Cluster Network Action Plan 2016/17

Newport West NCN

Our network: - We are a Network with six main Practices (Grange Clinic, Isca Medical Centre, Malpas Brook Medical Health Centre,

Richmond Clinic, St Julian’s Medical Centre, The Rogerstone Practice).

There are good working relationships with our Partners from

the Local Authority, Third Sector Organisations and Secondary Care Colleagues.

2

Strategic Aim 1: To understand the needs of the population served by the Cluster Network Health Care Standard 1.1, Health Care Standard 3.1

Objective For

completion/

Key partners

Outcome Actions / Progress to Date RAG

1.1 Managing Obesity

1.1.1. To establish a

baseline to measure the

size of the obesity

challenge and demand

for obesity services.

Supports Newport SIP

– Food & Nutrition /

Physical Activity /

Active Travel /

Alcohol and

Substance Misuse

31.03.17.

Public

Health,

NCN,

One Newport,

ABUHB –

Dietetics,

GAVO.

NCN membership and stakeholders

will be able to plan for integrated

service provision across the

Newport NCN areas.

Identify baseline data for NCN area.

Develop Directory of available services.

Ensure referrals are made to the reconfigured Adult

Weight Management Service.

Develop pathways for available Childhood Obesity

Services.

Progress

20.9.16 – Obesity evidence collation started. Contacts

identified to approach for quantitative and qualitative evidence.

A

1.2 Dementia Services

1.2.1 Updated –

Ensure web based portal

is maintained and used

regularly by patients,

families, carers and

professionals.

Supports Newport SIP

– Mental Wellbeing

and Resilience

31.03.17.

PC & ND,

Dementia

Friendly

Community

Coordinator.

Patients and their families / carers

can access up to date information

on services available to them

relating to dementia support.

Raise awareness of Road Map.

Measure usage.

Progress

20.9.16. – GAVO approached for usage statistics on web

usage.

A

1.3 Public Engagement

1.3.1 To support the

work of the ABUHB

Engagement Team in

implementing the

Engagement Strategy.

Supports Newport SIP

On-going.

NCN,

NM / NSO,

C1st,

GAVO,

One Newport,

Formal and informal consultation

opportunities for all residents to

influence the development and

improvement of all services

(including integrated services)

across ABUHB.

NCN and PC & ND to be represented at at least two

Listening Events in the NCN area during 2016/17.

Feedback findings from Listening Events to NCN and

ABUHB Engagement Teams.

Where possible build feedback in to actions for future

NCN Plans.

A

3

Objective For

completion/

Key partners

Outcome Actions / Progress to Date RAG

– Integration of

Health and Social Care

ABUHB. Progress

20.9.16. – Discussions held with Engagement Team. Standing

invite to attend regular events in NCN areas. Also to develop

NCN specific engagement events for individual NCN areas.

1.4 Alcohol Treatment

Pathway

1.4.1 New - Increase

awareness of the harm

to health from alcohol

through local

enhancement of national

social marketing

campaigns.

31.03.17.

PHW,

NCN Lead,

NCN,

GDAS.

An integrated Alcohol Treatment

Pathway process to deliver

appropriate interventions and

support for residents across the

NCN.

To develop the Alcohol Treatment Pathway.

Scope a business case for GP enhanced service for

alcohol misuse and GPwSI roles.

Establish an Alcohol Care Team at RGH and NHH, in

conjunction with GDAS in-reach provision, and

telephone support at YYF (subject to funding being

identified).

Progress

20.9.16. - Initial scoping meeting with PHW arranged to

develop the NCN role of implementing the developing Pathway.

A

1.5 Screening

Programmes

1.5.1 To achieve

National Targets for

eligible patients to be

screened (breast,

cervical, bowel, prostate

cancers).

31.03.17

PHW,

NCN,

National

Screening

Services,

GP Practices.

Earlier detection of cancer with

improved chance of survival.

Baseline established within

PHW to liaise with national screening services

regarding providing practices with a list of specific

Programme non-responders.

Identify achievements against national targets.

Practices to complete work according to protocols.

Progress

20.9.16. – Links strengthened with PHW Screening Programme

Team. Discussions underway to relocate mobile Breast

Screening Units for the next scheduled Newport Programme.

