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Transcript of Caerphilly East Neighbourhood Care Network Action Plan ... East NCN Action... · Caerphilly East...
Caerphilly East Neighbourhood Care Network Action Plan & Progress Report 2015-16
Complete Started Not Started
Strategic Aim 1: To understand the needs of the population served by the Network
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
1.1 Smoking
1.1.1 Achieve/work towards the National
Tier 1 target of 5% of smokers make a quit
attempt via smoking cessation services, with at least a 40%
CO validated quit rate at 4 weeks
Supports Caerphilly SIP – Healthier Caerphilly H1, H2, H3, H4 Supports IMTP SCP3
NCN
PHW
Smoking Cessation Wales
Housing
Associations Communities
First
Community Pharmacy
31.03.16 Increased numbers of staff who have access to brief
intervention training
Increased access for patients to staff trained in brief intervention techniques
Patients will be motivated to
make a quit attempt and will receive effective treatment to quit smoking
Progress: 2014-15 Figures for Caerphilly
Patients scheduled to
attend a smoking cessation appointment = 441 (467 initial
assessments undertaken)
Number of treated
smokers = 263
% of patients who quit
at 4-weeks (CO-validated) = 54% (40% target level)
Actions
Develop local communication plan with the Communities
First Smoking Cessation Officers
Increase numbers of
staff who have access to
brief intervention training
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
Review data on uptake
of smoking cessation services and quit rates at NCN meetings
including with non-medical members
Continue to improve
referral rate through
collaborative working
Ensure every practice has appointed a smoking champion
Increase number of
pharmacies offering Level 3 smoking
cessation services
1.1.2 Communities First Staff to offer
Maudsley Smoking Cessation advice to
patients across Caerphilly funded
from NCN monies for 2015-16
See 1.1.1 Supports Caerphilly SIP – Healthier Caerphilly H1, H2, H3
Communities First
NCN
31.03.16 Increase in patients making a quit attempt as service can be
offered on a 1-2-1 basis
Delivery staff will have established relationships with
patients
Provide regular reports to NCN on progress of
Communities First Staff.
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
1.2 Obesity
1.2.1
To address Obesity issues within the NCN
Network through Partnership working
Supports Caerphilly SIP –
Healthier Caerphilly H2, H3, H4
NCN
Social Services/ Communities
First Adult Weight
Management Service
PHW
GAVO
31.03.16 NCN membership and stakeholders will be able to plan
for integrated service provision across the Caerphilly NCN
areas. Families will have access to a
wide range of children and young people’s services,
initiatives and projects addressing obesity issues
Identify baseline data for NCN area regarding
the number of citizens attending services.
Map Level 2 services for
weight management
and refer/recommend – Foodwise, commercial
clubs, NERS, led walks
Increase in the number of citizens attending the services.
Refer routinely to Adult
Weight Management Service
To develop identify existing service
pathways to address childhood obesity needs
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
1.3 Bowel Screening
1.3.1 Achieve the National
Target of 60%
eligible patients
screened
Supports Caerphilly SIP –
Healthier Caerphilly H2,
H3, H4
NCN
PHW
National Screening
Services
GP Practices
31.03.16 Earlier detection of bowel
cancer with improved chance of
survival
PHW to liaise with
national screening services regarding
providing practices with a list of non-responders
Identify achievements against national target
of 60% and action to achieve
Practices to complete
work according to
protocol
1.4 Public Engagement
1.4.1 To support the work of the ABUHB
Engagement Team in implementing the
Engagement Strategy and seeking /
collecting information on service provision and change from the
wider Gwent resident population.
Supports Caerphilly SIP – Healthier Caerphilly H4, H5
Network Team
NCN
GP Practices
Communities First
GAVO
On-going Formal and informal consultation opportunities for all
residents to influence the development and improvement
of all services (including integrated services) across
ABUHB.
