rhondda gp cluster network action plan 2014-17 · • promoting integration/better use of health,...

1 | P a g e

Rhondda GP Cluster Network Action Plan 2014-17RHONDDA NETWORK CLUSTER ACTION PLAN 2014-17

This plan has been developed by the following 16 practices which operate in the Rhondda Cluster Area, through facilitated discussion with the Local

Clinical Director and Primary care LHB Locality Management :-

• Calfaria Surgery

• Cwm Gwyrdd Medical Practice

• Ferndale and Maerdy Surgery

• Forest View Surgery

• Horeb Surgery

• Llwynipia Surgery

• New Ty Newydd Surgery

• Park Lane Surgery

• Penygraig Surgery

• Pontnewydd Surgery

• Porth Farm

• St Andrew’s Surgery

• St David’s Surgery

• Tonypandy Health Centre

• Tonypandy Health Centre (Rao)

• Tylorstown Surgery

2 | P a g e

The plan

The plan has been informed by the practice development plans produced by practices; public health information on key health needs within the area;

information provided by Cwm Taf uHB re current activity/referral patterns; an understanding of our localities baseline services (current service provision)

and identification of potential service provision unmet needs. The plan also embraces key UHB priorities for the next three years. The plan details cluster

objectives for years 1-3 (2014/2017) that have been agreed by consensus across practices, providing where relevant background to current position,

planned objectives and outcomes and actions required to deliver improvements. The plan is by its very nature fluid /flexible and evolving over the next 3

years the plan itself will be reviewed and updated in response to changes in cluster planning.

The RAG rating score indicates progress against planned action:

Red- future work

Amber- work in progress

Green – work completed.

A number of key principles underpin the plan:

• Management of variation/reducing harm/sharing good practice: in acknowledgement of the fact that healthcare must be delivered on the basis of

safety, effectiveness and efficiency, the practices have considered and analysed variation in performance and where appropriate have considered

steps by which to map standardise practice based on clinical guidelines.

• Maximising use of local cluster resources: practices have taken into account the capacity, capability and expertise that exists within primary care,

community services and voluntary/third sector services to deliver more care closer to home and reduce unnecessary demands within the acute care

services.

3 | P a g e

• Promoting integration/better use of health, social care and third sector services to meet local needs: practices have considered current

arrangements/links with RCT Council and the voluntary sector and will also consider any action plans from stakeholders that evolve over the 3 year

cycle of this plan.

• Considering and embedding new approaches to delivering primary care: this includes increased use of technology, new roles and service models

considering an embedding new approaches to delivering primary care: this includes increased use of technology new roles

• Maximising opportunities for patient participation: this includes consideration of models of good practice that exist with within/locality/cluster

and nationally and within the rest of the UK.

• Maximising opportunities for more efficient and effective use of resources: this includes consideration of current resources, opportunities to

utilise and current and new services more efficiently and effectively

Additional contributors to the plan/potential evolving contributors to the plan subject to evolution of plan

• Health and social care facilitators.

• Primary care practice managers.

• Practice Nursing and allied health professions representatives.

• Local voluntary sector providers and third sector.

• Prescribing advisers.

• Potential educator partners including third sector TEDS for brief alcohol intervention training.

• Primary Care Support Unit Nursing advisory expertise/local university school of health care re Health care assistant initiatives and informingcommunity care planning e.g. diabetes.

• Public Health

• Acknowledgements Cynon cluster plan authors re layout.

4 | P a g e

Strategic Aim 1: to understand the needs of the population served by the Cluster Network

Outline of cluster population profile

The Cwm Taf UHB population estimate in 2007 was 289.4 thousand with 233.7 thousand in the RCT locality .Approximately 10% of the population of Wales

live within Cwm Taf UHB. The UHB locality is the second smallest in Wales but the second most densely populated area (Cardiff is first). The Rhondda Valley

in recent CMO for Wales reports and based on recent Public Health Wales data is an area of high social deprivation. Due to our high deprivation status, our

population has high rates of mental health issues, long term disability/morbidity, a high rate of poverty/benefits uptake and high rates of chronic illness

from legacy heavy industry, particularly mining.

Recent CMO reports have indicated a low level of car ownership with an obvious impact on service planning. The neighbourhood has a higher proportion of

persons aged 0-15 and 30-44 than the Cardiff average. Public Health Wales indicate that our area consists mainly of most deprived and next most deprived

classifications. 34% of Cwm Taf as a whole is designated most deprived on the Welsh Index Multiple Deprivation Scale (WIMD). Within our cluster this figure

rises to 55.4% in the Rhondda.

The Public Health Observatory for Wales publications in the field of child health highlight for our locality that:

• our rate of low birth weights is significantly higher than the welsh average 1 in 15 cf all Wales 1 in 18

• the % of children (<20 years old) living in poverty is 26.6% cf all Wales 22.2%.

All Wales public health observatory data on levels of unemployment in the 16-24 yr old age group show a rate of 18.4% for Cwm Taf cf all Wales 15.7%.

With regard to our older population the data for those living alone at 43.9% is near to the all Wales average of 43%.

Our localities Black and ethnicity population data suggest an LHB rate of 1.1% lower than the all Wales average of 2.1 % which in turn is lower than

England’s data.

Finally Public Health Wales Data indicates that for Cwm Taf’s population as a whole, life expectancy is reduced by 1.5 years for males cf the welsh national

average i.e. 75.5yrs as opposed to 77 years old. Further in the 2 WIMD classifications of most deprived and next deprived (the 2 majority classifications for

our cluster area) this falls to 71.5 and 73 years respectively. Our locality has in recent years seen and will see several large scale residential developments

with obvious impacts on primary care provision planning.