A

1.6 Learning Disability Enhanced

Service Annual Reviews

1.6.1 New - Increase

up-take of Learning

Disability Enhanced

31.03.17.

NCN,

Practices,

Reconciliation of GP Practice and

Social Services Registers for people

with Learning Disabilities.

Work with Social Services to reconcile Registers.

Use reconciled register to contact patients and invite

in for an annual review.

A

4

Objective For

completion/

Key partners

Outcome Actions / Progress to Date RAG

Service Annual Reviews

to deliver reviews to

target of 90% of all

eligible patients.

Social

Services.

Increased uptake of LD LES annual

reviews by participating Practices.

Progress

20.9.16. – Social Services colleagues approached to arrange a

date to meet and discuss client service criteria for both Social

Services and ABUHB. Update Report in Q3 NCN meeting.

Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients Health Care Standard 7.1

Objective For

completion/

Key partners

Outcome Actions RAG

2.1 Access

2.1.1 New - Explore

the implications of the

Care Closer to Home

Programme (CCTH).

31.03.17.

NCN Lead,

Practices.

An initial option appraisal regarding

future provision of GP services

across Newport and within the

NCN, in particular.

Hold CCTH session for NCN.

Develop a work programme and action plan.

Progress

20.9.16. – Pan Newport presentation held in August 2016.

Write up from the day will inform developing Work Programme

for CCTH.

A

2.1.2 To increase the

usage of Patient Texting

resources.

31.03.17.

NCN Lead,

Practices.

Patients will be able to be

contacted directly to remind them

of appointments / invites to

screening programmes / reduce

DNAs. Complements existing

Welsh Government funding /

investment in patient contact

initiatives.

Practices to establish if currently pilot funded two

texts per patient will be sufficient for Practice needs.

NCN Lead to secure agreement to purchase additional

‘Text Bundles’, as appropriate.

Progress

20.9.16. – My Health On Line statistics being analysed re:

current usage of allocated texts before decision is taken to fund

additional text bundles.

A

2.1.3 To provide

accessible services for

Homeless and

Vulnerable Groups.

Supports Newport

SIP – Integration of

31.03.17.

Public

Health,

PC & ND,

NCN Lead.

Increase in availability and

accessibility of services for the

homeless and vulnerable groups

within the NCN area.

Assess the need for services from the homeless and

vulnerable groups.

Ascertain what is available locally.

Arrange a multi-agency meeting to discuss ‘needs’

Implement the HAVG Health Action Plan.

Progress

A

5

Objective For

completion/

Key partners

Outcome Actions RAG

Health and Social

Care

20.9.16. – Post consultation event analysis being undertaken

to inform next stage of implementation.

2.1.4 Monitor the

continuation and uptake

of My Health Online

(MHOL).

Supports IMTP SCP3

31.03.17.

NCN,

Practices.

Ease of access to GP services. All practices to offer appointment availability and

repeat prescription ordering via MHOL.

NCN Lead / NM / NSO to liaise with SCP Lead for

regular updates to feed back to NCN members.

Progress

20.9.16. – Latest statistical report shows continued uptake of

MHOL facilities by Newport West NCN.

G

2.1.5 Support Practices

in developing business

cases related to Phase 2

of the Access LES.

31.03.17.

NCN Lead,

Practices.

Ease of access to GP services. Advise and assist Practices with queries on

developing business cases, where requested.

Progress

20.9.16. – No requests received to date for assistance from

Practices.

A

2.1.6 Support the

continued

implementation of the

Local Oral Health Action

Plan.

31.03.17.

NCN Lead,

Dental Lead

Potentially clearer information for

access to Dental Services

treatment programmes and

pathways.

Work alongside dental colleagues to promote and

raise awareness of the Local Oral Health Action Plan.

Progress

20.9.16. -

A

2.2 Workforce

2.2.1 Re-worded - To

enable continued Peer

Support for Healthcare

Support Workers,

Practice Nurses and

Practice Managers via

their appropriate

Forums.

Supports IMTP SCP3

31.03.17. Potentially streamlining of services

at Practices through process

improvements for Practice based

Staff.

