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Taff Ely

 
Cluster Leads: Dr. Esther Lomas, Dr Ian Morris 

Practice Manager Leads - Jayne Taylor-Lloyd, Susan Davies
Primary Care Development Manager/Cwm Taf UHB Cluster Support – Janet Kelland.  Telephone no. 01685 351483. 

Taf Ely Primary Care Cluster Services

The cluster serves approx. 93,000 patients. Taff Ely practices have a long history of working together, which the cluster now builds on.  Public Health Wales, Dental, Pharmacist and Optometrist representation along with community co-ordinator, 3rd sector and Local Authority members attend meetings to ensure multi-disciplinary working across Primary, Community and Social Care.

GP Practices
There are seven practices that operate in the Taff Ely Cluster Area.

Ashgrove Surgery 
Eglwysbach Surgery 
New Park Surgery 
Old School Surgery 
Parc Canol Surgery 
Taff Vale Surgery 
Taffs Well Surgery 

Individual Cluster Plans and Reports

Taff Ely Cluster IMTP 2020-2023
Taff Ely Cluster Network Action Plan 2017/20  

What we are working on?

Signposting patients appropriately through use of technology, websites, promotional banners and posters.  Also through joint working across primary care contractors, with community co-ordinators and voluntary sector organisations.   

Care Navigation - The Cluster have invested in training for frontline staff to allow additional skills to actively signpost patients on choices and services available to them when accessing services.  Partners include Community Pharmacies, Dentists, Optometrists, Department of Work and Pensions, Local Authority Supporting People and Merthyr and the Valleys Mind. This will provide staff with skills actively signpost patients on choices and services available to them when accessing services.  This programme will delivered through elements of on-line learning and face to face training.  

Social Prescribing – this is being developed through use of community based services and ensure these are being utilised by the population.   Specific projects include:  

Community Wellbeing Co-ordinator.  Taff Ely have recently employed a wellbeing co-ordinator to work across Taff Ely in community settings to provide health & wellbeing information, advice and support.  Some of this will be targeted in line with national and local campaigns.  They will also become the screening champion for the Cluster working in areas to improve uptake of bowel, cervical, AAA and breast screening by talking to groups and individuals, providing information and myth busting.  

Valley & Vale Art based therapy 'Breathing Space' is held once a week at a local community church Sessions include topics such as art, relaxation, photography.  

Mens Sheds – the cluster have supported the set-up of men’s and women’s shed groups, collaborating with local shednet, Local Authority, Community Co-ordinator, Public Health Wales.  This has included Walking Rugby and Football activities, garden initiatives a bowling club and canal group.  

Homeless Day - The Cluster have supported an idea proposed by one of the Pontypridd Town Centre practices in a bid to reach out to those that are homeless in the area.  The aim: to provide a ‘one stop shop’ for advice from agencies such as Citizens Advice Bureau, Safe, Barod, the Job Centre, Mind, and Hapi Project.

The event was held in St Catherine’s, Pontypridd, who provided the use of their church and kitchen to host the event. Practice staff across Taff Ely and also local businesses donated items of clean clothing and toiletries for distribution and food supplies to provide access to a breakfast and sandwich.  On the day the event was supported by the local police community officers who went around town that morning to encourage some of the homeless to join in.

The Cluster plan to hold a second event and will continue to support this initiative each winter. 

Multi-Disciplinary Meetings and collaborative working - The Cluster continue to engage with the other Primary Care Contractors and widened its membership.  This now includes community dental, optometrist and pharmacist colleagues, Social Care, Public Health Wales and also community co-ordinators to ensure 3rd sector involvement.  Multi-Disciplinary Meetings are held, outside of the main Cluster meeting, to allow a fuller discussion and support joint working and future initiatives.   The first ‘annual network event’ is currently being planned to allow primary care contractors, social care and 3rd sector colleagues to come together to network and receive information and updates on Cluster initiatives.  

What we have already done

Community Initiatives

3C’s (Companionship, Conversation and Creativity) – The Cluster have supported, through Drink Wise Age Well,  community based sessions with an aim to boost the confidence of older people, encourage new friendships, and allow individuals to find out about hobbies to help to improve their well-being creativity for participants. Once of these groups have continued to meet and are now linking with a ‘Lean, Green & Healthly Project’ in the area.  

Nutrition and wellbeing - Hapi project (Newydd Housing Association) have an established relationship with the Taff Ely Cluster.  They are now, in partnership with Parc Canol GP practice, Local Authority, Garth Olwg Lifelong Learning Centre, delivering a 10 week course providing sessions on nutrition, cooking skills, exercise, meditation and general health and wellbeing. A Parc Canol GP has set up Facebook group to provide health and wellbeing advice to interested patients.  This initiative is now being run by Hapi and Garth Olwg.  

Cluster Pharmacists 3 x practice based pharmacists have been funded for 4 years by the Cluster and have integrated well into the GP practice Multi-Disciplinary Team. All three were supported to undertake their ‘Independent Prescribing’ qualification and are all now IP trained.   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.  Specific medication reviews include: 

INR reviews

Asthma reviews

Chronic disease management

Hay fever medication reviews

Many of the practices are now directly employing the pharmacists.  

Merthyr and the Valleys Mind – A Service Level Agreement is in place and services are being provided across the 8 GP practices in Taff Ely to provide an Active Monitoring service for those suffering with mild to moderate mental health issues e.g. dealing with bereavement.

This model of MIND practitioners providing sessions from the practice base offering brief interventions for early presentations of anxiety and depression. Expected outcomes are a reduction in demand on GP appointments, reduced referral to secondary care and a promotion of multi skilled, multi agency working as well as earlier intervention and support for the patient with the aim of  preventing their condition from becoming chronic.  

Minor ailments Scheme – The scheme has now been launched in Taff Ely.   All Practices within the Clusters will promote and sign post patients where appropriate with the overall aim of ensuring patients access the most appropriate care provider in line with prudent healthcare.   

Choose Well Campaign – work continues across the cluster to ensure that this is promoted in the best way to ensure patients are choosing the right primary care and community support services.  This has included attending events such as the ‘The Big Bite – and having a presence in the Health & Wellbeing Zone’.  

Make Every Contact Count Training held by Public Health Wales has been attended by all practices within the Cluster – this approach aims to empower staff working particularly in health services to recognise the role they have in promoting healthy lifestyles, supporting behaviour change and contributing to reducing the risk of chronic disease.  All members of the Primary Care Team are involved in the training which is provided by the Public Health Team.  This has already brought about increased referrals to the ‘Smoking Cessation Services’ and ‘Joint Care Programme’.  

Staff training and education will continue to ensure that information is available to frontline staff e.g. Reception, practice nurses, advisors, GPs, Dentists, Optometrists, Community Pharmacists, community co-ordinators to direct patients to appropriate primary and community services.     Care navigation training – which provides staff with skills to inform patients on choice and access to available services.

Future priorities for the cluster

Sustaining Primary Care services, improving recruitment and retention, exploring new roles and ways of working through joint workforce planning events. 

Improving Primary Care and Secondary working to improve communication, referral pathways, discharge and care planning.

Further development of partnership working across primary care contractors and voluntary sector organisations.  This includes co-ordinated referral pathways

Patient awareness on health & wellbeing support - development of clear pathways, signposting information.

Staff skill mix and training development for primary care staff.  To improve access and range of training there will be a co-ordinated approach to opportunities across the Clusters in Cwm Taf.

To evaluate the Cluster projects and determine through a business case, where necessary, the need and ensure sustainability of services such as pharmacists, active monitoring within the GP practice multi-disciplinary team.