To promote the work of ABUHB & NCN where
possible
To attend events to provide a range of
information relating to e.g. Flu / smoking cessation / Health
initiatives
Feedback findings from Listening Events to NCN and ABUHB
Engagement Teams
Where possible build
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
feedback into actions
for future NCN plans
Work with partners in
Wellbeing Delivery Group to maximise communication and
engagement opportunities
1.5 Influenza
1.5.1
Achieve the national
target of 75% for
immunisation against
influenza
GP Practices
NCN Contractor
Services
DNs
31.03.16 Decrease in hospital admissions
Decrease in morbidity
Progress:
63% achieved in 2014-15 for immunisation against influenza for 65yrs and
older for Caerphilly East NCN
49% achieved in 2014-15 for immunisation against
influenza for 6months to 64yrs for Caerphilly East
NCN
Hold discussions
between practices regarding best practice
Receive regular practice
updates during flu
season
NCN Management Team to agree an approach to deliver the programme
(see 1.6)
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
1.6 NCN Management Team
1.6.1 Establish a
Management Team Structure for Caerphilly East NCN
NCN Lead
NCN Partnership
Teams
Network team
31.03.16 Improved guidance, co-
ordination and development / skills, knowledge and engagement
Implement
NCN/Integrated Management Team
Agree Priorities for 2015/16
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 Agreed actions / Progress to Date
RAG Rating
2.1 Access
2.1.2 Achieve LMC agreed access figures
GP Practices
NCN Lead
31.03.16 Practices to engage with project to optimise access in keeping
with emerging guidance to be agreed with CHC, Health Board and LMC
Practices to monitor performance against
LMC standards
Monitor & report
performance to NCN Lead on a
monthly/quarterly basis
2.1.3 Monitor the
continuation and uptake of My Health Online
Supports Caerphilly SIP – Healthier Caerphilly H5
NCN, Practices 31.03.16 Ease of access to GP services All practices to offer
appointment availability and repeat prescription ordering via MHOL
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
Supports IMTP SCP3
2.2 Workforce
2.2.1
Improve locum
arrangements and ensure that practices
in difficulty have access to NCN salaried support
team to ensure continuity of service
in the short term.
Supports IMTP SCP3
ABUHB
GP Practices
PC&ND
31.03.16 Patients experience shorter
waits for GP appointments and increased patient appointment
capacity Increased access to
appointments, measured through audit
Continuity of services
Support against potential practice fragility
Practices to inform NCN
verbally/in writing if anticipating having
difficulty, and agree to meet with NCN Lead and CD to discuss next
steps
2.2.2 To support relevant
education and development opportunities across
the NCN
NCN Lead 31.03.16 Sharing education sessions
across practices providing up to date enhanced skills to provide better patient care
Utilise the NCN Training Plan
from NCN slippage monies
Develop a process for
Practice and other staff to access training Identify Training
providers and costs
NCN practices and partners apply for relevant funding
0515 Providing for the Future.pdf
2.2.3 To enhance the
delivery of NCN based services, specifically dental,
AMD
CDs NCN Leads
31.03.16 Patients will benefit from the
appointment of Independent Advisors and the value of debate they will bring from
Allocate funding from
NCN budget
Appoint Independent
0715 Strengthening General Practice.pdf
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
optometry and
pharmacy. Supports IMPT SCP3
across ALL Primary Care
Services in the development and delivery of NCN Work Programmes.
1 x Dental, Pharmacy,
Optometrist Advisors
2.2.4 Provide Practice Based Social Workers (Pilot)
NCN Lead
Social Services
Identified
practices
31.03.16 Better GP Access
A greater focus on achieving
people’s well-being outcomes through holistic integrated
assessment and co-productive solutions
Increased capacity for GP’s where people can access the
right person, with the right skills and at the right time.
