Non-Clinical Lead - Jayne Taylor-Lloyd
Cluster Development Manager – Janet Kelland.
Taff Ely Cluster is one of 8 Primary Care Clusters and geographically central to Cwm Taf Morgannwg University Health Board. It serves a GP practice population of around 95,128 with 7 GP practices, namely:
The cluster area also includes the following to provide access and services for its patient population:
Individual Cluster Plans and Reports
Active Monitoring - The cluster have continued their contract with Cwm Taf Morgannwg Mind to deliver a service for those presenting with mild to moderate mental health concerns and symptoms. This provides support and allows individuals to recognise the cause and put mechanism in place to manage and improve their mental health and wellbeing. This service is currently being reviewed to consider 1:1 counselling provision alongside active monitoring.
Healthy Lifestyles programme ‘My change, my life’ - focusses on healthy eating, cooking skills, food choices, physical exercise, healthy families and chronic condition intervention e.g. pre-diabetes.
The plan is for a nurse led service to provide support to individuals to implement lifestyle changes, using Make Every Contact Count (MECC) principles and motivational interviewing techniques, to encourage small changes and help inform patient choices to tackle obesity and improve general health and wellbeing.
Dermoscopy training and equipment - The cluster have supported purchase of dermoscopes and funding for GP training to improve identifications and diagnosis of both benign and cancerous skin lesions. This will hopefully support future developments and connections with secondary care consultants, using consultant connect and teledermatology.
Physiotherapy service - This service allows patients to have access to a First Contact physiotherapist to aid effective management of their condition. Through earlier contact and intervention it will provide better outcomes for patients, reduce the need for repeat visits and also reduced referrals to secondary care, unnecessary treatments and prescribing.
Families 2gether 4 wellbeing – Six week courses are provided by Valleys Steps promoting mental and emotional wellbeing for young people with the support of a parent/guardian. There is a mix of community sessions and secondary school based sessions being planned for this year.
Pharmacy Technicians – The cluster GP practices now have dedicated pharmacy technician time to support the practices with medicines management for patients, including medication reviews, discharges, repeat prescribing.
Frailty Nursing Service – Two Frailty Nurses have been employed to support GPs with pro-active reviews and care planning for their frail elderly patients who have more complex needs. Through assessments the Frailty Nurses will support GPs to review care plans and improve nursing care and support for patients and their families/carers to ensure that this is done in a way that they want, whilst ensuring safe, effective management of their needs at home. The nurses will link with other health and social care services.
Multi-Disciplinary Meetings and collaborative working The Cluster continue to engage with the other Primary Care Contractors and partners to widen its membership. This 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 collaboration and future initiatives.
The Cluster funded practice based pharmacists for four years 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, INR, asthma and hay fever reviews and chronic disease management. Many of the practices are now directly employing the pharmacists which demonstrates the value felt in utilising this non-GP workforce.
The Cluster invested in training for frontline staff to allow additional skills to actively signpost patients on choices and services available to them. This have now developed further with a ‘champion’ network, further choices being provided to patients and examples of advanced navigations taking place.
The Cluster have concentrated efforts on communication to ensure patients can receive information to allow them to ‘choose well’ and ‘take care of their own health & wellbeing’, this has been supported through:
The Cluster supported two morning events in a bid to reach out to those that are homeless in the area, in partnership with a community church, agencies such as Citizens Advice Bureau, Barod, the Job Centre, Mind, and Hapi Project during winter months. This project has led to employment of a Specialist Nurse role to support access to health services.
IT support for practices
Community Wellbeing Co-ordinator - Taff Ely employed, via Interlink, a wellbeing co-ordinator to provide health & wellbeing information, advice and support in the community. Some of this will be targeted in line with national and local campaigns. These roles are now employed through transformational monies and is now part of Community Health & Wellbeing Team.
The Cluster continue to be supported by Public Health Wales Specialists and will use the information and data provided in the Taff Ely population profile to inform planning, with a focus on smoking, obesity, alcohol misuse and detection and optimum management of hypertension and atrial fibrillation.
Work will also include utilising data from the PHW population segmentation tool, when this is rolled out in Taff Ely to inform targeted interventions to specific groups.
To continue to work in collaboration with the Rhondda and Taff Ely Integrated Locality Group to develop services, review pathways to support access to services for its patient population in Primary Care and Community Settings.
To develop strengthened relationships with the Community Health & Wellbeing Team MDT model, enabled by the Stay Well in Your Community Transformation Programme.
The cluster will continue to be aware of the need to consider their plans against national and local targets, particularly taking into account: