Upper Valleys Cluster Network Action Plan 2016/17 Port Talbot...Upper Valley Cluster Action Plan 2016-2017 Page | 10 No Objective Key partners For completion by: - Outcome for patients

Abertawe Bro Morgannwg University Health Board Upper Valley Cluster Action Plan 2016-2017

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Upper Valleys Cluster Network

Action Plan 2016/17


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Introduction The Upper Valley Cluster includes four practices delivering services from across eight sites. The cluster serves a population of 31,196 patients. One practice is engaged in GP training and two practices offer training to medical students. The Upper Valleys Cluster Network area contains 7 Nursing/Residential Homes. There are 10 community pharmacies and 3 dental practices. The Community Pharmacies offer a range of enhanced services including, smoking cessation, just in case scheme, emergency supply and emergency hormonal contraception. The public health profile for the Upper Valley Cluster and the Welsh Health Survey identifies the following:

21.2% of the registered practice population are smokers. The Welsh Government has set a population prevalence target of 16% by 2020.

49% of the registered population are living in the most deprived two fifths (40%) of areas in wales.

Influenza immunisation uptake in the Upper Valley for patients aged 65 and over is 59% and for under 65 years and at risk, 37% and for

children, 14.5%. The NHS Tier 1 target is 75% uptake for seasonal flu for those aged over 65 and those at risk.

59.4% of the registered practice population are overweight or obese, as recorded by the Welsh Health Survey (BMI of 25+)

Bowel screening uptake for the Upper Valley in 2014/15 was recorded as 53% (target of 60%)

Cervical screening coverage for the Upper Valley as at 31/03/15 was 76.9% (target of 80%)

33.1% of the registered practice population are aged 65+ and live alone.

The cluster achieved a number of priorities during 2015/16 including:

Improved access to mental health and wellbeing services through provision of a local cluster counselling service.

Improved skills and knowledge with practice to deliver public health brief advice and intervention

Introduced medical triage to streamline and signpost patients to the most appropriate health professionals.

Improved antimicrobial stewardship in conjunction with the Big Fight.

The Upper Valley Cluster Action plan will support practices and multi-agencies to work collaboratively to:

• Understand local health needs and priorities. • Develop an agreed Cluster Network Action Plan linked to elements of the individual Practice Development Plans.


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• Work with partners to improve the coordination of care and the integration of health and social care. • Work with local communities and networks to reduce health inequalities.

The Cluster Network Action Plan includes: -

Objectives that can be delivered independently by the network to improve patient care and to ensure the sustainability and modernisation of services.

Objectives for delivery through partnership working

Issues for discussion with the Health Board For each objective there are specific, measureable actions with a clear timescale for delivery. The Cluster Action Plan compliments individual Practice Development Plans, tackling issues that cannot be managed at an individual practice level or challenges that can be more effectively and efficiently delivered through collaborative action. This approach supports greater consistency of service provision and improved quality of care, whilst more effectively managing the impact of increasing demand set against financial and workforce challenges.


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Upper Valley 2016/17 including 4 GP Practices serving a population of 32743

KEY THEMES & PRIORITIES IDENTIFIED FROM PRACTICE DEVELOPMENT PLANS

Assessment of workforce and skill mix within practices/cluster required due to ongoing GP recruitment issues

High proportion of welsh speaking patients who wish to communicate with health professionals in their chosen language

High proportion of elderly patients with multiple conditions

High level of substance misuse and alcohol dependency

Limited transport links identified by most practices

Significant levels of deprivation, with high levels of unemployment

Continue working with stop smoking Wales to improve uptake

Large number of care homes requiring increasing support

High prevalence of chronic illness/high disease risk

High prevalence of COPD

Priority areas identified as pre diabetes, smoking and obesity

High prevalence of patients with dementia

Increasing prevalence of mental health issues in children, adolescents and adults – lack of available services.

Need to consider collaboration with partners, particularly 3rd sector who might be able to provide advice and support for vulnerable groups.

Need to improve structured chronic condition management.

