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Taff Ely

 
Cluster Leads: Dr Victoria Whitbread

Non-Clinical Lead - Jayne Taylor-Lloyd
Cluster Development Manager – Janet Kelland.   

Taf Ely Primary Care Cluster Services

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 95,000 with 7 GP practices, namely:

Taff Vale Practice
Ashgrove Surgery
Egwlysbach Medical Practice
Old School Surgery
Talbot Green Practice
Parc Canol Practice
Taffs Well Medical Centre

The cluster area also includes the following to provide access and services for its patient population:  

  • 21 community pharmacies  
  • 13 Dentists
  • 9 Opticians
  • Community Groups and services represented Interlink
  • Local Authority – social care services

Individual Cluster Plans and Reports

Taff Ely Primary Care Cluster IMTP 2020-2023
Taff Ely Cluster Annual Delivery Plan 2021-2022
Taff Ely Cluster Network Action Plan 2017/20  

What we are working on?

Pharmacy Technicians  - The cluster have four technicians working across the GP practices to allow dedicated time and support to practices with medicines management for patients and project work. 

Frailty Nursing Service - Two Frailty Nurses continue to support GP frail elderly patients with pro-active reviews and care planning.  The Frailty Nurses work with the patient, their families and carers to carry out assessments, review care plans to allow safe, effective management of their needs at home.   The nurses will link with other health and social care services as needed.   They now also work with Optometrists who provide the Low Vision Service, to support with patients at risk of falls due to their eye sight.

The Frailty nurses also support specific pieces of work, namely a chronic conditions/winter pressures project, where through population segmentation data searches were able to identify those at risk of having their health conditions and wellbeing affected due to fuel poverty, potential of cold homes and inability to access warm food.  Individuals were contacted to ensure they are linked in with the best suited support and services. 

First Contact MH assessments Employment of MH practitioner time in each practice allows receptionists/care navigators to book someone directly with the practitioner for assessment.   Practitioner will refer, signpost patient to  the right service and support.  This allows

  • Improved referrals to MH services across Primary Care, Secondary Care and 3rd sector organisations. 
  • Collaborative working to develop 'simpler' and 'clear' pathways.
  • Dedicated resource to ensure patients are booked in most appropriate cluster funded services commissioned from Mind and therefore better engagement.

Cluster Safeguarding group - Taff Ely Group of GP safeguarding leads & other interested clinicians to meet quarterly and form a peer group of experts.

This will allow learning and development through presentations that are then shared back in practice by lead and also opportunties to:
- share protocols and best practice and ideas
- discuss complex safeguarding cases in a supportive, challenging & confidential environment.
- will encourage working together in other ways, facilitating cluster development.
- allow multidisciplinary approach, with attendance from a range of professionals including Safeguarding Specialist Nurses, Social Services, Domestic Violence experts (IRIS), Health Visitors & solicitors.

ADHD community support group - The cluster have supported a pilot project targeted at those with ADHD.  Valleys Steps will provide community support through psychoeducational/self-help courses for those dealing with ADHD.  Work continues to implement and evaluate and determine ongoing resources.

Red Cross community integration and resilience support - Monitoring & evaluation of the pilot to expand the service in Taff Ely for adults 18+ with dedicated resource to support 1:1 and group sessions.

Young person social prescriber/youth worker role - A part time link worker (social prescriber) for young people has been employed to ‘mirror’ the adult wellbeing co-ordinator roles.  This provides a trusted person, in trusted spaces to have conversation and get the support young people need to help them manage their mental health & wellbeing out in the community rather than needing to always look for health interventions.

Managing Women's health & menopause - To help manage demand on services this initiative is being developed to provide improved advice, awareness, support and treatment for women health & menopause in Primary Care.

Through joint working and support between Primary & Secondary Care clinicians and service, this year plans are focussing on:

  • Education sessions / lifestyle support for patients
  • Practice nurse and health professional educational sessions
  • Identified GP 'specialists' across the cluster following  IMPART training
  • Interactive educations sessions for clinicians who manage menopause
  • Specialist advice and guidance email support for GPs
What we have already done

Cluster Pharmacists - 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. Most of the practices now directly employ pharmacists which demonstrates the value felt in utilising this non-GP workforce.

Care Navigation - The Cluster invested in training for frontline staff to allow additional skills to actively signpost patients on choices and services available to them. This \developed further with a ‘champion’ network, further choices being provided to patients and examples of advanced navigations taking place.

Community Development include:

  • Arts based therapy sessions ‘Breathing Space’.
  •  Healthy Lifestyles – a programme where sessions are delivered on nutrition, cooking skills, exercise and general health and wellbeing. 
  •  Mens Shed - The cluster have supported development of sustainable community groups. This has included walking, rugby, football, garden initiatives, bowling club and canal group, Dewi Sant Men’s Shed. This project was shortlisted for the NHS Wales Awards 2019.

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 a media company to allow:

  •  Taff Ely Cluster website development
  •  More targeted use of social media

Support for Homeless and Vulnerable Adults - Following cluster support for events in a bid to reach out to those that are homeless in the area, during winter months a Specialist Nurse was employed to support access to health services.  This role now works across Cwm Taf Morgannwg and the work has supported development of an Outreach Service, via Local Authority and Area Partnership Board funding bids to bring together health, housing, social care and third sector agencies to address the treatment and support needs for individuals who reside in temporary accommodation, “Housing First” services and those in supported housing that are at risk of losing their tenancy because of their health needs.

Community Wellbeing Co-ordinator - employed, via Interlink, a wellbeing co-ordinator provides health & wellbeing information, advice and support in the community. These roles are now employed through other funding streams and part of Community Health & Wellbeing Team.

Future priorities for the cluster

Weight management support for young people - Work with Public Health Wales to explore data and information available will allow the cluster health professionals to start a mapping exercise and build a picture on needs of the practice population.

Health & wellbeing pathways, information and awareness - for all Primary Care Contractors to ensure signposting information, skills and pathways are available to Optometry, Community Pharmacy and Dental.

Marginalised & Vulnerable Groups - Targeted Population Health support in harder to reach groups / more deprived communities

Improving services and access to quality assessments for those with Learning Disabilities - The cluster will continue to be aware of the need to consider their plans against national and local strategic plans and targets.

 

Updated 25/07/2023