The South East Cardiff Cluster consists of 8 GP practices and services a population of circa 67,000 with a significant ethnic population and a large student population. The Cluster is ranked as the 12th most deprived registered population by cluster area in Wales, out of a total of 63 clusters.
General Practices in Cardiff South East
There are eight practices that operate in the Cardiff South East Cluster area
Cathays Surgery
Clifton Surgery
Cloughmore Surgery
Four Elms Medical Centre
Meddygfa Albany Surgery
North Road Medical Practice
Roathwell Surgery
The City Surgery
Individual Cluster Plans and Reports
The South East Cluster is currently in the process of developing its individual plans for 2024-25 which will be based on population needs assessment and local priorities identified by the cluster.
Cardiff South East Cluster Network Action Plan 2017/20
To improve the health and social care needs of the SE Cardiff population we have recently launched Phase 2 of the South East Wellbeing Centre, Cardiff (SEWeCC), a collaborative initiative between Primary Care Health services, the Local Authority and Third Sector agencies to align with the Cardiff & Vale University Health Board’s Shaping our Future Wellbeing - In our Community: Shaping our Future Wellbeing - In our Community - Cardiff and Vale University Health Board (nhs.wales).
The service is being implemented in 4 phases with the aim of coordinating the proactive and holistic management, as a supplement to GP care that will meet both the health and social needs of patients where these may be better supported through the intervention of Local Authority, community, and /or third sector services and SEWeCC employs, supported by pharmacists and an occupational therapist.
As a Cluster we are also looking at other initiatives to improve the quality of health care in different ways that will involve all primary care professional healthcare partners such as GPs, Pharmacists, Optometrists, Dentists and are currently looking to include the introduction of Frailty Nurses, Wound Care Nurses, Health Care Support Workers and Paramedics that will increase patient access to these primary care community services.
Endorsed and promoted the integration/better use of health, social care and third sector services to meet local needs in launching Phases 1 & 2 of the South East Wellbeing Centre, Cardiff (SEWeCC), launched earlier this year that includes:
Facilitation of Cluster Level Primary Care MDT meetings: These meetings occur on a 2-weekly basis, to manage the ongoing care coordination responsibilities, aimed at individuals with complex needs, who are at risk of deterioration/admission to hospital.
Proactive discharge follow-up and welfare checks for patients recently discharged from hospital within defined criteria: The aim of these calls is to identify ‘what matters’ to the patient in their recovery and to assess if / what additional support may be of use to them.
A centralised management of discharge medication reconciliation: All patients, where a medication change has occurred in the hospital setting, will receive a telephone call from the Cluster Pharmacist to update their prescribed medicine requirements.
To improve uptake of Bowel Cancer Screening services by working with our Public Health teams to promote the importance of screening and to raise awareness of the simplicity of the process.
To improve uptake of immunisation and vaccinations in conjunction with colleagues in the Local Public Health Team, we are aiming to increase the uptake of immunisation and screening.
To improve the care of patients whose first language is not English by working with link workers and faith leaders to facilitate effective cross-cultural communication so that all patients can receive the support and care they deserve.
To increase basic understanding of the 5 key areas of lifestyle behaviours that all have major implications on health and wellbeing for the population of South East Cardiff; smoking, alcohol, physical activity, diet and immunisations.
To promote and facilitate advanced care planning for those with life limiting illnesses who wish to complete advanced directive documentation: https://www.nia.nih.gov/health/advance-care-planning/advance-care-planning-advance-directives-health-care
Last updated: November 2023