5 | P a g e

Recent public health presentations to our locality identify several top challenges to morbidity and mortality:

• Malignancy (Cancer survival levels in Cwm Taf are amongst the lowest in Wales)

• Cardiovascular disease/circulatory disease

• Smoking levels

• Obesity levels

Subsequent review of Welsh statistics highlighted further areas of concern (see next page)

Data from the combined 2012-2013 Welsh Health Survey show that:

• 29% of adults in Cwm Taf reported binge drinking on at least one day in the past week, compared to 26% for the whole of Wales;

• 25% of adults in Cwm Taf reported being a current smoker with 21% in Wales reported being a current smoker;

• 27% of adults in Cwm Taf did at least 30 minutes of at least moderate intensity physical activity on five or more days a week compared with an all-Wales figure of 29%, further those in Cwm Taf reporting that they did no physical exercise in the survey was 38% compared with an all Wales figureof 34%. Those respondents classified as overweight or obese in Cwm Taf were 63% the all Wales average was 58%.

• 27% of adults in Cwm Taf had eaten five or more portions of fruit or vegetables on the day prior to the survey date compared to 33% for the wholeof Wales.

• Cwm Taf overall had statistically highlighted higher levels of mental illness, Respiratory illness, Hypertension, arthritis, and diabetes mellitus in thecombined 21012-2013 Welsh Health Survey compared with Cardiff and Vale UHB.

References: Public Health Wales’s presentations to Cwm Taf locality GP’s (power point), Public Health Wales Observatory data web site, Health of

Young Children and Young People Wales Report. Welsh Health survey reports.

The areas of concern identified by the cluster through this analysis of our cluster populations health status and needs e.g. OBESITY/OVER WEIGHT

STATUS, BINGE DRINKING/PROBLEMATIC ALCOHOL USAGE, HIGHER RATES OF CURRENT SMOKERS & its relationship to higher levels of cardiac and

respiratory illness in our cluster, LOWER LEVELS OF PHYSICAL EXERTION will be areas that we will initially address in our action plan (detailed in later

tabulated form)

6 | P a g e

No Objective Keypartners

Completion by: -

Outcome forpatients

Progress to Date RAGRating

1a Review theneeds of thepopulationusing availabledata

Local PublicHealthTeam

November2014

To ensure thatservices aredevelopedaccording to localneed

Analysis complete and outlined in detailabove, subsequently used by cluster todevelop action planning on key priorities.See above text.

1b Implementhealthpromotionsignposting andsupportmechanisms,which will helpto address:

• Obesity• Smoking• Alcohol

dependence

Ensure that

healthcare staff

maximise

opportunities to

provide health

care advice

GPs

HealthBoardPrimaryCare

3rd sectorpartners

PublicHealth

Lead GP –Dr KarenPascoe

March2017

Healthimprovements

Improved take-up bypatients in fundedservices

Increasedcollaborationbetween practicesand 3rd sector

Increasedengagement bypractices in publichealth promotion

Cluster practices feel that buy-in frompatients to improving their health / lifestylewill be increased through obtaining supporton a one-to-one basis from an individual(rather than being handed a leaflet /information from a GP).

• Practices within the cluster havearranged and attended a meeting onBrief Intervention training as well asreceiving updated information aboutwhat is available in the cluster to referto for: smoking cessation services,drugs and alcohol services, weightmanagement services, etc

• The cluster is appointing a journalistto work in partnership with theRhondda Practices to produce healthpromotion articles in the local mediato educate patients on relevant healthissues.

7 | P a g e

The cluster are appointing a screening linkperson to identify those patients who havedna’d their screening appointment. Thescreening link person will identify thereasons for the patient not attending andeducate them on the screening process withthe aim of the patient making an informeddecision on screening.

1c To identifyadditionalinformationrequirements tosupport servicedevelopment

Local PublicHealthTeam

NWIS

December2015

Improved supportfor servicedevelopment

For example, High premature cardiovascularmortality – need local Dashboard tounderstand consistency of prevention andrisk management

Action: - for development with UHB

1d To considerlearning frompreviousanalyses toidentify anyoutstandingservicedevelopmentneeds

GPPractices

UHB

2015-17 Investing manpowerin areas with provenoutcomes

Action 1: Through UHB 3 year planningprocess identify areas of shift fromsecondary to community/primary (UHB)

Action 2: Ensure all project/ newdevelopments have written in evaluationprocess to inform future servicedevelopments (UHB)

8 | P a g e

1e Training todevelop Fluchampions inthe practicesthroughout tRhondda.

GP Lead-Dr. RekhaShroff.

GPPracticeNursesReceptionistHCSW

March2016

Improve the fluvaccination uptakein patientsthroughoutRhondda.

Training sessions to be organised inconjunction with the Vaccination Lead Nursefor Cwm Taf UHB with the aim of educatingflu champions to work within the practices,share best practice with peers and providepatients with up to date, evidence basedinformation regarding flu vaccination.

9 | P a g e

Strategic Aim 2: To ensure Sustainability of Core GP Services and Access Arrangements that Meet

Reasonable Need (including new approaches to Delivering Primary Care)

Cluster practice members have considered this area already in their individual Practice Development Plans, with a range of access and sustainability issues

considered including: number of GP appointments provided, hours of services, inappropriate use of A+E, unscheduled admissions +GP Out of Hours services

by patients, DNA rates, Promoting use of technology such as My Health on Line/Texts messaging etc.

Further WAG briefing on primary care clusters also advocates use of new technology including ultimately via My Health patient access to their records

online repeat prescription ordering, online appointment booking as well as new technologies for consultation, practices are at various stages with these

developments within the cluster. In addition to practices individual development plans in this area those areas of common interest across the Cluster are

identified in this section.


