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Rhondda

 
Cluster Lead: Dr Bikram Choudhary 

Practice Manager Lead – Lindsey Sandhu

Primary Care Development Manager/Cwm Taf UHB Cluster Support –Caitlin Jacob   Telephone 01685 351341

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

Public Health Wales, Dental, 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.

General Practices
There are twelve practices that operate in the Rhondda Valley Cluster area.  Two of the practices are directly managed by Cwm Taf UHB.

Forest View Medical Centre 
New Tynywydd Surgery 
St. Davids Surgery 
Llwynypia Surgery 
St. Andrews Surgery  
Dewinton Fields Surgery 
Penygraig Surgery 
Pont Newydd Medical Centre 
Tylorstown Surgery 
Maerdy/Ferndale Surgery 
Park Lane Surgery 
Cwm Gwyrdd Surgery 

 

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 Valley Cluster Network Action Plan 2017/20 

What are we working on?

Care Navigation the Cluster have invested in training for frontline staff to allow 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, 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 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 order to facilitate improved collaborative working, representatives from the pharmacies in the Rhondda meet together before the main cluster meeting to discuss issues which are relevant to the cluster, including cluster priorities and projects. An update from the Rhondda community pharmacy forum is now a standing agenda item at the main Primary care cluster meetings. The Cluster Pharmacist Forum has been in place in the Rhondda since November 2019. In this short time we are already seeing benefits in terms of greater collaboration and improved relationships. This has been recognised by CPW as a positive step in terms of collaborative working.

Cluster Pharmacists. The Cluster continue to fund 5 FTE pharmacists to work in practices.  Included in the work is poly pharmacy / patient medication reviews which could be by telephone, face to face, in care homes and for housebound patients.  Many of the practices are now directly employing the pharmacists.

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.

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. Grow Rhondda format has been revised to allow referrals from third sector partners. The group is based within gardens at the local community hospital, thus improving the environment for patients and staffThe group have also set up a Facebook page to share gardening tips and support each other outside of weekly sessions.

Joint Working with Third Sector. The Rhondda Cluster have strong links with three Well Being Co-ordinators who are based in GP Practices on a rota basis. The role of the Wellbeing Co-ordinator is to signpost patients to services within the community to support them in addressing any issues affecting their health and wellbeing

   What have we already done

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.

Active Monitoring MIND Active Monitoring (AM) is a self-directed psycho-educational programme made up of 5 face to face interventions over an 8 week period with a total of 2.25 hours of face to face support. The service was offered to people presenting to GPs 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.

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

Educational sessions for GP's Nurses and Community Pharmacists on the presenting symptoms of Lung Cancer.

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.

HCSW and Nurse Up skilling. The cluster has undertaken a review of the skills of their Health Care Support Workers (HCSW) and Practice nurses and developed a training plan to upskill staff in line with Prudent Healthcare

Developed Flu champions within each practice to promote flu immunisation to patients

Recruitment and Retention project.  This piece of work has now been completed. The final report has been circulated throughout the cluster and there has been a discussion on the outcomes and a plan has been developed to action these.

First Contact Physio. The cluster piloted having a physiotherapist based within 2 GP practices to see patients presenting with an acute MSK problem.  The aim of the pilot was to test having other health care providers working in the practice as part of the primary care team.  The results were very positive on the impact that having a physiotherapist within the practice had on access.  There are now 4 practices who have a physiotherapist working in the practice on a regular basis with other practices currently exploring the model.

   Future priorities for the Cluster

We have identified the following key areas to prioritise for 2020 - 2023 in order to improve outcomes for the future health and wellbeing of our population:

Obesity

Five Healthy Behaviors

Mental Health

Chronic Pain

In addition:

To support the sustainability of General Practice and other Primary Care services.

To improve Primary Care and Secondary Care communication, referral pathways, discharge and care planning.

To further develop partnership working across primary care contractors and voluntary sector organisations.  This includes co-ordinated referral pathways

To increase patient awareness on health & wellbeing support – including self-help resources, signposting information and the development of clear pathways.