Cluster Network Action Plan 2016-17
Monmouthshire North - Neighbourhood Care Network (NCN)
2
Strategic Aim 1: To understand the needs of the population served by the Network
Objective For completion
by: -
Outcome for patients Action/Progress to Date RAG
Rating
1.1 Obesity
1.1.1
To tackle obesity and work
towards a reduction in the
number of ante-natal women
& children aged 0-4 years old
in defined geographical areas,
who are overweight/obese
Aligned to Monmouthshire SIP-Nobody Is Left Behind Healthcare Standard 1.1/3.1 Links SCP2 Adopted as population need priority
On-going
Local Authority
Public Health
NCN
Housing
Adult Weight
Management
Service
NERS
Midwifery
Flying Start
Families First
Community
Based initiatives
Families have access to
children and young
people’s services,
initiatives and projects
addressing obesity issues
‘Place Based Working’
Principles underpin work-
streams
Action:
To establish a task & finish group to support delivery of
key actions:
Establish baseline position to measure progress
To map level 2 services for weight management &
refer/recommend following brief intervention
To increase awareness & access to level 2 services for
target groups
Raise issue of weight & health routinely with brief
advice/intervention & refer to level 2 (community) /
3 ABUHB Adult Weight Management Service (AWMS)
Attend a Childhood Obesity Strategy (COS) event &
support implementation / delivery of local action plan
To monitor progress of NCN funded Community
Dietician
Progress:
- NCN Management Team themed meetings focus on clear
action for NCN/MT delivery
- Joint COS workshop held to inform 3 year action plan
- Making Every Contact Count (MECC) training undertaken
with GPs, Practice & District Nurses & planned for Health
Visitors & School Health Nurses
- NCN funding considered for ante-natal & junior referral
scheme with NERS
- Linked to NUTRITION SKILLS FOR LIFE™ training
- 2015-16: 105 referrals to the AWMS (highest ranking out of
12 NCNs) with a projection of 220 in 2016/7 (Red)
A
3
Public Health exercise - Childhood obesity
Children aged 4-5 years who are overweight or obese -
Monmouthshire wide: 21% Source:
Public Health Wales (2016) Child Measurement Programme for Wales
2014/2015
1.2 Engagement
1.2.1
To be a central source of
information, identifying gaps
in service locally and sharing
its work programme with
stakeholders
Aligned with SIP-People are confident, capable and involved/Nobody Is Left Behind Healthcare Standard 1.1 Links to SCP2
On-going
NCN
ABUHB
Practices
Third Sector
Public Health
Severnside Trust
Mechanisms are in place
to ensure patients,
services and partners are
informed of the work of
the NCN
Shared learning &
communication leads to
improved services & local
knowledge
Action:
To respond to findings from ABUHB Engagement Team
events relating to accessing Healthcare
To publish a monthly NCN newsletter
Progress:
- GAVO Rep attends NCN meetings representing the Third
Sector
- NCN newsletter developed to share new developments and
current issues across ABUHB & partners
A
1.3 Learning Disabilities
1.3.1
New: Increase up-take of LD
Enhanced Service Annual
Reviews
Aligned with SIP-People are confident, capable and involved (Approximately 2,396 people have a learning disability in Monmouthshire of these approximately 753 are children between the ages of 0-17) Healthcare Standard 1.1/2.7/3.1/3.2 Links to SCP1/2/8
31.03.17
Practices
ABUHB
Local Authority
NCN
90% of patients with a
LD, who are eligible,
have access to Annual
Health Reviews via
Primary Care Services
Increased access for
assessment to identify
healthcare needs
Action:
Liaise with Monmouthshire County Borough Council LD
lead to assess barriers against meeting the 90% target
Review number of claims made against number of
eligible patients assessed
Progress:
- Meeting needed to agree action
- 2014/15: 160 people (2.3455%) received GP Practice health
checks (Source CMWEB)
A
4
Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the
reasonable needs of local patients
Objective For completion
by: -
Outcome for patients Action/Progress to Date RAG
Rating
2.1 Access
2.1.1
New: To identify
opportunities for shared
working & Good Practise
across Practices
Links to SCP2 Healthcare Standard 1.1
31.03.17
Practice
Managers
NCN Lead &
team
