Dwyfor Cluster Network Action Plan V2 Redacted Version

Cluster Network Action Plan 2015-16 (second year of the Cluster Network Development Programme) Dwyfor Cluster v1 SR

The Cluster Network 1 Development Programme supports GP Practices to work to collaborate to:

• Understand local health needs and priorities. • Develop an agreed Cluster Network Action Plan linked to elements of the individual Practice Development Plans. • Work with partners to improve the coordination of care and the integration of health and social care. • Work with local communities and networks to reduce health inequalities.

The Action Plan should be a simple, dynamic document and in line with CND 002W guidance.

The Plan should include: -

• Objectives that can be delivered independently by the network to improve patient care and to ensure the sustainability and modernisation of services. • Objectives for delivery through partnership working • Issues for discussion with the Health Board

For each objective there should be specific, measureable actions with a clear timescale for delivery.

Cluster Action Plans should compliment individual Practice Development Plans, tackling issues that cannot be managed at an individual practice level or challenges that can be more effectively and efficiently delivered through collaborative action.

1 A GP cluster network is defined as a cluster or group of GP practices within the Local Health Board’s area of operation as previously designated for QOF QP purposes

To understand the needs of the population served by the Cluster Network

The Cluster Profile provides a summary of key issues. Local Public Health Teams can provide additional analysis and support. Consider local rates of smoking, alcohol, healthy diet and exercise – what role do Cluster practices play and who are local partners. Is action connected and effective? What practical tools could support the delivery of care? Health protection- consider levels of immunisation and screening- is coverage consistent- is there potential to share good practice? Are there actions that could be delivered in collaboration- e.g. Community First to support more effective engagement with local groups

No Objective For completion by: - Outcome for patients Progress to Date 1 To review the needs of the October 2015 for initial To ensure that services All practices have been supplied with population using available data analysis then to fit in with are developed according to population profile resources which Health Board planning cycle local need together with the GP Cluster profiles are being used to interpret local needs. Further work is ongoing to complete the analysis of this information to help inform both the cluster plan and the Health Board IMTP 2 To identify additional November 2015 Improved support for Practices are currently being provided information requirements to service development with information on referrals, admission support service development rates etc which will be issued in cluster meetings starting in September. This will inform what additional information is required. 3 To consider learning from Improved support for To be discussed during cluster 2

previous analyses to identify November 2015 and on an service development meetings and also at an Area any outstanding service ongoing basis. Management Team and Health Board development needs level.

4 To develop a plan to contribute For discussion in September Improved health outcomes Draft plan is shown below which is for to the reduction in prevalence cluster meeting Improved quality of life discussion and agreement in the of smoking cluster meeting in September

Overview of Dwyfor Cluster

Although a small area, Dwyfor has a relatively high proportion of older people; 26.5% of residents are aged 64 and over, and 4.3% are aged 86 and over. This compares with only 21.4% and 2.8% respectively for BCU as a whole.

The prevalence of frailty increases steadily with age and is estimated to affect 25% of those aged over 85 years or over. Health Profile of Gwynedd in Infographics North Wales Public Health Team Internet http://www.wales.nhs.uk/sitesplus/888/page/65092

Statistics produced by the Public Health Wales Observatory using the Welsh index of multiple deprivation 2011, show that Dwyfor has relatively low numbers of people living within the most deprived 40% of areas in Wales.

According to ONS data, 57.5% of patients in Dwyfor live in rural LSOAs, against a BCU average of 21.3%. At the same time, it is estimated (from Census data) that around 34.7% of people aged 65 and over are living alone, a slightly higher figure than the BCU average.

The area has a high proportion of Welsh speakers (71.7% against a BCU average of 30.6%), meaning that services need to be delivered through the medium of Welsh where required.

2.8% of the registered population are resident in care homes, lower than the BCU average of 4%, however this figure varies with 3 practices identified as having relatively high proportions of care home residents registered.

Key to the development of services in Dwyfor is moving care closer to home based on appropriateness and need. In addition, integration and collaboration of services is at the forefront of priorities leading to more streamlined and person-centred care for all our population.

