Bridgend East Cluster is one of three clusters within Bridgend and has five practices within the Cwm Taf Morgannwg University Health Board footprint. Being the largest of the three clusters it serves a population of approximately 83,689 predominantly in an urban environment with some areas of deprivation. The practices within the cluster include:
New Surgery (Pencoed)
Pencoed Medical Centre
Oak Tree Surgery
Riversdale House
Bridgend Group Practice
All five practices are training practices and the clusters estate includes five main surgeries and two branch surgeries. The cluster also includes the following to provide access and services for its patient population:
12 community pharmacies
9 dentists
7 opticians
6 residential homes
3 nursing homes
First Contact Physio – In collaboration with the Health Boards Physiotherapy team the cluster has commissioned a First Contact Physio (FCP) service. Providing FCP appointments to the clusters population from each of the 5 GP practices aiming to improve access and patient outcomes, avoiding the need for patients to travel to hospital sites for initial assessment providing the right care by the right person at the right time.
The cluster has also invested in Vision 360 software to support the appointment booking of the service. This allows practices to give patients the opportunity to access the earliest available appointment whether that be at the registered practices or in one of the other 4 practices if the patient is willing.
Cluster Chronic Conditions Nurse – The Cluster Chronic Conditions Nurse provides a person-centred, holistic approach to managing the cluster’s house bound patients living with a chronic condition. Providing education on the condition and life style advice as well as ensuring they are receiving all the medical help and support including reviews to stay well for longer and independently.
Digital Innovation – Trials are being undertaken by practices within the cluster to decide which digital platform will provide the best opportunities to improve communication and access to services and information to their population. The software includes E-Consult and Accurex. Both packages are an online consultation and triage platform providing access for medical or administrative request, it also allows services users to digitally consult.
Heart Failure Project –The Cluster invested in this project as typically, a heart failure (HF) patient will take 8-12 weeks (4-8 appointments) for medications to be initiated and doses fully optimised. Patients in need of optimisation are identified from PULL approaches (from audits of primary care heart failure registers) and PUSH approaches (where referrals are taken/accepted from the local heart failure team for newly diagnosed patients). A Consultant Cardiologist at the local hospital is the clinical lead/supervisor, providing liberal access to specialist advice and support throughout.
The model adopted by the cluster has ensured that practice employed pharmacists have been trained and utilised to deliver HF optimisation clinics. This project improves cardiovascular outcomes for patients with HF reducing HF hospitalisations, reduced decompensations and CV events. Reducing overall mortality for patients with HF, improving symptoms and functional capacity of patients with heart failure, improved symptoms and functional capacity of patients with HF. This project supports building the strength of the MDT in Primary care, there is improved communication and collaboration with secondary care HF services and more joined up care. It also provides improved patient access to specialist care for medicines optimisation closer to home.
Healthy Homes Project - The Cluster has continued to fund the Healthy Homes project for a further year. By working in collaboration with Bridgend Care and repair, this service provides a dedicated Caseworker and Occupational Therapist linked with the GP surgeries in the East Cluster. Delivering an alternative, proactive model of care that focuses on early intervention and prevention. The Caseworker and Occupational Therapist have worked together during the course of this project to provide patients with a holistic, housing focused service which offers practical solutions for the home environment, provision of aids and adaptations as well as practical advice and support to help them live more comfortably, safely and independently at home.
Cluster Pharmacist – The cluster has a well-established cluster pharmacy team which consist of one band 8a and two band 7 pharmacists. The cluster has also funded a band 5 Pharmacy Technician which has supported the integrated team.
These roles have increased the pharmacist capacity, progressed the development of the pharmaceutical services and the integrated medicine management agenda. By ensuring safe, evidence based and cost effective primary care prescribing within the cluster GP practices.
Children and young people Resilience project – In collaboration with Valley Steps the cluster provided funding to commission the delivery of a 6 week “building resilience course “ to pupils within local comprehensive schools which was supported with a mindfulness course.
Community Therapy Technician – The Community Therapy Technicians perform a variety of assessments and interventions providing rehabilitation for complex people in the community who need a multi-agency approach. They also support with practising washing and dressing, meal preparation, outdoor mobility to access the community and exercises within the home environment. Therapy Technicians also assess and provide mobility aids and assistive equipment. All this enables the patient’s to be more independent with their everyday tasks, manage their long term conditions and become less reliant on other services.
Community Pharmacy technician - The Pharmacy Technician works with G.P. Surgeries; the Integrated Cluster Network Team and Pharmacy staff working in and supporting collaborative working across the East Network footprint. The project Supports the integrated team to deliver effective and prudent medicines management support and education for patients in partnership with other professionals. Contributing to improving patient outcomes and minimising harm, which may lead to unscheduled care, pressure on professionals who work in the community and avoid unnecessary hospital admissions.
Through collaboration with a range of health and social care professionals, the post holder assesses medicines management requirements and enable patients (service users/clients) to manage their own medicines at home, or otherwise facilitate appropriate support, contributing to the training of staff involved. Promoting independence and improving support for the frail elderly on multiple medicines will be key along with involvement in discharge planning. Providing the opportunity for home visits to patients and underpin the education opportunities for them in managing both their own independence, understanding and compliance with their prescribed medication.
In line with Accelerated Cluster Development (ACD) the cluster model has evolved to include each of the professional collaborative. The cluster will continue to work with the collaborative cluster members to ensure that they are supported in this new programme of work and that they are aware of the clusters remit and responsibilities. Exploring new collaborative ways of working to collectively meet the needs of the population improving the Health and wellbeing of the cluster population and supporting sustainability within Primary Care.
In collaboration with cluster members analyse the population segmentation / risk stratification data to aid specific cluster projects ensuring it meets the health needs of the cluster population. This will allow the cluster to address population behaviours / life style choices such as obesity, smoking, substance misuse, lack of exercise and poor diet with support from cluster members such as 3rd sector and Public Health etc.
To continue to support and increase update of the vaccination programmes in conjunction with colleagues from the local public health and health protection teams.
To build on the delivery on innovation at pace expanding the capabilities of digital resources to improve access across our communities.
Updated 14/11/2024