Conwy East Cluster Network Action Plan 2015 Redacted

Cluster Network Action Plan 2015-16 (second year of the Cluster Network Development Programme) Conwy East Cluster

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

2015 Final Draft 1

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 Ongoing – to align with To ensure that services PHW Cluster Profile used to population using available data BCUHB Planning Cycle. are developed according to identify the following priorities: local need lifestyles: Smoking, obesity and alcohol. Chronic disease management- self management, Mental health and Older people

Key issues arising from practice profile (access, services, training etc). Mental Health – Lack of appropriate counselling services Access – Appointments and availability Training – Capacity, consider on- line protected time

2 To identify additional December 2015. Improved support for This will be identified at future information requirements to This is work in progress, and service development cluster meetings as the Area support service development will be agreed with the Public structure support is further

2015 Final Draft 2 Health Wales lead for the embedded. Area and Cluster. 3 To consider learning from Ongoing Improved patient care and The actions later in the plan previous analyses to identify health promotion highlight learning from individual any outstanding service practices that will be shared and development needs discussed across the Cluster eg. Audit patients on medications likely to cause hypovolaemia and added risk of reduced kidney function.

4 To develop a plan to contribute The actions required for this Improved health outcomes To be detailed following review to the reduction in prevalence will be agreed with the PHW Improved quality of life with PHW. of smoking lead for the Area and the Cluster.

The Priority 1 actions below refer to this and need to be agreed with the Cluster to take forward.

PLEASE NOTE THIS PIECE OF WORK WILL BE SUPPORTED BY PUBLIC HEALTH WALES AND YOUR LOCAL AREA TEAMS

2015 Final Draft 3 POPULATION NEED (Priority 1 – Smoking Cessation)

Priority 1 The issues Aims and objectives How will this be done? Named Time Lead Scale Smoking There are over 9218 adult Implementation of • All Practices to ensure all staff cessation smokers in the Locality BCUHB smoking implement BCUHB smoking according to QOF data for cessation pathway in all cessation pathway . 2014/15 (SMOK0004 Practices

denominator) . • Sign up to the Smoking cessation

Smoking is linked to social Increase demand for audit LES from October 2014 and class and accounts for a high specialist smoking use the CO Monitors (supplied free) proportion of the inequalities in cessation services health outcomes. • All staff to undertake training (brief Offer timely and intervention training for clinical staff Quitting smoking offers better appropriate support for and ask/assist/advise training for improvement to healthy life all adult smokers who administrative staff) expectancy than almost any wish to make a quit

other medical or social attempt • Share smoking cessation data: intervention. Patients are 4 referrals to specialist services, times more likely to quit if they Ensure tailored numbers of treated smokers and quit access support from specialist interventions and equity rates services. of access and outcomes for specific groups, such • Work in partnership with SSW / PHW NICE guidance is that 5% of as pregnant women, / WG to provide improved quantity adult smokers should be manual workers, people and quality of services. treated every year. This is now with mental health a Health Board Tier 1 target, problems and • Ensure an integrated smoking with 40% quit rate. socioeconomically cessation service across community, disadvantaged secondary care, mental health, social In Conwy East Locality, 20.9% communities. care and other relevant settings. of registered practice population in Conwy East

2015 Final Draft 4 (aged 15 or over) smoke - this is higher than BCU average 20.4%. (Ref - General Practice Population Profiles (2015 accessed services last year.

Concerns in relation to variable practice and accessibility to services POPULATION NEED (Priority 2 to be chosen by Cluster)

Priority 2 The issues Aims and objectives How will this be done? Named Time Lead Scale Priorities Priorities (identified by the The objectives and actions have yet to be developed with the Cluster Dec 2015 (identified Practices) Cluster supported by the PHW lead for the Area Lead, by the PHW Lead Practices)

Dementia awareness Older Frailty People

Chronic Diabetes, heart disease, conditions respiratory problems

managem

ent

Lifestyle management e.g Preventio smoking, weight management n (physical activity and healthy eating) , alcohol, Sexual health

2015 Final Draft 5 Mental Access to counseling services To provide improved Utilisation of WG cluster monies to Cluster Dec 2015 Health services to patients with commission additional support. Coordinat Well- mild mental health or, problems Consideration of other well-being Cluster being support Lead, PHW Lead Drug & Joint Working One practice suggests To be agreed at by the Cluster as a Cluster April 2016 Alcohol working with the Cluster priority Lead misuse on service provision relating to Drug and Alcohol misuse services, mental health and social services