Other priorities for Dwyfor include safety, quality and inequalities of health. The Welsh Government advocate adherence to the principles of prudent health care and these are also features of our cluster plan which will be advanced with the development of services within the Dwyfor area.

Developments – ( information taken from Practice Development Plans and locality plans)

Single point of access – Ffordd Gwynedd project within Porthmadog/Criccieth area may influence current working models

Care homes – Extension planned in one home near Criccieth with EMI beds planned.

Change in use of residential home beds – Plas y Don reablement and rest bite beds unit recently opened

Audit+ data 2013/2014 for Cluster:

Audit+ data shows that cluster prevalence for identified conditions is around the middle 50% for Asthma, Hypertension and Heart failure, and in the lowest 25% for CHS, COPD, Diabetes and Epilepsy.

58.3% of adults in Dwyfor are overweight or obese, as compared with the BCU average of 57.8% Percentage of practice patients over the age of 15 who smoke is slightly lower than the BCU average of 20.4%, at 19.8%. 24.4% of patients over age of 16 heavily (binge) drink, compared with the BCU average of 26.1%.

According to GP Practice Registration data extracted July 2014, around 26.5% of the registered population are aged 65 and over. This is higher than the BCU average of around 21.4% of the population but represents only around 6,632 people. Around 4.3% are aged 85 and over, the highest percentage in BCU (where the average is around 2.5%) but represents only around 1,089 individuals.. 4

Deprivation is relatively low with an estimated 7.1% of the registered population living in the most deprived two fifths of areas in Wales, against a BCU average of 30.6%

Rural isolation and access to transport – Dwyfor has the highest level of rurality in BCUHB,. 72% (18,030 people) live in a rural area (village/hamlet/isolated dwellings); and 0% (less than 5 people) live in an urban area.

Limited transport links : There are limited transport links in Dwyfor. For those without transport, access to secondary care can be significant issue. Bryn Beryl and Alltwen are the closest community hospital, and some outreach services such as physiotherapy are provided there. Limited transport links can cause access problems and can make it more difficult for patients to access services

Welsh language 65% of Gwynedd’s population aged 3 years and over speak Welsh (77,000 people). This is higher than the averages for North Wales (35%) and Wales (19%). In Dwyfor 71% of the population are Welsh speakers.

Chronic Disease Registers as a Cluster Group:

Data provided by PHW shows that while the crude burden of disease for Hypertension, CHD, Diabetes and Heart failure are all higher than the BCU average, the age adjusted data shows a lower overall burden than might be expected.

Crude variation at practice level for identified registers is shown below:

Practice Id Practice name Practice CHD % HF01& HF 03&04 HYP % DM % AST % COPD % EP % List Size 02&05 % % W94011 Treflan (Pwllheli) 7419 4.0 1.1 0.1 19.0 5.4 8.3 2.3 0.7 W94021 The Health Centre (Criccieth) 3810 4.4 1.5 0.0 21.4 5.6 7.1 2.9 0.9 W94025 Meddygfa Rhydbach (Botwnnog) 5385 4.6 1.4 0.1 19.6 5.0 6.5 2.0 0.7 5

W94037 Ty Doctor (Nefyn) 4489 3.6 0.8 0.1 17.5 5.2 6.7 1.7 0.6 W94612 Y Feddygfa Wen (Porthmadog) 3094 4.2 1.8 1.0 17.1 5.7 7.9 2.7 0.6 W94615 Madoc Surgery (Porthmadog) 791 7.0 1.0 0.1 29.6 9.4 4.0 2.4 0.4

Comments from PDPs

• Primary Care is faced with providing high quality services to a population who are dispersed around a rural area, leading to a burden of travel for practitioners

• The influx of tourists to the area, particularly in the summer months means that practices often struggle to meet demand.

• Practices will continue to support patients with chronic disease and continue good management. Cluster groups give GPs the opportunity to support one another and expand good practice and exchange ideas. Over the next three years Cluster Groups have the opportunity to help towards the improvement of services and the health of the County.

• We hope the introduction of GP cluster groups will establish excellent working relationships and allow stronger strategic planning at all levels. We also hope the locality networking groups will provide a more effective delivery of local services with a focus on positive outcomes for patients.