For completionby: -

Outcome forpatients


2a Work withthe healthboard ondevisingsolutions forthe currentissue of GPrecruitmentandsuccessionplanning

Healthboard

Dr DavidMiller – lead

GPs asrequired

To becompleted byMarch 2017

The issue is asignificant onewithin the clusteras manypractices arestruggling to fillvacancies andreplace retiringpartners

Dr David Miller has volunteered to act aslead for the cluster on a health boardcommittee to review this issue.

As the health board has recruited to fillPCSU vacancies, these GPs may beavailable to practices across the cluster.The UHB has successfully employed anumber of PCSU doctors however due tothe increased number of managedPractices in the past 12 months limitedresource has been distributed to Practices.

The issue has also led to a significant andunsustainable increase in locum rates,

10 | P a g e

which is having a severe detrimentalimpact on those practices, which areforced through circumstances to employlocums. Note that the Cwm Taf practicemanager forum is discussing theagreement of consistent locum terms andconditions across practices to ensure thata standard of locum tasks required bypractices will be put in place (avoiding thecurrent practice of locums dictating theirown varying terms to practices). We wouldalso look to link with neighbouring healthboards to ensure regional consistency.

2b To reviewcurrentdemand andcapacity

SpecificEmphasison DNArates

Patientparticipationgroups if inplace

CHC

UHB

GP practices

Servicesdeveloped toreflect local need

The UHB currently has data availablewhich shows:

• GP face to face contact• GP telephone contact• Practice Nurse face to face contact• Practice Nurse telephone contact• All collected on a weekly basis

There is regular review of the data toinform service needs

Review of DNA rates across locality2c Establish

local datacollectionsystems tomonitor

NWISUHBGP Practices

UHBNWIS

Capacity moreeffectivelymatched to localdemand

UHB reviewing our own data to determinehow this could be presented and used toinform service development

Action via national DQS group – for

11 | P a g e

trend national development

2d To developlocalworkforcedevelopmentplans

Welshgovernment

Deanery

UHB

GP Practice

March 2017Ensure highqualitysustainability oflocal services

Actions• Establish data collection to monitor

scale of difficulty and trend• Add issue to UHB Risk Register• Utilise appropriately resources such

as PCSU for development• Recruitment campaign ‘Positive

working opportunities in the valleys’.• Cluster developing own website to

promote working throughout theRhondda Valleys.

• UHB have produced a promotionalvideo to advertise the benefits ofworking in the Rhondda Valleys andCwm Taf.

• Cluster appointing a Journalist toproduce promotional material toadvertise good work throughout theRhondda.

• The cluster to canvass thosedoctors who have worked withinpractices in the Rhondda andenquire as to why they chose toleave with the aim of identifying keythemes in the difficulties retainingGP’s in the Rhondda.

• Target schools, colleges etc ascareer choice

• Have training practices in locality wemay then be in a better place to

12 | P a g e

recruit• Influence Deanery to review options

for alternative models to increasetraining practice numbers/ spaces

• Survey study questioning final yearstudents/FY1/junior doctors relatingto career choices

2e Developfurther GPswith SpecialInterests(GPwSIs)

(Links inwith 4a and9f – seebelow)

Healthboard

GPs

August 2016 Develop animproved rangeof servicesavailable topatients withincluster practices

Practices have already submitted data tothe health board on current GP and nursespecialist interests as part of their practicedevelopment plans.

The next stages are:• Health board to identify gaps in skill

sets across the cluster• Health board to identify GPs, who

would be interested in developing asGwPSI for gap specialist areas

• Health board to review and increaseGPwSI rate and share revised payscale with practices, as current ratedoes not cover backfill requirement

• Health board to identify GPs, whocan provide training for the gapspecialist areas and facilitatetraining. This could be throughhealth board funded trainingsessions in practice, via formalobservation or by backfilling.

2f Improve GP’s March 2016 Use Vision Vision Anywhere is a piece of software that

13 | P a g e

upon qualityandtimeliness ofrecording ofpatient dataforconsultationaway fromthe practice

Anywhere toaccess andupdate patientsrecords at thetime ofconsultationwhilst out of thepractice

allows the GP to download a patientscomplete electronic medical record to ahand held device and take with them onhouse visits, nursing homes and anyconsultations that happen away from thesurgery. Medical information can beinputted onto the medical record during theconsultation so reduces additionaladministrative work and improves onpatient safety.

14 | P a g e

Strategic Aim 3: Planned Care- to ensure that patient’s needs are met through prudent care pathways,

facilitating rapid, accurate diagnosis and management and minimising waste and harm.


Forcompletionby: -

Outcome forpatients


3 To ensure eachnursing home has aquality serviceprovided by adedicated GPresource whichshould in turn freeup some muchneeded capacity

Equalisation ofpatients betweenpractices!Development of newLESRestructure anddifferentiateEMI/Residential

GPPractices

UHB

NursingHomes

December2016

• Continuity ofcare

• Morededicatedaccess

• Improvedquality

Action: Develop proposal and engagewith all GP’s and Nursing homes.

Current LES does not facilitate thechange of current working practices.Under review by UHB.

The Rhondda Cluster has proposed thepurchase of Vision Anywhere to allowaccess to patients medical records awayfrom the practice premises. This willgive the GP access to the patientscomplete medical history to supportthem in making decisions whilstconsulting with the patient.

