Primary Care Clusters 2019 FOREWORD I am pleased to present this Yearbook, which has been prepared for the 4th National Primary Care Conference, ‘Clusters Past Present and Future’. This synopsis showcases the wide range of good work being undertaken locally by clusters; delivering a positive impact to patients across Wales. Providing and connecting people to a wide range of care and support in local communities is essential in meeting the health and wellbeing needs of the people of Wales. Collaborating at community level through the clusters to plan and deliver this care and support is vital to transforming our health and care system and achieve the vision set out in A Healthier Wales. Taken together, the submissions from each cluster demonstrates how clusters have developed since the National Plan for a Primary Care Services for Wales was published in 2014 and the collective and ongoing commitment to the Primary Care Model for Wales. The impressive examples of work in specific clusters across Wales, together with the enthusiasm and commitment of staff working with and within clusters, is clear in reading this synopsis. We must now reflect on the progress to date and continue to make further improvements. For my part, I will continue to encourage clusters to evolve and mature to respond to local challenges to improve the health and wellbeing of the population they serve. Vaughan Gething AM Minister for Health and Social Services Foreword 1 CONTENTS Foreword by Sian Millar . .6 Foreword by Chris Stockport . 32 Aneurin Bevan Betsi Cadwaladr Blaenau Gwent East . 8. Anglesey . 34 University Blaenau Gwent West . 10 University Arfon . 36 Health Board Caerphilly East . 12 Health Board Central & South Denbighshire . 38 Caerphilly North . 14 Central Wrexham . 40 Caerphilly South . 16 Conwy East . 42 Monmouth North . 18 Conwy West . 44 Monmouth South . 20 Dwyfor . 46 Newport East . 22 Meirionnydd . 48 Newport North . 24 North Denbighshire . 50 Newport West . 26 North East Flintshire . 52 Torfaen North . 28 North West Flintshire . 54 Torfaen South . 30 South Flintshire . 56 South Wrexham . 58 West & North Wrexham . 60 Cardiff & Vale Foreword by Len RIchards & Anna Kuczynska . 62 University Cardiff City & South . 64 Cardiff East . 66 Health Board Cardiff North . 68 Cardiff South East . 70 Cardiff South West . 72 Cardiff West & Western Vale . 74 Central Vale . 76 Eastern Vale . 78 Western Vale . 80 2 PRIMARY CARE CLUSTERS 2019 Contents 3 Foreword by Alan Lawrie . 82 Foreword by Jamie Marchant . 116 Cwm Taf Powys Teaching Bridgend East . 84 Mid Powys . 118 Morgannwg Bridgend North . 86 Health Board North Powys . 120 University Bridgend West . 88 South Powys . 122 Health Board Merthyr . 90 North Cynon . 92 Rhondda . 94 Foreword by Hilary Dover . 124 South Cynon . 96 Swansea Bay Afan . 126 Taff Ely . 98 University BayHealth . 128 Health Board CityHealth . 130 Cwmtawe . 132 Hywel Dda Foreword by Jill Paterson . 100 Llwchwr . 134 Amman/Gwendraeth . 102 Neath Central . 136 University Llanelli . 104 Penderi . 138 Health Board North Ceredigion . 106 Upper Valleys . 140 North Pembrokeshire . 108 South Ceredigion & Teifi Valley . 110 South Pembrokeshire . 112 Tywi Taf (2ts) . 114 4 PRIMARY CARE CLUSTERS 2019 Contents 5 Email [email protected] Anuerin Bevan ClusterForeword Tel 029 1234 5678 Web www. Aneurin Bevan University by Siân Millar Health Board Director, Primary Care & Community Services I am delighted to introduce the Yearbook contribution Representation from primary care, public health, local for ABUHB. authorities, hospital services and third sector organisations was established at an early stage of NCN development Clinical Futures (CF) has been the consistent ABUHB and investment was made into clinical leadership and organisational strategy since 2007, aiming to provide more management support. A Neighbourhood Care Network care closer to home, harnessing the important role of Strategic Plan guided the progression of this work from 2013- patients and their carers in maintaining independence and 2018 delivering:- improving health. A network of Local General Hospitals The NCN Development Programme 2019 • 12 clinically led Neighbourhood Care Networks (enabling has been developed, providing local access to safe The Integrated Medium Term Plan for ABUHB requires NCNs to hospital services that people use most frequently. A single services to be planned and delivered on population bases 30-50,000). accelerate the pace of change from April 2019 to implement Specialist and Critical Care Centre is under construction the Care Closer to Home agenda. Many aspects of the work • A frailty model across Gwent at Llanfrechfa, near Cwmbran, to provide rapid access to being undertaken by the NCNs are testing new ground and the most specialist