Workshop 1

The Cwmtawe Cluster approach

#PrimaryCare19 #GofalSylfaenol19

WHOLE SYSTEM TRANSFORMATIONCwmtawe Cluster

Mrs Sharon Miller, Head of Primary CareDr Iestyn Davies Cwmtawe Cluster Lead

What is the Cwmtawe Cluster?

A multi agency, multidisciplinary, partnership seeking to improving Health and Wellbeing in the Clydach, Morriston and Llansamlet areas of Swansea

NEW MODELS – An overview of our project

The vision is a Cluster-led integrated health and social care system.

The overall strategic aims are:

• Improve wellbeing across the age spectrum, with a key focus on the earliest years and young carers.

• Co-ordinate services to maximise wellbeing, independence and care closer to home. Design, co-ordinate and implement services in partnership with the community. A particular focus on older people.

• Test out the vision and aims within the ten year plan and to implement components of the overall model proving proof of concept, and an ability to evaluate and redesign.

NEW MODELSQuadruple Aims -inter-related projects

OVERVIEW OF PROJECTS

Improved Population health and well being • Establish Social enterprise• Pro active communication campaign • Community involvement• Interactive engagement • Local area co-ordination• Improved mental health and well being • Young Carers

Better Quality More Accessible Services• Expand Primary Care MDT• Community Phlebotomy• Outpatient clinics e.g. Glaucoma, • Closer working with Acute Response Team • Speech and Language walk-in clinics • Space utilisation

Active Learning

Transformation Journey

Higher Value Health and Social Care• Advanced Eye Check scheme• Improved oral health in care homes

• Chronic Conditions Management – Heart Failure and COPD

Motivated and sustainable workforce • Workforce Optimisation • Clinical Leadership• Workforce development

Cwmtawe Medical Group

New model of primary care?

• 9 GP partners• 6 salaried/ 3 registrars• 2 practice pharmacists• 2 advanced nurse practitioners• 1 practice paramedic• 1 practice physiotherapist• 1 Minor illness nurse• 9 practice nurses• 2 Health Care Support Workers

With access to:

Primary Care audiology Cluster occupational therapy Cluster social prescribing link

worker Cluster early years worker Cluster-commissioned third sector

services Cluster pharmacist Dementia link worker (ICF) Our Neighbourhood Approach –

community development worker

What’s new?

• Transformational resources secured by Health Board secured in advance • Bringing together key components to maximise synergy and whole system impact, scale

and pace• Sustained focus on active community partnership using the social model of health. • Extensively testing the expanded MDT at primary care level to create strong and stable

primary care.• Moving services closer to home.• Dedicated clinical leadership time to focus on transformation • Cluster-led decisions are taken closer to (and with the involvement of) patients, carers

and clinicians• Built-in research and evaluation and active learning • A cross organisation Governance Board established under the RPB

Cwmtawe Whole System

Singleton/Neath Unit

Community Opticians

CWM ALLIANCE

Social Enterprise Directors

Patients / Community Members

MH & LD Unit

Health Board – Primary

Care

Swansea Council

GP practices

SCVS

Acute Clinical

Response Team

Community Opticians

Care Homes

Integrated Nursing Teams

Welsh Government

Audiology/Speech and

language

Medicines Management

WHO IS INVOLVED

Progress since November 2018

Local area Co-ordinator appointed January – Llansamlet Young Carers project commenced Community Interest Company established July – Cwm AllianceNew pathway for enhanced eye care developed and implemented

(community opticians) Community Primary Care Audiology Service commenced Practice MDT expanded in Llansamlet/ Strawberry Place – new roles/

models of access Medical records moved (36,000)Health literacy training undertaken - Belfast Healthy City Repeat dispensing project Initiated

Progress since November 2018

Oral health in care homes project commenced ( assessment and treatment) New model for phlebotomy developed - recruiting currently New model of primary care mental health developed Contributed to chronic conditions management framework - COPDGlaucoma clinics commenced in Morriston Speech and language – walk in /talk in clinics launched JulyWorkforce development supported (additional qualifications) Very pro active communication campaign implemented including

newsletters, media, websites and social media.

Progress since November 2018

50 + multi agency/multi disciplinary scoping meetings Clinical/Senior Leadership Group established ( meets

monthly – project board) Project manager appointed Detailed project plans completed Baseline profile completed Communications officer in post since January Research undertaken – FROME / Glasgow/ Belfast Shared learning – other clusters and All Wales

SUSTAINABILITY

Sustainable funding routes

1) Social Enterprise2) General Practice3) Re-modelling of Core Services4) Business Case through Health Board IMTP

Each Project identified expected benefits and measures

Next Steps

Strengthen further community engagement / interactive feedback

Establish co-ordinated Phlebotomy service Cluster based Mental Health and Well Being Chronic Conditions management framework Continue delivery of existing projects

Monitoring and evaluation Share learning –

• Swansea Bay University Health Board

• All wales

Initiate remaining projects – Next Stage Delivery

TRANSFORMATION

GP surgeries are prescribing gardening or Pilates instead of drugs

Principal GP Robert Boulton said they have referred many people to social prescribing and that, so far, the results have been really positive

Access to 11 doctors, two nurse practitioners, ten nurses, a mental health nurse, a paramedic, physiotherapist, audiologist, three pharmacists and a social prescribing worker.

A patient with the pharmacist during one of her regular visits to the practice

A group of trailblazing GP practices have launched a new appointment aimed at pulling a local Swansea community closer together. Anne Robinson is the new Local Area Co-ordinator for Llansamlet.

Sessions, such as a gardening club, a conversation club or a yoga taster session are run to build the confidence of people who may not be ready to step into a group straight away.

“Congratulations to Cwmtawe cluster. Excellent service ideas. Sincerely hope this funding will be rolled out to all GP clusters across Swansea"

I think this is an excellent initiative. Not everyone needs to see a GP and with such pressure on this precious resource it’s great that primary care is looking at using the skills of other healthcare professionals in the delivery services. Via Facebook

“This [social prescribing] is fantastic, it is really helpful. Social

prescribing should be in every surgery. Cindy gave me the

courage and motivation to do these things.”

Congratulations to Cwmtawe Cluster, excellent service ideas. Sincerely hope this funding will be rolled out to all GP clusters across Swansea to ensure equity of care & access to support all Swansea patients regardless of postcode.

I think this is an excellent initiative. Not everyone needs to see a GP and with such pressure on this precious resource it’s great that primary care is looking at using the skills of other healthcare professionals in the delivery of services. I think the challenge is to change the perception of patients on what is realistic for GP practices to provide and also to take more responsibility about caring for themselves.

Thankyou for listening

Questions and Answers

Contact Details Iestyn.Davies3@wales.nhs.ukSharon.Miller@wales.nhs.uk

Find us on Facebook: @CwmtaweCluster and Twitter: @cwmtawecluster