Cluster Overview

Conwy East

Population – 57,875 resident population

Our Cluster network:-

The Betsi Cadwaladr University Health Board, Conwy County Council and organisations across the third (voluntary sector) are working together to ensure we provide the best possible services and support for residents of Conwy East to meet their health and social care needs with a focus on the following:

Promoting good health and well being Improving and maintaining independence Shifting services out of District hospitals into the community

2015 Final Draft 6 Helping people to stay in their own homes or return home as quickly as possible after a period of ill health

There are 14 localities (clusters) across North Wales set up in order to have sufficient population to allow for efficient planning but small enough for the locality teams to be able to develop services tailored to local needs. The average population of a locality is approximately 50000, with some variance either way depending on geography and historical working arrangements between health and social care, as well as existing local authority boundaries.

The Conwy East Cluster of GP practices have been meeting since April 2014. Each practice in the Cluster (There are seven – please see below) is required to produce a Practice Development Plan which is sent to the PCSU, Central Area Team and Locality Lead for the Cluster (currently vacant). The practices send two representatives to meet with the locality lead and other members of the wider locality team such as Public Health Wales, during these meetings a Cluster Development Plan is created and its content reviewed at six meetings held at approximately six weekly intervals, at the end of the year a Cluster Annual Report is produced. The aim of the meetings is to look at methods of joint working with other services, sharing ideas and potential gains around access by sharing resources across the cluster. Locality Services & Estates Colwyn Bay Community Hospital, Hesketh Road, Colwyn Bay has two inpatient wards one which is under the care of general practitioners from Rhoslan Surgery, Colwyn Bay and one which has care provided by a Consultant in Health Care for the Elderly. The hospital has rehabilitative services such as physiotherapy and occupational therapy as well as X-ray, ultrasound, dental clinic provided by a very busy general out patients department.

Intermediate and enhanced care for patients in the Conwy area are provided by an integrated approach from core community nursing services, therapies, social care, medicines management and third sector.

The Abergele Clinic provides a base for district nursing services and social services.

District Nursing Service District nursing services for the Conwy Easy Locality are based on two sites. For the east cluster the base is the Abergele Health Clinic and in the west the base is Colwyn Bay Community Hospital.

General Practitioners The Conwy East Locality has within its boundaries seven general practices:- Abergele 2015 Final Draft 7 Gwrych Medical Centre, Cae Eithin, Abergele, Conwy, LL22 8LJ (Davies HO) 01745 824111 Website - http:// www.abergele-surgery.co.uk Meddygfa Cae Glas, Cae Glas, Llanfairtalhaiarn, Abergele (Branch Surgery) 01745 822277 Abergele Road, Bodelwyddan (Branch Surgery) 01745 583807 Nant Mor Surgery, Towyn, Abergele (Branch Surgery) Services provided – general medical services:-

Kinmel Bay Kinmel Bay Medical Centre, The Square, Kinmel Bay, Rhyl, LL18 5AU (Hardway RJ) 01745 353965 Website: http:// www.kinmelbaymedicalcentre.com Maes Gwyn, Towyn Road, Abergele, LL22 9ER (Branch Surgery) 01745 354496

In the west of the locality there are five general practice, the western cluster (Population 31500):- Colwyn Bay Rhoslan, 4 Pwllycrochan Avenue, Colwyn Bay, Conwy, LL29 7DA 0844 477 2588 Website: http://www.rhoslansurgery.co.uk Services provided:- Rysseldene Surgery, 98 Conway Road, Colwyn Bay, Conwy, LL29 7LE 0844 4778574 Website: http://www.rysseldenesurgery.co.uk Tyn-y-Coed Surgery, 61 Conwy Road, Colwyn Bay, Conwy, LL29 7LG 01492 533806 Website: http://www.wales.nhs.uk/tyn-y-coed Services provided;- Old Colwyn Cadwgan Surgery, 11 Bodelwyddan Avenue, Old Colwyn, Colwyn Bay, LL29 9NP 01492 515410 Website: http:// www.cadwgansurgery.org Services provided:- Dr Bisarya 16 Wynn Avenue, Old Colwyn, Colwyn Bay, LL29 9RF 01492 515500 Website: http:// www.rashmisurgery.org.uk

