Caerphilly North Neighbourhood Care Network Action Plan & Progress Report 2015-16
Complete Started Not Started
Strategic Aim 1: To understand the needs of the population served by the Network
No Objective Key Partners For Completion
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Outcome Agreed actions / Progress to Date
RAG Rating
1.1 Smoking
1.1.1 Achieve/work towards the National
Tier 1 target of 5% of smokers make a quit
attempt via smoking cessation services, with at least a 40%
CO validated quit rate at 4 weeks
Supports Caerphilly SIP – Healthier Caerphilly H1, H2, H3, H4 Supports IMTP SCP3
NCN
PHW
Smoking Cessation Wales
Housing
Associations Communities
First
Community Pharmacy
31.03.16 Increased numbers of staff who have access to brief
intervention training
Increased access for patients to staff trained in brief intervention techniques
Patients will be motivated to
make a quit attempt and will receive effective treatment to quit smoking
Progress: 2014-15 Figures for Caerphilly
Patients scheduled to
attend a smoking cessation appointment = 441 (467 initial
assessments undertaken)
Number of treated
smokers = 263
% of patients who quit
at 4-weeks (CO-validated) = 54% (40% target level)
Actions
Develop local communication plan with the Communities
First Smoking Cessation Officers
Increase numbers of
staff who have access to
brief intervention training
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
Review data on uptake of smoking cessation services and quit rates
at NCN meetings including with non-
medical members
Continue to improve
referral rate through collaborative working
Ensure every practice
has appointed a
smoking champion
Increase number of pharmacies offering
Level 3 smoking cessation services
1.2 Obesity
1.2.1 To address Obesity issues within the NCN
Network through Partnership working
Supports Caerphilly SIP – Healthier Caerphilly H2, H3, H4
NCN
Social Services/ Communities First
Adult Weight
Management Service
PHW
GAVO
31.03.16 NCN membership and stakeholders will be able to plan
for integrated service provision across the Caerphilly NCN areas.
Families will have access to a
wide range of children and young people’s services, initiatives and projects
addressing obesity issues
Identify baseline data for NCN area regarding
the number of citizens attending services.
Map Level 2 services for weight management
and refer/recommend – Foodwise, commercial clubs, NERS, led walks
Increase in the number
of citizens attending the services.
No Objective Key Partners For Completion
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Outcome Agreed actions / Progress to Date
RAG Rating
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
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
Network Team
NCN
GP Practices
Communities
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
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Outcome Agreed actions / Progress to Date
RAG Rating
on service provision
and change from the wider Gwent resident population.
Supports Caerphilly SIP – Healthier Caerphilly H4, H5
First
GAVO
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:
69% achieved in 2014-15 for immunisation against influenza for 65yrs and
older for Caerphilly North NCN
55% achieved in 2014-15 for immunisation against
influenza for 6months to 64yrs for Caerphilly North
NCN
Hold discussions
between practices regarding best practice
Receive regular practice
updates during flu
season
Hold discussions with DNs regarding
No Objective Key Partners For Completion
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Outcome Agreed actions / Progress to Date
RAG Rating
immunising
housebound patients
Hold discussions with
Midwifery regarding immunising pregnant
women
1.6 NCN Management Team
1.6.1 Establish a
Management Team Structure for Caerphilly North NCN
NCN Lead
NCN Partnership
Teams
Network team
31.03.16 Improved guidance, co-
ordination and development / skills, knowledge and engagement
Implement
NCN/Integrated Management Team
Agree Priorities for 2015/16
Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients
No Objective Key Partners For
Completion by
Outcome Agreed actions /
Progress to Date
RAG
Rating
2.1 Access
2.1.1 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
No Objective Key Partners For Completion
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Outcome Agreed actions / Progress to Date
RAG Rating
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 continuity of service in the short term.