Increased patient safety and the
promotion of carer’s needs
Avoidance of admissions to
hospital through community support via Frailty, increased care at home, innovative co-
productive solutions or access to step up beds
Implement the service within the identified practices so that Social
Workers are integrated and become a member
of the multi-disciplinary team
Progress Three social workers
appointed across Caerphilly, (1 in
Caerphilly East NCN based at Risca Surgery). Feedback to
date extremely positive
Funding allocated from NCN budget
2.2.5 Recruit Primary Care Based Pharmacists
from NCN funding to integrated with NCN
and Partners (Also see 7.2.1) Supports IMTP SCP3
NCN Lead
Pharmacy
NCN Practices
31.03.16 Example outcomes from Welsh Governments Model of Care for
Pharmacy & Meds Management:
Medication review undertaken
Medicines optimisation
releases GP time and works towards GMS contract
Appointment made July/August 2015
Report progress, on
outcomes and impact at NCN meetings
Identify opportunities for Pharmacists to
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
targets
Improve patient adherence through co-production
Medication is clinically
appropriate and effective (Polypharmacy)
Reduced hospital admissions through better management of condition and safe use of
medicine Less waiting time as patients
signposted to appropriate service at the start
Good governance around
repeat prescribing Reduction in waste
Provides link for community teams dealing with complex
patients needing advice and support on medication
Nursing Homes: Reduction in
waste and polypharmacy
further develop
appropriate skills
Funding allocated from
NCN budget
2.2.6 Increase access to
Primary Care Community Phlebotomy Service
Supports IMTP SCP3
NCN
Community Nursing
31.03.16 Increased capacity and access
to Primary Care phlebotomy services
Releasing DN time to focus on wound care, vaccinations and
immunisations and other interventions Releasing DN time to support
patients with complex needs who will require greater time
spent with them and/or more
£1.1 Million NCN
funding agreed across NCNs plus funding from £4.4 million for
Phlebotomy Service across Gwent. Work
Programme to be developed and agreed by NCN
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
frequent interventions.
Enabling DNs to undertake specialist training to upskill to
support patients with complex needs eg wound care
Ensuring the core DN workforce has the capacity and skills to
respond to the ever growing demands, thus avoiding the
development of short term or bolt on specialist services.
2.3 Estates
2.3.1 Improve the
management of estate issues, lack of space in buildings,
lack of grants to be able to increase size
of premises Supports IMTP - SCP3
Clinical Lead,
PC & ND
31.05.16 High quality facilities available
to best meet patient need Annual practice reviews and
CHC statutory visit reports demonstrated facilities are to
required standard.
NCN Lead to clarify the
position regarding Caerphilly East estate/premises
development and refurbishment during
practice visits
Primary Care Estates
Strategy will highlight issues for action
Contact Local Authority
Housing Dept staff for
input re expected housing development
plans
2014-15
AMBER
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
2.3.2 To consider accommodation
requirements within primary care in
relation to wider delivery of services Supports IMTP SCP3
NCN 31.03.16 Patients are able to local access services in high quality
premises
NCN to consider wider accommodation needs
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 harm
No Objective Key Partners For
Completion by
Outcome Agreed actions /
Progress to Date
RAG
Rating
3.1 District Nursing
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
3.1.1 To maximise the
effectiveness of the District Nursing (DN) workforce by
appointing Community
Phlebotomists.
Practices
Community Division
District Nursing
Team Lead
31.03.16 Patients have improved access
to both DN Team services and to newly established Community Phlebotomy Team services.
See 2.2.6
See 2.2.6
3.2 Health Visiting
3.2.1 To build up relationships between Health Visitors and
practices
NCN, ABUHB Colleagues
31.03.16 Feedback from HVs and Primary Care demonstrates improved communication.
Improved services for patients
Consistency for patients in which members of staff they
see when having a visit from the Health Visiting Service.
Respond to work-streams from Pan Gwent Working Group
Team co-ordinator to
provide performance information for NCN meetings
3.3 Mental Health
3.3.1 To strengthen integration at practice
level between Primary Care and the PMHT
Supports Caerphilly SIP – Healthier Caerphilly H1, H2, H4, H5
Practices, PCMHSS,
Third Sector, Statutory
Services
31.03.16 Reduction in the number of referrals passed between
different teams within Mental Health services, and PMHTs
Clearer care pathways, including transparent, concise access criteria, will be in place
for patients
GP’s to make use of the PCMHSS Flowcharts and increase their use of the
PCMHSS Practitioners for advice/guidance.
Work ongoing regarding best working and sign
posting.
Team co-ordinator to provide performance information for NCN
meetings
Evaluate effectiveness of Primary Care Flowchart for use in practices and
flowchart for CYP via annual audit of GP
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
satisfaction with the
PCMHSS.
WG to fund in full the
proposals from Directors of Primary,
Community and Mental Health for a strategic programme of
pathfinder and pacesetting projects for
primary care - £8m allocated to MH. Feedback on how this
funding will be used in Caerphilly East to be
given to the NCN
3.3.2 To ensure that
patients are seen by the ‘right person in the right place at the
right time’.
