monmouthshire north neighbourhood care network action … north ncn... · sip links with supporting...

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Monmouthshire North Neighbourhood Care Network Action Plan 2015-16

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December 2015: Chippenham/Raglan surgeries have merged with Chippenham as main site and Raglan as the branch therefore reducing total number to 8 Practices. The new practice will be known as Castle Gate Medical Practice and will use the current Chippenham W code of W93036, Raglan branch will use W93036a.

Monmouthshire North Draft Action Plan 2015-16

Strategic Aim 1: To understand the needs of the population served by the Network (identified by Public Health)

No Objective Agreed actions Outcomes Key

Partners

Time-

scales

RAG

1.1 Obesity

1.1.1 NEW: Tackling obesity

Adopted as

Population Needs

priority 2015-16

Supports Monmouthshire SIP Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3/4/5

Identify baseline data for NCN

area

Measure height, weight and

electronically record BMI

Intervene more regularly, with

right information in the right

way – brief advice /

intervention

Map Level 2 services for weight

management and

refer/recommend – Foodwise,

commercial clubs, NERS, led

walks

Refer routinely to Adult Weight

Management Service

Increase AWMS capacity for

specific populations (e.g. Pre-

diabetes, pregnant women) e.g.

BG West

(See 2.1.4)

Number of people

who receive timely

and appropriate

support based on

their needs;

AWMS guidelines

are implemented

AWMS/NCN/

Public

Health/Practi

ces/Third

sector/ABUH

B Divisions

31.3.16 Actions to be agreed

Obesity by LA.docx Obesity slide.docx

Obesity slide 2.docx Childhood obesity slide.docx

Initial scoping meeting held with

service to agree role and budget

Diabetes presentation given at

NCN meeting:

Diabetes Consultants aligned to

NCNs

Consultant email advice line open

Consultant/DSN telephone advice

1.2 Bowel Screening

1.2.1 NEW: To increase up-

take of bowel

screening to achieve

60% target

To achieve national target of

60% for eligible patients;

PHW liaise with national

screening to provide list of non-

responders to Practices

quarterly;

Earlier detection of

bowel cancer – data

supports improved

survival rates;

Published evidence

NCN (Public

Health led) /

national

Screening /

Practices /

ABUHB

31.3.16 http://qir.bmj.com/content/3/1/

u205661.w2324.full

http://qir.bmj.com/content/3/1/u205661.w2324.full

http://qir.bmj.com/content/3/1/u205661.w2324.full

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Partners

Time-

scales

RAG

Adopted as

Population Needs

priority 2015-16

Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service

Change Plan No. 3/4/5

PHW to calculate predicted

increase in referrals for follow

up colonoscopy for each %

increase in uptake of screening;

Identify potential funding to

support Practices in targeting

non-responders: Follow up

letter +/- telephone contact

etc;

PHW data by NCN to monitor %

of non responders who

subsequently submit a sample

after follow up by Practices

Numbers of non responders by

NCN is available to work out

administrative costs of follow

up by Practices if needed

Complete significant event

audits

Carry out thematic analysis to

identify potential causes of

diagnostic delay

shows Practice level

interventions have

achieved clinically

significant increase

in uptake;

Evidence shows

that high % of

people responding

once to bowel

screening will

respond again

Divisions

u205661.w2324.full.pdf

Bowel screening up-take 2013-14.docx

2014-15 audit: National bowel

screening picked up 7 of the 77

GI tumours

Screening For Life 2015 by Public

Health Wales -

https://www.thunderclap.it/proje

cts/27059-screening-for-life-

2015 information circulated to

NCN members

PH meeting AWBS team

08.09.15 – take outcome forward

All Practices have received list of

non-responders from PH team

and are targeting with NCN

agreed funding

1.3 Immunisations

1.3.1 People in at risk

groups will be actively

encouraged to receive

a flu vaccination, to

achieve the national

target of 75% for

immunisation against

influenza

Supports Monmouthshire SIP / ABUHB Flu Plan Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3

Practices discuss and monitor

existing data on uptake, to

identify variation and areas for

improvement

Utilise Third Sector networks

to support the campaign NEW: Impact of new

phlebotomy service providing

DNs with capacity (See 2.1.2)

NEW: DN service success

against 100% offer target

NEW: Identify issues

between GP & Community Pharmacy LES provisions

Decrease in hospital

admissions;

Decrease in

morbidity

GP Practices

/ NCN /

Contract-or

Services /

DNs

31.3.16 IVOR latest needed for both

target groups

WHC-2015-028 - National Influenza Immunisation Programme 2015-16 - WORD Version - English.pdf

