caerphilly south neighbourhood care network action plan ... · (polypharmacy) reduced hospital...

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Caerphilly South Neighbourhood Care Network Action Plan & Progress Report 2015-16

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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

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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

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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

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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

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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

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


completion by


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

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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

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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

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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


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

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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

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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


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


Regular monitoring of

the referrals and the

effectiveness of the service

Monitor referrals to TVN

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by


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

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by


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

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by


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

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by


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

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by


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

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by


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

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Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needs and to support the continuous development of services to improve patient experience, coordination of care and the effectiveness of risk

management

No Objective

Key partners For Completion

by


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

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No Objective


by


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

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No Objective


by


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

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No Objective


by


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


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

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by


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)


Completion by


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

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by


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


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

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Strategic Aim 7: Minimising the risk of poly-pharmacy (National Priority – to be discussed locally and also Medicines Management)


Completion by


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


National Priority Target Audit Summary Polypharmacy 14-15.docx

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by


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

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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

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Strategic Aim 8– Delivery consistent, effective systems of Clinical Governance No Objective Key Partners For

Completion by


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

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by


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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

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Strategic Aim 9: Agreed Prioritised Locality issues No Objective Key partners For

Completion By


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

caerphilly south neighbourhood care network action plan ... · (polypharmacy) reduced hospital...

Documents