Community Pharmacies Abergele Lloyds Chemist, 17 Market Street, Abergele, Abergele, LL22 7AG 01745 824778 Lloyds Pharmacy, The Pharmacy, Kinmel Avenue, Abergele, Abergele, LL22 7LR 01745 832135 Colwyn Bay Cohens Chemist, 146 Conwy Road, Colwyn Bay, Colwyn Bay, LL29 7LR 01492 532326 Cohens Chemist, 56 Conwy Road, Colwyn Bay, Colwyn Bay, LL29 7LD 01492 530298 Morrisons Pharmacy, Seaview Road, Colwyn Bay, Colwyn Bay, LL29 8DG 01492 534313 Boots the Chemists Ltd, 34 Station Road, Colwyn Bay, Colwyn Bay, LL29 8BU 01492 532392 Kinmel Bay Lloyds Pharmacy, St. Asaph Avenue, Kinmel Bay, Kinmel Bay, LL18 5EE 01745 342178 BOOTS UK Ltd, 68 Foryd Road, Kinmel Bay, Kinmel Bay, LL18 5AU 01745 337614 2015 Final Draft 8 Old Colwyn BOOTS UK Ltd, 9 Bodelwyddan Avenue, Old Colwyn, Old Colwyn, LL29 9NP 01492 515372 Camella Healthcare Ltd, Old Colwyn Pharmacy, 397 Abergele Road, Old Colwyn, Old Colwyn, LL29 9PP 01492 516415 Rhos on Sea L Rowland & Co Ltd, 7 Rhos Road, Rhos on Sea, Rhos on Sea, LL28 4PP 01492 547814 BOOTS UK Ltd, 20 Rhos Road, Rhos on Sea, Rhos on Sea, LL28 4PP 01492 546220 Towyn Lloyds Pharmacy, Towyn Road, Towyn, Towyn, LL22 9EP 01745 342001

Our community:-

Our Locality extends from the ‘Blue Bridge’ in Kinmel Bay at its eastward extremity to Llandrillo Yn Rhos at its most westward. The locality has an extensive rural hinterland extending southwards to include Llanfairtalhaiarn and Llangernw. The population of the Conwy East Locality is 57,875. The majority of people in the Conwy east locality live along its northern coastal strip linked by the major A55 road. The towns of this coastal area are Kinmel Bay, Towyn, Pensarn, Abergele, Llandulas, Old Colwyn, Colwyn Bay, Llandrillo yn Rhos and Mochdre. The rural area which lies to the south of this coastal includes the towns of Llanfairtalhaiarn, Llansannan and Llangernw. The towns of Kinmel Bay and Llandrillo yn Rhos have for many years been considered ‘retirement areas and this is reflected by the average age of the population and their associated health requirements. The coastal area of Towyn and Pensarn are well known for their numerous holiday caravan sites and as such their population swells significantly in the summer months bringing significant challenges to health and social care services. Colwyn Bay and Old Colwyn were built as holiday destinations by the Victorians to be accessible by the newly built railways. The advent of cheap foreign holidays had a significant detrimental effect on both the towns resulting in their social and economic decline in the latter part of the twentieth century. Recent innovative council thinking with developments along the Colwyn Promenade and at Eirias Park promise much better things for the towns in the future with the emphasis on increasing green tourism and promoting the towns as a sporting and healthy lifestyle venue. Abergele is a market town which having been freed from the traffic congestion of the old A55 has developed into a busy residential and shopping area. Mochdre is an old market town which now has become a residential area with several business parks bringing employment into the area. To the south of the coastal strip the majority of the land is turned over to farming both livestock and arable. In fact the majority of the area of the locality could said to be rural with the farming communities based around the towns of Llanfairtalhaiarn, Llansannan and Llangernw.

The age of our population is increasing from already high levels in comparison to the rest of Wales.

2015 Final Draft 9 Age 85+ 2000 M-680 F-1320

75-84 4410 M-1950 F-2460

65-74 6590 M-3150 F-3440

45-64 14360 M-7260 F-7370

25-44 11670 M-5830 F-5840

15-24 6450 M-3400 F-3050

05-14 5730 M-2830 F-2700

03-04 1150 M-560 F-580 00-02 1630 M-840 F-790

2015 Final Draft 10

The needs of our community are:-

Conwy East Cluster/Locality has many challenging issues, as indicated in the previous section it has the highest percentage of over 85’s in Wales which will only continue to increase. This places significant stresses on all services including GP services. There are a high number of residential and nursing home beds in the Conwy East Cluster (>500), predominately in Colwyn Bay, this places great strain on services with high numbers of house calls for district nursing and GP practices. Temporary resident’s present high consultation rates and place great strains on practices in the east of the cluster particularly Kinmel Bay, this extra workload is unrecognised and poorly resourced. Conwy East Cluster has high levels of deprivation compared with other Health Board Localities.

