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Cynon North

 

Cluster Lead: Dr Owen Thomas

Practice Manager Lead – Hayley Rogers

Clinical Cluster Lead
Dr Owen Thomas (St Johns Medical Practice)
Owen.thomas4@wales.nhs.uk

Manager Cluster Lead
Hayley Rogers (Foundry Town)
Hayley.rogers@wales.nhs.uk

Primary Care Development Manager
Angharad Pitt
Angharad.pitt@wales.nhs.uk 

Our Community

10% of the population of Wales live within Cwm Taf, the locality is the second smallest and second most densely populated in Wales. The Cynon Valley (CMO for Wales reports, Public Health Wales data) has high rates of: social deprivation, mental health issues, long term disability/morbidity, and poverty/benefits uptake and of chronic illness from legacy heavy industry particularly mining.

GP Practices:

There are four practices that operate in the North Cynon Cluster area.
Hirwaun Medical 
St John's Medical Practice 
Park Surgery 
Foundry Medical Practice  

The Cluster practices have developed solid relationships with partner agencies which is reflected in the membership of the Cluster meetings which has representation from the following disciplines and organisations: 
Public Health Wales; Dental Services; Pharmacists; Optometry; Interlink; MIND; Care & Repair

Individual Cluster Plans and Reports

North Cynon three year IMPT 2020 -2023

North Cynon Cluster GP Network Action Plan 2017-20 

What we are working on?

North Cynon three year IMPT 2020 -2023

Service sustainability

The implementation of the ethos of prudent healthcare develops the workforce to ‘only do the work that only they can do’.  The workplace should then become more rewarding and less pressured thus improving staff recruitment and retention rates.  New models of primary care will be explored. Desired outcome is to create more cost effective and sustainable primary care services.

More services now available in the community

Engagement with the Third Sector and other health & social care agencies. Commissioning of Cluster initiatives for service delivery.

Delivery progress

Workforce Planning: both Clusters have completed the six month pilot project with Skills for Health and HEIW to inform the design of a national workforce planning tool specifically for Primary Care whilst producing two workforce plans – one for North and one for the South. These plans have provided the Clusters with sustainable workforce models which will have considered predicted population changes and local health needs. The outcomes of the pilot are currently being considered by HEIW with a view to roll out across Wales.  

Training: Care Navigation training is being considered by the South Cynon Cluster as possible investment for next year to promote prudent health care and social prescribing and compliment the role of the newly appointed Wellbeing Coordinator. 

Multi – skilled workforce:  Occupational Therapy - the post has been made permanent and is now working across the four Practices in North Cynon. The team has now expanded to include three Band 6 OT’s who are now working across the North Cynon Cluster releasing the Band 7 to move into South Cynon and develop the model across the South of the locality.  

Advanced Nurse Practitioner in North Cynon – an ANP has been recruited by the Cluster with slippage money funding the training and induction period. Following that period the Practices will pick up the costs of the post which will be primarily to manage the Care Home DES on behalf of the Practices. This is an exciting experiment in sharing staff across a group of Practices.

The South Cynon Cluster have recruited a Health & Wellbeing Co-Ordinator to provide a social prescribing service and community development function.  

Improved access

Cluster Pharmacists: Three full time Cluster Pharmacists are now embedded in the Practices and actively engaged in face to face patient consultations and medication reviews. The Pharmacy department is evaluating the scheme in terms of cost/benefit analysis and anecdotally from practice feedback the Pharmacists are increasing capacity for the GP’s and promoting a mixed skills model. Some independent prescribing courses have now been completed adding value to these roles. Both the South and North Clusters have committed Cluster funding to the same level of service for 2019/20.  

MIND active monitoring:  MIND therapists are providing sessions from the practice base offering brief interventions for early presentations of anxiety and depression. Final evaluation will seek to demonstrate that the intervention has prevented the patient from presenting to the GP with the same issue thus preventing the ‘revolving door’ pattern of attendance. The impact on other mental health service referrals will also be considered. The South Cynon Cluster have committed to re commissioning this service through 2019/20.

More services now available in the community

Care & Repair ‘Managing Better’ project: The engagement with Care & Repair in the Virtual Ward pilot in the North clearly evidences how multi-agency working across the sectors can assist organisations in achieving service delivery targets whilst improving outcomes for patients. Care and Repair now have representation at both Cynon Cluster meetings. 

Community Co-ordinators: community co-ordinators attend all Cluster meetings and regularly deliver ‘clinics’ from Practices to engage with patients to assist in health promotion initiatives and signposting. The Community co-ordinators also input into the weekly multi – disciplinary ‘virtual’ ward in North Cynon.

