There are two Neighborhood Care Networks (NCNs) in Monmouthshire (North & South) with registered populations of 53,701 and 47,353 respectively.
General Practices in Monmouthshire South
There are five practices operating in the Monmouthshire South (NCN) Cluster area.
Gray Hill Surgery (Caldicot Medical Group)
Mount Pleasant Practice
Town Gate Practice
Vauxhall Surgery
Wyedean Practice
Monmouthshire South Cluster Annual Plan 2023 - 2024
Monmouthshire South Cluster Annual Plan 2022 - 2023
Monmouthshire South NCN IMTP 2020-2023
Monmouthshire South NCN Plan on a Page 2020 / 2023
Monmouthshire South NCN Plan on a Page 2018-19
Monmouthshire South NCN Action Plan 2017 -20 Year 3
Monmouthshire South NCN Annual Report 2018 - 19 (Year 2)
Cluster Profile
We are a semi-rural Neighbourhood Care Network (NCN) Collaborative Cluster area and our local populations are supported by:
We are a population of approximately 48,600 with around 6,500 of those being resident in England and registered with a Monmouthshire GP due to geographical constraints.
Our aim as a NCN Cluster is to work in partnership to ensure people can receive support as close to home as possible and remain involved in their local communities with help from our GP practice colleagues, extensive wellbeing link services and Integrated Health and Social Care teams.
We recognise that all services face unprecedented pressure exacerbated by the global pandemic. Monmouthshire as a whole has specific challenges due to its rurality, demography and demand in relation to the growing complexity of need. We also recognise the need to change historical ways of working in particular to avoid hospital admission where possible, and build sustainable and resilient primary and community-based services.
Our alignment with the Monmouthshire Regional Partnership Board and the ISPB 3-year plan will help us build resilience in the long term and underpin our aim of ensuring our plans reflect the needs of local people.
Working across the NCN Cluster to test the concept for new roles e.g.; Physician’s Associates and Physiotherapists in response to sustainability concerns.
Implementing the Accelerated Cluster Development (ACD) Programme linked to enhancing the NCN Cluster Business Cycle and build professional collaboratives across Primary Care – including undertaking an extensive evaluation process for all NCN Cluster funded schemes to ensure objectives are being met.
Partnership working across the NCN Cluster, Public Health, Social Care and 3rd sector to utilise the vast network of non-medicalised well-being support to reduce demand on GPs.
Workforce planning in response to Primary Care sustainability concerns and Winter Pressures across the wider Primary & Community (Integrated) Care Services.
Building strong relations between Heath, Social Care and Third Sector with increased engagement with prioritisation planning for year 2 of the 3-year (2023-26) ISPB plan.
Identifying new local priorities for the 2024-25 NCN Cluster Annual Plan.
NCN investment to further embed the Wellbeing Links Advisor service to support growing demand for help with the social determinants of ill health providing non-medical support in GP practices.
Excellent high uptake in relation to influenza and Covid-19 booster programmes.
Good progress made through the initial ACD transition year with increased engagement & understanding across the partnership - dedicated ACD Service Improvement Manager (SIM) seconded to support key workstreams.
NCN investment in a Practice Manager led forum further building positive and collaborative links with practice managers relating to business continuity planning etc.
NCN investment in a range of digital solutions supporting business efficiencies in our GP practices.
Investment in digital solutions to create efficiencies and ease of access for people in South Monmouthshire.
Continue to demonstrate and promote the success of our Rapid Medical Service (aligned to the Redesign of Services for Older People programme) helping to retain care closer to home and avoid hospital admission.
To identify key priorities relating to the Marmot principles especially around Children’s Services - being taken forward via NCN and ISPB plans.
Explore options / new ways of working with hard-to-reach, vulnerable communities e.g., farming, migrants etc. to identify need and potential for expansion of the wellbeing network in key locations.
Continue to support the NCN Cluster funded GP led Safeguarding Forum and sharing best practice.
Continue to monitor the impact of workforce pressures across our cluster/ community teams to inform business continuity planning.
To work with community teams to consider an option for a ‘Falls’ service in reduce the potential for high numbers of hospital admission.
Updated 20/07/2023