GP Cluster Network Action Plan 2015-16 Upper Valleys Cluster
The Cluster Network 1 Development Domain supports GP Practices to work to collaborate to: Understand local health needs and priorities. Develop an agreed Cluster Network Action Plan linked to elements of the individual Practice Development Plans. 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 should be a simple, dynamic document. The Cluster Network Action Plan should include: - 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 should be specific, measureable with a clear timescale for delivery. Cluster Action Plans should compliment 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 should support 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. The action plan may be grouped according to a number of strategic aims. 1 A GP cluster network is defined as a cluster or group of GP practices within the Local Health Board s area of operation as previously designated for QOF QP purposes
1. Strategic Aim 1: To understand the needs of the population served by the Cluster Network by: 1.1. Increase the number of smokers making quit attempts. 1.2. Increase uptake of flu vaccinations 1.3. Increase uptake of PHW screening programmes 1.4. Support to reduce alcohol consumption ABM Public Health Team. Stop Smoking Wales. ABM Public Health Team. (NB for discussion PHW may have some funding to support this objective) Public Health Wales Screening Engagement Officer ABM Public Health Team. Public Health Wales Improved opportunities to improve health through quitting smoking. Increased protection from flu through increased uptake of flu vaccination. Reduced health risks though increased uptake of screening services. Reduced alcohol consumption, alcohol misuse and alcohol related injuries. Provide staff with training to deliver brief advice/or brief intervention for smoking cessation. Provide staff with information about the different stop smoking services available in ABM Ensure staff complete Public Health Wales e- learning module on flu. Ensure relevant? staff have good knowledge of the different screening programmes and key messages. Ensure all staff undertake Have a Word alcohol brief intervention training. 3
2. Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local 2.1. Provide accredited training for prescribing clerks 2.2. Improve access to local pulmonary rehab 2.3. Reduce DNAs by greater use of text messaging 2.4. Increase uptake of MHOL for ordering repeat prescriptions 2.5. Streamline and signpost to the most appropriate healthcare professional 2.6. Improve utilisation of NERS Medicines management team Pontardawe HC/ COPD physiotherapy Improved repeat prescribing systems Locally accessible PM service NWIS/LHB/VON Better information to to increase compliance VON Reduced burden of appointments and increased patient convenience All practices Reduce burden of appointments and targetted care provided to All practices/ners Increased physical activity Training packs in development Bid against slippage to procure exercise equipment Explore establishing practice triage Share ATP internal practice protocols Provide call handling training to practice staff Work with NERS to make best use of locally accessible programme(s) 4
3. Strategic Aim 3: Planned Care- to ensure that needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms 3.1. Develop alternative pathways for with non serious and enduring mental health issues 3.2. Improve the understanding and adherence to ABMU referral pathways by GPs and locums All practices/health Board/3 rd sector organisation All practices/identified secondary care directorates November 2016 Local accessible time limited therapeutic counselling interventions Consistency in service provision Develop and implement UVCN Counselling SLA with Ystradgynlais MIND Conduct six month review of service, evaluate and amend if necessary Continue to conduct regular reviews and evaluation Identify all relevant pathways Standardise practice systems to ensure compliance Ensure all clinicians are aware of guidelines and pathways Identify areas that need improvement or where there are problems with WCCG referrals and work with secondary care to address these 5
4. Strategic Aim 4: To provide high quality, consistent care for 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. Improve antimicrobial stewardship 4.2. Undertake a patient education campaign on use of appropriate NHS services Medicines management team Ongoing quarterly monitoring of trends Reduced resistance Reduced C.Diff Increased knowledge and empowerment to self care All GP practices Patients have the information they need to get the right care at the right time Discussed at all annual practice prescribing visits. Cluster level data to be shared at forthcoming cluster meeting Promote GP OOH phone number Display relevant posters Display educational messages on the screens and notice boards. Provide laminated card with useful telephone numbers for. Continue to educate in appropriate use of OOH service Provide education to who have inappropriately used A&E 6
5. Strategic Aim 5: Improving the delivery of end of life care 5.1. Implement the QoF national priority requirements for end of life care (2015/16) 5.2. Improve identification and recording of on the palliative care register 5.3. Lobby LHB about amending the terminology used in EOL care to read Allow natural death 5.4. Improve practice in discussing preferred place of death and other end of life care issues at an early stage 5.5. Explore sources of bereavement support to signpost relatives to [CRUSE] 5.6. Consider adapting the ICP in practices to improve recording of spiritual and other needs All practices Improved End of Life Care All practices Improved End of Life Care All practise Wishes of acknowledged and respected 3 rd Sector/practices December 2015 Improved sources of support Wishes of acknowledged and respected 7
6. Strategic Aim 6: Targeting the prevention and early detection of cancers 6.1. Work with Radiology to clarify pathway and improve access to Radiology, ultra sound, CT Scans 6.2. Implement the QoF national priority requirements for Prevention and Early detection of Cancer (2015/16) 6.3. Lung Cancers Clarify referral pathways in relation to with lung cancer with secondary care 6.4. Digestive Cancers Promote the bowel screening service and encourage to attend when invited GPs/Radiology Consistent and timely access to diagnostics All practices Early diagnosis and treatment of cancer GPs/Oncology GPs/PHW Early diagnosis and treatment of cancer Early diagnosis and treatment of cancer Negotiate direct access for initial Radiology, Ultrasound, CT scan to deliver 2 week deadline 8
7. Strategic Aim 7: Minimising the risk of poly-pharmacy 7.1. Provide accredited training for prescribing clerks 7.2. Provide support to with known problems managing medicines (including polypharmacy related issues) in their own home without a package of care, through a collaborative approach with community pharmacies. 7.3. Engage in the Prescribing Management Scheme (PMS) and PMS+ respiratory schemes (which contain polypharmacy elements) 7.4. Progress other polypharmacy plans identified in previous annual report Medicines management team Community pharmacists Medicines management team Initial assessment for completion by March 2016 PMS 15/16 by March 16 PMS + respiratory by November 16 Improved repeat prescribing systems 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. Improved medicines management including polypharmacy Practice teams Ongoing Improved prescribing and mechanisms for polypharmacy review Training packs in development Enhanced Service for community pharmacists to support this objective currently being developed. All practices engaged and making progress Ongoing 9
8. Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance 8.1. Complete the CGPSAT and achieve at least level 2 in the areas of safeguarding (CND 005W) 8.2. Report all delays in relation to USCs as Significant Events All GP practices Improved safety and quality All practices Improved access to cancer services 9. Strategic Aim 9: Other Locality issues 9.1. Continue to explore scope, with secondary care colleagues, to transfer aspects of managing Type 2 Diabetics on injectibles in primary GPs (VON/Diabetes Consultants Regular management of diabetes in the community 10