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