Most Deprived 27.5% (14,880) Next Most Deprived 21.1% (11,410) Middle 12.8% (6,900) Next Least Deprived 18.2% (9,830) Least Deprived 20.4% (11,010)

90% of population live in a defined urban area, 89% of population live within a 10 minute drive to their registered practice. Smoking prevalence is 22% in Conwy East Cluster.

Because of the age profile of the Conwy East Cluster as well as the areas of high deprivation we have significant burden on our population associated with chronic conditions.

Cluster Other HB Cluster HB Wales Count % Min% Max% % % Hypertension 8,620 17.0 12.2 18.1 15.7 15.3 Asthma 3,420 6.8 6.1 7.4 6.6 6.7 Diabetes 2,830 5.6 3.7 5.8 4.9 5.2 CHD 2,520 5.0 3.0 5.3 4.2 4.0 COPD 1,130 2.2 1.9 3.6 2.4 2.1 Epilepsy 410 0.8 0.6 0.8 0.7 0.7 Heart Failure 500 1.0 0.8 1.2 1.0 0.9

2015 Final Draft 11 Death Rates for Conwy County (not broken down into Clusters)

Source: Mortality by Cause* - 2011 Registrations To 2011 Boundaries, Office for National Statistics

Total 85

Cause of death (all Under 25- 35- 45- 55- 65- 75- and Sex ages) 25 34 44 54 64 74 84 over All causes M 689 11 5 14 25 75 132 208 219

F 786 6 3 6 17 54 90 225 385 Diseases of the circulatory system M 215 1 0 2 4 18 41 69 80 (including heart disease) F 256 0 0 1 3 7 25 69 151 Cancer M 216 1 0 2 6 33 58 74 42

(all types) F 210 0 1 1 8 28 46 75 51 Diseases of the respiratory system M 85 0 0 0 1 7 7 25 45 (including pneumonia & COPD) F 109 0 0 0 0 7 8 36 58

Mental and behavioural disorders M 36 0 0 0 1 1 4 10 20 (including dementia) F 80 0 0 0 1 1 0 16 62

Diseases of the digestive system M 32 0 1 2 5 6 7 4 7 (Including liver disease) F 35 0 1 2 3 6 3 3 17 External causes of morbidity M 37 1 3 7 5 5 2 6 8 and mortality

(including accidents) F 22 1 1 2 0 2 1 3 12 Diseases of the nervous system M 22 2 1 1 1 1 7 5 4

(including motor neurone and Parkinson's) F 32 0 0 0 0 2 3 11 16

Notes *Cause of death as given in the death register and based on the doctor's or coroner's certificate of cause of death; this is known as 'original' cause of death. 2015 Final Draft 12 For full details of the diseases included in each category please see the full spreadsheet: Deaths by age and cause 2011, source: CCBC Corporate Research and Information Unit Further information in relation to mortality rates, statistics and procedures in relation to coding and registering deaths is available from the Office for National Statistics at the web-link below. http://www.ons.gov.uk/ons/rel/vsob1/death-reg-sum-tables/2013/sb-deaths-first-release--2013.html#tab-Further-Information-

Deaths (numbers): area of usual residence, by age and sex, 2012 registrations, Conwy. Source: Mortality Statistics: Deaths registered in England and Wales by area of usual residence. This product is designated as National Statistics, from the Office for National Statistics.

Age Number Males Females Under 25 12 6 6 25-34 6 6 0 35-44 14 9 5 45-54 38 19 19 55-64 110 62 48 65-74 244 141 103 75-84 405 214 191 85 and over 662 237 425 Total 1491 694 797