Arrange dates and venues for Forums with the

respective Group representatives.

Progress

20.9.16. – Practice Managers Forum held in Q1 with a further

Forum scheduled to be held on 6.10.16. Q1 Forum had a

presentation from NWIS to discuss IM&T support for Primary

Care Practices across Newport.

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2.2.2 New - Recruit

additional Primary Care

Based Pharmacists.

31.03.17.

NCN Lead,

Practices.

NCN Pharmacists Project Team is

developing a suite of priorities and

outcomes for the Pharmacists.

Recruitment process undertaken.

Appointments made

Priorities and outcomes to be developed and

A

6

Objective For

completion/

Key partners

Outcome Actions RAG

Supports IMTP SCP3

Additional capacity and access

created for GPs.

finalised.

Integration of Pharmacists to be monitored.

Progress

20.9.16. – NCN is considering the option of using sessional

services from local Community Pharmacists to supplement the

existing Pharmacist employed through NCN funding.

Additionally there are interviews being held on 29/9 and 4/10

through which alternative candidates might be sourced.

2.2.3 New – To

investigate options for

introducing Social

Prescribing within

Practices / across the

NCN.

31.03.17.

NCN Lead,

NIP Officers.

Prudent health care principles

being adopted. Patient education

improved to ensure most

appropriate services are accessed

for the presenting issues – free up

GP appointments and increase

capacity for the most appropriate

patients.

Review service delivery options for Social

Prescribing.

Develop recommendations for the NCN membership

to consider.

Implement agreed recommendation.

Progress

21.9.16. – Option appraisal undertaken. Recommendations

due by mid October.

A

2.2.4 New – Direct

Access Physiotherapy.

31.03.17.

NCN Lead,

Practices.

Additional capacity for direct access

to physiotherapy services – free up

GP appointments and increase

capacity for the most appropriate

patients.

Develop a feasibility report for options to potentially

deliver direct access physiotherapy in the NCN.

Progress

21.9.16. – Initial outline service considered. More detailed

proposal being prepared.

A

2.2.5 New – Provision

of ANP training to

increase workforce

skills.

31.03.17.

NCN Lead,

Practices.

A completed pilot scheme to

employ nurses on training grades

to become Advanced Nurse

Practitioners.

Use successful outcome of pilot

scheme as basis for a business

case / submission for longer term

funding e.g. a bid to the

Intermediate Care Fund.

Develop a feasibility report for options to potentially

deliver support for ANP training within the NCN.

Progress

21.9.16. – Business Case being developed for consideration at

the November NCN meeting.

A

2.2.6 - IT 31.03.17. Improved Practice systems Receive outline proposals for consideration and

7

Objective For

completion/

Key partners

Outcome Actions RAG

Innovations: increase NCN

Practices IT options, operations and capabilities.

Practice Managers,

NCN Lead

operations.

Consistency in use of systems.

decision. Progress

22.9.16. – Two proposals received by NCN. One for a full time

post @ £26-£38k pa, the other for an NCN based services @

£5.4k for 6 months. Full time post rejected as unaffordable at

West NCN meeting on 8.9.16. NCN based service being

considered at NCN Leads meeting on 29.9.16.

2.2.7 Phlebotomy:

Increase access to

primary care

phlebotomy service.

Supports IMTP SCP3

31.03.17.

Community

Division

NCN

Increased capacity and access to

Phlebotomy services and within to

District Nursing service.

To implement local service closer to home and in care

homes.

Increase access to phlebotomy services.

Progress

21.9.16. – Evaluation Reports to be produced by Community

Division at six and twelve months. Six month evaluation due

at October NCN Management Team meeting.

A

2.2.8 To support

relevant education and

development

opportunities across the

NCN.

31.03.17.

NCN Lead

0515 Providing for the Future.pdf

Improved guidance, co-ordination

and development/skills &

knowledge.

Sharing education sessions across

practices providing up to date

enhanced skills to provide better

patient care.

Develop and deliver an NCN

Training Plan from NCN slippage

monies.

Develop a process for Practice staff to access

training.

Training providers and costs are identified.

Practices are informed of training options and

criteria.