15 | P a g e

Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needsand to support the continuous development of services to improve patient experience, coordination ofcare and the effectiveness of risk management


Forcompletion by: -

Outcome for patients Progress to Date RAGRating

4aOpen responsiveaccess todiagnostics,especially Echocardiograms(links in with 2e –see above and 9f– see below)

UHB

PrimaryCare andSecondaryCare

GPpractices

July 2016Faster access toinformation to aiddiagnostics andtreatment

Reduced anxiety due toshorter waiting period todiagnosis

Actions:• Explore purchase of ‘cluster’

ECG as part of developinglocalised diagnostic servicesOr

• Work with Acute UHB Dept toconsider alternative pathway toachieve objective

4b PADs

Public Defibs – 8defibs in theRhondda

RCT100 project

aims to provide 8

PADS in RCT.

The team

includes Welsh

Hearts Charity,

GPs, Welsh

Ambulance PADS

GPPractices

UHB

Lead GP –Dr BobBaron

March2016

Background.

1. Premature cardiac

deaths in RCT are the

highest in Wales which

itself is one of the

highest in Europe. RCT

has approx 50/100.000;

Cardiff 30 & Wales 40

(Cwm Taf Public Health

Team study

2009/2011).

Aims :-

1. Raise awareness, funds, skills &

training in RCT communities.

2. Recruit stakeholders including GP

practices, local chemist, businesses,

schools & community organisations to

publicise & recruit support with posters,

leaflets & simple fund raising initiatives.

3. Persuade WAG & UHB to prioritise,

support & develop an integrated

strategy for PADS in Wales.

16 | P a g e

& First

Responders,

Communities

First Teams,

local councillors,

fund raisers &

patient rep.

groups

2. Approximately 8000

cardiac deaths occur

outside hospital per year

in Wales.

3. Welsh Ambulance,

first responders & GPs

are already stretched &

cannot possibly provide

timely responses to

every cardiac arrest in

Wales.

4. Welsh Ambulance

PADS team consist of 2

people to cover Wales

which is woefully

inadequate.

5. There is no integrated

strategy for PADS as

yet; merely a piecemeal

& patchy provision.

6. PADS team are

developing a database

but as yet haven't

mapped the current

provision, location,

Actions:

• Raise awareness with all primarycare contractors through sendingthe posters for display at eachpractice

• Support dissemination ofinformation from the lead GP BobBarron on an ongoing basis

• Encourage practices to supportfundraising events as appropriate

• Dr Bob Barron to update regularlyat cluster meetings highlightingactivities practices could engagewith

• UHB to share information onUHB website, regular articles inUHB newsletter, support on goingcommunications with local media,

• Identify and provide a linkPrimary Care developmentmanager to attend meetings andrepresent the cluster

• Rhondda Cluster will support thisinitiative through providingfunding for 8 AED’s to bedistributed to areas of prioritythroughout the Rhondda.

17 | P a g e

ownership, maintenance

or training for existing

AEDs & PADS.

4c Early detection ofLung Cancereducationalevents.

Lead GP-Dr. GaynorThomas

PracticeManagerLead ClareJohnson.

GP’sPNPharmacistHCSW

March2016

Raise awareness of

presenting symptoms in

order to improve upon

early detection of lung

cancer

To organise educational meetings to be

attended by Gp’s Practice Nurses,

Pharmacists and Health Care Support

Workers and highlight the various

symptoms that patients present with in

relation to lung cancer.

To promote the use of Significant Event

Analysis within practices as a tool for

positive reflection.

To date there have been two training

sessions completed and a third session

is proposed for 2016.

Strategic Aim 5: Improving the delivery of end of life care


Forcompletio

Outcome forpatients


18 | P a g e

n by: -5a All Practices in

the Cluster toanalyse theirpalliative carepresentations2014-2015 QOFyear anddisseminatelessons learntand educationalneeds identified(see Appendix 1below)

LHB

IndividualClusterPrimaryCarePracticeTeams

End March2016

Lessons learntfrom practiceanalysis of casesof palliativecare/end of lifecare analysedduring QOF year2014-2015 fedback into servicedevelopment andeducationaldevelopment whenrequired

All Practices in the Cluster engaged on inpractice QP work on SEA of end of life carepresentations as per nationally agreed QPwork

5b Considereffective analysisat practice levelof end of life careand palliativecare registers

Macmillanlocal charityfundedresources

ClusterPractices

LHBresources

Third sectororganisations

March2016

Improved adoptedof EOL carepathways will leadto improved EOLcare for patients

• Implement an EOL care checklist acrossthe cluster, to ensure that all elements ofthe pathway have been considered andaddressed, where appropriate, for apalliative patient

• Target early involvement by Macmillanstaff in the care of palliative patients –measure to be agreed with Macmillanteam

• Implement a communication skillsframework (to be developed incollaboration with Macmillan staff) acrossthe cluster for GPs to use whendiscussing EOL care with palliativepatients, to ensure that GPs are using

19 | P a g e

appropriate communication techniques• A template has been developed and

distributed by Macmillan GP to practicesin order for them to record end of lifecare in a consistent manner.

General guidance is available on Cwm Tafhealth board intranet. Discuss with healthboard replicating this advice on the GPportal and ensure that this includes usefulphone numbers / websites

5c Continue QOF2014-2015individual clustermembers practicepalliative careteam meetings

IndividualClusterPrimaryCarePracticeTeamsDistrictNursingRepresentatives andPalliative

Ongoingindividualpracticework

Case reviewpatients identifyproactive end oflife planning forindividuals andadvice refuture/additionalmanagement ofthe individual.Lessons learnedfor individual

Continues in progress every QOF year

20 | P a g e

care teamrepresentatives

patients will benefitand inform futurepatients care.