POPULATION NEED (Priority 1 – Smoking Cessation) FOR DISCUSSION AND AGREEMENT AT SEPTEMBER CLUSTER MEETING

Priority 1 The issues Aims and objectives How will this be done? Named Time Lead Scale Smoking There are 19.8% smokers in Implementation of • All Practices to ensure all staff 6

cessation the Locality. Smoking is linked BCUHB smoking implement BCUHB smoking to social class and accounts for cessation pathway in all cessation pathway . a high proportion of the Practices inequalities in health • Sign up to the Smoking cessation outcomes. Increase demand for audit LES from October 2014 and

specialist smoking use the CO Monitors (supplied free) Quitting smoking offers better cessation services improvement to healthy life • All staff to undertake training (brief expectancy than almost any Offer timely and intervention training for clinical staff other medical or social appropriate support for and ask/assist/advise training for intervention. Patients are 4 all adult smokers who administrative staff) times more likely to quit if they wish to make a quit

access support from specialist attempt • Share smoking cessation data:

services. referrals to specialist services, Ensure tailored numbers of treated smokers and quit NICE guidance is that 5% of interventions and equity rates adult smokers should be of access and outcomes treated every year. This is now for specific groups, such • Work in partnership with SSW / PHW a Health Board Tier 1 target, as pregnant women, / WG to provide improved quantity with 40% quit rate. manual workers, people and quality of services. with mental health In Dwyfor ? accessed services problems and • Ensure an integrated smoking last year. Concerns in relation socioeconomically cessation service across community, to variable practice and disadvantaged secondary care, mental health, social accessibility to services communities. care and other relevant settings.

Smoking Cessation Action Plan

POPULATION NEED (Flu immunization)

Priority 2 The issues Aims and objectives How will this be done? Named Time Lead Scale Summary of health needs and priorities identified by practices and for discussion include: -

Chronic Respiratory Diseases; Ageing population; Mental Health; Palliative care – develop services with partners; Obesity; Alcohol use;

Identified by others:

Flu vaccination rates, Frailty, hypertension and Atrial Fibrillation and Antimicrobial stewardship (Health Board)

Flu vaccination To improve overall Share flu immunisation practice plans to Practice uptake variation uptake rates of flu share learning - vaccine Awaiting final vaccination data per practice, unverified data discussed at cluster meeting

Increase uptake of front line staff as part of business continuity planning to

maintain front line service Hospital Community hospital inpatient team administration

Community pharmacy flu vaccinations – offer as an alternative to patients initial

practice clinics

District nurse team vaccinations

Care home vaccinations

Patient awareness of clinics

Uptake Shared learning between Reduce variation in Ideas for discussion within practice Jan 16 practice on strategies used to rates between surgeries included – Saturday clinics, more active all increase uptake follow up for nonattenders including

telephone follow ups

Investigate in HCA can give Fluenze Flu team nasal spray for children

ACCESS (to ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients)

As the guidance on page 1 above states the following sections only include those areas ‘that cannot be managed at an individual practice level or challenges that can be more effectively and efficiently delivered through collaborative action’

Priority The issues Aims and How will this be done? Named Time objectives Lead Scale Service Service modernisation to Develop local Ongoing work with advance practice roles; modernizatio meet changing needs and workforce • Advance nurse practitioners or minor illness n ensure sustainability of nurses local services • Advance pharmacist role – clinics and repeat prescribing • Advance physio role – MSK clinics Maintaining Intermediate care To improve access • Increase awareness of reablement beds in Cluster patients at to step up beds local authority residential homes – Plas Y lead to home Don, Bryn Blodau dissemin ate info

• Lack of careers to provide care packages delaying discharges – especially problematic Area with palliative patients team Identify Delay in patient Improve • MTED discharges – surgeries to accept Informati waste in information arriving at communication electronic discharges from secondary care – cs current surgery causing waste of regarding patients Informatics within BCU training practices

systems time and resources care • Community hospital inpatients – EMIS/Vision terminal within hospital would improve access • Consultant to consultant referral – still occurring at times – practice will collate examples • DN not able to directly refer for audilogy and podiatry – look at direct referral pathways

