2
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
Ratings
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
3
No Objective Key Partners For completion by
Outcome Agreed actions / Progress to Date
RAG Ratings
brief intervention training
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
1.2 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
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,
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
4
No Objective Key Partners For completion by
Outcome Agreed actions / Progress to Date
RAG Ratings
PHW
GAVO
initiatives and projects addressing obesity issues
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
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
5
No Objective Key Partners For completion by
Outcome Agreed actions / Progress to Date
RAG Ratings
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
feedback into actions for future NCN plans
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: 70% achieved in 2014-15
for immunisation against influenza for 65yrs and
older for Caerphilly South NCN
50% achieved in 2014-15 for immunisation against
influenza for 6months to
6
No Objective Key Partners For completion by
Outcome Agreed actions / Progress to Date
RAG Ratings
64yrs for Caerphilly South NCN
Hold discussions
between practices regarding best practice
Receive regular practice updates during flu
season
Hold discussions with DNs regarding immunising
housebound patients
Hold discussions with Midwifery regarding immunising pregnant
women
Utilise Third Sector networks to support the campaign
1.6 NCN Management Team
1.6.1 Establish a
Management Team Structure for Caerphilly South
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
7
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
2.1.1 Practices to review performance against 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
2.1.2 Monitor the continuation and
uptake of My Health Online
Supports Caerphilly SIP – Healthier Caerphilly H5
Supports IMTP SCP3
NCN, Practices
Pharmacy Advisors
31.03.16 Ease of access to GP services All practices to offer appointment availability
and repeat prescription ordering via MHOL
2.2 Workforce
2.2.1
Improve locum
arrangements and ensure that
practices in difficulty have access to NCN salaried support
team to ensure
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
Practices to inform NCN
verbally/in writing if anticipating having
difficulty, and agree to meet with NCN Lead and CD to discuss next
steps
8
No Objective Key Partners For completion by
Outcome Agreed actions / Progress to Date
RAG Rating
continuity of service in the short term.
Supports IMTP SCP3
through audit
Continuity of services
Support against potential practice fragility
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,
optometry and pharmacy. Supports IMPT SCP3
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
across ALL Primary Care Services in the development and delivery of NCN Work
Programmes.
Allocate funding from NCN budget
Appoint Independent
1 x Dental, Pharmacy, Optometrist Advisors
2.2.4 Provide Practice
Based Social
NCN Lead
Social Services
31.03.16 Better GP Access
Implement the service
within the identified
0715 Strengthening General Practice.pdf
9
No Objective Key Partners For completion by
Outcome Agreed actions / Progress to Date
RAG Rating
Workers (Pilot)
Identified practices
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.
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 South NCN
based at Tonyfelin medical Centre). 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 targets
Improve patient adherence through co-production
Appointment made July/August 2015
Report progress, on
outcomes and impact at
NCN meetings
Identify opportunities for Pharmacists to further develop
appropriate skills
10
No Objective Key Partners For completion by
Outcome Agreed actions / Progress to Date
RAG Rating
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
Funding allocated from NCN budget
2.2.6 Increase access to
Primary Care Community
Phlebotomy Service Supports IMTP SCP3
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 frequent interventions.
£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
11
No Objective Key Partners For completion by
Outcome Agreed actions / Progress to Date
RAG Rating
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
31.03.16 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 South 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
Discuss and progress
12
No Objective Key Partners For completion by
Outcome Agreed actions / Progress to Date
RAG Rating
issues regarding Llanbradach, Aber Med
Centre and Lansbury (Troed Y Bryn)
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
team 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 Wound Management Service
3.1.2 Improved access for practices to wound
management services in Primary Care in Caerphilly
South NCN
NCN Lead and Support
NRMC
31.03.16 Release practice nurse time across Caerphilly South NCN
practices Reduced waiting times for
patients for TVN
Funding allocated from NCN budget
Regular monitoring of
the referrals and the
effectiveness of the service
Monitor referrals to TVN
13
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
3.2 District Nursing
3.2.1 To maximise the
effectiveness of the District Nursing (DN)
workforce by appointing Community
Phlebotomists.
