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 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 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. 3 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.