Practices,
PCMHSS, Third Sector, Statutory
Services
31.03.16 The usage of CCBT kiosks are
regularly monitored through the gathering of statistical information.
Computerised Cognitive
Behaviour Therapy (CCBT) kiosks are available for patients to
access at a number of accessible sites in the
Borough (telephone support is available)
Enhance the library of
available local resources
for use within primary care.
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
3.3.3 To increase the
uptake of psychological intervention through
the ‘Road to Wellbeing’
programme.
Practices,
PCMHSS, Third Sector, Statutory
Services
31.03.16 300 people to have accessed
Stress Control and ACTivate your Life classes in Caerphilly between September 2015 and
March 2016.
Help to promote the
Stress Control and ACTivate your Life courses offered locally
NCN to receive regular
feedback from service
3.4 Pulmonary Rehabilitation Services
3.4.1 NCN to explore the
feasibility of providing a Pulmonary
Rehabilitation Service in the NCN Network Supports Caerphilly SIP – Healthier Caerphilly H3, H4
ABUHB
Divisional Colleagues,
Thematic Leads
31.03.16
There will be a locally available
Pulmonary Rehabilitation service provision for Patients
within the NCN Network Decreased waiting time from
referral
Decreased travel for patients
NCN to explore the
feasibility of providing a Pulmonary Rehabilitation
Service in the NCN Network
Ongoing re-structuring and development of the
Pulmonary Rehabilitation Service
3.5 Diabetes
3.5.1 To improve diabetes services across the NCN for Patients
Supports Caerphilly SIP – Healthier Caerphilly H1, H3, H4 Supports IMTP SCP5
As above 31.03.16 Improved management of patient diabetic service needs across the NCN
Access to advice from multi-
disciplinary team and implementation of the new diabetes work plan leads to
improved outcomes for patients
Improved access to DSNs via email/telephone for
initiation of injectable therapy
• To implement the Diabetes Integrated Service Model across
the NCN
• To use PH Observatory data as a baseline for
improvement Refer routinely to Adult
Weight Management Service
Consider increasing
Adult Weight
Diabetes Work Plan NCN comms 16 45.ppt
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
Improved access to
Consultants for advice
Improved rapid assessment
of patients who need consultation opinion
Management Service
capacity for specific populations (e.g. Pre-diabetes, pregnant
women)
DSNs to cleanse lists to ensure appropriate patients are managed in
primary and secondary care
Monitor referrals to
diabetes secondary care
per practice
3.6 COPD
3.6.1
Improve Inhaler Technique for patients
Community Pharmacy
NCN
31.03.16 Patients using devices appropriately
To cascade inhaler technique training-
multidisciplinary strategy. NCN funding identified.
Accredited training
provided by WCPPE, pre and post course
learning, plus take away pack of placebo devices.
3.7 Osteoarthritis Knee
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
3.7.1 Improve management
of patients with Supports IMTP SCP5
NCN Lead
NCN
Practices
31.03.16 Osteoarthritis of the Knee
(OAK) education sessions -
scheduled to take place on a
Monday afternoon on a weekly
basis
General Practice been
invited to refer people with newly diagnosed OA knee to an
appropriate course
Improve numbers attending the group – DNA rate currently
below 50%
Monitor referral rates via regular update reports
Receiving referrals from
Physiotherapy, Orthopaedics and GPs
One course already held
at Risca Flying Start
Monitor referrals to MRI
3.8 Sustainable Care Homes Services
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
3.8.1 Move toward a more
sustainable service for delivery of care for patients in care
homes
NCN Lead
Practices
31.03.16 Improved care for residential
patients
Support the education
programme for nursing
staff in homes NCN to
support
NCN lead to undertake
data gathering exercise
around care homes
experience of primary
care
Monitor and increase
the uptake of the
enhanced service
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 Agreed actions / Progress to Date
RAG Rating
4.1 Urgent Access
4.1.1
Practices to review
performance against
LMC agreed urgent
access figures
GP Practices
31.03.16 Improved patient access to
primary care services
Practices to engage with project
to optimise access in keeping
Practices to monitor performance against LMC standards
Practices to monitor &
No Objective
Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
NCN Lead with emerging guidance to be
agreed with CHC, Health Board
and LMC
report performance to
NCN Lead on a monthly/quarterly basis
Monitor A&E attendances per practice
4.1.2 To improve utilisation
of available data sources to review