Practices apply for funding.

Courses - Minor Illness Training, HCA Training

Etc.

Process in place via proposal applications.

Progress

21.9.16. – Proposals for training being sought from Practices

for potential funding via Small Grant Scheme process.

Currently considering Wound Management Training for District

Nursing Team members in Newport West.

A

2.2.9 Early warning for

practices anticipating

difficulty with

recruitment / filling

31.03.17.

Practices,

NCN Lead,

CD.

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.

Progress

A

8

Objective For

completion/

Key partners

Outcome Actions RAG

vacancies.

Supports IMTP SCP3 0715 Strengthening General Practice.pdf

21.9.16. – nothing reported to NCN Lead as at 21.9.16.

2.2.10 To embrace

future development of

the NCN Team and to

ensure it is adequately

resourced to deliver the

NCN agenda.

Supports IMTP SCP3

On-going. PC

& ND,

NCN Lead,

NM / NSO.

NCN will be able to deliver against

a fluid, integrated service,

transformational NCN delivery

agenda.

Regular NCN meetings to review performance,

actions for delivery and potential bottlenecks.

Report back to NCN.

Progress

21.9.16. – NCN Support staff have been equipped with laptops

and associated equipment to enable mobile, flexible working

across the Team.

A

2.3 Estates

2.3.1. Improve the

management of estate

issues, lack of space in

buildings, lack of grants

to increase the size of

premises.

Supports IMTP SCP3

31.03.17.

NCN Lead.

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 East

Newport practices premises development and

refurbishment during Practice visits.

Primary Care Estates Strategy will highlight issues

for action.

Contact Local Authority Housing Department staff for

input re: expected housing development plans.

Progress

21.9.16. – Practice issues around estates identified from

Practice Development Plans. Formal process for discussing

estates issues and risks established via Newport NCN

Management Team.

A

2.3.2 To ascertain

accommodation

requirements within

primary care in relation

to wider delivery of

services.

Supports IMTP SCP3

31.03.17

NCN Lead

Patients are able to access local

services in high quality premises.

NCN determine wider team accommodation needs.

Progress

21.9.16. – Issues discussed and progressed via NCN meetings,

as and when raised. Option to raise via e-mail via NCN Lead /

Support Team if they arise between meetings.

A

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Strategic Aim 3: Planned Care- to ensure that patient’s needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms

Objective For

completion/

Key partners

Outcome Actions RAG

3.1 District Nursing

3.1.1 To support and

reinforce skills learned

on wound

management training

by DNs through

updating available

resources.

31.03.17.

Community

Division

NCN Lead,

Practices,

District Nursing

Team Leader.

Patients will be seen in Practice,

and ‘housebounds’ seen at home,

by trained Wound Management

DNs, freeing up GP time and

increasing available GP

appointment slots.

DN Teams to provide evidence to support purchase of

portable doppler machines for use at home visits and

clinic appointments.

Progress

21.9.16. – Business case provided by Community Division to

purchase two Doppler machines for NCN District Nursing

Teams. Funding approved by NCN. Initial evaluation report due

in Q4.

G

3.2 Health Visiting

3.2.1 To enhance

working relationships

between Health

Visitors and NCN

practices.

31.03.17.

NCN Leads,

Health Visitor

Manager,

Practices,

Family and

Therapies

Division.

Feedback from HVs and Primary

Care will demonstrate improved

communication.

Improved (and timely) services

for patients.

Develop an induction plan for new HVs to include

attendance at practice meetings and introduction to

practice staff.

Potential for HVs to link in and attend Practice

Manager Forum meetings.

Progress

21.9.16. – Health Visiting Service Manager regularly attends

the NCN meeting to provide updates on Team issues for the

Newport NCNs. Staffing challenges within the Team have been

identified and related to the NCN and an interim plan to deal

with the challenges has been developed and implemented.

Update due at September NCN Management meeting.

A

3.2.3 To resolve

Practice Nurse training

issues if

immunisations are no

longer given in

practices by Health

On-going

NCN Leads,

Health Visitor

Manager,

Practice Nurses,

Family and

Increase in the number of

Practices Nurses trained to deliver

immunisations.