DN service target: 100% of

housebound people to be offered

flu vaccination

2 x band 6 nurses employed to

support increased up-take

Flu road shows for practice managers 2015 handout-Sept 2015.docx

Seasonal influenza vaccine uptake in Wales 201415_v1a.pdf

https://www.thunderclap.it/projects/27059-screening-for-life-2015



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Partners

Time-

scales

RAG

Links to 9.1.1 GDAS

School fluenz programme started

Flu up-take at 26 October 2015:

65+ 52.4% / <65 years 33% (All

Wales figs for comparison -

42.4% in 65+ / 25.2% in <65

years)

1.4

Engagement

1.4.1

REVISED: To support

the work of ENGAGE

and attend ’listening

events’ to gauge local

opinion

Supports Monmouthshire SIP

Links with Supporting People Needs Mapping 9th June 2015

Links to ABUHB Service Change Plan No. 5

REVISED: To attend minimum

of 2 events to capture local

views & provide a range of

information relating to e.g. Flu /

smoking cessation / ‘Choose

Well’

Lessons learned are used at

Practice level, reported at NCN

to highlight to secondary care

colleagues

Listening events capture

opinions to be shared with

Practices as necessary

Feedback from

engaged,

disadvantaged

groups

demonstrates

improved service

delivery and

patient/carer

satisfaction

NCN 31.3.16

SPPG needs mapping.docx

ABUHB engagement team event

in Monmouth Town held with

feedback reported via Primary

Care & Networks Division

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

patients

Objective Agreed actions Outcomes Key

Partners

Time-

scales

RAG

2.1 Access

2.1.1 NEW: Phlebotomy:

Increase access to

primary care

phlebotomy service


To implement local service

closer to home and in care

homes

Increase access to phlebotomy

service for house bound

population

NEW: To identify District

Nursing impact on flu up-take

and progress against target

Increased capacity

and access

within/to DN service

NCN/ABUHB

Divisions

31.3.16 £4.4m funding to support this

Pan NCN initiative

5


Partners

Time-

scales

RAG

(See 1.2.1)

(WAO report on district nursing indicates

that 30% of community nursing time could

be released, for example to manage LTCs, if

no longer required to take blood)

2.1.2 NEW: Contracted

Services: To engage

with and utilise skills

of other Primary Care

services i.e.

Optometrists,

Pharmacists & Dentists

Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3

NCN funding to facilitate

recruitment

Contractors act as advisors to

NCNs with communication plan

established

Increased

communication

leads to improved

understanding of

Primary Care issues

AMD/NCN/C

Ds/NCN

leads

31.3.16 NCN funding agreed to support

this initiative

Scope of contribution to be

discussed/agreed

All 3 posts appointed to

All Gwent NCN Independent Contractor Support.docx

2.1.3 NEW: Obesity See 1.1.1 - Increase access to

AWMS

See 1.1.1 See 1.1.1 See 1.1.1 See 1.1.1

2.1.4 NEW: To implement a

Faecal Calprotectin

(FCAL) pilot for people

with Inflammatory

Bowel Disease (IBD)

To implement pilot in North

Monmouthshire (possibly

including South also) to reduce

number of referrals to GI

Consultants

To implement a request form

available to all Monmouthshire

GP Practices (pilot excludes

children)

Appropriate

requests are made;

Positive predictive

values based on

approx 100

requests estimated

over 3 months;

Proportion of

negative results

that might have

avoided a

colonoscopy

ABUHB

Divisions /

NCN lead /

NCN

TBC

Faecal Calprotectin Primary Care Request Form.pdf

Initial meeting held (NCN lead

sits on GI team)

