:

To scrutinise prescribing budgets on Practice by Practice

basis at all NCN meetings;

To monitor NCN performance against all other NCNs

Progress:

- Targeted approach with prescribing advisor supporting

individual Practices

- Up-dates provided at all NCN meetings

- Prescribing switch options discussed in the round

- Pharmacy Technician Practice visits undertaken to identify

potential efficiencies

A

12

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


by: -


Rating

8.1 Clinical Governance

8.1.1

To fully implement the

Clinical Governance Toolkit

Links to all SCPs All Healthcare Standards

On-going

QPS

NCN

Primary Care

Networks &

Community

Division

Practices

Consistency and safety in

Practices and NCN wide

Primary Care services

Action:

To remind Practices at NCN meetings to complete the

toolkit

To monitor progress via QPS reporting

Progress:

- Baseline: All Practices completed the toolkit in 2015/16 –

8 out of 8 Practices in progress 2016/17

- Practices have access to CPD sessions facilitated by ABUHB

- Monthly QP team reporting to NCNs shared with NCN lead

A

Strategic Aim 9: Other Locality issues


by: -


Rating

9.1 Alcohol Misuse

9.1.1

To reflect on the needs of

local people and raise

awareness of/tackle the

effects of Alcohol Misuse

Aligned with SIP- People are confident, capable and involved Links to SCP2/3/4/8/9/10 Healthcare Standard 2.7/3.1

On-going

NCN

Practices

Gwent Drug &

Alcohol Service

Identified approaches

ensure service users, and

carers where appropriate,

feel involved and

engaged in the

identification and

achievement of personal

outcomes

Reduced waiting time for

support through a new

Action:

To enable the on-going engagement with GP Practices

To receive progress reports from GDAS at two NCN

meetings per year

Progress:

- Referral form introduced with key message that clients can

self-refer into GDAS

- GDAS report provided to NCN meeting

- Q3 (2015/16):

- 54 referrals with 27 self-referrals (34 male & 20 female)

A

13

Single Point of Access - Q4 (2015/16):


- Q1 (2016/17):


9.2 Place Based Working

9.2.1

New: To support the

development of the Usk

‘Place Based Working’ model

Aligned to all aspects of the SIP Aligned to Monmouthshire Whole Place approach Aligned to Social Services & Well-Being (Wales) Act Aligned to Well-Being of Future Generations (Wales) Act Healthcare Standard 1.1/2.7/3.1 Links to SCP1/2/3/4/5/7/8/10

31.03.17

NCN

Integrated

Health & Social

Care Teams

People benefit from a

different way of working

based on “what matters”

to the individual (their

families and their carers)

A Whole Place approach

supports people to

develop opportunities,

which contribute to their

improved health and

well-being, and avoids

duplication of work

between organisations

and the community

Action:

To be informed of the framework surrounding the

development of a Place Based Working initiative &

implications for the NCN

Progress

- NCN funding application being considered

- Aligned to previous success & ethos of the Raglan Model

- “Place–based working is a person centred, bottom up

approach used to meet the unique needs of people in one

given location by working together to use the best available

resources and collaborate to gain local knowledge and

insight”1. “By working collaboratively with the people who

live and work locally, it aims to build a picture of the system

from a local perspective, taking an asset- based approach

that seeks to highlight the strengths, capacity and

knowledge of those involved”

A

Documents

Cluster Network Action Plan 2016-17 Monmouthshire North ... · Public Health Wales (2016) Child Measurement Programme for Wales 2014/2015 1.2 Engagement 1.2.1 To be a central source