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Cardiff City & South

Cluster Lead Vacant

General Practices Cardiff City and South Cluster 
There are seven practices that operate in the Cardiff City and South Cluster area

Cardiff Bay Surgery 
Butetown Health Centre 
Grangetown Health Centre 
Saltmead Practice 
Grange Medical Practice 
Clare Road Medical Centre 
The Corporation Road Surgery  


Individual Cluster Plans and Reports

Cardiff City and South Cluster Network Action Plan 2017 / 2020  

What are we working on?

Our Cluster has the highest prevalence of Diabetes in Cardiff, if not the whole of Wales. This is a reflection of the demographic makeup of our area, our patient’s lifestyle choices and their health seeking behaviour.  With help from secondary care we identified a need to appoint a Diabetic Specialist Nurse to work across the Cluster. The vision was that the nurses, as well as providing specialist service commitment have an educational and mentorship role to enable, in the future, practices nurses within the Cluster to develop the skills and necessary to deal with the ever increasing disease burden of Diabetes.  Unexpectedly we have had some recruitment issues and are due to re-interview until we find the most suitable candidate.

The role of the Cluster Pharmacist seems to have developed recently and we were able to look at lessons that could be learnt from other Clusters in the HB in relation to the recruitment and job specification for this role.   Medication reconciliation, poly-pharmacy reviews for the elderly and drug monitoring for anticoagulation and Disease Modifying Medication (DMARDS) are universal issues faced by all and we identified at an early stage the fact that all practices in our Cluster were constantly striving to improve on the safety and quality of their individual prescribing. Our Cluster Pharmacist is now in post and we are in the process of tailoring a job description that will ensure equity of work in each practice in the Cluster as well as the ability of the Pharmacist to look at specific needs in each individual practice.

We have recently commenced discussions with an academic and research oriented team from within our own Cluster. There has been a bid for Cluster investment, initially to carry out a piece of work as a pilot. The work would involve research within our own population to identify the specific barriers to accessing health care and why certain disease prevalence is high and targets continually fail to be achieved.  It would look at the evidence for such inequalities and mismatches and to ensure that future investments both have an evidence base, clear direction demonstrable outcome and remain specific to our population giving patients value in addition to the expected high quality GMS to which we all aspire.

What we have already done

The Cluster Fair was born out of the Annual Minority Ethnic Communities Health Fair. We decided to bring this concept and deliver it locally and initiate the event at Cluster level taking into account the barriers to accessing health care and obstacles to promoting health that we had highlighted in Cluster group discussions. The ideas behind this was to bridge the gap between the health care providers and the local community by promoting healthy living and presenting it in a fun, family, accessible and achievable manner. Our first Health Fair took place in early October in the Butetown Resource Centre where we were able to address a variety of health needs from smoking cessation, dementia awareness, dental health, self-help for certain mental health issues, education on the role of the ambulance service and practical CPR awareness. The fair has been an outstanding success with Cardiff City Football Club and Cardiff FM radio station showing interest in being involved in such future events.

Future Priorities for the Cluster

We have also taken lessons from individual experience of practices in our Cluster and have tried to disseminate good practice. One practice in the Cluster highlighted to all the experience that they had had with a frailty nurse that had worked with them. The practice experience and efficiencies described prompted us to look at investing Cluster funds into recruiting such a health care professional to work across the Cluster. The role would be innovative in nature, encompass the ethos of holistic care and be driven by outcomes and freeing up valuable GP and practice nurse time. We are yet to define the specific outcomes to be measured but understand that these are important drivers to ensure long-term investment continuity and sustainability for this role. We have been in liaison with other Clusters to define how these outcomes will be mapped and demonstrated.


Cluster lead update 13/09/2021