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Cluster Lead: Dr Bikram Choudhary 

Practice Manager Lead – Lindsey Sandhu

Community Pharmacy Cluster Lead – Gareth Hughes

Cluster Development Manager– Caitlin Jacob   

The Rhondda Primary Care Cluster serves approximately 89,000 patients.

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

There are 11 practices in the Rhondda Primary Care Cluster area:

Cwm Gwyrdd Medical Centre
De Winton Field Practice
Forest View Medical Centre
Llwynypia Surgery
Ferndale / Maerdy Medical Group Practice 
Park Lane Surgery
Penygraig Surgery
Pont Newydd Medical Centre
St. Andrew’s Surgery 
St. David’s Surgery
Tylorstown Surgery

Ferndale Medical Centre is directly managed by the Health Board.
Individual Cluster Plans and Reports

The whole of the cluster is involved in developing the Cluster Plans through making suggestions, discussing and planning new development, which is generally done in the cluster meetings.  The Cluster Leads write up the Cluster Plan on behalf of the Cluster.

Rhondda Cluster IMTP 2020-2023
Rhondda Primary Care Cluster Annual Delivery Plan 2021-2022

Rhondda Valley Cluster Network Action Plan 2017/20 

What are we working on?

MIND Blended Active Monitoring and Counselling service
This innovative MIND model is designed to create a seamless pathway from GP referral to an assessment to determine whether Active Monitoring or a Therapeutic Intervention (Counselling) is most suitable.  The service is offered to people presenting with a range of symptoms associated with common mental health problems such as anxiety, mild depression, stress and worry and low confidence and self-esteem. The service began remotely on 1st October 2020 due to national Covid “lockdowns” and is now moving to a blended virtual and face-to-face model with a presence in GP Practices.

MSK First Contact Physiotherapy
From 2021 all GP Practices in the Rhondda have access to refer patients to a First Contact Physiotherapy service within their premises to aid earlier contact and effective management of MSK conditions.

Healthy Weight
Cluster staff, primarily HCSW’s and nurses are undertaking the Agored Cymru accredited Level 2 Community Food and Nutrition Skills course to cascade evidence based, consistent food and nutrition messages to patients.

Care Navigation
The Cluster have invested in training for frontline staff to develop additional skills and knowledge to actively signpost patients to the most appropriate service available to them.  Partners include Community Pharmacies, Optometrists, Physiotherapy, Interlink (Wellbeing Coordinator), Staying Well at Work (local authority service) and Social Services Single Point of Access.

Rhondda Docs Website and Social Media Sites are used for recruitment and sharing information on cluster projects and public health messages.

Rhondda Radio Education Messages
The cluster are working with a local radio station to have regular messages broadcast voiced by two GP’s, a GP Practice Receptionist and a Pharmacist in the cluster to promote “we are here for you”, “please be kind to our receptionists”, “NHS 111” and “common ailment scheme” messaging.

Slimming World on Referral
The Rhondda Cluster have purchased Slimming World Vouchers that can be given out by GP’s, Practice Nurses and other health professionals to patients who meet the eligibility criteria (BMI 35 and above). The voucher entitles the patient to 12 weeks free attendance at a Slimming World group.

The Rhondda Cluster have purchased Hospify communication platform licenses to improve communication across GP Practices and Community Pharmacies.

Rhondda Cluster Pharmacy Forum
The Rhondda Cluster has a large number of GP Practices and Community Pharmacies (12 and 27 respectively). Accommodating Cluster meetings whereby each GP Practice and community pharmacy could have a place at the table, as well as optometry, dental, third sector and local authority, was proving a challenge. In 2019, in order to facilitate improved collaborative working, representatives from the pharmacies in the Rhondda developed the Pharmacy Forum. They meet together before the main cluster meeting to discuss issues which are relevant to the cluster, including cluster priorities and projects.

In 2021 the Community Pharmacists in the Rhondda have been developing and completing a short course with Bowel Cancer UK to encourage conversations with patients around spotting early symptoms and testing.

Joint Working with the third sector. The Rhondda Cluster have strong links with three Well Being Coordinators who are part of the Community Health & Wellbeing Team. The role of the Wellbeing Coordinator is to signpost patients to services within the community to support them in addressing any issues affecting their health and wellbeing and was previously a cluster funded role.

The Cluster have recently worked with Versus Arthritis to arrange education sessions for professionals and patients.

   What have we already done

Cluster Pharmacists
The Cluster continues to fund 5 FTE pharmacists to work in practices.  Included in the work is poly pharmacy and patient medication reviews. Many of the practices also directly employ pharmacists.

Grow Rhondda
The Cluster developed an 8 week gardening programme for patients who are experiencing Isolation, Mild anxiety or Mild depression, in collaboration with Men’s Sheds Treorchy. The group is based within gardens at the local community hospital, thus improving the environment for patients and staff. The group have also set up a Facebook page to share gardening tips and support each other outside of weekly sessions.

Nursing/Residential Home project
The cluster have rationalised the number of GP practices that visit any one nursing or residential home.  By allocating a home to just one or two practices, depending on the number of residents, the cluster has improved communication between the GP and the home who are now dealing with less GP practices and variances in systems, such as ordering repeat prescriptions.

Parkrun Practices – In a partnership between RCGP and Parkrun UK, practices are encouraged to develop close links with their local parkrun. All practices in the Rhondda have signed up to become Parkrun practices.

Appointment of a cluster communications officer to promote working and living within Rhondda.

Staff training – As well as Care Navigation training, administrative staff have undertaken Workflow Optimisation, Summarising, Medical Terminology and Read Code training on a cluster basis.

   Future priorities for the Cluster

To work with the Health Board to develop a Chronic Pain Management MDT.

To utilise population segmentation and risk stratification data to decide how best to use limited time and resources to deliver anticipatory and pre-emptive care for patients.

To develop strengthened relationships with the Community Health & Wellbeing Team MDT model, enabled by the Stay Well in Your Community Transformation Programme.

To work with the Regional Partnership Board to develop new models of integrated Health and Social Care that are innovative and address regional priorities.

To continue to work in collaboration with the Rhondda and Taff Ely Integrated Locality Group to develop services and review pathways to support access to services for patient populations in Primary Care and Community settings.


Updated 20/08/2021