Strategic Aim 6: Targeting the prevention and early detection of cancers


Forcompletionby: -

Outcome forpatients


6a All Practicesin the Clusterto analysetheir cancerpresentations2014-2015

LHB

ClusterGP’s andCLUSTERprimary

End March2016

Lessons learnt frompractice analysis ofcases of canceranalysed duringQOF year 2014-2015 fed back into

All Practices in the Cluster engaged on inpractice QP work on SEA of cancerpresentations as per nationally agreed QPwork.

Completed in 2014/2015, work ongoing for

21 | P a g e

QOF yearanddisseminatelessons learntandeducationalneeds

Care HealthTeams

servicedevelopment andeducationaldevelopment whenrequired

QOF 2015/2016.

22 | P a g e

Strategic Aim 7: Minimising the risk of poly-pharmacy


Forcompletionby: -

Outcome forpatients


7a Identify and

report the

number /% of

patients aged

85 years or

more

receiving 6 or

more

medications

(see

Appendix 2

below)

Lead GP ineach clusterpractice

LHBpharmacyadvisoryteam

End March2016

Decrease thepotential formedicationinteractions/morbidityby reviewing themedications currentlyprescribed againstpatients currentmedical conditionsand changes incondition relatedprescribingpractice/guidelinesi.e. optimisemedication andcondition.

Undertake face to face medication reviewsusing the NO TEARS approach or similartool for at least 60% of the cohort definedabove. Use the agreed read code forpolypharmacy review. All practices in thecluster are committed to completion of thiswork by end March 2016

Work was completed for 2014/2015. Allpractices in cluster using Polypharmacymedication review onto patients recordsonce review completed.

Work is ongoing for 2015/2016

23 | P a g e

Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance


Forcompletionby: -

Outcome forpatients


8a Engage witha robustvalidatedclinicalgovernanceprocessspecificallydesigned withClusterplanning inmind

Individualclusterpractices

PublicHealthWales

End March2016

Allmeasures/proposalsoutlined andassessed in avalidated all walesclinical governancetool

Clinical Governance Practice SelfAssessment Tool(CGPSAT) each individual cluster memberwill be entering their areas of responsibilityinto their PDP’s (practice developmentplans) and CGPSAT.

Aspiration level 4/5 maturity on CGPSAT recluster network work.

The cluster has now developed a GPSATworking group. The aim of the group is tosupport each other in developing policesand procedures and undertaking identifiedtraining.

24 | P a g e

Strategic Aim 9: Other Locality issues

No Objective Key partners Forcompletionby: -

Outcome forpatients


9a Practices toreceive robustand timelydischargeAdvice Letters(DALS)

UHB – PrimaryCare andSecondary Care

Lead GP – DrIan O’Sullivan

Improved quality ofcareReduced risk due totimely informationreceived by practice

• Highlighted as key risk toUHB

• Process in place within UHBfor reviewing

Action:• Poor DALS to be forwarded

to UHB• Electronic solution being

progressed• Training of all relevant staff in

Secondary Care as a priority• Feedback at cluster meetings

by Ian O’Sullivan• There are three wards

currently who can transmittheir discharge summarieselectronically to practices.

9b DecreaseAntibioticPrescribing byone third withincluster

GPUHB pharmacyteam

March 2016 Reduction ofresistance incommunity

Action:• All practices to agree to do

an audit in antibiotic use andshare this with the cluster

25 | P a g e

9c Ensure allelderly and atrisk housebound patientsreceive a timelyflu vaccination

UHBGP practice

March 2016 Protection againstinfluenza

• Agreement by District NurseLeads to prioritise this clientgroup through the DistrictNurse resource - written(email) confirmation to eachpractice of this support beingprovided

• Practices to identify cohort ofpatients

• Review of uptake at end ofimmunisation process

• District Nursing service wereinvolved with vaccinating thepatients in Nursing homesthis year.

9d Targetedidentificationand interventionfor cardiovasculardisease

GP practice

UHB

NWIS

September2016

• Fasteridentificationof risk

• Swifteraccess tosupport andadvice

• Reduction inthe possibilityof developingchronicdisease

Action:• Utilisation of Inverse Care

Funding monies to supportthe development of HealthCare Assistants to supportlife style issues with patients

• Work with NWIS/INPS toestablish software for riskstratification

26 | P a g e

9e Better access tophysiotherapyservices – in-house withshorter waitingtimes

GP practiceUHB – PrimaryCare andPhysiotherapy

Lead – MrDerrick Fishwick

September2015

Timely qualityintervention toreduce pain andlonger term MSKproblems

Actions:• Influence the UHB therapy

service to review currentposition

• Explicit needs of patientsexpressed via GP’s

• New service specification tobe negotiated

• Feedback at cluster meetingby Mr Derrick FishwickThe Manager of the therapiesdepartment has attended theRhondda Cluster meeting todiscuss the current issuesidentified by the Rhonddacluster with relation to currentwaiting times for patients tobe seen. . The cluster awaitan update from therapies onhow the pilot in the Cynonhas been evaluated and whatdevelopments in service areproposed for Rhonddapatients.

9f Identify andbuildrelationshipswithconsultants,who are willingto run clinics inprimary care

Primary andsecondary care

September2016

Knowledge and skillsharing betweensecondary andprimary care willresult in improvedpatient care andimprovedcommunication

As a consequence of the Healthboard sponsored COPD project withGSK, Dr Paul Neill has carried out anumber of COPD clinics with leadGPs and practice nurses in anumber of participating practices.

It would be beneficial to identify

27 | P a g e

(links in with 2eand 4a – seeabove)

channels other clinical areas and consultants,who would be prepared to put inplace a similar arrangement.

