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:
First Contact Physiotherapy - Cluster and Health Board collaboration and joined up physiotherapy service, which are providing first contact physiotherapists working in GP practices to provide early assessment and intervention for patients.
First Contact Mental Health Assessments - Employment of mental health practitioner time in each practice allows receptionists/care navigators to book someone directly with the practitioner for assessment. The practitioner will refer, signpost the patient to the right service and support. This allows:
Mental health and wellbeing support for young people - To provide early assessment and support to young people. Referral/signposting of young person and potentially the parent/guardian to an appointment to provide support and understand feelings, what they can do, what services and support is available to them.
Weight management support for young people - The cluster have worked with Public Health Wales and Dietetics to implement a families approach to healthy lifestyles, weight and physical exercise. They have introduced the PIPYN project to support families and children in the community and schools environment.
Health and 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 and vulnerable groups - Targeted population health support in harder to reach groups/more deprived communities. The cluster have funded a role with Valleys Ethnic Minority to support ethnic minority individuals in accessing local services - health, social, community activities, employment, careers advice.
Improving services and access to quality assessments for those with Learning Disabilities - The cluster are working with Improvement Cymru to act as a cluster to test change of the electronic health assessments. This work has:
Supporting those living with Dementia - a number of elements of this project set out to provide improvements for clinical and community access pre and post diagnosis support.
ADHD community support group - The cluster 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. This will now be rolled out across Cwm Taf Morgannwg with longer term funding via the health board.
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. This will now be continually implemented as part of the HEIW learning and development.
Pharmacy Technicians - The cluster employed 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 Services - 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 patients at risk of falls due to their eyesight.
The Frailty nurses also support specific pieces of work, namely a chronic conditions/winter pressures project, using population segmentation data searches to identify those at risk of having their health conditions and wellbeing affected due to fuel poverty, the potential of cold homes and inability to access warm food. More current pieces of work include proactively working with sheltered accommodation providers to engage with their residents.
Cluster Safeguarding group - The Taff Ely Group of safeguarding leads and 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 opportunities to:
Young person social prescriber/youth worker role - A part time link worker (social prescriber) for young people employed to 'mirror' the adult wellbeing co-ordinator roles. This provides a trusted person, in trusted spaces to have conversations and get the support young people need to help them manage their mental health and wellbeing out in the community rather than needing to always look for health interventions.
Managing women's health and menopause - To help manage demand on services this initiative is being developed to provide improved advice, awareness, support and treatment for women's health and menopause in primary care. Through joint working and support between primary and secondary care clinicians and service, this year plans are focussing on:
This continues to be supported and developed with more recent discussions around women's health hubs.
Close working with the health board on commissioning and service provision in primary and community settings to support the patient population closer to home, with early intervention and aim to avoid deterioration and better 'self' management of conditions e.g. First Contact Physiotherapy, mental health assessments and support.
Consideration of population health need an d links with colleagues and partners to ensure projects and priorities are planned accordingly, including public health, regional partnership and through development of accelerated clusters to work on a locality (pan cluster) level.
Updated 30/10/2024