activity for the NCN
NCN Lead
Network Team
GP Practices
31.03.16 Informed understanding of
urgent access referrals for NCN patients to secondary care
services
Identify make up of
urgent referrals
Share findings at NCN meetings and instigate remedial action where
appropriate
4.1.3 Appropriate utilisation of WECS Scheme –
Eye Health Examination Wales
(EHEW)
NCN
WECS
31.03.16 Reduction in avoidable referrals/admissions
Education session for NCN with regard to the
WECS services by ABUHB Optom Advisor
Baseline data for
attendance updated by
Optom Lead
No Objective
Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
4.1.4 Appropriate use of
YYF Minor Injuries
Unit
NCN
YYF Minor Injuries Unit
31.03.16 Clarification of MIU services
within YYF Reduction in avoidable
admissions
Hold education session
for NCN with regard to services available
Obtain practice data with regards to
attendance at A&E and YYF MIU
Ensure YYF MIU has details of how to access
emergency/urgent slots in each practice
4.2 Frailty (CRT)
4.2.1 Improve appropriate utilisation of the Frailty Service
Supports IMTP SCP4
NCN, Practices,
CRT Team
31.03.16 Improved access and communication with Frailty and between Frailty and the OOH
Service
Less hand offs between services, and improved communication about the needs
of the individual will result in better quality, more timely care
Increased GP referrals
Reduction in rejection of referrals
Frailty run charts will show improvements
Work proactively to improve communication and working
relationships through regular invitation to
NCN meetings
Monitor referrals to the
frailty service per practice
Gain better understanding of pressures that all
services are working under including OOH
Ensure appropriate use of the SPA contact number by all practices
No Objective
Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
from 01.09.15
4.3 Social Services
4.3.1 To improve communication
between Health Services and Social Services
Supports Caerphilly SIP – Healthier Caerphilly H3, H4
NCN Lead
Network Team Caerphilly
Integrated Partnership
31.03.16 Feedback from GP Practices, Health Visitors,
District/Community Nurses will demonstrate improved communications
Patients will receive seamless
service transition between primary care and social services
Raise any issues with Caerphilly Integrated
Partnership / NCN Management Team
Continuously monitor impact and consider
best ways of working and communication issues at NCN meetings
Strategic Aim 5: Improving the delivery of end of life care (National Priority – to be discussed locally)
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
5.1 Review the delivery of End of Life Care
using the Individual
NCN Leads, Practices, NCN
Support Teams
31.3.16 Better care received by individuals at EoL.
NCN to support Practices to review audit
of patients who have 0815 Gwent Palliative Care Strategy.docx
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
Case Review Audit died to be reflected
upon/inform future care delivery.
5.2 Summarise case
review data, and
any arising issues
and actions
identified, for
sharing with the
network and the
wider health board
NCN Leads, St
Davids Palliative
Care Team,
Practices, NCN
Support Teams
31.03.16 Learning through shared
experience will inform future
care improvements for patients
on the EOL pathway.
Highlight best practice for improvement to be
shared in a multi-professional discussion
0715 EOLC All Gwent Summary.docx
Caer East National Priorities Audit Summary 0315.docm
5.3 Establish a review
cycle, to monitor progress (or
maintenance of high quality), with further submission of
reports to the GP network and wider
health board as appropriate
NCN Leads,
Practices, NCN Support Teams
31.03.16 Improved consistency in
standard of care delivered
Agree of ‘best practice’
in EOLC. Identify and monitorf
areas for improvement so that appropriate education and support
can be delivered
Strategic Aim 6: Targeting the prevention and early detection of cancers (National Priority)
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
6.1 Review the care of all NCN, NCN 31.03.16 All lung, gastrointestinal and Practices complete Audit
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
patients newly
diagnosed between 1 January 2015 to 31 December 2015 with
lung, gastrointestinal and ovarian cancer
Leads,
Practices
ovarian cancer patients will
have their referral information reviewed and o/p appointments / results followed up
Tool and discuss
findings
6.2 Learning and actions to be shared with the
GP network and the wider LHB
NCN, NCN Leads,
Practices
31.03.16 Audit tool to ensure continuous review, reflection and
improvement in processes and care pathways for patients with a diagnosis of cancer.
