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Cluster Network Action Plan 2015-16

Afan Cluster

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The Cluster Network1 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 actions 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.

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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

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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 RAG Rating

1 Deliver testing/monitoring/screening/lifestyle on an annual basis to all those with Pre diabetes or at risk of Pre-diabetes

Afan Cluster Lead GP: Dr Mark Goodwin

3 year rolling programme in first instance

Lifestyle advice and support for patients to delay onset of diabetes

All practices have started to provide advice. Waiting for the delivery of agreed leaflet October 2015 – 2 practices have hit 90%. 3 have not started. Small practices are doing very well

Amber

2 To strengthen GP multi-disciplinary team engagement with other stakeholders in community networks and other service users via QOF levers

Individual Practices/Patients/LHB/LA

March 2016 Provision of co-ordinated holistic care; reduced duplication

October 2015 – some practices have carried out MDT practices

Amber

3 Improve patient and carer engagement to maximise benefit from reviews as required in QOF, enabling the patient to have the opportunity to feedback

Individual Practices/patients

March 2016 Red

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to the development of priorities through a PPG or other formal/informal feedback (CND001W)

4 Increase flu immunisation uptake in general practice

PHW Lead GP: Dr Mark Goodwin

March 2016 Protect patients at risk and the wider population

October 2015 Dr Mark

Goodwin agreed to

become flu champion to

support practices identify

a flu champion, share flu

uptake information with

the cluster, share

resources, and identify

and share best practice.

Green

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

needs of local patients

No Objective Key partners

For completion by: -

Outcome for patients Progress to Date RAG Rating

1 To develop a generic

solution for communication

to and from locum GPs and

secondary care

Afan Cluster/LHB Lead GP: Dr H Browning PM Lead: Paul Carmichael

March 2016 Improved continuity of care/reduced risk/ streamlined consistent processes

October 2015 – lead GP and PM identified

Red

2 To reduce pressures in

primary care:

1. To collect examples of

inappropriate work passed

to primary care from

secondary care and Care

Homes:

Requests for

expedited referrals:

Patients told to

contact GP for

expedite letter.

Change of

Afan Cluster

Lead GP: Dr

Kristy Mellin

Lead PM:

Katie Harris

March 2016 Improved access to primary and secondary care services/diagnostics; less avoidable delay; more timely intervention to medical care

October 2015 –Lead GP

and PM identified

Red

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management by

OPD – First

prescription to be

issued by OPD

(specifically mental health)

Delayed, illegible and incomplete discharge summaries

Requests to

prescribe medication

following hospital

discharge: Patients

should be given

interim prescription

on discharge

3 To provide accredited training for prescribing clerks

Medicines Management Team

Lead PM: Rachel Griffiths/Phillipa Thomas

Lead GP: Dr Richard

March 2016 Improved repeat prescribing systems

Training packs in development

Amber

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Penney

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

No Objective Key partners

For completion by: - Outcome for patients Progress to Date RAG Rating

1. Implement a case management approach to co-ordinate the care of the most frail in the community, as one of the early adopter sites

Afan Cluster/LHB/LA Lead Manager: Paula Heycock

Co-ordinated approach to care; timely access to appropriate services; reduced unplanned admissions

Implemented in Kings Surgery; further practices in the Afan valley identified as next cohort Progress October 2015: Cymmer and Afan Valley practices in discussion as next phase

Green

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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

No Objective Key partners

For completion by: - Outcome for patients Progress to Date RAG Rating

1 To improve antimicrobial stewardship

Medicines Management Team

Ongoing quarterly monitoring of trends

Reduced resistance

Reduced C.Diff

Increased knowledge and empowerment to self care

Discussed at all annual practice prescribing visits. Cluster level data to be shared at forthcoming cluster meeting

Amber

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

No Objective Key partners

For completion by: - Outcome for patients Progress to Date RAG Rating

1 Feed any safety concerns into the palliative care service regarding use of Just in Case box scheme where appropriate

Afan Cluster Lead GP: Dr Steve Rohman?

