the cwmtawe cluster approach - primary care one · new models – an overview of our project the...
TRANSCRIPT
Workshop 1
The Cwmtawe Cluster approach
#PrimaryCare19 #GofalSylfaenol19
WHOLE SYSTEM TRANSFORMATIONCwmtawe Cluster
Mrs Sharon Miller, Head of Primary CareDr Iestyn Davies Cwmtawe Cluster Lead
What is the Cwmtawe Cluster?
A multi agency, multidisciplinary, partnership seeking to improving Health and Wellbeing in the Clydach, Morriston and Llansamlet areas of Swansea
NEW MODELS – An overview of our project
The vision is a Cluster-led integrated health and social care system.
The overall strategic aims are:
• Improve wellbeing across the age spectrum, with a key focus on the earliest years and young carers.
• Co-ordinate services to maximise wellbeing, independence and care closer to home. Design, co-ordinate and implement services in partnership with the community. A particular focus on older people.
• Test out the vision and aims within the ten year plan and to implement components of the overall model proving proof of concept, and an ability to evaluate and redesign.
NEW MODELSQuadruple Aims -inter-related projects
OVERVIEW OF PROJECTS
Improved Population health and well being • Establish Social enterprise• Pro active communication campaign • Community involvement• Interactive engagement • Local area co-ordination• Improved mental health and well being • Young Carers
Better Quality More Accessible Services• Expand Primary Care MDT• Community Phlebotomy• Outpatient clinics e.g. Glaucoma, • Closer working with Acute Response Team • Speech and Language walk-in clinics • Space utilisation
Active Learning
Transformation Journey
Higher Value Health and Social Care• Advanced Eye Check scheme• Improved oral health in care homes
• Chronic Conditions Management – Heart Failure and COPD
Motivated and sustainable workforce • Workforce Optimisation • Clinical Leadership• Workforce development
Cwmtawe Medical Group
New model of primary care?
• 9 GP partners• 6 salaried/ 3 registrars• 2 practice pharmacists• 2 advanced nurse practitioners• 1 practice paramedic• 1 practice physiotherapist• 1 Minor illness nurse• 9 practice nurses• 2 Health Care Support Workers
With access to:
Primary Care audiology Cluster occupational therapy Cluster social prescribing link
worker Cluster early years worker Cluster-commissioned third sector
services Cluster pharmacist Dementia link worker (ICF) Our Neighbourhood Approach –
community development worker
What’s new?
• Transformational resources secured by Health Board secured in advance • Bringing together key components to maximise synergy and whole system impact, scale
and pace• Sustained focus on active community partnership using the social model of health. • Extensively testing the expanded MDT at primary care level to create strong and stable
primary care.• Moving services closer to home.• Dedicated clinical leadership time to focus on transformation • Cluster-led decisions are taken closer to (and with the involvement of) patients, carers
and clinicians• Built-in research and evaluation and active learning • A cross organisation Governance Board established under the RPB
Cwmtawe Whole System
Singleton/Neath Unit
Community Opticians
CWM ALLIANCE
Social Enterprise Directors
Patients / Community Members
MH & LD Unit
Health Board – Primary
Care
Swansea Council
GP practices
SCVS
Acute Clinical
Response Team
Community Opticians
Care Homes
Integrated Nursing Teams
Welsh Government
Audiology/Speech and
language
Medicines Management
WHO IS INVOLVED
Progress since November 2018
Local area Co-ordinator appointed January – Llansamlet Young Carers project commenced Community Interest Company established July – Cwm AllianceNew pathway for enhanced eye care developed and implemented
(community opticians) Community Primary Care Audiology Service commenced Practice MDT expanded in Llansamlet/ Strawberry Place – new roles/
models of access Medical records moved (36,000)Health literacy training undertaken - Belfast Healthy City Repeat dispensing project Initiated
Progress since November 2018
Oral health in care homes project commenced ( assessment and treatment) New model for phlebotomy developed - recruiting currently New model of primary care mental health developed Contributed to chronic conditions management framework - COPDGlaucoma clinics commenced in Morriston Speech and language – walk in /talk in clinics launched JulyWorkforce development supported (additional qualifications) Very pro active communication campaign implemented including
newsletters, media, websites and social media.
Progress since November 2018
50 + multi agency/multi disciplinary scoping meetings Clinical/Senior Leadership Group established ( meets
monthly – project board) Project manager appointed Detailed project plans completed Baseline profile completed Communications officer in post since January Research undertaken – FROME / Glasgow/ Belfast Shared learning – other clusters and All Wales
SUSTAINABILITY
Sustainable funding routes
1) Social Enterprise2) General Practice3) Re-modelling of Core Services4) Business Case through Health Board IMTP
Each Project identified expected benefits and measures
Next Steps
Strengthen further community engagement / interactive feedback
Establish co-ordinated Phlebotomy service Cluster based Mental Health and Well Being Chronic Conditions management framework Continue delivery of existing projects
Monitoring and evaluation Share learning –
• Swansea Bay University Health Board
• All wales
Initiate remaining projects – Next Stage Delivery
TRANSFORMATION
GP surgeries are prescribing gardening or Pilates instead of drugs
Principal GP Robert Boulton said they have referred many people to social prescribing and that, so far, the results have been really positive
Access to 11 doctors, two nurse practitioners, ten nurses, a mental health nurse, a paramedic, physiotherapist, audiologist, three pharmacists and a social prescribing worker.
A patient with the pharmacist during one of her regular visits to the practice
A group of trailblazing GP practices have launched a new appointment aimed at pulling a local Swansea community closer together. Anne Robinson is the new Local Area Co-ordinator for Llansamlet.
Sessions, such as a gardening club, a conversation club or a yoga taster session are run to build the confidence of people who may not be ready to step into a group straight away.
“Congratulations to Cwmtawe cluster. Excellent service ideas. Sincerely hope this funding will be rolled out to all GP clusters across Swansea"
I think this is an excellent initiative. Not everyone needs to see a GP and with such pressure on this precious resource it’s great that primary care is looking at using the skills of other healthcare professionals in the delivery services. Via Facebook
“This [social prescribing] is fantastic, it is really helpful. Social
prescribing should be in every surgery. Cindy gave me the
courage and motivation to do these things.”
Congratulations to Cwmtawe Cluster, excellent service ideas. Sincerely hope this funding will be rolled out to all GP clusters across Swansea to ensure equity of care & access to support all Swansea patients regardless of postcode.
I think this is an excellent initiative. Not everyone needs to see a GP and with such pressure on this precious resource it’s great that primary care is looking at using the skills of other healthcare professionals in the delivery of services. I think the challenge is to change the perception of patients on what is realistic for GP practices to provide and also to take more responsibility about caring for themselves.
Thankyou for listening
Questions and Answers
Contact Details [email protected]@wales.nhs.uk
Find us on Facebook: @CwmtaweCluster and Twitter: @cwmtawecluster