Practices complete audit and discuss findings
Caer East National Priorities Audit Summary 0315.docm
6.3 Identify and include
any relevant actions to be addressed in the Practice Development
Plan
NCN, NCN
Leads, Practices
31.03.16 Improved patient information.
Patients preferred place of death.
Practice by practice NCN
USC cancer data will be collated to provide better informed
demographic data relating to cancers on a
regular basis
6.4 Summarise themes and actions for review with the GP network
and share information with the LHB as
required
NCN, NCN Leads, Practices
31.03.16 Improved patient information. Patients preferred place of
death.
NCNs to share learning with secondary care
National Priority Target Audit Summary Cancer 14-15.docx
6.5 Develop protocols to
ensure Practices refer patients as ‘USC’ rather than ‘Urgent’ if
cancer was suspected and that Practice
based systems should be established to track USCs referred.
NCN Lead Practices
30.09.15. Patients will be referred for
Secondary Care interventions with the appropriate level of urgency and seen accordingly.
Practices to discuss and
agree to use USC notation on suspected
Cancer patient referrals
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
Supports IMTP SCP3
6.6 Practices to encourage
patients to attend appointments with the
Bowel Screening Programme. Supports IMTP SCP3
Public Health NCN Lead Practices
31.03.16. Earlier detection of bowel
cancer. Data supports improved survival rates. Patients may receive diagnostic
and procedural interventions quicker than via a non-Screening Programme referral.
PHW to liaise with
national screening
services regarding provision of list of non-responders
Practices to discuss and
agree a process to write to patients who have not attended scheduled
bowel screening appointments
encouraging them to reconsider and do so.
6.7 to ensure referring GPs are informed by Secondary Care
Consultants of downgrades to USC
referrals. Supports IMTP SCP3
PC & ND / AMD Secondary Care Consultants GPs
31.03.16. Improved patient information. Appropriate treatment pathways initiated.
PC & ND / AMD to contact Divisional Leads
to ensure consultants inform referring GPs of
downgrades. Practices to consider
processes to follow up all USC referrals and
subsequent potential downgrades.
Strategic Aim 7: Minimising the risk of poly-pharmacy (National Priority – to be discussed locally and also Medicines Management)
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
7.1 Poly-pharmacy
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
7.1.1 Identify and record
numbers and rates for patients aged 85 years or more
receiving 6 or more medications.
NCN, NCN
Leads, Practices
31.03.16 Identify patients at high risk or
harm of either over or under medicating.
Using audit +, a review
of practice clinical systems to identify (‘at-risk’ only) patients over
the age of 85yrs in receipt of 6 or more
medicines.
7.1.2 Undertake face to face medication
reviews, using the ‘No Tears’ approach
NCN, NCN Leads, Practices
31.03.16 Reduction in unnecessary admissions to hospital.
Identification of further
untreated conditions. Number of MUR Consultations
Using data from the review audit book
appointments for medication reviews of
patients over the age of 85yrs receiving 6 or more medicines.