Patients can access childhood

immunisations at GP practice

Work with service to ensure any changes are

communicated to practices in a timely fashion.

New HVs will be in post across Newport in September

2015.

Practice Nurse training to be delivered by HVs as

needed.

A

10

Objective For

completion/

Key partners

Outcome Actions RAG

Visitors.

Therapies

Division,

Public Health.

level. Progress

21.9.16. – Health Visiting Team continues to provide

immunisation services and training to Practices to undertake

immunisations. Services and support will continue to be

provided until training issues are resolved.

3.3 Mental Health

3.3.1 To strengthen

integration at practice

level between Primary

Care and the PCMHSS.

Supports Newport

SIP – Mental

Wellbeing &

Resilience

31.03.17.

MH&LD,

Practices,

NCN Lead,

Third Sector.

Reduction in the number of

referrals passed between different

teams within Mental Health

services, and PCMHSS.

Clearer care pathways, including

transparent, concise access

criteria, will be in place for

patients.

Better understanding of referral

arrangements.

Waiting lists demonstrate reduced

handoffs between services will

result in quicker access to

appropriate service.

PC&ND Leads to work with Mental Health Division to

raise Practice issues at a Gwent wide level to develop

and agree solutions and appropriate service

pathways.

Consider moving staff between scheduled sites when

they have capacity to deliver in another setting.

Progress

21.9.16. – Work programme being developed with Mental

Health and Learning Difficulties Division, ABUHB to address

challenges identified.

A

3.3.2 Refocused - To

deliver universal

counselling services in

conjunction with the

South Wales School of

Counselling and

Psychotherapy.

31.12.16.

SWCAP,

MH&LD,

Practices,

NCN Lead.

Access to high quality counselling

services delivered from accessible

venues, for an identified and finite

patient cohort.

Agree service levels for period 1.8.16 – 31.03.17.

Agree contract variation to existing SLA.

Finite level of service to be agreed.

Implement and monitor service.

Progress

21.9.16. – Service Level Agreement developed and agreed

between NCN, SWCAP and Mental Health and Learning

A

11

Objective For

completion/

Key partners

Outcome Actions RAG

Supports Newport

SIP – Mental

Wellbeing &

Resilience

Difficulties Division, ABUHB to provide Counselling Services.

First performance data expected in Q4.

3.4 CAMHS

3.4.1 Refocused - To

improve condition

specific referrals

between primary care

and CAMHS to meet

demand, particularly

for Specialist CAHMS.

Supports Newport

SIP – Mental

Wellbeing &

Resilience

31.03.17.

Families and

Therapies

Division,

NCN Lead,

Mental Health

and Learning

Difficulties

Division,

ABUHB,

Practices.

Reduction in the number of

referrals passed between different

teams within CAMHs.

Waiting lists demonstrate reduced

handoffs between services will

result in quicker access to

appropriate services.

GP feedback demonstrates that

access has improved.

Number of referrals responded to.

Improved access to CAMHS.

Gwent wide review to be undertaken by Children’s

Board.

Pilot Gwent triage in Monmouth and Newport.

Findings reported to ABUHB and NCNs.

Recommendations to be implemented.

Impact on service provision including referrals to

CAMHs to be reported to NCN on a monthly basis.

Establish an NCN wide Working Group to investigate

reducing barriers, improving urgent referrals and

signposting to CAMHs.

Progress

21.9.16. – MH&LD Division reports working in partnership with

the Greater Gwent Commissioning Group to deliver the pilot

triage initiatives. Update report expected at November NCN

meeting.

A

3.4.2 To improve

delivery of Services to

the NCN by PCMHSS.

31.10.16.

Mental Health

and Learning

Disabilities

Division,

NCN Lead,

Practices.

A more responsive PCMHSS

Team.

Improved, sustainable staffing

levels to meet demand on

Service, in particular for Children

and Young People’s services.

Division to develop a report to address recruitment

and provide options for Division to move forward

with recruitment.

Progress

21.9.16. – MH&LD Division to develop options appraisal paper

to address recruitment issues and sustainability of services.

Update report expected at November NCN meeting.

