Clinical Cluster Lead
Dr Jennifer Lewis-Jones (Meddygfa Glan Cynon)
Manager Cluster Lead
Ann Brown (Abercynon Medical Centre)
Primary Care Development Manager
There are five GP practices that operate in the South Cynon cluster area.
Meddygfa Glan Cynon Surgery
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. South Cynon Primary Care Cluster
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.
Individual Cluster Plans and Reports
What we are working on?
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).
Advanced Nurse Practitioner
Successful recruitment to the post of Advanced Nurse Practitioner in January 2020, the ANP assists GPs in the management of care home patients in line with the directed enhanced service.
The post regularly and effectively engage with care home staff in the comprehensive management of care home residents on a weekly basis, undertaking a “weekly ward round”, followed up where necessary with structured clinical consultations to care home residents.
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 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.
Pain Management Programme
The cluster have invested in a new pilot, to provide pain management support by a multi-disciplinary team comprising a physiotherapist, occupational therapists and pharmacist, all with experience supporting people living with pain. The team work closely with EPP Cymru, Cluster Social prescribers and other local services as needed.
What we have already done
Dermoscopy Equipment and Training
The cluster have recently invested in Dermatoscopes and the GP’s have attended a virtual training course, this is to improve the diagnosis of benign and cancerous skin lesions. This will support with building links with secondary care by referring via consultant connect.
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.
Pre–Diabetes pilot project with Public Health Wales
The cluster are working with Public Health on this pilot, the aim of the pilot was to Identify individuals from GP practice registers who have previously had a HbA1c blood test result which identifies them as ‘pre diabetic’. The patients have had their height, weight, BMI and blood pressure taken.
The team have worked with the practices to obtain patients data for the evaluation part of the pilot.
Future priorities for the Cluster
The Cluster will work with Public Health Wales and use the population segmentation and risk stratification data to support with future planning of cluster plans as well as providing preventive care to patients. With the support of the Community Health & Wellbeing Team.
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’
To work with the Regional Partnership Board to develop an integrated Health and Social Care model.
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.
Cluster objectives to include obesity, cancer screening and diabetes prevention.