Clinical Cluster Lead
Dr Owen Thomas (St Johns Medical Practice)
Manager Cluster Lead
Hayley Rogers (Foundry Town)
Primary Care Development Manager
The North Cynon Primary Care Cluster serves approximately 31,000 patients.
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.
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
The cluster have invested in training for their frontline staff to be able to signpost patients to the most appropriate service. Partners include; Citizens Advice Bureau RCT, Common Ailments Scheme, Optometry, Physiotherapy, Single Point of Access & Interlink (Wellbeing Coordinators).
Care Home Managers Forum
Due to the pandemic and the support needed in care homes, North Cynon’s ANP setup a virtual forum for all the care home managers to join on a bi-monthly basis. They have been able to speak with GP’s and discuss any issues, they have also had ACP support, the care home managers have really engaged in the forum and found it beneficial.
Community Pharmacy Ear Service
The cluster are working collaboratively with a local pharmacy to ensure patients can access appropriate assessment and advice for the management of acute ear conditions, including ear wax and otitis externa.
The cluster are currently funding 8 counselling sessions a week with Vitality Therapies, they offer active listening support and signpost to local activities and additional support. The counsellors rotate between the three practices in the cluster.
The cluster recruited a dietician to work within the cluster and provide weight management, obesity service and GP education. The dietician provides 10 weekly sessions and rotates around three different practice.
What we have already done
First Contact Physiotherapy
Patients have had access to a first contact physiotherapy service since September 2020, the physiotherapist undertake a clinical assessment and produce a clinically reasoned differential diagnosis to patients who present with musculoskeletal problems the cluster have 10 sessions per week and the physiotherapist rotate around the different practices.
Three full time Cluster Pharmacists are now embedded in the practices and actively engaged in face to face patient consultations and medication reviews. Both the South and North Clusters have committed Cluster funding to the same level of service for 2021/2022.
Practices have continued to engage with the multi-disciplinary team, with GP’s working on a rotated basis to chair the weekly meetings. The team is made up of therapies, mental health practitioners, wellbeing coordinators, social worker and district nurses.
The cluster have employed a wellbeing coordinator within the cluster, the coordinator rotates between GP practices and community settings. They refer patients to a range of local, non-medical services and community groups. It is to ensure that patients get access to the support they need to overcome the social issues impacting on their health and wellbeing and tackles the underlying issues. They aim to reduce the pressure on GPs and allow people to access support in their community instead.
There will be a focus in the next three years, for the cluster to liaise with third-sector organisations to explore approaches to lifestyle changes in line with the ‘Five Ways to Wellbeing’
Continue working with the Merthyr and Cynon Integrated Locality Group, support with developing new services and pathways in order to enhance access for patients within Primary Care and Community.
To work with the Regional Partnership Board to develop an integrated Health and Social Care model.
Work closely with the cluster dietician to improve weight management and diabetes prevention.
Work with the health board to setup a pain management programme within the cluster.ying issues. They aim to reduce the pressure on GPs and allow people to access support in their community instead.