Supports IMTP SCP3
ABUHB
GP Practices
PC&ND
31.03.16 Patients experience shorter waits for GP appointments and
increased patient appointment capacity
Increased access to
appointments, measured through audit
Continuity of services
Support against potential practice fragility
Practices to inform NCN verbally/in
writing if anticipating having difficulty, and
agree to meet with NCN Lead and CD to
discuss next steps
2.2.2 Long term viability and sustainability of Caerphilly north NCN
practices
NCN practices and ABUHB
31.03.16
Maintained availability of local primary care GP service provision
Meetings to be arranged to discuss possible future
configuration of GP practice provision
over the next 5 years in the NCN.
0715 Strengthening General Practice.pdf
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Outcome Agreed actions / Progress to Date
RAG Rating
2.2.3 Diversify the range of
allied professional supporting GPs in practices through
training etc
Practices
ABUHB
31.03.16
Improved access to a more
diverse range of allied specialties within surgeries, i.e HCAs, NPs, minor illness trained
Nurses , Pharmacists, Social Workers etc
Ongoing training to be
accessed and active recruitment.
2.2.4 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
2.2.5 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
2.2.6 Practice Based Social Workers (Pilot)
NCN Lead
Social Services
Identified
practices
31.03.16 A greater focus on achieving people’s well-being outcomes
through holistic integrated assessment and co-productive
solutions
Increased capacity for GP’s
Implement the service within the identified
practices so that Social Workers are integrated
and become a member of the multi-disciplinary
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Outcome Agreed actions / Progress to Date
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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.
team
Progress Three social workers
appointed across Caerphilly, (1 in
Caerphilly North NCN based at Gelligaer Surgery).Feedback to
date extremely positive Funding allocated from
NCN budget
2.2.7 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 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
Appointment made
July/August 2015 Report progress, on
outcomes and impact at NCN meetings
Identify opportunities
for Pharmacists to
further develop appropriate skills
Funding allocated from NCN budget
No Objective Key Partners For Completion
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Outcome Agreed actions / Progress to Date
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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
2.2.8 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.
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.
£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
2.3 Estates
No Objective Key Partners For Completion
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Outcome Agreed actions / Progress to Date
RAG Rating
2.3.1 Improve the
management of estate issues, lack of space in buildings,
lack of grants to be able to increase size
of premises Supports IMTP - SCP3
Clinical Lead,
PC & ND
31.05.16 High quality facilities available
to best meet patient need Annual practice reviews and
CHC statutory visit reports demonstrated facilities are to
required standard.
NCN Lead to clarify the
position regarding Caerphilly North 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
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
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Outcome Agreed actions / Progress to Date
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3.1 Secondary Care
No Objective Key Partners For Completion
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Outcome Agreed actions / Progress to Date
RAG Rating
3.1.1
To improve
communication with secondary care and explore obtaining
access to Cwm Taf CWS for data to be
available to Caerphilly North NCN practices
Practices, NCN
Lead, ABUHB
Cwm Taf LHB
and ABUHB
31.03.16 Discharge notes will be received
and updated to Practice notes in a timely fashion.
GPs are fully informed of patient history at time of appointment
thereby minimising the harm from incomplete or inaccurate information.
To identify poor quality
or absent discharge information
Audit data
3.2 Living Well Living Longer
3.2.1 Introduce the Living
Well, Living Longer Programme across the NCN
Supports Blaenau Gwent SIP – Theme 3 Supports IMTP SCP3
NCN, PHW,
ABUHB
31.03.16. Screening and assessment
services for cardiovascular
disease, diabetes and stroke will
be widely available to patients
over the age of 40
The Living Well Living
Longer Programme was launched by the Deputy Health Minister Vaughan
Gethin on the 12th of January 2015.
Start date for Caerphilly
North NCN awaited
3.3 District Nursing
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
3.3.1 To maximise the
effectiveness of the District Nursing (DN) workforce by
appointing Community
Phlebotomists.
Practices
Community Division
District Nursing
Team Lead
31.03.16 Patients have improved access
to both DN Team services and to newly established Community Phlebotomy Team services.
See 2.2.8
See 2.2.8
3.4 Health Visiting
3.4.1 To build up
relationships between Health Visitors and practices
NCN, ABUHB
Colleagues
31.03.16 Feedback from HVs and Primary
Care demonstrates improved communication.