Dr. Sanjeet Rao is currently in talkswith Dr. Neil along with GP input onhow we can develop a COPDservice out of YCR, the identifiedcluster hub.

28 | P a g e

Appendix 1Lessons learnt from practice analysis of cases of palliative care/end of life care

No. Key issues Actions

1 The template used was felt to not be clinically relevant Suggest re-write

2 Entering patients on the palliative care register - some

practices noted that they were unclear on the point at which

patients should be entered and also that the register tends to

predominately represent patients with cancer rather than

patients with end stage dementia or chronic diseases such as

COPD.

Some practices felt that read-coding to distinguish between

care home patients and community based patients may help

co-ordinate care better, but others felt this would not make any

difference to quality of care delivered.

Explore inclusion of non-cancer patients on the

palliative care register (in conjunction with district

nurses and palliative care nurses, nursing home

staff)

Work closely with nursing homes on the palliative

care of patients with end stage dementia , in

collaboration with palliative care nurses to create a

joint approach

3 Identifying whether the patient had had a DS1500 form

completed was often difficult

Read code DS1500 completed in records

4 Where patients are attended by district nurses or palliative care

nurses or are residents in care homes, care plans produced are

sometimes not shared with GP practices (either for reference

for the patient’s care or after death, for audit purposes). These

plans contain information that is not otherwise documented in

the patient’s record.

Implement mechanism to ensure end of life care plan

is available to all healthcare professionals attending

a patient. This could be via shared palliative care

record

5 There is sometimes a lack of co-ordination in the Establish communication framework between

29 | P a g e

communication process with the patient and family members

between health care professionals i.e. district nurses, palliative

care nurses, GPs. This results in the risk of difficult questions

and conversations being duplicated at what is a very difficult

time

healthcare professionals to ensure that

communication with a palliative patient is planned,

shared and documented in order to avoid duplication

and upset. This could be via shared palliative care

record.

6 Some practices routinely discuss all deaths on a regular

(daily/weekly) basis and identify and act on learning points

Consider implementing regular discussion of all

deaths within practice to identify and act on learning

points

7 Some practices found that elements of the Integrated Care

Pathway (ICP) tool would be more appropriately undertaken by

a healthcare professional, who has more regular contact with

the patient e.g. palliative care nurses – for example patients’

spiritual, physical and social needs, or pastor / priest on

spiritual matters

Multidisciplinary approach to holistic care of patient

8 Most practices found that the care of the majority of patients

reviewed had followed the majority of the end of life care

guidelines. There were however some exceptions, where care

and communication could be improved.

Increase use of Just in Case boxes at an earlier

stage in the patient’s condition

Discuss agreement to implement a standardised

prescription form, pre-printed with Just in Case

medication

Ensure that the OOH palliative care handover form is

used for all appropriate patients, establishing

guidance on when it should be used

Ensure that nominated GPs are allocated for each

30 | P a g e

palliative care patient as lead

Discuss with palliative care / advanced care planning

nurses how to give family members more support in

order to avoid last minute 999 calls

9 After death procedures e.g. bereavement counselling, letters or

phonecalls from the GP – is there anything that could be

applied consistently? Also ensuring all members within the

practice are aware of the death.

There are voids sometimes when a patient dies in the

community and the practice is not informed of the death.

Importance of speaking to family after death

highlighted.

Communication within practice re deaths of patients

e.g. notice board

Lynne Shaw to contact Coroner’s office to see if any

procedures for informing practice of patient deaths

possible

Appendix 2

31 | P a g e

Lessons learnt from practice analysis minimising the risk of polypharmacy

No. Key issues Actions

1 Most practices felt that undertaking polypharmacy medication

reviews was beneficial and that there should be a pro-active

approach to reviewing the medication of elderly patients. All

practices felt they were already effectively undertaking this work

but that the reviews presented an opportunity to review those

patients who might not always attend surgery for face-to-face

medication reviews. Practices received positive feedback from

patients regarding the reviews and the opportunity to discuss

concerns about their medicines. It was felt that awareness of

polypharmacy was raised.

Build on existing processes to aid continuous

improvement e.g. identify and address any barriers to

ensure continued engagement by all practices.

2 Practices noted that the NO TEARS tool in a 10 minute

consultation was inadequate to perform the medication review

as they are time consuming, and modified the tool accordingly.

Discuss whether this is the preferred method of

undertaking polypharmacy medication reviews and

whether it can be made into a template in Vision.

Would primary care funded research into this area be

useful?

3 It was suggested to have the NO TEARS or STOP/START

review system “template” in the computer system, though not all

practices felt this was necessary.

Further discussion how this could be implemented

and whether this is an effective method to share

across the cluster.

4 Most practices suggested the role of the UHB prescribing

advisors should support this work as their current work is mainly

perceived as cost saving.

Secure funding for pharmacist funding / engage with

UHB

32 | P a g e

5 Polypharmacy reviews were time-consuming, particularly for

housebound and care home patients. New residents in care

homes are often allocated to practices after long stays in

hospital, and there was a feeling that their medications should

have been reviewed during their stay. They also are allocated to

practices with very little information sent with them.

Liaise to ensure comprehensive clinical handover of

patient when being discharged from hospital to care

home. Is this a role for the Care Home Support team if

funded?

There was a suggestion to explore an integrated IT

system for Care Homes and GP practice patients,

though issues about clinical governance and data

protection were raised by other practices

6 There is often lack of information about secondary care follow up

for care home patients, particularly in mental health areas

Ask for more information and improve communication

from secondary care. Is this possibly a role for the

Care Home Support team if it is funded?