Patients benefit from
increased collaboration,
standardised and
streamlined processes;
Increased GP capacity
Action:
NCN lead attends Practice Manager meetings to address
NCN related issues
Undertake NCN lead annual Practice visit
Progress:
- Practice Manager Forum discussions, NCN leads attend on
rotational basis
- NCN lead Practice visit undertaken early 2016
A
2.1.2
New pilot: To enable
implementation of the NHS
England Constitution for
patients resident in England
Aligned with Monmouthshire SIP-People are confident, capable and involved Healthcare Standard 3.1 Links to SCP10
31.01.17
Practices
NCN lead
NHS England
NHS Wales
ABUHB
National guidelines are
adhered to
Patients in England,
registered with a GP in
Wales, access healthcare
in a Hospital of their
choice
Action:
To overcome barriers impacting on cross border flow
changes
Referral pathways are tested and lessons learned prior to
full implementation
Progress:
- 6 month test phase with 5 North & South GP Practices
(starting July 2016)
- Training for Practice staff within the WCCG test facility
- Test phase to be evaluated before wider roll-out
A
2.1.3
New: To support the
development of a ‘Care Closer
To Home’ (CC2H) strategy
On-going
NCN
ABUHB Divisions
Local Authority
Patients benefit from a
clear strategy, which
underpins partnership
working, allowing for the
Action:
To facilitate a multi-agency workshop in each NCN
locality/borough
NCN to contribute to the development of joint local action
A
5
and action plan
Aligned with SIP-Nobody Is Left Behind Healthcare Standard 1.1/3.1/5.1 Links to SCP4
ISPB
Third Sector
sharing of local skills,
expertise and resources,
leading to appropriate
care being provided
either at home or close to
it
plans
Progress:
- CC2H team presentation at NCN meeting
- Scoping/planning workshop held August 2016
- Resource maps provided by all stakeholders during
workshop to understand what agencies can bring and
identify duplication of resources/skills
- Draft strategy in development
2.2 Estates
2.2.1
New: To enable wider
delivery of services in primary
care
Links to SCP7 Healthcare Standard 5.1
On-going
NCN
Practices
ABUHB Facilities
ABUHB
Housing
Patients are able to
access local services in
premises which are fit for
purpose
Action:
To engage with Practices via Practice visits, NCN
meetings and Practice Development Plans to understand
accommodation issues
Progress:
- Practice visits undertaken
- Assessing impact of new housing developments
- Practices engaged in development of the ABUHB Estates
Plan
- Analysis of PDPs undertaken
- Melin Homes presentation July 2016:
- Monmouthshire has largest population boom, with
increase in populate of 1.7 people per house built
- Significantly higher house prices
- Population is predicted to shrink, however trend has
been 15% increase since 1991
A
2.3 Workforce
2.3.1
New: To enable local access
to a Direct Access
Physiotherapy (DAP) service
Aligned with SIP- People are
31.03.17
NCN
Practices
ABUHB
Physiotherapy
Improved GP access
Improved quality of
referrals to Physiotherapy
service
Action:
To support the work programme of the DAP
Progress against expected outcomes presented at NCN
meetings
A
6
confident, capable and involved Healthcare Standard 1.1 Links with SCP10 NCN Funding Priority
Service Progress:
- NCN agreement to allocate funding to support band 6 level
service function
- DAP recruited October 2016
- Service specification presented to the NCN
- On-going reports expected when in post
2.3.2
Early warning for Practices
anticipating difficulty with
recruitment / filling vacancies
Healthcare Standard 7.1 Links to SCP7
On-going
Practices
Primary Care
Team
NCN Clinical
Team
NCN
Continuity of services;
Support against potential
Practice fragility
Action:
Practices inform NCN if anticipating difficulty
Practices meet with NCN clinical team to discuss action
Progress:
- Practices reporting increased pressures & difficulties in
retaining and finding new partners/salaried GPs via PDPs
- ABUHB website developed to allow vacancies to be shared
A
2.3.3
New: To enable wider
delivery of services in primary
care
Links to SCP7 Healthcare Standard 5.1
On-going
NCN
Primary Care
ABUHB Facilities
ABUHB
Housing
Patients are able to
access local services in
premises which are fit for
purpose
Action:
To consider accommodation requirements identified via
Practice visits, NCN meetings and Practice Development
Plans
Progress:
- Practice visits undertaken
- Assessing impact of new housing developments
- Practices engaged in development of the ABUHB Estates
Plan
- Analysis of PDPs undertaken
- Melin Homes presentation July 2016:
- Monmouthshire has largest population boom, with
increase in populate of 1.7 people per house built
- Significantly higher house prices
- Population is predicted to shrink, however trend has
been 15% increase since 1991
A
2.4 Performance
2.4.1 On-going Patients benefit from Action: A
7
New: To reinforce links
between the NCN & NCN
Management Team
Healthcare Standard 5.1 Links to All SCPs (excluding 6)
NCN
Public Health
Service Leads
ABUHB Finance
Team
increased collaboration,
standardised and
streamlined processes
Management Team to agrees priorities & clear action to
support delivery of the NCN Plan
To monitor spend against NCN budget and agreed
processes
Progress:
- Agreement that Management Team meetings focus on lead
priorities from NCN Plans with themed meetings
- Action logs linked to NCN Plan Strategic Aims
- Quarterly (CORE) performance reports considered at
Management Team
- Key Performance Indicators reviewed to ensure links with
the NCN action plan are in place
- Small Grant Scheme implemented
- Monthly combined finance/NCN meetings implemented
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
by: -
Outcome for patients Action/Progress to Date RAG
Rating
3.1 Planned Care
3.1.1
New: To explore the potential
for a local Cardiology Service
Healthcare Standard 3.1 Aligned with SIP- People are confident, capable and involved Links to SCP3/7/10 Source: PDPs
31.03.17
NCN
Secondary Care
GP with Special
Interest
Practices
Patients have access to
local care provided in
partnership between
Primary and Secondary
Care
Improved local access to
relevant diagnostics &
assessments
Action:
To be informed of progress via the Chepstow Hospital
Development Group
NCN to liaise with Cardiology Directorate colleagues to
support development & address barriers
Progress:
- Chepstow Hospital Development Group considering PFI
implications
- On-going work with directorate to establish local service
- Directorate visit to site held
A
8
- Progress reported at NCN meeting
3.1.2
New: To explore the potential
for an extra-ordinary local
counselling service for young
people
Healthcare Standard 2.7/3.1 Aligned with SIP-People are confident, capable and involved Links to SCP3/10 Source: PDPs
31.03.17
NCN
Practices
MH Division
Third Sector
Young people have
access to professionals
trained in counselling
during school holidays
Action:
To respond to identified gap in counselling for young
people
Progress:
- Identified via analysis of Practice Development Plans
- Discussed with wider NCN and agreed as a priority in
principle, depending on available funding and competing
proposals
- NCN funding proposal from Young People’s Mental Health
Counselling service being considered
A
3.1.3
New: To explore the potential
for a Practice based Complex
Wound Care service
Aligned with SIP - People are confident, capable and involved Links to SCP3/10 Source: PDPs Healthcare Standard 3.1 Adopted as local priority
31.03.17
NCN
Tissue Viability
Nurses
Practices
Patients benefit from
increased Practice Nurse
knowledge & skills
through dedicated
sessions and training
Action:
To understand demand levels across Practices in relation
to available capacity
To explore an option to develop a Practice Nurse led CWS
from NCN funding
Progress:
- Known high number of patients needing regular post-
discharge wound care
- Discussion held at NCN meeting with Secondary Care Tissue
Viability Nurses – to agree action around a proposal for
Practice based service & training
A
3.1.4
Pilot: To enable a direct
referral pathway for people
with Faecal Calprotectin
(FCAL)
Aligned with SIP- People are confident, capable and involved Links to SCP10 Healthcare Standard 3.1
On-going
Secondary Care
NCN lead
Practices
Patients with
Inflammatory Bowel
Disease who require a
Secondary Care referral,
follow an agreed pathway
Improved quality of
referrals
Action:
Practices support the FCAL pilot by using the agreed
referral pathway
Referral data is presented to the NCN