Need to manage demand and identify innovative ways of meeting demand imposed by multi-morbid population with high expectations


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Upper Valleys

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Directed Enhanced Services

Childhood Immunisations

Influenza for those 65 and over and others at risk groups (2-3 year olds)

Extended Minor surgery

Care of People with Learning Disabilities N

Care of People with Mental Illness N N

National Enhanced Services

Anti Coagulation (INR) Monitoring

LARC

Shingles Catch-Up Programme

Services to patients who are drug/alcohol misusers N N N N

Local Enhanced Services

Shared Care

Gonadorelins/Zoladex

Immunisations during outbreaks (MMR)

Care Homes N

Care of Homless Patients N N N

Hep B Vaccination of At-Risk Groups N

Wound Management N N

Wound Management Part B N N N N Men C Catch-up for University

Phlebotomy N


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

No Objective Key partners For completion

by: Outcome for patients

Progress to date/Possible actions RAG Rating

1.1 To review the needs of the population using available data To understand the profile of the cluster and the effect that deprivation has on the practice populations

Local Public Health Team Public Health Observatory

Ongoing To ensure services are developed according to local need

Action:

Cluster planning to be informed by PDPs and public health profiles.

Proactively utilise the Primary Care Portal to identify areas for improvement.

To consider the demographics of the community network and the impact on service delivery

1.2 Increase the number of smokers accessing specialist smoking cessation support to quit through ABM Smoking Cessation Services (SSW, ‘Start Here’ Level 3 Community Pharmacy service; ABMU ‘Time to Quit’ Hospital Service) in line with the Welsh Government Tier 1 Targets. (at least 5% of smoking population) in line with best practice and evidenced based activities

ABM Public Health Team ABMU HB Primary care team Stop Smoking Wales Community Pharmacies ‘Time to Quit’ Hospital Service

March 2017 Smokers being supported through their quit attempt via evidence based services (four times more likely to succeed and maintain longer term quit) Improved opportunities to improve health through quitting smoking.

Action:

Practices identify a smoking champion

all patients have updated smoking status on records

proactive identification of smokers from lists with invitation to cessation services

Introduce electronic referral to SSW

training for all practice/cluster staff across cluster on VBA

scrutinise referrals to cessation services on cluster basis


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No Objective Key partners For completion by:

Outcome for patients


To ensure patient smoking status is recorded and regularly updated Review asthmatics that

smoke with spirometry to

establish if COPD patients

1.3 Increase the uptake of flu vaccinations in target groups in line with the Welsh Government Tier 1 Targets; in line with best practice and evidenced based activities : Towards 75% Over 65s 6 month-64 years at risk Children aged 2-3 Pregnant women Towards 50% Practice Staff

ABM Public Health Team PHW Vaccine Preventable Disease Programme ABMU Immunisation Co-ordinator ABMU Primary care team Third Sector

March 2017 Increased protection from flu through increased uptake of flu vaccination. Reduce morbidity & mortality over winter period (particularly in vulnerable)

Action:

participate in PHW VPDP flu cluster support scheme

ensure all practice flu plans are completed and submitted to Health Board

1:1 support from ABM PHT on development of flu vaccination campaign around good practice

each practice identify vaccination champion

all cluster staff complete PHW flu e-learning module

raining for non clinical practice staff on flu myth busting

scrutinise IVOR flu vaccination uptake data on cluster basis

1.4 Increase the uptake of childhood immunisations in line with the Welsh

Health Visitors ABM Public Health Team

March 2017 Improve health and wellbeing of children. Reduce morbidity &

Action:

Scrutinise uptake data on cluster basis


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No Objective Key partners For completion by:



Government Tier 1 Targets to 95% of all scheduled vaccinations by age 4

PHW Vaccine Preventable Disease Programme ABMU Immunisation Co-ordinator ABMU Primary care team

mortality consider fluenz parties

1.5 Support patients to reduce alcohol consumption in line with new national guidelines

ABM Public Health Team. Public Health Wales Have a word programme

March 2017 Reduced alcohol consumption, alcohol misuse and alcohol related injuries.

Action:

All practice/cluster staff undertake ‘Have a Word’ Alcohol Brief intervention training and utilise alcohol screening tools in practice

1.6 Practice staff to undertake Dementia Friends training and work towards becoming a dementia friendly Surgery

Alzheimer’s Society March 2017 Practice staff will be better equipped to support patients with a dementia diagnosis who attend the surgery

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

No Objective Key partners For completion by: -



2.1 Improve recruitment and retention of GPs through the development of the GP Fellowship Scheme, .

ABMU Health Board March 2017 Improved access to GP services and increased sustainability of core GMS.