7 Other issues were often identified from the polypharmacy

reviews incidentally e.g. falls risk, frailty, weight loss and need

for dietetic input, hearing issues, need for ophthalmology follow

up

Act on incidental findings as necessary

8 Clinical themes identified: dementia patients on anti-psychotics,

diuretics with no indication, long term treatment doses of PPIs,

AF patients on aspirin, overuse/inappropriate use of laxatives,

anticholinergic burden of drug regime.

Interventions to target each of these areas as

necessary.

Other particular suggestions: putting warning on

ACEI, NSAIDs and diuretics stating not to take if

diarrhoea and vomiting symptoms to reduce risk of

AKI.

33 | P a g e

Appendix 3

Lessons learnt from practice analysis of understanding cancer care pathways

Introduction

Lung and digestive system cancers are the leading cause of cancer deaths in Wales. Cancer also widens the gap in life expectancy

between the lower and upper socioeconomic groups of the population. Unfortunately the gap is widening. Whilst there is major work

being undertaken in Wales to prevent, diagnose and treat cancers i.e. initiatives to encourage healthy behaviours and increase

uptake of screening programmes, there is still room required for improvement in early detection of lung and digestive system

cancers as well as effort to prevent such cancers . Services need to be developed in all parts of Wales to close the gap between

most and least deprived communities.

The Rhondda has some of the highest incidences of cancers, and poorest survival in the whole of the UK. There are many reasons

for this including (1) high prevalence of all the major risk factors e.g. smoking, obesity, alcohol, etc, (2) late presentation of

symptoms (3) vague presenting complaints (4) late recognition by GP and (5) delays in secondary care, etc. All these factors need

discussion and suggestions for improvement at each stage in order to reduce risk of cancer and improve earlier diagnosis.

Discussions of each area will be ongoing over the next year within the cluster and link in with secondary care, Public Health and

third and voluntary sectors will occur.

Aims

In order to support the delivery of the Cancer Delivery Plan

1. Practices are expected to carry out a significant event analyses of newly diagnosed lung cancers (including mesothelioma),

and digestive system cancers including stomach cancer, liver cancer, pancreatic and bowel cancer between 1st January and

31st December 2014.

34 | P a g e

2. To summarise learning and identify appropriate actions for inclusion in the Practice Development Plan

3. To propose actions for the GP Cluster Network Action Plan where appropriate

The information provided by practices regarding their reviews of these newly diagnosed cancers from January 2014 - December

2014 has been used to inform this report. The findings are summarised below, along with suggestions for improving earlier

diagnosis to be discussed on an ongoing basis at future Cluster Meetings.

Some of the suggestions to try and improve earlier detection of cancer are based on work that has been done using the QCancer

risk tool. For further information, Practices are encouraged to review:

https://www.google.co.uk/search?q=Q+risk+lung+cancer&oq=Q+risk+lung+cancer&aqs=chrome..69i57j69i60l3j69i59.13687j0j8&so

urceid=chrome&es_sm=122&ie=UTF-8

and http://www.qcancer.org/

Lung cancer

In summary

1. Many lung cancers are picked up incidentally on cxr

2. Patients that were symptomatic and diagnosed with lung cancer tended to have cough for more than 6 weeks.

Some had copd but not all.

Most of the patients diagnosed did have other co-morbidities eg diabetes, ischaemic heart disease. Evidence suggests that

comorbidities besides copd and risk factors besides smoking are associated with an increased diagnosis of lung cancer.

35 | P a g e

Solutions for earlier diagnosis

Whilst smoking is a well established major risk factor for lung cancer, a significant proportion of cancers develop in non-smokers,

and not all long term heavy smokers develop lung cancer suggesting that other factors play an important role.

Evidence suggests that age, deprivation, previous diagnoses of other cancers, previous pneumonia, family hx of lung cancer and

asbestos exposure increase long term risk independently. Red flag symptoms eg haemoptysis, loss of appetite, dyspnoea, cough

may herald existing condition of lung cancer.

1. One solution would be to combine all these factors into a risk prediction algorithm to help clinicians better assess and

prioritise patients at high risk of lung cancer. This has been done in the form of the Q lung cancer algorithm to include age,

haemoptysis, appetite loss, weight loss, cough, body mass index, deprivation score, smoking status, copd, anaemia and

prior cancer. This could identify those patients at highest risk for early referral and investigation.

a. This could be done through an electronic template in GP clinical systems which is displayed when a red flag symptom

is recorded in the patient’s record. This template could then help structured data entry of other related symptoms

including significant negative findings. An approach could also be based on a risk estimate derived from the new

algorithm which might include the possibility of a spiral CT or referral for a high risk patient even in the presence of a

normal chest xray

b. Risk scores could be automatically calculated for every patient aged 30 – 84 years registered with a practice by

running a programme within the clinical computer system. This could then generate a rank ordered list of high risk

patients who need to be recalled for further assessment or investigation.

36 | P a g e

Colorectal cancer

In summary from practice reviews

1. Iron deficiency anaemia seems to pick up a significant number of bowel cancers.

2. Some of the bowel cancers had negative bowel screening.

3. PR bleeding, diarrhoea, weight loss, altered bowel habit also seem to be common presenting signs of bowel cancer

4. Patients tended to have multiple co-morbidities

Solutions for earlier diagnosis (http://www.nice.org.uk/guidance/cg27/chapter/1-recommendations#lower-gastrointestinal-cancer)

1. Research shows that overall rectal bleeding has a positive predictive value. Current UK referral guidelines suggest that

patients over the age of 60 with persistent rectal bleeding with or without associated bowel symptoms should be referred for

urgent investigation.