Progress:
- Pilot phase extended to Autumn 2016 with outcomes to be
reported at NCN
A
9
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
by: -
Outcome for patients Action/Progress to Date RAG
Rating
4.1 Frailty
4.1.1
New: To scope potential for
urgent diagnostics, refuge
beds & Hot-Clinics across 3
sites
Aligned with SIP-Nobody Is Left Behind Healthcare Standard 2.5/3.1 Links to SCP9 Source: PDPs
On-going
NCN lead
ABUHB
Integrated
Services
Partnership
Board (ISPB)
NCN
Supported management
of patients in primary
care setting;
Reduced admissions to
secondary care;
Improved access to
relevant diagnostics &
assessments
Action:
To support the development of a 12 month ‘proof of
concept’ proposal for Consultant led service
Progress:
- Action monitored via the Chepstow Hospital Development
Group
- Issues with Single Point of Access noted (Source: PDPs)
- Status and finance monitoring considered at Integrated
Services Partnership Board meetings
A
Strategic Aim 5: Improving the delivery of end of life care
Objective For completion
by: -
Outcome for patients Action/Progress to Date RAG
Rating
5.1 End of Life Care
5.1.1
Review the delivery of End of
Life Care using the Individual
Case Review Audit
Aligned with SIP- People are confident, capable and involved Healthcare Standard 3.1/4.1 Links to SCP3/10
31.03.17
NCN Lead
Practices
Palliative Care
Team
NCN
Improved care processes
for individuals and
families / carers
regarding End of Life
Care provision
Action:
Summarise case review data, identify arising issues and
actions
Establish a review cycle, to monitor progress
Progress:
- Audit findings shared with the NCN on an annual basis &
informs NCN lead year-end report
A
10
Strategic Aim 6: Targeting the prevention and early detection of cancers
Objective For completion
by: -
Outcome for patients Action/Progress to Date RAG
Rating
6.1 Suspected Cancer
6.1.1
Review the care of all
patients newly diagnosed
between 1 January 2016 to
31 December 2017 with lung,
gastrointestinal and ovarian
cancer
Aligned with SIP- People are confident, capable and involved Healthcare Standard 3.1 Links to SCP3/9/10
31.03.17
NCN
GP Macmillan
Lead
NCN Lead
Practices
St David’s
Foundation
All lung, gastrointestinal
and ovarian cancer
patients will have their
referral information
reviewed and outpatient
appointments/results
followed up
Action:
Summarise case review data, identify arising issues and
actions
Establish a review cycle, to monitor progress
Progress:
- Audit findings shared with the NCN on an annual basis &
informs NCN lead year-end report
- GP Macmillan lead attended NCN meeting & will facilitate
outcomes being shared with Secondary Care
- Gwent-wide Community Health Champions Project (funded
via Wellbeing Activity Grant in partnership with PHW)
awareness training module designed to help increase
knowledge and understanding of:
- The different screening services available
- Who is eligible for screening and when
- How to signpost to appropriate services
A
Strategic Aim 7: Minimising the risk of polypharmacy
Objective For completion
by: -
Outcome for patients Action/Progress to Date RAG
Rating
7.1 Polypharmacy
7.1.1
Identify and record numbers
and rates for patients aged
85 years or more receiving 6
31.03.17
NCN Lead
Pharmacist
Practices
Patients at high risk or
harm, of over or under
medicating, are identified
and reviewed
Action:
Undertake a review of practice clinical systems to
identify patients over the age of 85yrs in receipt of 6 or
more medicines
A
11
or more medications
Aligned with SIP- People are confident, capable and involved Healthcare Standard 2.6/3.1 Links to SCP3/4/7
NCN
Undertake face to face medication reviews
Progress:
- Audit findings shared with the NCN on an annual basis &
informs NCN lead year-end report
7.1.2
Continue to support the roles
and integration of GP Practice
based Pharmacists
Aligned with SIP- People are confident, capable and involved Healthcare Standard 3.1/7.1 Links to SCP3/4/7
On-going
NCN
Pharmacy
Practices
Patients have local access
to, and benefit from
evidence based
interventions;
Patients benefit from
reduced waiting times;
Increased GP capacity
Action:
Pharmacist to present progress against expected
outcomes at two NCN meetings
Pharmacist provides quarterly performance data
presented at NCN leads meeting