2015 Final Draft 13

ACCESS

(to ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients) Priority The issues Aims and How will this be done? Named Time objectives Lead Scale Improving Managing the demand To improve patient To increase the use of ‘My Health on Line’ Practice March and and in particular in relation access to (MHOL). e.g advertise on website and managers & 2016 Managing to telephone access appointments and continue to display posters and messages on Cluster Access increase prescriptions Coordinator satisfaction with the appointment system Practices: W91038, W91007, W91048 Provide Practice – patient To improve patient Undertake patient satisfaction questionnaires Practice March appropriate questionnaire access to (access audit) (practice’s to feedback to Managers & 2016 help and appointment and Cluster) Cluster support to all increase Coordinator patients satisfaction with Replicate questions used at Conwy surgeries according to system to share ideas and results their needs Practices: W91038, W91007, W91048 Improving Ensuring adequate To reduce the Consider Text-messaging service to patients Diane Lewis Jan and appointment capacity to number of DNAs for and Karen 2016 Managing meet demand GP and other Practices: W91048 (consider pilot and share Williams, Access practice outcomes with wider cluster) with Cluster appointments Cadwgan have implemented, action- practice Coordinator to feedback to Cluster Improving Capacity to provide re- To maintain pre- Cluster will need to agree this as a common Cluster March and bookable appointments bookable access to standard (as W91031) Lead with 2016 Managing within reasonable time within one week Coordinator Access Link to all other objectives to improve

2015 Final Draft 14 appointment access Improving Need to improve access To reduce patient To consider an audit of the number of GP W91038 & June and for primary care to waiting times for appointments and admin time generated by W91007 to 2016 Managing appropriate investigations further the need to chase appointments for lead with Access usually carried out only tests/investigations investigations etc. Cluster after seen in OP. and diagnosis and Coordinator reduce the need for Practices: W91038, W91007 Address related issues repeat highlighted via significant appointments event meetings Improving Requests from secondary To reduce demand The cluster has previously worked with Head of March and care for GPs to write for primary care secondary care to clarify the guidelines which Pharmacy & 2016 Managing prescriptions creating generated state that if the prescription is urgent the Cluster Access work within the practices prescriptions. consultant should prescribe for 7 days. This Coordinator will be revisited in terms of impact.

Collate examples of secondary care requests for drugs not on the practice formulary.

To invite Area Head of Pharmacy/Chief Pharmacist to cluster meeting to discuss the issue and agree appropriate actions Improving Increased demand for To reduce the To review with Area Head of Pharmacy/Chief Head of March and prescriptions during peak number of Pharmacist. The Pharmacy LES for Supply of Pharmacy & 2016 Managing holiday periods etc and prescriptions issued Emergency Medicines, is supporting all Cluster Access related influx of temporary by GPs for TRs relevant practices Coordinator residents (TRs)

2015 Final Draft 15

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 Need to GPs unable to afford time To appoint Review outcome of attempt to recruit (Sept 2015) Head of ASAP appoint to Lead on Locality issues Locality/Cluster Primary Locality/ due to the existing and Lead Discuss options to support interested GPs in Care, Area Cluster Lead increasing pressures of addressing resulting capacity issues. (NB Team work Discussed at Cluster meeting in June 15, BCU to look into recruiting a locum to free up time for GP’s within the Cluster) GP Capacity Reduction in GP To develop a Suggested actions from PDPs to be considered Cluster January & Workforce workforce due to cluster approach to by Cluster: Lead, Head 2016 Sustainabilit retirements and inability to improving GP of Primary y recruit capacity & • Advertise vacancies as a Cluster to recruit Care & recruitment GPs and GPRs Area • Share learning regarding alternative Medical methods of working, using practice nursing Director staff, HCSWs and practice pharmacy team • Develop a Cluster workforce model • Review GP workforce requirements for Colwyn bay Hospital • Review availability of locums with Area Team and link to recent recruitment of salaried GPs by BCUHB • Improve links with Liverpool & Manchester Medical Schools • Review GPR training opportunities within 2015 Final Draft 16 the Cluster

Practices: W91014, W91038, W91031, W91007

Workforce Cluster work and changes To put in place Cluster to consider the possibility of sharing staff W91031 – March Capacity in QOF may require actions to reduce as well as buildings Dr C Close 2017 different skills; staff etc to demand for all staff best manage this groups Practices: W91031 Workforce Increasing demand for To put in place To develop links with Llandrillo College for training Head of June Capacity administrative and actions to reduce and recruitment (NB some work has commenced Primary 2016 management in practices demand for all staff via the Area Team) Care groups Explore possibility of outsourcing certain Practice administrative function, e.g. pension, payroll and Managers accounting – re-assignment of admin duties and roles