A

3.5 Diabetes

3.5.1 Continued 31.03.17 Access to advice from a multi- • To implement the Diabetes Integrated Service Model G

12

Objective For

completion/

Key partners

Outcome Actions RAG

implementation of the

Diabetes Integrated

Service Model across

the NCN.

Supports IMTP

SCP5

NCN,

Public Health,

ABUHB

Divisions,

Diabetes

Nurse.

disciplinary team &

implementation of the Diabetes

Integrated Service Model and

work plan will lead to improved

outcomes for patients and

increased diabetes services being

provided from GP Practices, led

by a team of Primary Care

Diabetes Nurse Specialists.

Delivery of in-house led training

opportunities for Staff.

across the NCN.

Intervene more regularly, with right information in

the right way – brief advice / intervention.

Discuss increasing Adult Weight Management Service

capacity for specific populations (e.g. Pre-diabetes,

pregnant women) with dieticians.

Progress

21.9.16. – PCDSN Team is delivering services in Practices and

training Practice based staff. Team is also initiating insulin

treatment with patients at Practices reducing the need for

patients to attend secondary care venues for this 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

Objective For

completion/

Key partners

Outcome Actions RAG

4.1 Urgent Access

4.1.1 To maximise the

utilisation of

alternative avenues for

advice prior to

referral, adopting

Prudent Healthcare

Principles, ensuring

increased

appropriateness of

referrals.

31.03.17.

Primary Care

and Networks

Division,

ABUHB

Divisions.

Reduced waiting time for

appointments demonstrated by

secondary care waiting list data.

Maximise the utilisation of alternative avenues for

advice where these exist.

Health Board to continue to work with Divisions to

develop alternatives to traditional referral processes.

Progress

21.9.16. – This objective will progress alongside the work of

under 2.2.3. above which relates to Social Prescribing.

A

4.1.2 To improve

utilisation of available

data sources to review

On-going.

NCN Lead /

NM / NSO,

Informed understanding of urgent

access referrals for NCN Patients

to secondary care services.

Regular deep dive analysis of the Newport Core NCN

Performance Report and Single Sheet Reports.

Identify make up of urgent access referrals.

A

13

Objective For

completion/

Key partners

Outcome Actions RAG

urgent access activity

for the NCN.

Practices. Share findings at NCN meetings and instigate

remedial action where appropriate.

Progress

21.9.16. – Performance Reports are continuously being

reviewed and honed. NCN Management Team have been

analysing the Reports to inform strategic and operational

direction within the NCN footprint.

4.2 Frailty

4.2.1 To improve

communication

between Practices and

Frailty and between

Frailty and the OOH

Service.

Supports IMTP

SCP4

31.03.17.

NCN Lead,

Frailty Team,

District Nurses,

OOHs,

Integrated

Forum.

Less hand offs between services,

and improved communication

about the needs of the individual

will result in better quality, more

timely care.

Frailty run charts will show

improvements.

Establish feasibility of co-locating services on the

NCN patch i.e. creating an NCN Hub.

Gain better understanding of pressures that all

services are working under, especially OOH.

Further develop established working relationships,

especially between NCN and Frailty Services.

Monitor at Monthly NCN Management Team meetings.

Progress

21.9.16. – Frailty Team Manager is currently undertaking a

review of the Service and is looking to involve staff on a more

NCN oriented work programme. Update report expected at Q4

meeting.

A

4.3 Social Services

4.3.1 To ensure

improved

communication

between Social

Services Older Adult

Teams and Primary

Care / District Nursing

/ Community Nursing.

Supports Newport

SIP – Integration of

Health & Social Care

31.03.17.

NCN Lead,

Newport

Integrated

Partnership.

Feedback from practices / Health

Visitors / District Nurses /

Community Nurses will

demonstrate improved

communications.

Patients will receive seamless

service transition between

primary care and social services.

NCN links with Social Services

enhanced via named Team

Recent correspondence from a DN Team that they

were having to take up to an hour to reach the

correct contact in the LA in relation to SS

requirements for patients.

Raise issue with Newport Integrated Partnership for

resolution.

Continuously monitor impact with DN Team via NCN

meetings.