7.1.3 Identify any actions
to be addressed in the Practice
Development Plan
NCN, NCN
Leads, Practices
31.03.16 Poly-pharmacy at NCN
meetings Quarterly information to NCN on
utilisation of notional budget
Caer East National Priorities Audit Summary 0315.docm
National Priority Target Audit Summary Polypharmacy 14-15.docx
7.2 Medicines Management
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
7.2.1 Appointment of
Primary Care Pharmacists to assist the delivery of safe
and cost effective prescribing to the
NCN population
NCN Lead,
Practices
31.03.16 See 2.2.6 Recruit and appoint
Pharmacists in Primary Care
Agree range of duties expected of appointees
Report and monitor
activities and impact of
appointments to NCN Lead
0715 Pharmacists in Primary Care.docx
7.2.2 To monitor the NCN prescribing budget and delivery of the
Medicines Management Plan
NCN Lead Prescribing
Lead
GP Practices
31.03.16 Efficient use of resources leads to re-investment & more appropriate care
To receive regular prescribing information at NCN meetings
Budget performance
and delivery of the savings plan
National Indicators/Clinical
Effectiveness Prescribing Programme
Pharmacy and NCN Leads to meet and decide priorities for
NCNs to achieve in terms of service
improvement, costs and quality
7.2.3 To review the variation in prescribing compared
NCN Lead GP Practices
31.03.16 Patients and professionals have access to a named Pharmacist in Primary Care
NCNs to work with Primary Care and Networks Division Pharmacy staff to:
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
to national guidance
in relation to Diabetes and Respiratory and deliver the NCN
savings target for these work streams
within the three year plan
Pharmacy
Efficient use of resources that can be re-invested more appropriately into patient care
Minimise avoidable harm from
the adverse effects of inhaled steroids
Undertaking the minimum appropriate intervention to
ensure prudent prescribing aligned with NICE Guidance.
Arrange scheduled visits
by the NCN Lead to discuss Dashboards and
Practice performance
Monitor performance
change through actual prescribing spend on high dose
corticosteroids and diabetes drugs
Identify prescribing
leads rep and identify
progress against the SCEP;
Prescribing guidance to be developed by
Pharmacy Team
7.2.5 To provide
consistency in medicines reviews in both Practice and
home visit settings.
NCN Leads Practices
On-going Patients will have a consistent
medicines review in Practice or at home.
Practices to consider
printing out the NOTEARS template for
use on home visits to provide consistency of
reviews. Develop NCN Standard.
For discussion at
NCN Meeting 03/09/15
Strategic Aim 8– Delivery consistent, effective systems of Clinical Governance
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
8.1 Clinical Governance
8.1.1 To fully implement the Clinical
Governance Toolkit
NCN
Primary Care & Network Division
GP Practices
31.03.16 Consistency and safety in Practice and NCN wide primary
care services
Ensure practices are supported in completing
the CGSAT Sessions to be
established to support
GP practices in completing the CGSAT
Target support for areas of the CGSAT which are identified as
showing low levels of achievement
Access arrangements – core access arrangements; aids to
access user experience; the impact of MHOL
How practices respond to urgent and same day requests from Care
Homes, WAST and Hospital Emergency
Depts Actions to foster
greater integration of health and social care
Consideration of how
Third Sector support may be maximised
Map local services to highlight where services are delivered across
practices (e.g. contraceptive services,
minor surgery)
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
How new approaches to
the delivery of primary care might aid service delivery and ensure
sustainability of local services
Consideration of the impact of local care pathway work relating
to previous QOF work
Strategic Aim 9: Agreed Locality Priority Issues
No Objective Key Partners For
Completion by
Outcome Agreed actions /
Progress to Date
RAG
Rating
9.1 To Improve communication and utilisation of Mental
Health / Mental Wellbeing services in
the Locality
NCN, NCN Lead, Practices, PCMHSS,
ABUHB Divisional
Colleagues
31.03.15 Better referrals and access to services in appropriate timescales
Presentations shared with NCN. Ongoing work regarding PMHT
and signposting
Continued liaison with Communities First and Third Sector
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
9.2 Establishment of an
NCN Web based solution that provides information for local,
available services for Dementia patients.
PC & ND
Phil Diamond - (Dementia Friendly
Community Lead)
31.03.16 Patients and their families /
carers can access up to date information on services available to them relating to
dementia support.
Implement and
promote Dementia Roadmap
All practices to be encouraged to sign up
for Dementia Friends Training
9.3 Increase awareness of dementia friendly
communities
ABUHB,OAMH,
Social Services,
LA,
NCN
GP Practices
31.03.16 Patients are supported in their communities
Training practice staff as Dementia Friends
Collate the number of
practice staff completed training
9.4 To improve utilisation of available data
sources to review activity for the NCN
NCN Lead, NM, NSO
Practices
31.03.16 Informed understanding of recorded activity for NCN
patients accessing Primary and Secondary Care services
NCN to undertake regular deep dive
analysis of the Caerphilly Core NCN
Performance Report
Identify availability of
other data sources for analysis
Share findings at NCN
meetings and instigate
remedial action where appropriate