This could be for individual practice or as a Cluster

Practices: W91048, W91014

Workforce Reduction in practice To attract more Review provision of the extensive training Area Nurse June Capacity nurse workforce due to nurses into General required to cover the diversity of practice nursing Lead and 2016 retirements and inability to Practice requirements practice recruit nurses Management Nurse’s time spent on Reduce Nurses Discussed at last Cluster meeting with ideas for Area Nurse Sept of Leg caring for patients with time attending to the area to develop within the Cluster Lead and 2016 Ulcers Leg Ulcers Leg Ulcers Practice

2015 Final Draft 17 Agreement to use new ‘Cluster monies’ to employ Managers Difficult to refer and a nurse to provide leg ulcer clinics etc. seems disparity in service available within the Cluster Practices: W91007 Workforce Increasing demand from To identify and Invite Hospital Director to future Cluster Meeting Cluster March Capacity processes in place with agree appropriate to highlight specific issues and agree actions e.g. Coordinator 2016 secondary care actions to reduce Large amount of post operative work carried out & Head of demand on primary in practice Primary care workforce Care Practices: W91007

2015 Final Draft 18

REFERRAL MANAGEMENT AND CARE PATHWAYS

Priority The issues Aims and How will this be done? Named Time objectives Lead Scale Planned Care Gestational Diabetes To ensure women Discuss options with Cluster to carry out a Practice Sept with gestational retrospective search for women with gestational Managers 2016 diabetes are being diabetes over the past 5 yrs – 6 monthly audits and Cluster followed up Coordinator appropriately following delivery and in the future Practices: W91038 Planned Care Acute Kidney Injury To ensure patients Audit patients on medications likely to cause Cluster Sept are on appropriate hypovolaemia and added risk of reduced kidney Lead, 2016 medication function, including those listed by BCY, 6 Practice monthly audits Managers and Cluster Practices: W91038 Coordinator Cancer Care Patients do not attend To reduce the Identify which Practices are experiencing the Practice March Reviews surgery for review number of DNA’s same issues/problems Managers 2016 for reviews and Cluster Identify and implement solutions e.g. texting Coordinator (see above) Referral Varying referral rates To review referral Cluster to invite Secondary Care to attend Head of March Management and potential for rates and use of future meeting to understand issues and agree Primary 2016 shared learning/peer agreed care actions to be taken. Care review pathways across Area the cluster Medical Practices: W91038, W91014 Director, Cluster Lead

2015 Final Draft 19 Summary Care Access to summary To identify the Invite Hospital Director to attend Cluster Head of March Records care records by YGC. process for shared meetings to highlight specific issues and work Primary 2016 access?? with the Cluster Care, Currently there are no Hospital GPs within the Cluster Director that are using this and Cluster service Coordinator Dermatology Improve referral times Decrease waiting All practices to use the protocol for skin lesion Practice Dec Referrals for Dermatology times by allowing photography GPs and 2015 easier triage Cluster Practice: W91007 Lead

USC’s Urgent suspected To discuss protocol Discuss with Director of Cancer Network Cluster Jan cancer referrals being protocols in place and whether a review is Lead 2016 downgraded with required. catastrophic result

2015 Final Draft 20

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 and effectiveness of risk management) Priority The issues Aims and How will this be done? Named Time objectives Lead Scale Unscheduled Care Jointly managing the To reduce hospital The Cluster to review services and Cluster Sept 2016 growing demand for admissions pathways, to support intermediate care, Lead with unscheduled care reduce hospital admissions and deliver Head of e.g. avoidable appropriate care for patients in the Primary hospital admissions community –with support from the new Care, Area Area Management Team Nurse Lead, Prioritised shared actions will need to be Cluster agreed Coordinator

Practice: W91038 Unscheduled Care No protocol …??? To introduce a Practices to work across the Cluster – to Practice Sept 2016 protocol??? introduce a standard protocol Mangers and Cluster Co- ordinator Practice: W91038 Managing ED Supporting regular To review the Discuss options within the Cluster for Cluster March demand attendees at ED patients regularly Signposting patients to the best way of Lead and 2016 attending ED accessing services. Compare monthly Cluster depts. to determine reports within the Cluster and discuss Coordinator if alternative ways that patients can be made aware of support could be services available. Closer working with provided OOH to identify these patients Practices : W91031

2015 Final Draft 21 Discharge Poor ED Discharge Improve ED To provide efficient seamless care to Area March Summaries Summaries discharge patients between primary and secondary Medical 2016 summaries to care Director include more Cluster to monitor and discuss significant and Cluster relevant information events. Lead and receive in a Discuss at Cluster level timely manner Clinical Governance Input required Feedback to HB via a report