Progress

21.9.16. – Social Services Older Adult Teams have now altered

their ‘geographic footprint’ in the City to match the NCN Team

footprints, ensuring greater cohesion with each other’s

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Objective For

completion/

Key partners

Outcome Actions RAG

Leaders. planning foci.

4.4 Out of Hours

4.4.1 Review usage of

Out of Hours services

provision by Newport

West NCN

On-going.

NCN Lead,

ABUHB.

Fewer inappropriate referrals in to

the OOH service

Receive quarterly performance reports from OOH.

Identify areas of high usage.

Develop plan to address.

Progress

21.9.16. – Review undertaken on a quarterly basis to ascertain

performance. Next report due at the November NCN meeting.

A

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

Objective For

completion/

Key partners

Outcome Actions RAG

5.1 Review the

delivery of End of Life

Care using the

Individual Case Review

Audit.

31.03.17.

NCN Lead,

Practices.

0815 Gwent Palliative Care Strategy.docx

Improved care processes for

individuals and families / carers

regarding EoLC provision.

Summarise case review data, identify arising issues

and actions.

Establish a review cycle, to monitor progress.

Progress

21.9.16. – Practices collecting audit data for end of year

analysis.

A

5.2 To review and

implement actions

arising from 2015/16

Audit.

31.03.17.

Practices,

NCN Lead.

Improved consistency in standard

of care delivered.

READ Code training for all Practice staff.

Develop patient recording protocols for Care Homes.

Identify and record carer details.

Ensure availability of carers packs at Practices.

Ensure adequate available access to interpreter

services.

Progress

21.9.16. – Read coding has been provided for Practice staff via

NCN funding. Patient recording protocols are still being

considered, as are recording of carer details. Carers Packs

A

15

Objective For

completion/

Key partners

Outcome Actions RAG

have been distributed to all the NCN Practices. Interpreter

services adequacy is being reviewed. Report on progress of

the above expected in the November NCN meeting.

Strategic Aim 6: Targeting the prevention and early detection of cancers Health Care Standard 3.1

Objective For

completion/

Key partners

Outcome Actions RAG

6.1 Review the care of

all patients newly

diagnosed between 1

January 2016 to 31

December 2016 with

lung, gastrointestinal

and ovarian cancer.

31.03.17.

NCN,

NCN Lead,

Practices.

All lung, gastrointestinal and

ovarian cancer patients will have

their referral information

reviewed and o/p appointments /

results followed up.

Summarise case review data, identify arising issues

and actions.

Establish a review cycle, to monitor progress.

Progress

21.9.16. – Practices collecting audit data for end of year

analysis.

A

6.2 To review and

implement actions

arising from 2015/16

Audit.

31.03.17.

NCN,

NCN Lead,

Practices.

Findings from 2015/16 audit

reviewed and implemented, as

appropriate.

Ensure Practices refer patients as ‘USC’ rather than

‘Urgent’ if cancer was suspected.

Encourage patients to attend appointments with

Screening Programmes.

Ensure referring GPs are informed by Secondary Care

Consultants of downgrades to USC referrals.

Progress

21.9.16. – Progress report expected on the above at the

November NCN meeting.

A

16

Strategic Aim 7: Minimising the risk of poly-pharmacy Health Care Standard 2.6

Objective For

completion/

Key partners

Outcome Actions RAG

7.1 Poly-pharmacy

7.1.1 Identify and

record numbers and

rates for patients aged

85 years or more

receiving 6 or more

medications.

31.03.17.

NCN Lead,

Practices,

Community

Pharmacists.

Identification of patients at high

risk or harm of either over or

under medication.

Undertake a review of practice clinical systems to

identify patients over the age of 85yrs in receipt of 6

or more medicines.

Undertake face to face medication reviews.

Progress

21.9.16. – Practices collecting audit data for end of year

analysis.

A

7.2 Medicines

Management

7.2.1 Appointment of

Pharmacists in Primary

Care to assist the

delivery of safe

prescribing to the NCN

population.

On-going.

NCN Lead,

Practices,

Community

Pharmacists

0715 Pharmacists in Primary Care.docx

Efficient use of resources that can

be re-invested more appropriately

into patient care.