My health Increased choice in ways Improve patient All practice to have ordering repeat prescriptions 2016 online of accessing services access in line with and booking appointment live by end March 2016 WG objectives Transport Poor public transport link Work with voluntary Explore options with Voluntary sector to bring in some areas due to sector improve patients into surgery to avoid GP house call rurality access Appointment Ensure patients access Increased Awareness raising of local services within s the right service for their signposting and practices need utilization of local Maintain or increase referral to; (data available) services that could • Community pharmacy choose pharmacy support general • NERS practice • Others including community dental service, voluntary sector services • Eye care Wales • MIU

WORKFORCE

Important Note: Each Practice has submitted practice specific plans to detail what will be done in order to meet any practice specific workforce needs e.g to cover a period of maternity leave, recruit to a specific vacancy. The table below refers to matters that can be taken forward at a Cluster level and/or require HB input. Priority The issues Aims and How will this be done? Named Time objectives Lead Scale Training Lack of skills in nursing Identify training required and utilization of cluster Health homes care home support staff to support care homes – Board Training IT systems EMIS, Vision training – explore training needs and possibility of a pooled session Training Access to local training Improve access Develop list of core training needs for practices practices and possible source of training – pool resources locally? Training Triage training for Improved To build on last years work on triage training – Treflan/ reception staff signposting and Treflan practice in contact with university Nicky Horne utilization of regarding ongoing training services Recruitment There are problems with To be addressed with Area Management Team recruitment in this locality for both GP’s and Nurses. This will be further compounded by retirements in the next five years 12

PLANNED CARE/ REFERRAL MANAGEMENT AND CARE PATHWAYS

Priority The issues Aims and How will this be done? Named Time objectives Lead Scale Waiting Times Long waiting times for Up to date information on waiting list items Area various specialism’s would be useful in primary care Team Enhanced Care Not currently Look after patients GP Cluster Groups – take to area management Area team End of commissioned closer to home team March 2016 Mental health Service continuity Confirmation from area team if there is a Area planned replacement for Dr Chandran in the Team community mental health role District nursing Day time service only Increase service Core hours under review, discuss with area Area team End services with no evening service provision management team 2015 Response from practice to the DN consultation Referral Extremely long waiting Management times for various Reduce waiting discuss at meetings the reasons behind waiting GP End of specialism’s within Sec times. times and alternative that pathways that could Cluster March Care be looked at Groups 2016

Rest bite care To improve access Map current provision offered to families – do Extra provision for rest and utilisation of practices know whats available to offer families?

bite care for the elderly service

IV therapy in the Increase utilisation and Deliver care closer • Increase awareness of current provision and community range of therapies to home for utilisation hospitals delivered patients and • Work with area team to look at demand and increase access staffing requirement • Scope further therapies that could be delivered

UNSCHEDULED CARE (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, co-ordination of care ad effectiveness of risk management) Priority The issues Aims and How will this be done? Named Time objectives Lead Scale Falls High levels of people To reduce people promote ‘Healthy Ageing’ e.g. Falls, accidents falling and having to be falling and the use of medication, to try to reduce the admitted unnecessarily. number of unscheduled care users. Discuss in cluster

Choose well Promoting appropriate Patient education Ongoing support and utilisation of community All choice and also self regarding pharmacy scheme practices care appropriate choice of service MIU opening hours Variation in MIU hours Improved patients Ensure MIU service match GP practice core Area across the cluster access hours as a minimum Team Care homes High number of homes Reduce demand on Cluster bid funding for ANP to support homes in the area unscheduled care and assess if planned interventions reduce demand on unscheduled care VC link between Polish home and MAU – Cartref project COTE rapid Improved access Community based COTE clinic Wed pm in Bryn Beryl – rapid All GPs access clinics locally to consultant rapid access clinics access – cluster awareness of new service and clinics referral process Ffordd Gwynedd Integrated team health Integrated working Porthmadog and Criccieth area only at present. and social care Practice awareness of service such as ABLE for low level needs

IMPROVING THE DELIVERY OF END OF LIFE CARE (Refer to National Priority Areas CND 007W)