Seek an update on the electronic discharge pilot

Invite Hospital Director to future Cluster meeting

Practice: ALL Enhanced Care Enhanced Care To implement the Review current service Cluster March Service not provided Enhanced Care Lead, 2016 by all practices in the Service in all Discuss roll-out to the remaining practices Head of Cluster practices and with the Cluster Primary Care , head of Community services COPD Growing demand in To Reduce the Discuss the options within the Cluster of Cluster June 2016 COPD Admissions number of COPD to re-introducing the Met Office winter Lead, Area Admissions weather warnings, liaise with Health Medical Board, PHW and ongoing Respiratory Director Project to agree and indentify other and Head related actions of Community Services

2015 Final Draft 22

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 End of Life Care Improving End of Life To complete SAE Cluster Sept Care for deaths Document responses to these reviews and feed Lead, 2016 occurring between back to practice and cluster Practice 1st January and Managers 31 st December and 2015, carry out a Cluster search to Coordinat determine patients Practices: W91038 or and assess delivery of end of life care End of Life Care Improving End of Life Ensure multi- Continue with current arrangements of palliative Cluster Sept Care disciplinary care meetings and discussions, including use of Lead 2016 meetings for End of analysis tool, with District Nurses / Palliative Life Care care Teams and review arrangements across practices

Practices: W91007, W91048, W91031

2015 Final Draft 23

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

Priority The issues Aims and objectives How will this be done? Named Time Lead Scale Cancers Earlier detection of To Improve expected Work with Cluster to recommend batch of Cluster Dec Cancers outcomes tests/investigations that GPs can refer to directly. Lead 2015

Present recommendations to Area team for support in implementation Cancers Newly Diagnosed Review with SAE Continue with discussions, this will ensure our Cluster Sept GI, ,lung and ovarian proforma findings and lessons learnt. Feed back to Cluster Lead 2016 cancers

Practices: W91038, W91031,W91007

Cancers Targeting the To see patients within To see patients within a two week period as per Cluster Sept prevention and early a two week period as nice guidelines (SF) added 2016 detection of per nice guidelines cancers – most are not seen within 2 weeks of referral

2015 Final Draft 24

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 Frailty and Ensure care plans in Ensure MURs for Identify support from BCUHB pharmacists Practice March Polypharmacy place for ‘at risk’ all identified GPs with 2016 patients living alone patients Prioritize reviews support >85 from Review outcomes as a Cluster Head of MM Practices:W91048 Antibiotic stewardship Practice and LHB pharmacy team working Practice ongoing Medicines reduction in prescribing together. Cluster agree actions with Head of GPs with Management of PPI /Tramadol waste Pharmacy to further reduce antibiotic support prescribing from Head of Practices: W91014 MM

2015 Final Draft 25

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? (Practi ce; GP Cluster; Health Board) Named Time done at Lead Scale Cluster Level Inadequate Population to Abergele Area Management team support for the relevant practice(s) Abergele March premises to increase Application to affected and to ensure links with LA and planning. Practice, 2016 facilitate significantly LHB to kit out Head of growing over the next available Primary Undertake a Health Impact Assessment on the plans and discuss demand few years due expansion Care to LDP and space outcome and recommend solutions. Bodelwyddan development Practices: W91038 Lack of clarity Several Undertake risk • Risk Assessment to be led by Area Team at Cluster meeting Cluster Dec for Primary practices have assessment • Develop a joint estates plan with Area Team Lead, Head 2015 Care Estates individual supported by of Primary • Agreed priority by Cluster is a new building for Kinmel Bay strategy for the requirements Area Care Cluster that need Management Surgery (in relation to insufficient space, confidentiality in consideration Team reception to be reviewed by the HB and Practice. which also needs to link with the ongoing development of cluster working Records Lack of Secure Cluster to consider storage solutions and/ or computerising all Practice Sept

2015 Final Draft 26 Storage storage additional paper records to discuss with Area Team Managers, 2016 space storage or Head of develop Primary alternative Care Practices: W91014 solutions for consideration