Optometry & Dentistry: The Health Boards Optometry advisor is an active member of the Cluster meetings thus promoting a ‘Primary Care’ focus to the group. A management and clinical representative for dentistry have recently been identified and will attend meetings on an ‘as needed’ basis.  

Community Pharmacy: there has been positive engagement this year with Community Pharmacy colleagues who now attend the Cluster meetings and have been positive about the sharing of information and potential for improving joint working.

What we have achieved 2018/19

All practices actively engaged with the Virtual Ward model with integrated service delivery established and clinical system interoperability via Vision Anywhere with developed templates to facilitate networked enhanced services and collaboration.

Finalists in the General Practice Awards 2018 for the Virtual Ward multi-disciplinary General Practice Team.

Recruited a shared ANP to deliver the Nursing Home DES across the Cluster

Cluster Nurse service evaluated where 400 patients were seen saving 152 GP Home Visits

Engagement in a six month pilot with Skills for Health and HEIW to develop and test a tool for workforce planning in Primary Care. This process has produced a workforce plan for the Cluster, which will feed into the transformation plan.

Continued collaborative working project with valleys MIND for Active Monitoring interventions delivered from cluster practices for identified patients.

Our plans for 2019/20

Evaluate the impact of the Virtual Ward model throughout 2018/19

Continue collaboration with secondary care colleagues to progress the DVT pathway and IT path links

Further develop the IT infrastructure and interoperability

Improve information governance across the cluster, with joint agreements in place

Explore possibilities for forming a legal entity from which to hold contracts and apply for grants to invest in and  improve  patient services

Continue to commission Cluster  pharmacy services

Improve uptake of screening in conjunction with Public Health

Continue close partnership working from the platform of the virtual ward and further embed the model to provide equity across the Cluster.

What we have already done

Completed and submitted cluster plan to reflect priorities, supporting the Health Board’s IMTP, a Healthier Wales and the National Transformation Programme

Engagement in a six month pilot with Skills for Health and HEIW to develop and test a tool for workforce planning in Primary Care. This process has produced a workforce plan for the Cluster and feeds into the transformation plan

All practices actively engaged with the Virtual Ward model with integrated service delivery established and clinical system interoperability via Vision Anywhere with developed templates to facilitate networked enhanced services and collaboration.

Finalists in the General Practice Awards 2018 for the Virtual Ward multi-disciplinary General Practice Team.

Recruited a shared ANP to deliver the Nursing Home DES across the Cluster

Virtual Ward

The ‘virtual ward’ is a new method of working developed at St John’s Medical Centre, supporting their own patients and referrals from practices within the cluster. A multi-disciplinary team of about 10 staff, including GP, district nurse, pharmacist, social worker, community paramedic, occupational therapist, manager and third sector services collaborate to take services to their patient at to avoid crisis admissions to hospital.

They meet once a week to discuss sick or vulnerable patients who may need more intensive support from the Primary Care Team to continue to live and function safely at home.

The initiative frees up GPs time to concentrate on complex medical cases and keeps patients out of hospital and supports the new Primary Care Model by implementing cultural change, prevention and risk stratification to reduce demand on Primary & Acute Care; Enhanced MDT working in Primary Care and Stabilising Primary Care.

An Advanced Nurse Practitioner has been recruited primarily to manage the Care Home Direct Enhanced Services on behalf of the Practices.

Multi – skilled workforce:  Occupational Therapy - the post has been made permanent and is working across the four Practices in North Cynon. The team has now expanded to include three Band 6 Occupational Therapists who are now working across the North Cynon Cluster.

Care & Repair ‘Managing Better’ project: The engagement with Care & Repair in the Virtual Ward clearly evidences how multi-agency working across the sectors can assist organisations in achieving service delivery targets whilst improving outcomes for patients. Care and Repair now have representation at both Cynon Cluster meetings.

Community Co-ordinators: community co-ordinators attend all Cluster meetings and regularly deliver ‘clinics’ from Practices to engage with patients to assist in health promotion initiatives and signposting. The Community co-ordinators also input into the weekly multi–disciplinary ‘virtual’ ward in North Cynon.

Diabetes Community Clinic: Supported the development of intermediate clinics and support groups in the form of a Diabetes Community Clinic, delivering services closer to home, reducing wait times and improving patient experience and outcomes.

What’s next?

Explore possibilities for forming a legal entity from which to hold contracts and apply for grants to invest in and improve patient services

DVT Pathway Research with Cwm Taf Morgannwg Pathology department

Further develop the IT infrastructure and interoperability

Improve information governance across the cluster, with joint agreements in place

Continue close partnership working from the platform of the virtual ward and further embed the model to provide equity across the Cluster.

Future priorities for the Cluster

Sustainable Primary Care Development of multi skilled approaches to include evaluation of Virtual Ward and Advanced Emergency Practitioner pilots.

Explore models of Group Consultations.