Priority The issues Aims and How will this be done? Named Time objectives Lead Scale Practice clinicians to review the delivery of End National Clinical Improve end of life care To review the of Life Care using individual case review audit Complet National priorities experience of tool – Appendix 2. e end of Clinical patients at end of March priorities life. To complete the exercise as laid out in 2016 requirements for cluster domain in QOF 2015/16. Results of this to inform cluster network annual report. Training and Improve end of life care Identify and training GP education session on end of life care, local Treflan education needs training session medical society Care home Improve end of life care To maintain Polish home trial of treatment escalation plans Botwnno End Nov patients patients in their to aid planning and patient choice g/Pwllhel place of choice i/ palliative care team

TARGETING THE PREVENTION AND EARLY DETECTION OF CANCERS (Refer to National Priority Areas CND 006W)

Priority The issues Aims and How will this be done? Named Time objectives Lead Scale Cancer Referrals GP referrals – no GP Improve access Health Board to address issues with secondary AMT access to diagnostic care tests Promote best practice Clinicians to complete individual case reports for All GPs National Clinical into the prevention and patients newly diagnosed with lung, digestive Complet priorities early detection of system and Ovarian cancers via the Significant e end of Cancer Event Analyses Templates (SEA) 2014/15 – March Appendix 1. 2016

To complete the exercise as laid out in requirements for cluster domain in QOF 2015/16. Results of this to inform cluster network annual report

MINIMISING THE HARMS OF POLYPHARMACY (Refer to National Priority Areas CND 008W)

Priority The issues Aims and How will this be done? Named Time objectives Lead Scale Safe and effective Identify patients – GP has to complete All End of Frailty and use of medicine medication reviews of patients who are over practices March polypharmacy 80years old and on more than four repeat 2016 prescription items.

Prudent Building on national Safe and effective Sharing of educational resources and key All prescribing policy use of medicine identified intervention from polypharmacy pracitces reviews

PREMISES PLAN

Important Note: Each Practice has submitted practice specific plans to detail what will be done in order to meet any practice specific needs relating to premises. The table below refers to matters that can be taken forward at a Cluster level and/or require HB input.

Issue Why? What will be How will this be done? (Practice; GP Cluster; Health Board) Named Time done at Lead Scale Cluster Level Abersoch Practice in discussion with estates and BCUHB branch Criccieth None Grant had been achieved but work was held back disabled toilet available Porthmadog Space for Practice development plan – for locality awareness clinicians

CLUSTER NETWORK ISSUES

Issue Why? What will be How will this be done? (Practice; GP Cluster; Health Named Time done? Board) Lead Scale Primary/Secon There is a lack Discuss with Develop forum between primary and secondary care To be dary care of good Area Team Utilize local educational evening – agreed communication contact/relation Link in with Ynys mon/Arfon VC evenings – ship between GPs and Consultants. Antimicrobial Suggested as cluster action so that uniformity of practice stewardship across the locality

Cluster support Cluster actions Allocate staff To be resolved through new Area structures in the coming AMT Dec – lack of difficult to and recruit lead months 2015 management/a progress over the dmin support without lead coming for clusters and support in months. place. Temporary Increase Work with area team to look at plans for next summer residents demand on including increased MIU skill mix services during spring/summer Transportation Many areas of Explore Transportation to hospital clinics, also to surgery Dwyfor are very opportunities to

CLUSTER NETWORK ISSUES

Issue Why? What will be How will this be done? (Practice; GP Cluster; Health Named Time done? Board) Lead Scale rural with work with limited public voluntary transport sector Social isolation People moving Increase public Third sector awareness days – ie during flu clinics to the area to awareness of Link to third sector – ie mantel Gwynedd on surgery website retire support networks Community Service Scope out Alltwen –meeting planned with area team and local GPs – Area team hospitals development future service 14/10 delivery from Bryn Beryl – capital bid for site development community sites

LHB Issues (in addition to any issues raised above requiring Health Board input) TO BE DISCUSSED AND COMPLETED BELOW AT CLUSTER MEETING

Issue Why? What will be How will this be done? (Practice; GP Cluster; Health Board) Named Time done? Lead Scale •

•