2015 Final Draft 27

CLUSTER NETWORK ISSUES

Issue Why? What will be How will this be done? (Practi ce; GP Cluster; Health Board) Named Time done? Lead Scale Lack of Key Issues Provide Agreement reached to use cluster monies to support this Cluster January appropriate arising from appropriate development. Lead, 2016 Counseling practice profile support to BCUHB Services and identified patients who Proposal to be developed, costed and implemented. lead unmet need fall between (confirmed) Parabl and CPN Practices: W91038, W91014 services Cluster links Complexity of Review of Cluster to feed into work to be undertaken through the Cluster June with joint different LLT and establishment of the Central Area Lead with 2016 working with groups e.g. other groups Area Team other strategic LLT with partners groups Communication To improve Invite Cluster Lead to discuss with Area Director Cluster March between referrals and Secondary Lead 2016 primary & to better care to secondary care engage to Cluster manage Meetings to patients agree expectations actions for on their care improvement pathways Cluster Capacity to Discuss Review current arrangements and make recommendations for Cluster March Networking attend cluster amongst future preferences across the cluster Lead, Head 2016 meetings & cluster and of Primary

2015 Final Draft 28

CLUSTER NETWORK ISSUES

Issue Why? What will be How will this be done? (Practi ce; GP Cluster; Health Board) Named Time done? Lead Scale impact on feedback in Care other work relation to e.g. teaching arrangement time s for future meetings Practices: W91007 Access to Opportunities Consider Recommendations to be developed by practice managers for Practice Sept training to improve joint training consideration Managers 2016 across the sessions cluster with neighboring practice Practices: W91048 Delivery of To provide Compare Discuss at Cluster level and develop ideas for consideration Cluster Sept services across appropriate services Lead 2016 the cluster help and offered by support to all other patients practices according to within the their needs Cluster and explore co- operative working arrangement with SS/MH Practice: W91014

2015 Final Draft 29

LHB Issues (in addition to any issues raised above requiring Health Board input)

Issue Why? What will be How will this be done? (Practice; GP Cluster; Health Board) Named Time done? Lead Scale Consideration of the following areas: Cluster Review To provide Proactive Hospital Lead, Area progress efficient actions Director to • Waiting times e.g. pulmonary rehab, diabetes structured Medical in Sept seamless care required to be invited to programme Director 2016 to patients improve cluster • Illegible TTO’s between efficiencies meeting to • Long Delays in provision of clinic letters primary and and process discuss • Requests to provide scripts outside BCU formulary secondary care between concerns • Delays caused by patients being referred back to GP for primary & and ideas to onward referrals to another speciality or for a 2nd opinion secondary improve • Upload more pathways and keep them up to date providers • Availability of most recent diagnostic test results across Review both primary & secondary care (raise with NWIS for the arrangement availability of integrated technology in GPP links to stop the s for more duplication of tests regular joint • Growing number of requests from YGC for information working from GP Records across

primary and

secondary

care Practices: W91014, W91038, W91007

To improve To improve Discussion Discussions already taken place at Cluster level with regards to W91007 – March communication MH services with MH telephone access to consultants during a specific time Dr Williams 2016 between GP for patients nurses and MH Lead and local new Review improvements to date and agree any further action

2015 Final Draft 30

LHB Issues (in addition to any issues raised above requiring Health Board input)

Issue Why? What will be How will this be done? (Practice; GP Cluster; Health Board) Named Time done? Lead Scale mental health consultants required services Practices: W91007 Expert Training Practices Discussion Include on cluster meeting agenda for initial discussion and Area team June Programme seeking with Area prioritisation against other actions to identify 2016 support for Team lead managing regarding increasing options to demands for improve CDM access Practices: W91014 Temporary Increase in Development Consider suggestion of a walk in Clinic during the day to provide Area team Sept residents demand of alternative a service for T/R’s throughout Conwy Area in Central location to identify 2016 during models to lead holidays provide a periods minor ailments service Practices: W91014 Changing Development Close Include on cluster meeting agenda for initial discussion and Area team Sept demands due of Community working with agree more detailed actions in relation to community service to identify 2016 to changing Services the Area delivery, capacity and innovation lead practice according to Team in

population. needs of the reviewing incoming and population developing 2015 Final Draft 31

LHB Issues (in addition to any issues raised above requiring Health Board input)

Issue Why? What will be How will this be done? (Practice; GP Cluster; Health Board) Named Time done? Lead Scale services to best meet population Practices: W91014 need Medicines Practice Review To invite Head of Pharmacy to Cluster meeting to discuss Practice Septemb Review for new capacity Protocol and pharmacy support for practice patients, e.g. new patients (MURS and Health er 2016 patients consider – Medicine Use Reviews) and agree actions Board Pharmacy Access to Pharmacy Support (Review) support Practice :- W91038

2015 Final Draft 32