Action:

Participation in recruitment, training and mentorship


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2.2 Streamline and signpost patients to the most appropriate healthcare professional

All practices INPS

ongoing Reduce burden of appointments and targeted care provided to patients. Increased access to allied health professionals

Action:

Implementation of Vision 360 across cluster

2.3 Support training and development opportunities to increase workforce resilience and skill mix

All Practice

31st March 2017 Enhanced skills and improved efficiency of services

Action:

Consider ongoing opportunities for training and development opportunities

2.4 Increase access and signposting to community services that support self care and independence.in

order to help patients self help and improve their wellbeing independently.

NPTCVS ABM

March 2017 Increased awareness of available services/groups within the local community to support their health and wellbeing.

Action:

Development of local community services leaflet

Scope opportunities for a wellbeing centre.

2.5 Improve access to pulmonary rehabilitation services

ABMU Health Board Neath Port Talbot County Borough Council

March 2017 More COPD patients will have access to pulmonary rehabilitation.

Action:

Recruitment of additional NERS instructor to enhance the existing pulmonary rehabilitation service

2.6 Improve utilisation of National Exercise Referral Scheme to support patients to increase patients physical activity

NERS co-ordinators

March 2017 Reduced health risks through increased participation of physical activity

Action:

Review attrition compliance and completion of NERS programme in conjunction with NERS co-coordinators


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levels in line with national physical activity guidelines (linked with pre diabetes screening objective)

2.7 To provide standardised training for prescribing clerks and seek opportunities to build on initial training to further develop staff

Prescribing Clerks Medicines Management team Practice Managers

Completion of packs - June 2016 Further development ongoing

Improved repeat prescribing systems

Action:

Prescribing clerks to undertake training

To work with Health Board to build on initial training to further develop staff as opportunities become available

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 harms




3.1 Proactively identify patients who are pre diabetic or at risk of pre diabetes in order to help reduce the onset of diabetes in later life. Support those patients in

undertaking lifestyle

changes which will benefit

their health and wellbeing

All Practices

Ongoing Early diagnosis and proactive intervention to prevent or delay the onset of diabetes

Action:

Implementation of the pre diabetes service specification

Brief interventions

Referral to NERS


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3.2 Provide proactive, timely care to those who are most vulnerable and complex to manage

NPTCBC ABMU HB Practices

ongoing Vulnerable patients who have complex care needs, who are at risk of losing their independence will be proactively supported to help, avoid unnecessary admission to hospital or Long Term Care Homes.

Action:

Actively refer appropriate patients to the local care navigator for development of an anticipatory care plan

3.3 Early identification and

proactive management of

respiratory patients.

Improve reporting and interpretation of spirometry results

General Practice ABM Swansea University

31st March 2017 Early diagnosis of COPD, access to education and pulmonary rehab. Access to high quality spirometry testing

Action:

All appropriate practice staff will engage with the national ARTP spirometry training which is being delivered locally to improve reporting and interpretation of spirometry results

Smoking status of all patients to be captured

Flu vaccination to be promoted

Referral to Pulmonary Rehab for all COPD patients

3.4 Develop alternative pathways for patients with non serious and enduring mental health issues

All practices/Health Board/3rd sector organisation

Local accessible time limited therapeutic counselling interventions

Action:

All practices to continue to refer appropriate patients for 121 counselling.


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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 to improve patient experience, coordination of care and the effectiveness of risk management




4.1 To improve antimicrobial stewardship through appropriate use of antibiotics Implement mechanisms to ensure appropriate use of antibiotics (see also PMS 2016-17)

Practice team Big Fight Team Medicines management team

Ongoing with monitoring of trends See also PMS 16-17 for deadlines: Dec 16: Overall antibiotic use and choices Acute Cough Audit Improvement Plan March 17: Evidence of patient engagement activities

Reduced antimicrobial Resistance Reduced C.Diff Increased knowledge and empowerment to self care

Action:

Discuss at all annual practice prescribing visits.

Engagement with PMS actions related to antimicrobial stewardship

Share good practice and discuss cluster level data available on GP portal at meeting in January

4.2 Utilise CRP testing in order to reduce the use of antibiotics for adult patients with upper respiratory tract infections

All practices ongoing Reduction in antibiotic prescribing and re-education of patients regarding the use of antibiotics

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http://howis.wales.nhs.uk/sites3/page.cfm?orgid=872&pid=55559


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




5.1 Engage in the national clinical priority area for the management of End of Life Care. Providing peer support to review the experience of end of life care.

General Practice 31st March 2017 Improved end of life care

Action: Identify all deaths occurring between 1st January 2015 and 31st December 2016; 2 in 1000 patients Review significant event analysis approach to access delivery of end of life care (with particular focus on continuity of care).