Improved services for patients
Consistency for patients in which members of staff they
see when having a visit from the Health Visiting Service.
Respond to work-
streams from Pan Gwent Working Group
Team co-ordinator to provide performance
information for NCN meetings
3.5 Mental Health
No Objective Key Partners For Completion
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Outcome Agreed actions / Progress to Date
RAG Rating
3.5.1 To strengthen
integration at practice level between Primary Care and the PMHT
Supports Caerphilly SIP – Healthier Caerphilly H1, H2, H4, H5
Practices,
PCMHSS, Third Sector, Statutory
Services
31.03.16 Reduction in the number of
referrals passed between different teams within Mental Health services, and PMHTs
Clearer care pathways, including transparent, concise
access criteria, will be in place for patients
GP’s to make use of the PCMHSS Flowcharts and
increase their use of the PCMHSS Practitioners for advice/guidance.
Work ongoing regarding
best working and sign posting.
Team co-ordinator to provide performance
information for NCN meetings
Evaluate effectiveness of Primary Care Flowchart
for use in practices and flowchart for CYP via annual audit of GP
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
No Objective Key Partners For Completion
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Outcome Agreed actions / Progress to Date
RAG Rating
3.5.2 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.
3.5.3 To increase the uptake of psychological
intervention through the ‘Road to
Wellbeing’ programme.
Practices, PCMHSS, Third Sector,
Statutory Services
31.03.16 300 people to have accessed Stress Control and ACTivate your Life classes in Caerphilly
between September 2015 and March 2016.
Help to promote the Stress Control and ACTivate your Life
courses offered locally
NCN to receive regular feedback from service
3.5.4 Evaluate the
effectiveness of LEAP and feedback experiences and
outcomes to NCN
Leap team
members
31.03.16 Signposted care by the most
appropriate person
NCN to receive
feedback from LEAP and the NCN practices involved
3.6 Pulmonary Rehabilitation Services
3.6.1 To improve the provision of the Pulmonary
Rehabilitation Service in the NCN Network
ABUHB Divisional Colleagues,
Thematic Leads
31.03.16
Reduced waiting times Reduced DNA’s
Practices to encourage patients to attend by promoting the service
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
Supports Caerphilly SIP – Healthier Caerphilly H3, H4
3.7 Diabetes
3.7.1 To improve diabetes services across the
NCN for Patients Supports Caerphilly SIP – Healthier Caerphilly H1, H3, H4 Supports IMTP
SCP5
As above 31.03.16
Improved management of patient diabetic service needs
across the NCN Access to advice from multi-
disciplinary team and implementation of the new
diabetes work plan leads to improved outcomes for patients
Improved access to DSNs via email/telephone for
initiation of injectable therapy
Improved access to Consultants for advice
Improved rapid assessment
of patients who need
consultation opinion
• To implement the Diabetes Integrated
Service Model across the NCN
• To use PH Observatory data as a baseline for
improvement Refer routinely to Adult
Weight Management Service
Consider increasing
Adult Weight
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
Diabetes Work Plan NCN comms 16 45.ppt
No Objective Key Partners For Completion
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Outcome Agreed actions / Progress to Date
RAG Rating
care
Monitor referrals to
diabetes secondary care
per practice
3.8 COPD
3.8.1 Improve Inhaler Technique for patients
Community Pharmacy
NCN
31.03.16 Patients using devices appropriately
To cascade inhaler technique training-
multidisciplinary strategy. NCN funding
identified.
Accredited training
provided by WCPPE, pre and post course
learning, plus take away pack of placebo devices.