Quarterly report to be shared with Community Nursing
Leads
Undertake annual evaluation of performance
Progress:
- Presentation given at NCN meeting 2
- Quarter 1 report submitted
A
7.2 Medicines Management
7.2.1
To monitor the NCN
prescribing budget and
delivery of the Medicines
Management plan
Healthcare Standard 2.6 Links to SCP3/4/7
31.03.17
Prescribing
Advisors
Practices
NCN Support
Efficient use of resources
that can be re-invested
more appropriately into
patient care
Action:
To scrutinise prescribing budgets on Practice by Practice
basis at all NCN meetings;
To monitor NCN performance against all other NCNs
Progress:
- Targeted approach with prescribing advisor supporting
individual Practices
- Up-dates provided at all NCN meetings
- Prescribing switch options discussed in the round
- Pharmacy Technician Practice visits undertaken to identify
potential efficiencies
A
12
Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance
Objective For completion
by: -
Outcome for patients Action/Progress to Date RAG
Rating
8.1 Clinical Governance
8.1.1
To fully implement the
Clinical Governance Toolkit
Links to all SCPs All Healthcare Standards
On-going
QPS
NCN
Primary Care
Networks &
Community
Division
Practices
Consistency and safety in
Practices and NCN wide
Primary Care services
Action:
To remind Practices at NCN meetings to complete the
toolkit
To monitor progress via QPS reporting
Progress:
- Baseline: All Practices completed the toolkit in 2015/16 –
8 out of 8 Practices in progress 2016/17
- Practices have access to CPD sessions facilitated by ABUHB
- Monthly QP team reporting to NCNs shared with NCN lead
A
Strategic Aim 9: Other Locality issues
Objective For completion
by: -
Outcome for patients Action/Progress to Date RAG
Rating
9.1 Alcohol Misuse
9.1.1
To reflect on the needs of
local people and raise
awareness of/tackle the
effects of Alcohol Misuse
Aligned with SIP- People are confident, capable and involved Links to SCP2/3/4/8/9/10 Healthcare Standard 2.7/3.1
On-going
NCN
Practices
Gwent Drug &
Alcohol Service
Identified approaches
ensure service users, and
carers where appropriate,
feel involved and
engaged in the
identification and
achievement of personal
outcomes
Reduced waiting time for
support through a new
Action:
To enable the on-going engagement with GP Practices
To receive progress reports from GDAS at two NCN
meetings per year
Progress:
- Referral form introduced with key message that clients can
self-refer into GDAS
- GDAS report provided to NCN meeting
- Q3 (2015/16):
- 54 referrals with 27 self-referrals (34 male & 20 female)
A
13
Single Point of Access - Q4 (2015/16):
- 55 referrals with 33 self-referrals (29 male & 26 female)
- Q1 (2016/17):
- 62 referrals with 26 self-referrals (36 male & 26 female)
9.2 Place Based Working
9.2.1
New: To support the
development of the Usk
‘Place Based Working’ model
Aligned to all aspects of the SIP Aligned to Monmouthshire Whole Place approach Aligned to Social Services & Well-Being (Wales) Act Aligned to Well-Being of Future Generations (Wales) Act Healthcare Standard 1.1/2.7/3.1 Links to SCP1/2/3/4/5/7/8/10
31.03.17
NCN
Integrated
Health & Social
Care Teams
People benefit from a
different way of working
based on “what matters”
to the individual (their
families and their carers)
A Whole Place approach
supports people to
develop opportunities,
which contribute to their
improved health and
well-being, and avoids
duplication of work
between organisations
and the community
Action:
To be informed of the framework surrounding the
development of a Place Based Working initiative &
implications for the NCN
Progress
- NCN funding application being considered
- Aligned to previous success & ethos of the Raglan Model
- “Place–based working is a person centred, bottom up
approach used to meet the unique needs of people in one
given location by working together to use the best available
resources and collaborate to gain local knowledge and
insight”1. “By working collaboratively with the people who
live and work locally, it aims to build a picture of the system
from a local perspective, taking an asset- based approach
that seeks to highlight the strengths, capacity and
knowledge of those involved”
A
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