Request form developed by GI

Consultant and shared with

group

Priorities for pilot success

discussed and agreed

6


Partners

Time-

scales

RAG

2.1.5 NEW: Early warning

for Practices

anticipating difficulty

with recruitment/filling

vacancies


Practices to inform NCN

verbally/in writing if having or

anticipating difficulty

Agree to meet with the NCN

lead to discuss next steps

Continuity of

services

Support against

potential Practice

fragility

Practices /

AMD / NCN

lead

31.3.16

Strengthening General Practice_ Actions for a brighter future for patien .pdf

QOF

2.1.6 NEW: Practices in

difficulty have access

to NCN salaried

support team to

ensure continuity of

service in the short

term

Links to ABUHB Service Change Plan No. 3 / Primary Care Plan

As above Continuity of

services

Support against

potential Practice

fragility

As above 31.3.16

2015 plan for primary care.pdf

QOF

2.1.7 NEW: Monitor the

continuation and

uptake of My Health

Online

Links to ABUHB Service

Change Plan No. 3

All practices to offer

appointment availability and

repeat prescription ordering via

MHOL

Ease of access to

GP services

NCN /

Practices /

Pharmacy

Advisors

31.03.16

Clinical Director appointed as lead

with NCN support

2.2

Workforce

2.2.1 NEW: Practice staff

can access timely,

relevant training

Links to ABUHB Service Change Plan No. 3 Health and Care Standards: 7.1

Establish a Divisional/NCN Task

& Finish group – training plan

developed

Develop a process for Practice

staff to access training

Training providers and costs are

identified

Practices are informed of

training options and criteria

Establish Practice Nurse forum

Quality of care /

skilled workforce –

enables sharing of

ideas/skills and

good practice

NCN/ABUHB/

Practices

31.3.16 Process in place via proposal

applications

£1.1m allocated to NCNs:

Training options considered from

slippage funds year on year –

T&F group established

7


Partners

Time-

scales

RAG

2.2.2 NEW: Ensure local

support structure is fit

for purpose to meet

demands of strategic

NCN development


To be appraised of South

Monmouthshire developments

Improved guidance,

co-ordination and

development to

meet the needs of

the local population

NCN lead /

HoPN /

PC&ND /

ISPB / NCN

31.3.16 Workshop held with key

stakeholders to agree

membership of Management

Group, remit and immediate

action required

Action Plan developed

2.3

Estates

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


partners

Time-

scales

RAG

3.1 Mental Health

Services

3.1.1 To strengthen

integration with GP

Practices (PCMHSS)

Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3 /4/5

Respond to work-streams from

Pan Gwent Working Group

Team co-ordinator to provide

performance information for

NCN meetings

Evidence shows

services collaborate

to ensure timely

access to support

NCN/Practice

s/PCMHSS/M

H Division

31.3.16

GAVO Mental Health Service Directory for Gwent.pdf

PCMHSS acts as member of NCN

with reports provided re progress

against waiting times

3.1.2 NEW: Dementia: To

make up to-date local

and national

information available

in relation to accessing

dementia care support

Adopted as a local

priority 2015-16

Supports Monmouthshire SIP

Links with Supporting People Needs Mapping 9th June

Implement Dementia Roadmap

Identify stakeholders e.g.

libraries etc

Promote ‘Dementia Friend’

training across partners

Increased access to

local and national

information sources

for people with

dementia, families

and carers

Phil Diamond

– DFC lead /

MH Div

/CMHT /

Community

Division /

3rd sector /

NCN

31.3.16

£4 million from WG to fund MH

related projects for primary care.

£0.24 million from for national

nurse led programme to train

care home staff and respond

better to their needs and ensure

their diagnosis is recorded on GP

registers.

All Gwent dementia roadmap.docx

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partners

Time-

scales

RAG

2015 Links to ABUHB Service Change Plan No. 3/4/5

NCN funding allocated to support

implementation of an on-line

dementia Roadmap – steering

group in place

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


partners

Time-

scales

RAG

4.1

Integrated Services

Team (IST)

4.1.1 Increase the range of

services available

closer to home

Supports Monmouthshire SIP Links to ABUHB Service Change Plan No. 3/4/5

Clarify points of contact for

GPs/PMs & develop a Case for

Change to identify medical

model for IST (See 3.1.1)

Improve access to IV antibiotics

at home service

To consider ABUHB Policy re

management of infection in

exacerbations of COPD, with IV

antibiotics access

Data provided by CORE

performance report

On-going development of

Integrated Hubs at Monnow

Vale / Mardy Park

Review existing service and

work to identify a medical

model

Number of

avoidable

admissions is

reduced with care

managed at home

with Multi-

Disciplinary Team

HoPN/NCN/

IST

31.3.16 Work on-going as part of ‘Hub’

development team remit - paper

presented to Community

Transformational Group

Local action plans developed

Strategic Aim 5: Improving the delivery of end of life care [EOLC] (National Priority – to be discussed locally)

No Objective Agreed Actions Outcomes Key

partners

Time-

scales

RAG

5.1.1 Review delivery of

EOLC using Individual

NCN to support Practices to

review audit of patients who

Audit outcome leads NCN Leads/

Practices/

31.3.16 Year-end reporting requirement

9


partners

Time-

scales

RAG

Case Review Audit


have died to be reflected

upon/inform future care

delivery.