care when needed. A core component • Continued emphasis on developing core primary care require a robust and supportive professional framework to of the CF strategy is to strengthen and develop primary, including a proactive approach to the management of GP prepare, deliver and evaluate new approaches. The Medical community and social care services. In order for us to sustainability challenges Director requested that an intensive development programme continue to improve the health and well-being of our • Increased emphasis on the interface between primary and be introduced to support the NCN leads and their teams in growing and ageing population, we need to change how community services and the acute sector order to create mature Neighbourhood Care Network systems we do things. We have developed a place-based model of • Implementation of new community services including to articulate and address local needs. The programme aims well-being called Integrated Well-being Networks. Community Resource Teams and Primary Mental Health to provide the pace and scale of primary care development This work is creating the capacity to support and treat Services. necessary for the ABUHB integrated care system, through which organisational priorities can be delivered. This will more patients in their homes and communities:- As concerns increased in relation to the sustainability of include significant programmes of work, including the • Helping people to live a healthy and independent life GP services, the organisation took action to encourage Compassionate Communities initiative, arising through the recruitment, support practice mergers and facilitate • Detecting health problems quickly Transformation Programme. collaborative working across networks. The implementaion of • Delivering timely, effective local integrated care and the New Model of Primary Care has been strongly supported, The NCN Development Programme is coordinated by support introducing new roles such as clinical pharmacists, advanced a Steering Group- ensuring the engagement of senior • Involving people in decisions about local services and nurse practitioners, physicians associates and physiotherapists leadership. It is delivered by ABCi through 18, monthly, 1hour their care into primary care practice. A Primary Care Academy has diagnostic workshops and informed by a Resource Pack to • Planning, organising and delivering local integrated care been introduced, as a Transformation Fund initiative, to collate all the relevant policy, strategy and ‘how to’ guidance. provide experience in a primary care setting and encourage There are plans for a Peer Review programme. This is an action The Neighbourhood Care Network (NCN) teams (our recruitment into local services. learning approach that tailors learning to real challenges and local terminology for clusters) work at the centre of this the application of knowledge to achieve local solutions. significant transformation agenda, engaging a wide range An NCN Indicator Dashboard and Comparison Tool guides of local partners to understand local priorities and to local analysis and provides regular feedback on the progress Each NCN has produced a Plan on a Page to illustrate local create appropriate and effective solutions. This requires a against agreed objectives. Each NCN Lead also takes priorities. This detailed focus allows us to respond to the population health approach, a detailed understanding of responsibilty for the development of integrated care pathway particular needs of each community and to identify where national policy and local strategies and an ability to work solutions across service boundaries. NCN leads have been common solutions can be developed. We are also committed across organisational boundaries to maintain focus on encouraged to undertake personal development and many to learn from good practice and look forward to using the collaborative community-focussed solutions. have completed the Confident Leaders Programme. Yearbook as a source of ideas for future work. 6 PRIMARY CARE CLUSTERS 2019 Aneurin Bevan University Health Board 7 Blaenau Gwent East Cluster Lead Dr Isolde Shore-Nye [email protected] WHO WE ARE & WHERE The NCN has a Practices based population of 33,604 across five Practices, WHAT IS NEXT? WE CAME FROM? two of which are Health Board Managed Practices. Practice Population % • Sustainable, quality and safe local services - Enabling Practice • Blaenau Gwent is the smallest Local Population >65 years age our resident populations to access local services fit for Authority in Gwent. Abertillery Group Practice 7,476 1,505 20.13 purpose and without the need to travel for them. OUR AIMS • 2017 Census shows 69,609 total Aberbeeg Medical Practice (Managed) 4,528 844 18.64 • Improving