Contacts by multi-disciplinary team in the last two weeks of life

The completion of DNACPR

Completion of Out of area

The availability of the just in case boxes

Emergency admissions of patients at the end of life

Identify any learning and action required which should be linked into the Practice Development plan Summarise themes and actions for discussion at cluster network meetings and share information with the HB as required.


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




6.1 Participate in the ACE Pilot which allows practices to refer into a diagnostic hub to improve early diagnosis of cancer.

ABMU Cancer Commissioning Board

March 2017 Rapid access to diagnostics for patients suspected of cancer with vague symptoms

6.2 Increase the uptake of PHW screening programmes in line with expected targets Bowel screening 60% Cervical screening 80% AAA screening 80% Breast screening 70%

Public Health Wales Screening Engagement Team ABM Public Health Team.

March 2017 Reduced health risks through increased uptake of screening services. Earlier detection of cancers

Action:

Review results from Bowel screening pilot to inform actions (due October 2017)

Scrutinise screening programme uptake data on cluster basis on quarterly basis

Promotion campaign during Screening awareness month (July)

Training for cluster staff on screening engagement

6.3 National Clinical priority for early detection of Cancer. Understanding cancer care pathways and identifying opportunities for service improvement.

All practices March 2017 Early diagnosis and treatment of cancer

Action: Review the care of all patients newly diagnosed between 1st January 2016 and 31st December 2016 with lung (including mesothelioma) and digestive system cancer using a Significant Event Analysis tool. Review the care of all patients newly diagnosed with ovarian cancer between 1st January 2016 and 31st December 2016 using a Significant Event Analysis tool. Summarise learning and actions to be shared with the network and the wider LHB.


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Identify and include any relevant actions to be addressed in the PDP

Strategic Aim 7: Minimising the risk of poly-pharmacy




7.1 Provide support to patients with known problems managing medicines (including polypharmacy related issues) in their own home without a package of care, through a collaborative approach with the medicines management domiciliary care team (MMDCT).

Practice teams Medicines management domiciliary care team Community Pharmacies Anticipatory care teams

Ongoing Advice and practical support to help individuals manage medicines in their own homes will reduce risk from adverse drug events, reduce unscheduled care and improve outcomes from the treatment of chronic diseases.

7.2 To engage in the Prescribing Management Scheme (PMS) and PMS+ respiratory schemes. Undertake a range of prescribing initiatives to improve: respiratory,

GPs Practice Nurses Medicines Management team

PMS 16/17 by March 17 (some Dec16 deadlines) PMS+ respiratory by November 17

Improved medicines management including polypharmacy Investment in other service areas for

Action:

Discus at annual practice prescribing visits


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antibiotic, pain management prescribing and yellow card reporting

patient benefit

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




8.1 Engage with a robust validated clinical governance process

All GP practices 31st March 2017 Improved safety and quality

Action:

To complete the Clinical Governance Practice Self Assessment Tool and achieve at least level 2 in the areas of safeguarding (CND 005W)

Participate in peer review and governance lead meetings.

8.2 Promote shared learning and good practice through increased incident reporting.

General Practice ongoing Improved quality and safety of services

Action: Encourage use of DATIX for incident reporting

8.3 Produce and maintain a cluster risk register

Cluster Ongoing Action:

Identify and agree risks


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Strategic Aim 9: Other Locality issues




9.1 To ensure that inequities and inconsistencies of referral mechanisms are minimised for practices and patients affected by cross border problems

Multi Health Board areas

Ongoing Appropriate channels of referrals through improved cross border working arrangements

Action:

Continued development work by the LHB’s to ensure that referral pathways are identified and implementation does not impact upon delivery of patient care

9.2 Premises improvement to enable capacity to deliver new pathways and increase capacity.

ABM VON/ATP

31st March 2017 Improved facilities and sustainable services

9.3 Manage public expectations and understanding of advanced, specialist and new roles, promoting alternative models of care through patient engagement

ABM CHC

31st March 2017 Improved access and prudent care

Action:

Undertake patient engagement

Develop leaflets to inform patients

9.4

To introduce new models of effective and efficient delivery of service supported and facilitated by technology

GP Practices Health Board NWIS

March 2017 and Ongoing

More sustainable services


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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.

Documents

Upper Valleys Cluster Network Action Plan 2016/17 Port Talbot...Upper Valley Cluster Action Plan 2016-2017 Page | 10 No Objective Key partners For completion by: - Outcome for patients