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Cluster Lead Dr Dyfrig Ap-Dafydd

GP Practices in Anglesey
There are eleven practices that operate in the Anglesey Cluster area.

Cambria Surgery  
Coed Y Glyn Surgery 
Gerafon Surgery 
Amlwch Surgery 
Longford House Surgery 
Meddygfa Star Surgery 
Meddygfa Victoria 
Parc Glas Surgery 
The Health Centre (Llanfairpwll) 
The Health Centre (Beaumaris) 
The Surgery (Gwalchmai) 


BCUHB Cluster Population Health Directory

The North Wales Population Health Directory (NWPHD) focuses on the public health priorities and provides information on population health need at different geographical levels (including at Anglesey Cluster level) to NHS staff for planning purposes. The directory  is on the Public Health Wales website.  

Individual Cluster Plans and Reports

Anglesey Cluster IMTP 2020-2023

What are we working on?

Faecal Calprotectin (FCP) Pathway

Anglesey and Arfon clusters are undertaking a pilot study of the effectiveness of accessing FCP diagnostic tests.  NICE guidance recommends FCP testing as an option to support clinicians with the differential diagnosis of Inflammatory Bowel Disease (IBD or Irritable Bowel Syndrome (IBS) in adults with recent onset of lower gastrointestinal symptoms for whom specialist assessment is being considered.  This initiative is a cost effective use of NHS resources and also has great benefits to the patient who, without this test, may have had to undergo an invasive colonoscopy procedure.  Anglesey and Arfon clusters have purchased 500 FCP tests from cluster funds, the first 100 tests completed are being audited, a full audit of the 500 tests will be undertaken in due course.

CRP machine to reduce antibiotic prescribing
A pilot study was undertaken in a GP surgery in Anglesey to demonstrate the effectiveness of C-Reactive Protein (CRP) testing in GP surgeries to guide antibiotic prescribing. The pilot involved CRP point of care tests on 94 patients over a 3 month period and showed a 22% decrease in antibiotic prescribing compared to the previous year.  Positive feedback was also obtained from patient and user surveys. Following the results of the pilot a bid was submitted to WG to purchase an additional 10 CRP machines to be rolled out to outlier GP surgeries in Gwynedd and Anglesey. The effectiveness of the additional CRP machines once implemented in other GP surgeries will be evaluated to inform the further introduction of point of care analysers into clinical practice. There is limited experience of CRP Point of Care analysers in GP practices and this study examined the impact on antibiotic items and the practical experience and learning for further rollout across practices.

Ambulatory ECG (AECG)
Since October, several practices on Anglesey have been able to access primary care-based AECG monitoring for their patients rather than being referred at the outset to specialist cardiology services. A full evaluation will be undertaken to review effectiveness of access to this primary care investigation and any subsequent reductions on referrals to specialist services.  Initial data review indicated a positive outcome where only 31% of patients required onward referral to cardiology. The tests can also provide reassurance to the patient by the GP as a result of access to the tests results within primary care.

What we have already done

Anglesey Cluster Network Action Plan 2018 / 2020 

Môn Enhanced Care (MEC)

MEC has been operating successfully across Anglesey since 2012 and provides a suitable, safe and effective alternative to admission to hospital. This forms part of the introduction of Enhanced Care at home across North Wales.  The Service is provided by the Health Board in conjunction with Social Services.  This intensive service can provide rapid access to diagnostic tests, a consultant opinion, specialist nursing, and other health and social care professionals to GPs, patients, and their families. It gives the option of looking after patients at home, in certain circumstances, when before the only option was to admit them to hospital.  In early 2016, Dr Linda Dykes, Emergency Department Consultant and GP joined the MEC team for a 12 month secondment – Community Care of the Elderly.  Linda joined the other members of the MEC team comprising of an ANPs, HCAs and a GP all of whom continue to offer an excellent service to patients on Anglesey.  Other Clusters in the West are looking to implement a similar model of enhanced care in their localities.

Future Priorities for the Cluster

Exciting plans for the Clusters coming in the near future!!

  •  Sustaining Primary Care Services, improving recruitment and retention, exploring new roles and   ways of working
  •  Maximising joint working, e.g. sharing contraception services and clinics between practices
  •  Improving communication between primary and secondary care by planning for evening
     engagement sessions across all areas
  •  Supporting Mental Health and Wellbeing, including continuing investing in additional   counselling services
  •  Looking at new ways to access diagnostics, including Phlebotomy and Radiology
  •  Pioneering new chronic conditions management, including Diabetes and Leg Ulcer services
  •  Investing in our Care Homes, including recruiting Advanced Nurse Practitioners (ANPs)
  •  Tackling long term health and wellbeing, including targeting obesity and smoking cessation


 Cluster lead update 13/09/2021