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
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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
Practices to monitor
performance against LMC standards
Practices to monitor &
No Objective Key Partners For Completion
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Outcome Agreed actions / Progress to Date
RAG Rating
with emerging guidance to be
agreed with CHC, Health Board
and LMC
report performance to
NCN Lead on a monthly/quarterly basis
Monitor A&E attendances per practice
4.1.2 To maximise
utilisation of
alternative avenues
for advice prior to
referral, adopting
prudent healthcare
principles
PC&ND
ABUHB
Radiology and
USC Divisions
31.03.16 Data shows reduction in reliance
upon multi agency services
Contributes to reduce waiting
times for secondary care
services
Identify other methods of contacting secondary
care e.g. email/telephone (incl
mobile) for advice
To record secondary care email advice
incidents
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
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
emergency/urgent slots
in each practice
Monitor data on
numbers redirected to YYF services
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
4.3 Social Services
4.3.1 To improve communication
between Health Services and Social Services
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
Raise any issues with Caerphilly Integrated
Partnership
Continuously monitor
impact and consider best ways of working
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
Supports Caerphilly SIP – Healthier Caerphilly H3, H4
service transition between
primary care and social services
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
31.03.16 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
5.2 Summarise case
review data, and any arising issues
and actions identified, for sharing with the
network and the wider health board
NCN Leads, St
Davids Palliative Care Team,
Practices, NCN Support Teams
31.03.16 Learning through shared
experience will inform future care improvements for patients
on the EOL pathway.
Highlight best practice
for improvement to be highlighted and shared
in a multi-professional discussion
0715 EOLC All Gwent Summary.docx
Caer North National Priorities Audit Summary 0315.docm
5.3 Establish a review
cycle, to monitor progress (or
maintenance of high quality), with further submission of
reports to the GP network and wider
health board as
NCN Leads,
Practices, NCN Support Teams
31.03.16 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
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
appropriate
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 lung, gastrointestinal and ovarian cancer
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
Audit Tool
6.2 Learning and actions
to be shared with the GP network and the
wider LHB
NCN, NCN
Leads, Practices
31.03.16 Audit tool to ensure continuous
review, reflection and improvement in processes and
care pathways for patients with a diagnosis of cancer.
Practices complete audit
and discuss findings
Caer North National Priorities Audit Summary 0315.docm
6.3 Identify and include any relevant actions to
be addressed in the Practice Development Plan
NCN, NCN Leads,
Practices
31.03.16 Improved patient information.
Patients preferred place of
death.
Practice by practice NCN USC cancer data will be
collated to provide better informed demographic data
relating to cancers on a regular basis
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
6.4 Summarise themes
and actions for review with the GP network and share information
with the LHB as required
NCN, NCN
Leads, Practices
31.03.16 Improved patient information.
Patients preferred place of death.
NCNs to share learning
with secondary care
National Priority Target Audit Summary Cancer 14-15.docx
6.5 Develop protocols to
ensure Practices refer patients as ‘USC’ rather than ‘Urgent’ if
cancer was suspected and that Practice
based systems should be established to track USCs referred. Supports IMTP SCP3
NCN Lead Practices
30.09.15. Patients will be referred for
Secondary Care interventions with the appropriate level of urgency and seen accordingly.
Practices to discuss and
agree to use USC notation on suspected
Cancer patient referrals Develop an NCN
Standard
6.6 To ensure referring GPs are informed by Secondary Care
Consultants of downgrades to USC
referrals. Supports IMTP SCP3
PC & ND / AMD Secondary Care
Consultants GPs
31.03.16. Improved patient information. Appropriate treatment pathways
initiated.
PC & ND / AMD to contact Divisional Leads
to ensure consultants inform referring GPs of
downgrades. Practices to consider
processes to follow up all USC referrals and
subsequent potential downgrades.
Strategic Aim 7: Minimising the risk of poly-pharmacy (National Priority – to be discussed locally and also Medicines
Management)
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
7.1 Poly-pharmacy
7.1.1 Identify and record numbers and rates for
patients aged 85 years or more receiving 6 or more
medications.
NCN, NCN Leads, Practices
31.03.16 Identify patients at high risk or harm of either over or under
medicating.
Using audit +, a review of practice clinical
systems to identify (‘at-risk’ only) patients over the age of 85yrs in
receipt of 6 or more medicines.
