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Bridgend West

Cluster Lead Dr Charlotte Reilly

GP Practices in Bridgend West 
Bridgend West Network is one of 8 Primary Care Clusters within Cwm Taf Morgannwg University Health Board footprint.  There are 3 GP practices in the West Cluster, namely:

Porthcawl Group Practice who are also a training practice
North Cornelly Surgery who have a branch surgery in Kenfig Hill
Heathbridge House 

The West is the smallest of the three clusters within Bridgend with a total practice population of 34,528.   The geographical area covers Porthcawl, Pyle, Kenfig Hill and Cornelly, which is coastal, rural and urban with pockets of severe deprivation.  Porthcawl is a holiday resort and home to a large static caravan park which results in  a high transient and seasonal patient population.

The West Cluster area also has:

  • 4 nursing homes 
  • 6 residential homes
  • 8 community pharmacies
  • 4 dental practices

The Cluster all work together with partners from the voluntary sector and the Health Board’s Integrated Team.  Porthcawl Group Practice moved to their new purpose built premises at Clos Y Mametz, Porthcawl in February 2019.   In addition to general medical services provided by Porthcawl Group Practice there are a number of Health Board community services being delivered from these premises including district nursing, midwifery, health visiting, wound care, physiotherapy and AA screening.

Individual Cluster Plans and Reports

Bridgend West Annual Delivery Plan 2023_2024

What we are working on?

Cluster Pharmacy Team
Experienced and well established team consisting of 2 Pharmacists (1.6 WTE) and a Pharmacy Technician (0.8 WTE).  

The Cluster has increased Cluster Pharmacist capacity in order to facilitate and improve prescribing, patient experience and concordance.  This releases GP time and improves patient safety though effective use of Cluster pharmacists.

Pharmacy Technician support enables expansion of work streams in line with prudent healthcare principles.

Chronic Conditions Management Nurse
The role provides a person-centered, holistic approach to the management and education of patients with chronic morbidities.

The Cluster Band 6 Nurse undertakes patient reviews and develops support plans to enable patients living with a chronic disease to manage their condition effectively.    This improves the quality and structure of chronic disease monitoring for the housebound.

Working within an Integrated Health and Social Care team has allowed the Nurse to have direct access to therapists within the multi-disciplinary team, including members of the third sector.

Children & Young People Resilience Project
The Cluster and Valleys Steps are working with the two local Comprehensive Schools in the delivery a 6 week ‘Building Resilience Course’ to pupils of Year 10 followed by a 6 week ‘Mindfulness Course’.

The aim is to give students a toolbox of skills to help them improve their resilience and overall wellbeing.  

First Contact Physiotherapy
Delivery of a first contact physiotherapy service across the Cluster.  Working in conjunction with the Physiotherapy Department at CTM UHB the service provides physiotherapy sessions within GP practices, which aims to improve access and outcomes for patients, avoiding the need for patients to travel to hospital sites for initial assessments.

Through earlier contact and intervention it will provide better outcomes for patients, reduce the need for repeat visits and also reduced referrals to secondary care, unnecessary treatments and prescribing.

The Cluster has also invested in Vision 360 software to support the First Contact Physiotherapy service roll out.  This software package enables GP Practices to book appointments directly to this service.

Mental Health Project 
GP Practices offer frontline service for patients suffering with mental health issues. Such issues have become increasingly prevalent, particularly due to reduction in stigma associated with mental health and the impact of Covid so it’s crucial that Practices are more equipped to offer the best possible service and care to patients.  

Following an audit carried out by one of the Cluster GP Practices this Practice is trailing a dedicated face to face weekly mental health clinic, the aim of which is to try and reduce emergency crisis calls. 

The Practice is updating the Cluster as to the effectiveness of its dedicated mental health clinic, sharing lessons learnt.  The Practice also aim to work with both BAVO and Integrated Team who can possibly offer these patients additional support with their unmet needs.

AWDPP – All Wales Diabetes Prevention Project
Public Health Wales are leading the development and implementation of an All Wales Diabetes Prevention Programme with plans to roll it out across Wales over the next 3 years.  Merthyr and the West Cluster have been chosen as pilot areas for CTM UHB.  

The AWDPP involves a brief intervention, delivered by trained Health Care Support Workers, supervised by local dietitians, to people identified as being at risk of developing type 2 diabetes (HbA1c 42-47 mmol/mol.

Between October 2022 and April 2023:

  • 371 People have been identified using AWDPP search template
  • 246 invitations sent to attend the AWDPP (following manual exclusions)
  • 164 AWDPP consultations booked, 154 face to face, 10 telephone consultations,
  • 141 AWDPP consultations completed
  • 67% uptake

Additional Information:

  • 44 people referred to weight management programme
  • 49 people referred to physical activity
  • 5 referred to other support services
What we have already done

Special Families Project
Ty Elis (Porthcawl Counselling Service) provide therapeutic counselling for adults within families accessing support from the Special Families Project in Maesteg.  Funding was given via a grant of £5,000 as a start-up pilot which funded a 16-week provision.  This enabled partnership working between Ty Elis and Special Families to offer 6-week counselling interventions to adults and/or couples for their members.

Ty Ellis submitted a request the West Cluster to secure on-going funding Jan-March 2023 to meet the needs of these vulnerable families living in the West.

Paediatric Pulse Oximeters
Investing in additional paediatric pulse oximeters for Cluster Practices to assist with diagnosis of RSV in young patients attending surgery.  Having additional paediatric pulse oximeters within the practice helps with timely consultations and also assist with accurate diagnosis especially during the winter months when pressures within primary and secondary care can be unprecedented.

Dance to Health
Dance to Health is a falls prevention class through dance for older people. The sessions combine evidence-based exercise with the creativity, energy and sociability of dance. The programme was devised and is managed by Aesop (Arts Enterprise with a Social Purpose). 

The West Cluster agreed to act as the partner health organisation for the application for funding.  The Cluster members were keen to get involved as there are great benefits to its patient population.   

Dance to Health classes run in Porthcawl, North Cornelly and Pyle/Kenfig Hill area.

   Future priorities for the Cluster

Making Every Contact Count (MECC) training for all Primary Care Staff, to support healthy behaviour conversations with individuals on smoking, alcohol, physical activity, healthy eating and immunisation.

This will ensure Cluster members are maximising contact opportunities with patients to deliver health promotion messages on:

  • The different cancer screening programmes and symptom identification.
  • Addressing behavioural and clinical risk factors such as smoking and obesity.
  • The importance of vaccination and immunisation and how to get vaccinated.

Continue to improve influenza vaccination rates for the children aged 2 and 3yrs old and uptake for those patients at risk aged 6 months to 64 years.

Use Population Segmentation/Risk Stratification data to aid specific Cluster projects which meet is cluster population health needs.

Increasing Cancer Screening uptake by improving patient/public awareness of the Cancer Screening Services available.

Date of next review:  September 2024

Cluster lead update 17/10/2023