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Cynon South

 
Cluster Lead: Dr Jennifer Lewis-Jones

Practice Manager Lead – Graeme Hunter

Clinical Cluster Lead - Dr Jennifer Lewis-Jones (Rhos House Surgery)
Jennifer.lewis-jones@wales.nhs.uk     

Manager Cluster Lead - Graeme Hunter (Cynon Vale Medical Practice)
Graeme.hunter@wales.nhs.uk    

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

GP Practices
There are six GP practices that operate in the South Cynon cluster area.

Abercwmboi Medical Practice 
Cwmaman Surgery 
Cynon Vale Medical Centre 
Rhos House Surgery 
Penrhiwceiber Medical Centre 
Abercynon Medical Centre 

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

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.

Individual Cluster Plans and Reports

South Cynon Three Year IMPT 2020-2023 

South Cynon Cluster GP Network Action Plan 2017-20 

What we are working on?

Pre-Diabetes pilot project with Public Health Wales

A pilot project will commence in February 2020 within South Cynon focusing on pre-diabetes. Phase 1 focuses on the  identification of individuals from GP practice registers who have previously had a HbA1c blood test result which identifies them as ‘pre diabetic’ and thus at a higher risk of developing type 2 diabetes mellitus.

After being invited for a repeat blood test if required, all individuals age 18-74 years who are not on a diabetic register but have a HbA1c within ‘pre diabetic range’ will be invited into the practice for a 20-minute structured brief intervention with a band 3 Health Care Support Worker who has received additional training on prediabetes, nutrition and physical activity advice. The consultation will also include measurement of height, weight, BMI and blood pressure.

Patients will be contacted again at 12 months’ post intervention and offered a repeat HbA1c and follow up appointment with a healthcare support worker. Measurements will be repeated together with a discussion of any lifestyle changes undertaken. Evaluation of patient experience and outcomes will be supported by academic partners.

Mountain Ash Primary Care Centre – A £4m purpose built facility in Mountain Ash will become the modern home for two GP practices, Cynon Vale Medical Centre and Rhos House Surgery, as well as a range of services delivered by District Nurses and Health Visitors. The new primary care centre will provide an environment suitable for the delivery of safe, modern day sustainable services and help to improve the recruitment and retention of skilled multi professional primary and community staff.

Bowel Screening promotion to increase patient uptake, in partnership with Cancer Research UK and Public Health Wales

Care Navigation training is being considered as possible investment for next year to promote prudent health care and social prescribing and compliment the role of the cluster’s Wellbeing Coordinator

Social prescribing, occupational therapist and care navigation pathways with the expanding MDT in line with the workforce plan developed in Autumn 2018, establishing future priorities and new roles

Explore community engagement strategies and potential for a Cluster Patient Participation Group to facilitate co-production in community development

Further develop patient support programmes & pathways to include fibromyalgia, EPP, pre-diabetes & obesity

Explore young people and mental health support possibilities with third sector partners.

Develop the IT infrastructure and interoperability, including robust data sharing processes

What we have achieved 2018/19

Completed and submitted transformation plan

Commissioned service from Interlink for a full time Wellbeing Co-Ordinator for signposting, advocacy and Community Development purposes.
 

North & South Cynon

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

Social prescribing, occupational therapist and care navigation pathways with the expanding MDT in line with our workforce plan developed in Autumn 2018, establishing future priorities and new roles

Continue MIND and Cluster  pharmacy services

Start educational sessions using in-house CPET sessions

Improve uptake of screening in conjunction with Public Health

Explore  community engagement  strategies and potential for a  Cluster PPG to facilitate co-production in community development; with third sector partners support

Further develop patient support programmes & pathways to include: Fibromyalgia,  EPP, prediabetes & obesity

Explore young people and mental health support possibilities with third sector partners.

Develop the IT infrastructure and interoperability

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

Comms. and promotional initiatives
 

What we have already done

Cluster Pharmacists Two 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. The Cluster has recently recruited one additional Cluster Pharmacist to increase the team to three full time Pharmacists.

Cluster governance arrangements Terms of office have been agreed and election of officers will take place on an annual basis. The Cluster terms of reference to include the decision 

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.