Practices
Community
Division District Nursing
Team Leader
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
3.3 Health Visiting
3.3.1 To build up
relationships between Health Visitors and practices
NCN, ABUHB
Colleagues
31.3.16 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
3.4 Mental Health
3.4.1 To strengthen integration at practice level
between Primary Care and the PMHT
and achieve nationally agreed
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
Work ongoing regarding best working and sign posting.
Achieve nationally
agreed waiting times of 28 days from receiving
14
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
waiting times of 28
days from receiving referral to
assessment Supports Caerphilly SIP –
Healthier Caerphilly H1, H2, H4, H5
for patients
GP’s to make use of the
PCMHSS Flowcharts and increase their use of the PCMHSS Practitioners for
advice/guidance.
referral to assessment
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 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
15
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
3.4.2 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.
3.4.3 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
16
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
3.5 Pulmonary Rehabilitation Services
3.5.1 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
3.6 Diabetes
3.6.1 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
• 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
Diabetes Work Plan NCN comms 16 45.ppt
17
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
via email/telephone for
initiation of injectable therapy
Improved access to
Consultants for advice
Improved rapid assessment
of patients who need consultation opinion
Service
Consider increasing
Adult Weight
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
3.7 COPD
3.7.1 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
18
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
pack of placebo devices.
3.8 Osteoarthritis Knee
3.8.1 Improve
management of patients with OA Knee
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 appropriate
OA Knee groups
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 Courthouse Medical
Centre
Monitor referrals to MRI
19
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 NCN Lead
31.03.16 Improved patient access to primary care services
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
Practices to monitor &
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
20
No Objective
Key partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
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
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
21
No Objective
Key partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
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 from 01.09.15
22
No Objective
Key partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
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
Case Review Audit
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
died to be reflected upon/inform future care delivery.
0815 Gwent Palliative Care Strategy.docx
23
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
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
31.3.16 Learning through shared
experience will inform future care improvements for patients
on the EOL pathway.
Highlight best practice
for improvement to be highlighted and shared
in a multi-professional discussion
0715 EOLC All Gwent Summary.docx
South Caerphilly Summary of Learning Points from National Priorities Feedback 0315.doc
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
31.3.16 Improved consistency in standard of care delivered
Agreement of ‘best practice’ in EOLC.
Identification and monitoring of 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 patients newly
diagnosed between 1 January 2015 to 31 December 2015 with
NCN, NCN Leads,
Practices
31.03.16 All lung, gastrointestinal and ovarian cancer patients will
have their referral information reviewed and o/p appointments / results followed up
Practice complete Audit Tool and discuss
findings
24
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
lung, gastrointestinal
and ovarian cancer
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
South Caerphilly Summary of Learning Points from National Priorities Feedback 0315.doc
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
25
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
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
31.3.16 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
31.3.16 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
31.3.16 Poly-pharmacy at NCN meetings Quarterly
information to NCN on utilisation of notional budget
South Caerphilly Summary of Learning Points from National Priorities Feedback 0315.doc
National Priority Target Audit Summary Polypharmacy 14-15.docx
26
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
7.2 Medicines Management
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
31.3.16 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
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
27
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
quality
7.2.3 To review the
variation in prescribing compared
to national guidance in relation to Diabetes and Respiratory and
deliver the NCN savings target for
these work streams within the three year plan
NCN Lead
GP Practices
Pharmacy
31.3.16 Patients and professionals have
access to a named Pharmacist in Primary Care
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.
NCNs to work with
Primary Care and Networks Division Pharmacy staff to: 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
28
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
29
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
Map local services to
highlight where services are delivered across
practices (e.g. contraceptive services, minor surgery)
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
30
Strategic Aim 9: Agreed Prioritised Locality issues No Objective Key partners For
Completion By
Outcome Agreed actions /
Progress to Date
RAG
Rating
9.1 Establishment of an NCN Web based solution that provides
information for local, available services for
Dementia patients. Supports Caerphilly SIP – Healthier Caerphilly H3, H4
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
9.2 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
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