Increased face to face meetings

with Pharmacists in Primary Care

thus releasing capacity for GPs.

Recruit and appoint additional Pharmacists, on either full

time, part time or sessional bases.

Consider working with Community Pharmacists on a

sessional basis.

Agree range of duties expected of appointees.

Reporting and monitoring activities and impact of

appointments to NCN Lead.

To review variations in prescribing.

Establish feasibility of extending age range for audit.

Provide consistency of medication reviews in

Practices/Home settings.

Progress

21.9.16. – Interview panels for additional Pharmacists in

Primary Care being held on 29/9 and 4/10. Suitable

candidates are expected to be recruited from the process.

Option to employ sessional Community Pharmacists still under

consideration by NCN. Existing Pharmacist performance

reports have been very positive and well received by Practices.

A

17

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

Objective For

completion/

Key partners

Outcome Actions RAG

8.1 Clinical

Governance

8.1.1 To fully

implement the Clinical

Governance Toolkit.

31.03.17.

PC&ND.

Practices are supported in

completing the CGSAT

Practices to ensure completion of CGSAT.

Progress

21.9.16. – Practices have started to complete the toolkit.

Regular progress reports have been provided by the QPS Team

to show which Practices have started their toolkits or not and

how much they have completed.

A

Strategic Aim 9: Other Locality issues

Objective For

completion/

Key partners

Outcome Actions RAG

9.1 Managing

Obesity

9.1.1 See 1.1.1

above.

A

9.2 Smoking

Cessation

9.2.1 To maintain

brief intervention and

referral levels of

residents wishing to

quit smoking.

Supports Newport

SIP – Tobacco

31.03.17. Increased numbers of staff who

have access to brief intervention

training.

Increased access for patients to

staff trained in brief intervention

techniques.

Continue to access brief intervention training

courses.

Identify Smoking cessation Champions across the

NCN Partnership Network.

Monitor via Core Performance Reports.

Progress

21.9.16. – awaiting NCN based activity reports that are being

developed between Public Health Wales and Stop Smoking

A

18

Objective For

completion/

Key partners

Outcome Actions RAG

Control /Smoking

Supports IMTP SCP3

Patients will be motivated to

make a quit attempt and will

receive effective treatment to quit

smoking.

Wales.

9.4 Newport

Directory

9.4.1 Improve

information available

to the NCN.

DEWIS information

portal to be

investigated.

31.03.17.

NCN.

An on line information directory

will be developed.

Staff provides informed

information, advice and support

to patients.

Progress

21.9.16. – NCN Management Team members have received a

demonstration of the DEWIS information Portal hosted by the

Local Authority and will consider how it can be utilised, in

conjunction with the Community Connector’s Directory, to meet

the requirement of this objective.

A

9.5 Living Well,

Living Longer

9.5.1 To prepare for

the introduction of the

Living Well, Living

Longer Programme

across the NCN.

31.03.17.

PHW, NCN,

ABUHB.

Screening and assessment

services for cardiovascular

disease, diabetes and stroke will

be widely available to patients

over the age of 40.

It is expected that the Programme will be launched in

Newport in 2016/17.

Progress

21.9.16. – At the September meeting of the Newport Health

Network it was announced that the Programme had been

delayed for implementation until Q4 of 2016/17.

A

9.6 Newport

Regeneration Plan

9.6.1 To participate in

a targeted approach to

deliver integrated

health and social care

services in the most

deprived communities,

as defined by the Local

Services Board Unified

Needs Assessment and

On-going.

Local Authority,

PC & ND,

NCN Lead,

NM / NSO,

Other LSB

Partners.

Targeted integrated health and

social care services for the most

deprived communities in the NCN

area.

PC & ND and NM / NSO to keep up to date with

integrated planning developments and

implementation plans and report back to NCN

membership.

Progress

21.9.16. – Network Manager and Practice Manager both

attending SIP meetings, providing planning and support to the

Health, Social Care and Well Being Sub Group and other

related Community Groups.

A

19

Objective For

completion/

Key partners

Outcome Actions RAG

Ward Profiles.

Supports Newport

SIP – Integration of

Health and Social

Care

Supports IMTP –

SCP 3