Timely, appropriate access to medication

October 2015- Review of Just in Case Scheme completed. Cluster to feed adhoc safety issues.

Red

2 To Improve communication with OOH services for patients considered at end of life

Afan Cluster March 2016 Better continuity of care between providers

Time limited LES launched November 2015. Participating practices to respond by December 11th 2015

Green

3 To take part in the QOF requirements for improving end of life care (CND 007W): - Using SEA to

assess delivery of end of life care

- Identify any learning and

Individual Practices/Afan Cluster

March 2016 Improved end of life care For review in January/February meeting

Amber

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actions - Summarise

themes for discussion at cluster meetings through use of proforma

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

No Objective Key partners

For completion by: - Outcome for patients Progress to Date RAG Rating

1 To liaise with Radiology to develop and follow

pathway for acting on abnormal chest X-ray

Afan Cluster/LHB Lead GP: Dr Pat Wong – Primary Care Executive Board

March 2016 Consistent and timely access to diagnostics

October 2015 – taken forward by Primary Care Executive Board with support from Cluster as appropriate

Amber

2 Complete and review significant events

relating to patients who have been

referred from one hospital speciality to another, with the GP

being asked to make that referral, which

Afan Cluster Lead PM: Deborah Picton

More timely access to treatment/diagnostics

October 2015 – Lead PM identified. LMC collecting similar information

Red

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places an unnecessary

step in the diagnostic process

3 To take part in the QOF National Priority Areas (CND 006W):

- Reviewing the care of all newly diagnosed lung , digestive and ovarian cancers

- Summarising learning and sharing actions

- Completion of proforma for discussion at cluster meetings

Afan Cluster March 2016 Improved cancer care and early diagnosis and treatment

For review in January/February meeting

Red

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Strategic Aim 7: Minimising the risk of poly-pharmacy

No Objective Key partners For completion by: - Outcome for patients Progress to Date RAG Rating

1 Review how practices can work together to organise themselves to streamline general medical services for patients in care homes

Afan Cluster Lead GP: Dr Kevin Hunt

Improved safety and quality and access to GP services

October 2015 – Lead GP identified. To look at feasibility of 1 practice per care home, Dr Hunt to hold discussions with care home and feedback to the cluster

Red

3 To provide accredited training for prescribing clerks

LHB Medicines Management Team

March 2016 Improved repeat prescribing systems

October 2015 - Training packs in development

Amber

4 To engage in the Prescribing Management Scheme (PMS) and PMS+ respiratory schemes (which contain polypharmacy elements)

LHB Medicines Management Team

PMS 15/16 – by March 16

PMS + respiratory – by November 16

Improved medicines management including polypharmacy

All practices engaged and making progress

Green

5 To take part in the QOF requirements to minimise the harms of polypharmacy (CND 008W)

- Identify patients in the cohort

- Undertake

Afan Cluster March 2016 Improved prescribing and medicines management

For review in January/February meetings

Red

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face to face medication reviews

- Identify actions for learning

- Summarise themes for sharing with the cluster

6 To explore the possibility of polypharmacy reviews in the early adopter group of patients

Medicines Management Team

Ongoing Improved medicines management including polypharmacy

Not yet started Amber

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

No Objective Key partners

For completion by: - Outcome for patients Progress to Date RAG Rating

1 To complete the CGPSAT and achieve at least level 2 in the areas of safeguarding (CND 005W)

Afan cluster March 2016 Improved quality and safety and efficiency of services

Amber

2 Encourage use of DATIX by all Practices

Afan cluster/LHB

ongoing Improved quality and safety of services

Green

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Strategic Aim 9: Other Locality issues

No Objective Key partners

For completion by: - Outcome for patients Progress to Date RAG Rating

1 To input into

solutions to the GP

recruitment crisis,

including options

to offer newly

qualified GPs

incentives to rotate

in different settings

coupled with

educational and

mentoring

Afan cluster/LHB Lead GP: Dr Paul Williams/ Primary Care Executive Board

ongoing Improved/more appropriate access to general medical services

October 2015 - Taken forward on a wider basis by Primary Care Executive Board with support from the cluster as required