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Monmouthshire North

Cluster Lead Dr Brian Harries


There are 2 Neighborhood Care Networks (NCNs) in Monmouthshire (North & South) with registered populations of 53,701 and 47,353 respectively.   

General Practices in Monmouthshire North
There are eight GP practices operating in the Monmouthshire North (NCN) Cluster area.

Castle Gate Surgery 
Dixton Road Surgery 
Hereford Road Surgery 
Old Station Surgery 
Medical Centre Usk 
The Surgery (Usk) 
Tudor Gate Surgery 
Wye Valley Practice 

Individual Cluster Plans and Reports
Monmouthshire North NCN IMTP 2020-2023
Monmouthshire North NCN Plan on a Page IMTP 2020 / 2023 
Monmouthshire North NCN Plan on a Page 2018-19
Monmouthshire North NCN Cluster Network Action Plan 2018-19 Year 3
Monmouthshire North NCN Annual Report 2018-19 (Year 2)


Cluster Profile

Monmouthshire as a whole has a total population of approximately 100,000 people residing across 850km2, divided into two Neighborhood Care Networks (NCNs), North and South. North Monmouthshire has a population of 53,701 (01.01.20 capitation report), a 4.2% upward shift since 2015. There are 8 GP Practices, 2 branch surgeries and 2 Integrated Health and Social Care teams serving the populations of Abergavenny, Monmouth, Usk, & surrounding areas. The NCN borders Torfaen to the East, Powys to the North and England to the West and as of 1st April 2019 there was a total of 4,747 people living in England registered with a North Monmouthshire GP.

The NCN has seen a 1.4% increase in population since 2017/18 and by 2036, it is projected that the number of people in Monmouthshire as a whole, aged 85 and over will increase by 147%, from approximately 13,000 in 2011, to 32, 0002. Further population growth is anticipated with new housing developments planned in North Monmouthshire, potentially enhanced by the removal of the Severn Bridge toll in December 2018.

Monmouthshire has for many years had perceived affluence, which can mask differences within and between communities. Wages in 2017/18 were some 10% below the UK average and only marginally above the Wales average. Some 34% of our working population were commuting out of county to earn a living1. We face many challenges as highlighted previously, especially around building resilient and sustainable community and primary care services. Our Health and Social Care system is stretched with new challenges in terms of difficulties in recruiting staff. We rely on Third Sector services to offer a range of support and these relationships are key when trying to deliver our three key priorities.

In terms of organisational structure, local governance and strategic links, the NCN is aligned to Aneurin Bevan University Health Board’s Clinical Futures and Care Closer to Home strategies, Monmouthshire Integrated Services Partnership Board (ISPB), the Greater Gwent Regional Partnership Board (GGRPB), and also The Well-being of Future Generations (Wales) and Health & Social Services Well-Being (Wales) Acts.
Sources: 1The Well-Being of Future Generations (Wales) Act – Monmouthshire County Council Well-Being Assessment 2017/ 2Monmouthshire SS&WBA Needs Assessment

What we are working on?

The NCN has agreed 3 key priorities which underpins its 2020-23 Integrated Medium Term Plan (IMTP):

  • Delivering Care Closer to Home
  • Tackling loneliness and social isolation
  • Building sustainable Primary care in the face of a growing population
What we have already done

Undertaken a comprehensive needs assessment to inform our IMTP priorities over the next 3 years.

Future Priorities
  • Practice based Pharmacists providing expertise for high number of patients reliant on increasingly complex medications;
  • Prescribing savings of £8,000;
  • Secured funding to develop Integrated Well-Being Centre’s;
  • Dementia Roadmap & new schemes, DEWIS Cymru funding;
  • Remodeled GP Practice based dietician role;
  • Improved links with Council planning/ housing team;
  • Higher flu up-take than the Wales average in all three target groups
  • Dedicated sustainability/workforce planning discussions, introduced Care Navigation
  • Continue to ensure NCN development plans reflect local need;
  • Continue to work in partnership with Primary & Secondary Care, Third Sector and local populations to support the delivery of the Care Closer to Home strategy;
  • Continue to work with GP Practices to understand issues with sustainability and identify & maximise areas for cross-practice working;
  • Continue to commit to NCN funding to test new schemes/ services linked to NCN Plan priorities.   


Cluster lead update 13/09/2021