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Merthyr Tydfil

Cluster Leads: GP Lead – Dr Shyama Velupillai; Dr. David Andrews     


The cluster serves approx 60,000 patients. Practices within Merthyr Tydfil have worked together for a number of years and networking arrangements have been in place in respect of some enhanced services. 

Public Health Wales, Dental, Optometry along with Local Authority members and Third Sector attend meetings to ensure multi-disciplinary working across Primary, Community and Social Care.

Practice Manager Leads - Kate Francis; Kevin Rogers

Primary Care Development Manager
Imran Gilani – Tel 01685 351357

GP Practices
There are nine practices that operate in the Merthyr Tydfil Cluster area

Brookside Surgery 
Keir Hardie Health Park Practice One 
Keir Hardie Health Park Practice Two 
Keir Hardie Health Park Practice Three 
Morlais Medical Practice 
Oaklands Surgery 
Pontcae Medical Practice 
Treharris Primary Care Centre 
Troed - y - Fan Aberfan 

Individual Cluster Plans and Reports

Merthyr Tydfil Cluster Network Action Plan 2017/20 

Cluster plans have been informed by:
Development plans produced by practices;
Public health information on key health needs within the area;
Cwm Taf UHB information on current activity/referral patterns;
Understanding of our localities baseline services (current service provision) and identification of potential service provision unmet needs.

The plans also embrace key UHB priorities for the next three years.

The plan details cluster objectives for years 1-3 (2014/2017) that have been agreed by consensus across practices, providing where relevant background to current position, planned objectives and outcomes and actions required to deliver improvements.
The plan is by its very nature fluid /flexible and evolving over the next 3 years the plan itself will be reviewed and updated in response to changes in cluster planning.
Individual Cluster priorities are planned to ensure that there are developments to address health needs of their population, whilst always working towards the following main themes:

  •  Achieve sustainability;
  •  Improve access;
  •  Reduce health inequalities;
  •  Workforce development;
  •  Multi agency working across the sectors;
  •  Transfer of services from secondary to primary care;
  •  Engaging with others to ensure collaborative working across Primary Care health professionals – GPs, Optometrists, Dentists, Pharmacist and also working with Community and 3rd sector   colleagues.
What are we working on?

General Practice Support Officer (GPSO)

This project has introduced GPSOs as part of the frontline resource within GP practices.

Six full time GPSOs are based across all GP practices in Merthyr Tydfil. The GPSO will work during surgery hours (Mon-Fri 08.00 – 18.30). GPSOs will receive referrals from all staff within each practice, alternatively patients have the opportunity to self-refer. Referral criteria is broad and allows anyone experiencing a non-medical problem to arrange an appointment with the GPSO. Length and frequency of appointments will vary. Some patients require practical support over the course of one to two appointments, others will benefit from on-going support, some examples include a home visit allowing a holistic assessment, multi-faceted referrals to third sector or other community services, whilst encouraging patients to build skills and confidence.

Staff, patients and the wider team are noting the advantages of this staff group and provide positive feedback.

This project is already proving successful and allowing scarce clinical (GP) resource to be more effectively used. This project has received funding via the cluster to run until the end of March 2019.

Cluster Physiotherapy Service

Physiotherapists are based at GP practices across the cluster, this has increased access to GP appointments and has been providing a more appropriate response to patients with muscular skeletal problems.

The Cluster Physiotherapy Service provides 13 weekly sessions across Merthyr in a primary care setting. The service is delivered by two local providers and has proven to be instrumental in the effective use of clinical time and delivering prudent health care. The resource has worked extremely well across the cluster and has now been extended via cluster funding until March 2019.

The service is currently being refined to further improve the patient experience for any onward referral to the Primary Care Physiotherapy Service.

Care Coordinator

Administrative staff at all GP surgeries have enrolled onto Care Navigation training. The aim of the course is to enable primary care staff to consistently work towards delivering exceptional customer service and improve patient experience, whilst working in a busy demanding environment.

Delegates have provided positive feedback and already at this early stage feel the training has instilled confidence and been empowering, allowing an easy adaption to change to improve the care delivered.

Cancer Aid

A local support service that provides practical and emotional support to cancer patients, relatives and carers through the medium of counselling and complementary therapies.

During the last quarter the service received 32 new patient referrals, all of which were offered an appointment for counselling and complementary therapy within 10 working days.

Patients and carers are reporting reduced levels of stress and anxiety. An improvement in general wellbeing has also been noted.

Baby Teeth Do Matter

The cluster is fully supportive and actively engaging in the Health Board initiative of “Baby Teeth Do Matter” - making it a priority to improve the oral health of our children. Dental practices have been paired with GP practices to introduce and promote this service.

The campaign aims to raise awareness of the importance of children adopting healthy dental habits early to prevent tooth decay.

The mid-year review of the “Baby Teeth Do Matter” pilot shows that there has been a 70.25% increase in the number of children under 2 years of age attending a dental practice compared to the same period in the previous financial year.

A full review of the pilot will be undertaken in April 2018 to determine whether to roll out the initiative elsewhere.

Primary Care Foundation

The Primary Care Foundation was established to support the development of best practice in primary care. The Foundation has been commissioned to work with participating practices to review demand and capacity to explore practical changes in the way practices work.  Participating practices have agreed to engage in the use of the audit tool (practice data will be captured for one week) during quarter four 2017-18. Results of participating contractors should be available during 2018/2019.

What we have already done

Workflow Optimisation - This initiative combines systems redesign with workforce development as administrative staff are trained to process routine administrative tasks which would traditionally be dealt with by the GP.  The outcome is that 80% of patient correspondence is completed without a GP. The cluster has now completed the training and is introducing innovative changes into working practice.  Feedback has been positive and there will be an evaluation later in the year.  Further information is available here:

Direct Access One Stop Cardiology Community Clinic

The Direct Access One Stop Cardiology Community Clinic is provided by a multi-disciplinary team consisting of a broad range of specialist staff.  The concept of the clinic is that the majority of patients will have appropriate tests on the day and then have their management plan and diagnosis explained.
At present, patients who require investigations are referred into secondary care and can wait up to and in excess of 26 weeks for an investigation and subsequent outpatient appointment if required.  The One Stop Cardiology Clinic is reducing waiting times for both diagnostics and outpatients and reduces the referral to treatment time for patients suitable for the service. 

To further improve communication, an interoperable solution that allows the Cardiology Clinic to write directly to the GP record was launched in May 2017.  

The solution is called Vision 360.  It fully interfaces with Vision and EMIS and provides all participating GP practices within Merthyr to view all consultations undertaken in the
Cardiology Clinic within minutes of the consultation ending.

Web GP/Econsult

This is the only online consultation tool created by GPs that catches clinical symptoms early and offers effective, time-saving, remote triage and consultation. Platform delivers better patient access and is embedded onto each GP practice website. This speeds up access to safe, efficient care, whilst at the same time reducing practices workload. One practice has been using the service for over 18 months. Over the last 6 months at this practice an estimated average of 30 appointments have been saved per week.

Future priorities for the Cluster

Further development of partnership working - expanding GPSO services through working closely with Health and Social partners. Outcomes expected to reduce frequent inappropriate attendance, improving patient experience and effectively utilising limited and scarce resources.


Cluster lead update 14/09/2021