to improved care

during End of Life

phase

NCN Support

5.1.2 Summarise case

review data, and any

arising issues and

actions identified, for

sharing with the

network and the

wider health board


Change Plan No. 4

Highlight best practice for

improvement to be highlighted

and shared in a multi-

professional discussion

Learning through

shared experience

will inform

improvements for

patients on the EOL

pathway

NCN Leads/

St Davids/

Practices/

NCN Support


5.1.3 Establish a review

cycle, to monitor

progress (or

maintenance of high

quality), report to NCN

and wider health board

as appropriate

Agreement of ‘best practice’ in

EOLC. Identification and

monitoring of areas for

improvement so that

appropriate education and

support can be delivered

Improved

consistency in

standard of care

delivered

NCN Leads/

Practices/

NCN Support

31.3.16 Audit outcomes reported to

ABUHB GP Macmillan co-

ordinator with learning points

included in the Palliative care

Delivery Plan. Monthly reports

also sent to all NCN leads

5.1.4 NEW: Themes

identified by audits

lead to agreed action


NCN to discuss +/- use of EOLC

template for all patients who

enter terminal stage of illness,

not just those with cancer;

NCN to discuss READ Code

training for Practice staff to

improve recording of diagnostic

symptoms;

Develop patient recording

protocols for Care Homes, by

using the Integrated Care

Pathway framework, to ensure

patient record consistency;

Practices identify carers and

record when patients are first

diagnosed / placed on the

register;

Improved

consistency in

standard of care

delivered.

Practices

NCN Lead

HoPN


10


partners

Time-

scales

RAG

Ensure Carer’s Packs are

available at all GP Practices;

To map/ensure access to

interpreter services for patients

whose first language is not

English;

Improve communication with

OOH Services re ‘Special Notes’

and use of Adastra to provide

up to-date patient records.

Strategic Aim 6: Targeting the prevention and early detection of cancers (National Priority)


partners

Time-

scales

RAG

6.1.1 Review care of all

patients newly

diagnosed between 1

January 2015 to 31

December 2015 with

lung, gastrointestinal

& ovarian cancer


Change Plan No. 4

Audit tool Patient referral

information

reviewed and

Outpatient

appointments /

results followed up

NCN/NCN

Leads/

Practices


NICE issued: Suspected Cancer

recognition and Referral – NG12

(June 2015)

GI Consultant attended NCN to

discuss learning points and

solutions – impact of new NICE =

WLIs / Weekend & evening clinics

6.1.2 Learning and actions

to be shared with

NCN and the wider

health board as

appropriate


Practices complete audit and

discuss findings

Audit tool ensures

continuous review,

reflection &

improvement in

processes/ care

pathways for cancer

patients

NCN/NCN

Leads/

Practices


6.1.3 Identify and include

relevant actions to be

addressed in Practice

Development Plans

Practice by practice NCN USC

cancer data will be collated to

provide better informed

demographic data relating to

cancers on a regular basis

Improved patient

information/ Patient

choice & preferred

place of death

NCN/NCN

Leads/

Practices


11


partners

Time-

scales

RAG


6.1.4 Summarise themes

and actions for review

with NCN / share

information with wider

health board as

appropriate


NCNs to share learning with

secondary care

As above NCN/NCN

Leads/

Practices


6.1.5 NEW: Themes

identified by audits



Develop protocol to refer

patients as ‘USC’ if cancer

suspected with Practice based

referral tracking system;

Practices encourage patients to

attend Bowel Screening

Programme;

GPs are informed by Secondary

Care Consultants when referrals

are re-prioritised;

Patients who DNA are contacted

Improved patient

information;

Appropriate

treatment pathway

initiated

PC&ND /

AMD /

ABUHB

Divisions /

Practices /

NCN lead /

NCN

31.3.16 NEW: Themes identified by audits


Links to ABUHB Service Change

Plan No. 4

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

Management)


partners

Time-

scales

RAG

7.1 Poly-pharmacy

7.1.1 Identify and record

numbers and rates for

patients aged 85 years

or more receiving 6 or

more medications.


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.

NEW: Consider extending the

audit age range to include lower

starting age

Identify patients at

high risk or harm of

either over/ under

medicating

NCN Leads


12


partners

Time-

scales

RAG

7.1.2 Undertake face to

face medication

reviews, using e.g.

‘No Tears’ approach


Using data from the review

audit book appointments for

medication reviews of patients

over the age of 85yrs receiving

6 or more medicines.

Reduced avoidable

admissions;

Identification of

untreated

condition(s);

Number of MUR

Consultations

NCN Leads/

Practices/

NCN Support


7.1.3 Identify any actions to

be addressed in

Practice Development

Plans

Identify and record

numbers and rates for

patients aged 85 years

or more receiving 6 or

more medications.


