Merthyr Tydfil cluster serves a GP practice population of around 60,000 patients with six GP practice:
Keir Hardie Health Park Practice 1
Keir Hardie Health Park Practice 2
Keir Hardie Health Park Practice 3
Morlais Medical Practice
Pontcae Medical Practice
Valleys Medical Group (Treharris)
Merthyr Tydfil Cluster Network Action Plan 2024/25
First Contact Musculoskeletal Service - Each GP practice encompasses first contact physiotherapists, the physiotherapists frequently provide same day assessments and reduce onward referrals into the UHB services. The current investment provides 22 weekly sessions.
Young Persons Counselling - The cluster are working in collaboration with Stephens and George. During 2024/25 the cluster has continued to produce 600 sessions. Stephens and George provide therapeutic counselling, thus improving the lives of people that are emotionally distressed.
Pre-Diabetes - The cluster are working with Public Health Wales on this pilot, the aim of the pilot is 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 as well as lifestyle advice provided.
Wellness Improvement Service - WISE follows an evidence-based, lifestyle medicine approach where patient empowerment forms the basis of the service and supports change through person-centered techniques to improve mental and physical well-being.
Through a sustained education programme, WISE aims to enable referred patients to better understand the root causes of their current medical conditions and choose lifestyle behaviours that improve their long-term health, as well as ensure a better quality of life with reduced symptom burden.
Childhood Obesity - The cluster is working with dieticians and have developed a families approach to healthy lifestyles. The PIPYN Programme (Healthy Children Healthy Weight) supports children aged 3-7 and their families to make health choices. Free support is available and covers topics such as eating healthier, meal planning, affordable food, good shopping habits, healthy recipes, screen time, active play, family play and much more!
Digital Interface - The cluster upgraded their visual information systems (Envisage) across all GP practices. The system is advanced that allows a patient call facility. The screens are placed in waiting areas and combine health awareness and practice specific information.
General Practice Support Officer (GPSO) - The primary aim of the cluster project is to collaborate with social services and change behaviour of patients and dependence on the GP for issues that do not need medical intervention.
Since March 2017, GPSOs have been based in GP practices as first contact practitioners for patients' non-medical requirements. The overarching remit of the GPSO is to encourage patients to take responsibility for their own health and wellbeing.
GPSOs work collaboratively with primary care, social care, third sector organisations, public health and community coordinators.
E-Consult - e-Consult is a form-based online consultation and triage platform, providing access for medical or administrative requests and sends it through to your GP practice to triage.
This interface allows service users to digitally consult. Service users can quickly and safely get help and advice from their doctors and GP practice online, for free, from anywhere.
Care Navigation - GP receptionists are now called Care Navigators. Care Navigators are empowered to safely refer service users to the most appropriate health professional. Patients are able to access the most appropriate service in a more efficient manner. Care Navigators feel they are doing a better job for patients and making a bigger contribution to the practice.
Dermoscopy Equipment and Training - The cluster invested in Dermatoscopes and GPs from each practice 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.
To improve uptake of Bowel Cancer Screening, reduce levels of smoking and ensure patients with diabetes type 2 are managed effectively, through collaboration with our Public Health teams.
Increase the uptake of immunisation and vaccinations in conjunction with colleagues in the Local Public Health Team.
In line with Accelerated Cluster Development (ACD) the Cluster model has evolved to include each of the professional collaboratives: General Medical Services, Dental, Optometry, Community Pharmacy, Community Nursing, Allied Health Professionals and the Third Sector.
As we move forward, we will continue to develop our collaborative approach, and explore new integrated ways of working, to collectively improve the health and wellbeing of the cluster population whilst supporting primary care sustainability.
Updated 23/10/24