7.1.2 Undertake face to
face medication reviews, using the ‘No Tears’ approach
NCN, NCN
Leads, Practices
31.03.16 Reduction in unnecessary
admissions to hospital.
Identification of further
untreated conditions.
Number of MUR Consultations
Using data from the
review audit book appointments for medication reviews of
patients over the age of 85yrs receiving 6 or
more medicines.
7.1.3 Identify any actions to be addressed in
the Practice Development Plan
NCN, NCN Leads, Practices
31.03.16 Poly-pharmacy at NCN meetings Quarterly
information to NCN on utilisation of notional
budget
Caer North National Priorities Audit Summary 0315.docm
National Priority Target Audit Summary Polypharmacy 14-15.docx
7.2 Medicines Management
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
7.2.1 Appointment of
Primary Care Pharmacists to assist the delivery of safe
and cost effective prescribing to the
NCN population
NCN Lead,
Practices
31.3.16 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 quality
7.2.3 To review the variation in prescribing compared
to national guidance
NCN Lead
31.3.16 Patients and professionals have access to a named Pharmacist in Primary Care
NCNs to work with Primary Care and Networks Division Pharmacy staff to:
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
in relation to Diabetes
and Respiratory and deliver the NCN savings target for
these work streams within the three year
plan
GP Practices
Pharmacy
Efficient use of resources that
can be re-invested more appropriately into patient care
Minimise avoidable harm from the adverse effects of inhaled
steroids Undertaking the minimum
appropriate intervention to ensure prudent prescribing
aligned with NICE Guidance.
Arrange scheduled visits
by the NCN Lead to discuss Dashboards and
Practice performance
Monitor performance
change through actual prescribing spend on high dose
corticosteroids and diabetes drugs
Identify prescribing
leads rep and identify
progress against the SCEP;
Prescribing guidance to be developed by
Pharmacy Team
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
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
completing the CGSAT
Target support for
areas of the CGSAT
which are identified as showing low levels of
achievement Access arrangements –
core access arrangements; aids to
access user experience; the impact of MHOL
How practices respond to urgent and same day
requests from Care Homes, WAST and
Hospital Emergency Depts
Actions to foster greater integration of
health and social care Consideration of how
Third Sector support may be maximised
Map local services to
highlight where services
are delivered across practices (e.g.
contraceptive services, minor surgery)
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
How new approaches to
the delivery of primary care might aid service delivery and ensure
sustainability of local services
Consideration of the
impact of local care
pathway work relating to previous QOF work
Strategic Aim 9: Agreed Locality Priority Issues
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
9.1 To establish a more
integrated service model of working for
practices and community based teams in the RIHSCC
NCN, NCN
Lead, partners based in
RIHSCC
31.03.15 More integrated working
providing care provided ‘by the right person at the right time’
Meetings to be arranged
9.2 To develop a 3-5 year
working plan for sustainability of GP practices within the
NCN
NCN, NCN
Lead, Practices, ABUHB Divisional
Colleagues
31.03.15 Appropriate General practice
service provision
Practice discussions
ongoing
No Objective Key Partners For Completion
by
Outcome Agreed actions / Progress to Date
RAG Rating
9.3 Establishment of an
NCN Web based solution that provides information for local,
available services for Dementia patients.
PC & ND
Phil Diamond - (Dementia Friendly
Community Lead)
31.03.16 Patients and their families /
carers can access up to date information on services available to them relating to
dementia support.
Implement and
promote Dementia Roadmap
9.4 Increase awareness
of dementia friendly community in Rhymney.
ABUHB,OAMH,
Social Services, LA, NCN
GP practices
31.03.16 Patients are supported in their
communities
Training practice staff
as Dementia Friends
Collate the number of
practice staff completed training
9.5 Work with new dementia primary
care support workers in the community supporting patients
and families with a new diagnosis of
dementia
ABUHB,OAMH, Social Services,
LA, NCN GP practices
31.03.16 Patients are supported in their communities
Invite DSW to feedback to the NCN on
management of caseload of patients who are supported post
diagnosis.
DSW to update the NCN on available dementia support services