Poly-pharmacy at NCN

meetings

Quarterly information to NCN

on utilisation of notional budget

As above NCN/

Prescribing

advisors/

Practices/

NCN Support


Using data from the review

audit book appointments for

medication reviews of patients

over the age of 85yrs receiving

6 or more medicines.

7.2 Medicines

Management

7.2.1 NEW: Recruit 0.8 wte

Primary Care based

Pharmacist from NCN

funding to integrate

with GP Practices, NCN

and partners


Initiate recruitment process –

Summer 2015

Induct Pharmacists into GP

Practices

Integration and outcomes

measured/ monitored via NCN

meetings

NCN Pharmacists

project team

developing a suite

of priorities &

outcomes;

Patients and

professionals have

access to a named

Pharmacist in

Primary Care

NCN

leads/NCN/P

C&ND


Post appointed to July/August

2015

Integration and outcomes

measured/ monitored via NCN

meetings

Identify opportunities for

Pharmacists to further develop

appropriate skills

Funding allocated from NCN

budget

13


partners

Time-

scales

RAG

7.2.2 To monitor the NCN

prescribing budget and

delivery of the

Medicines

Management plan


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 on priorities for

NCNs to achieve in terms of

service improvement, costs and

quality

For year-end review and final

report

Efficient use of

resources leads to

re-investment &

more appropriate

care

NCN Lead/

Prescribing

lead/

Practices


NCN meeting standing agenda

item with scrutiny of actual and

projected spend against

prescribing budget

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


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

Minimise avoidable

harm from adverse

effects of inhaled

steroids;

Undertake

minimum

appropriate

intervention to

ensure prudent

prescribing aligned

with NICE Guidance

NCN Lead


Regular updates at NCN meetings

Prescribing switch options

discussed in the round

Pharmacy Technician Practice

visits to identify and discuss

potential cost efficiencies

Strategic Aim 8– Delivery consistent, effective systems of Clinical Governance


Partners

Time-

scales

RAG

8 Clinical Governance

8.1.1 To fully implement the

Clinical Governance

Toolkit

To ensure practices are

supported in completing the

CGSAT

Consistency and

safety in Practice

and NCN wide

Practices / PC&ND / NCN

31.3.16

Year-end reporting requirement

14

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 My Health On Line.

How practices respond to

urgent requests and same day

requests from care homes,

Welsh Ambulance Services and

Hospital emergency

departments.

Actions to foster greater

integration of health and social

care.

Consideration of how

community resources can be

maximised to meet local needs.

Consideration of how Third

Sector support may be

maximised

Map local GP services to

highlight where services are

delivered across practices (for

example, 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

primary care

services

15

Strategic Aim 9: Other locality issues


partners

Time-

scales

RAG / Progress

9.1.1 NEW: To raise

awareness of and

tackle the effects of

Alcohol

Adopted as a local

priority 2015-16

Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3/4/5 Links with 1.2.1 vulnerable groups for increased flu up-take

• Scope ways of identifying

hazardous and harmful drinkers

• Engage with the development

of the integrated alcohol

treatment pathway (Newport

NCN lead)

• GDAS to attend NCN / Practice

Manager’s meetings

• GDAS to liaise with GP Practices

to raise awareness of new

service and support available

• Identify training needs and how

issues can be shared across

secondary care mental health

service providers

Identified

approaches ensure

service users, and

carers where

appropriate, feel

involved and

engaged in the

identification and

achievement of

personal outcomes

NCN / GDAS

/ Public

Health /

Partners

31.3.16

Assembly for Wales Alcohol report 2015.pdf

GDAS background.doc

NCN leads (N&S) meeting with GDAS:

• Alcohol brief intervention training

available for professionals

(midwives/community nurses –

NCN help to facilitate access to

GPs)

Refs received from any service

with consent of service user

5 year service for Monmouthshire

GDAS can refer to GSSMS directly

with regular meetings

All 18+ yrs D&A referrals engaging

in treatment detox / scripts /

recovery

GDAS to look into how GPs are

notified when people are engaged

in the service, outcomes and when

discharged

Simplified referral forms in place

but will take phone/GP own (e-)

referrals also

SPA email address

Data will be made available e.g.

referrals by Practice

Outreach campaign >65 group of

established alcoholics to engage

with service

Practices Flu campaigns would

help target >65+ year olds

starting October – GDAS team can

support flu campaign for any

queries

16


partners

Time-

scales

RAG / Progress

GDAS to liaise with Practice

Managers re promotional material

Scope potential for Practice based

D&A ‘champions’

GDAS attending referral/MDT

assessment meetings at St

Cadoc’s Hospital

See

3.3.2

Dementia

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