2. Practices noted that patients presenting with diarrhoea and constipation symptoms were both associated with cancer.

However neither symptom on its own warrants urgent investigation unless associated with other symptoms eg weight loss,

pr bleeding, change in bowel habit, and also depending on the patients age so anyone over the age of 60 with at least 2

symptoms including diarrhoea or constipation should be investigated for bowel cancer

3. Abdominal pain has also been shown to be associated with colorectal cancer particularly if accompanied by pr bleeding.

Serious consideration should be given to the possibility of cancer with abdominal pain and no clear diagnosis. This would

include asking about other symptoms, performing abdominal and rectal examinations, and testing of faecal occult blood and

haemoglobin. Positive findings of these would suggest referral for ix for colorectal cancer.

4. Iron deficiency anaemia is associated with bowel cancer. Even haemoglobin in the range 12 – 12.9 is associated with bowel

cancer particularly when symptoms are present. Research suggests that all patients with iron deficiency anaemia with

37 | P a g e

symptoms should be urgently investigated unless other causes can be excluded eg menorrhagia in women of child bearing

age, chronic kidney disease etc. There was some discussion in the cluster about use of ferritin versus iron store testing for

further investigation of anaemia and a learning need was identified and the following resources identified to help:

http://www.bsg.org.uk/pdf_word_docs/iron_def.pdf and http://cks.nice.org.uk/anaemia-iron-deficiency

5. Negative bowel screening does not exclude bowel cancer, several patients within the cluster had had negative bowel

screening but presented with a gastrointestinal cancer later. However, screening also picked up several bowel cancers in

asymptomatic patients. If a patient is symptomatic and/or has iron deficiency anaemia and had a negative bowel screening,

they should be urgently referred

Gastro- oesophageal cancer / stomach cancer (http://www.nice.org.uk/guidance/cg27/chapter/1-recommendations#upper-

gastrointestinal-cancer)

In summary patients who had oesophageal cancer were found to

1. Have presented (sometimes asymptomatically), and found to have iron deficiency anaemia on investigation

2. If symptomatic, have presented with worsening reflux, dysphagia and weight loss

Solutions

In order to identify upper digestive system and gastric cancers

1. A simple algorithm has been developed based on age, smoking, dysphagia, haematemesis, abdominal pain, weight loss

and anaemia to estimate absolute risk of a patient having gastro oesophageal cancer in primary care

(http://www.qcancer.org/)

38 | P a g e

2. This algorithm could potentially be used to identify those at highest risk of gastro-oesophageal cancer in order to facilitate

early referral and investigation.

3. In order to facilitate this the algorithm could be incorporated into a web calculator within consultations, with individual

patients presenting with new onset dysphagia, haematemesis etc. The results can then quantify risk which can be used

to inform urgency of further investigations. This web calculator could also be used by patients to prompt appointments

with their GP.

4. It was noted that the current template for referral for gastroscopy is outdated, and is too rigid, meaning many potential

upper gastrointestinal cancers may be missed/picked up late as patients do not fit the criteria for “urgent” referral.

5. The waiting lists for urgent and routine outpatient gastroscopies were also noted to be long and increasing.

Pancreatic Cancer

No pancreatic cancers had been diagnosed from the Practices that had sent in their reviews. Pancreatic cancer is often diagnosed

at an advanced stage partly because symptoms at presentation are vague and non-specific, unless accompanied by red flag

symptoms of weight loss and abdominal pain. Little is known about the natural history of the disease which makes it very difficult to

screen for.

1. A new algorithm has been suggested which predicts the chances of having pancreatic cancer based on a combination of

symptoms and baseline risk factors eg age, chronic pancreatitis , smoking and diabetes (http://www.qcancer.org/)

2. The algorithm also incorporates alcohol status, loss of appetite, weight loss, abdominal pain, dysphagia and constipation

and has been shown to quantify absolute risk of having pancreatic cancer (http://www.qcancer.org/)

a. Other symptoms noted to be associated with a higher risk of pancreatic cancer eg vomiting, nausea, fever, dyspepsia,

backache and depression could also be taken into account during a consultation.

39 | P a g e

3. The algorithm could be used as part of a simple web calculator which could then prompt symptomatic patients to consult

their GP. This algorithm could be integrated into GP computer systems and used to generate a list of high risk patients who

could then be recalled and systematically assessed so that early referral and investigation can be facilitated.

4. Pancreatic cancer is twice as likely to occur in patients with type 2 diabetes than those without it. Ideally all cases of newly

diagnosed type 2 diabetes should be reviewed to assess whether these patients have had upper and lower gastrointestinal

symptoms .

5. All practices should do the RCGP free e-learning module on pancreatic cancer to improve confidence in diagnosing this

disease: http://elearning.rcgp.org.uk/course/info.php?id=103

Hepatocellular Cancer

There was one patient who had hepatocellular cancer in the reviews, found incidentally. The patient had been asymptomatic, and

the only abnormality had been a mildly raised alkaline phosphatase on a routine blood test carried out 4 months prior to diagnosis.

Along with lung, pancreatic and gastro oesophageal cancer, a new algorithm could be developed based on combination of

symptoms and baseline risk factors eg alcohol, hx of hepatitis, non alcohol steatosis. Incorporated in this algorithm could be

symptoms of abdominal pain, weight loss, dysphagia. All this information could be inputed into a calculator which would help

quantify risk of this disease and then help determine whether such patients should be referred urgently for investigation

Summary

1. Some of the cancers eg lung , pancreatic, can present incidentally and atypically. The risks of having these cancers can be

assessed using a Qrisk calculator which is available on EMIS computer systems but not VISION, however, the online tool is

available at: http://www.qcancer.org/

40 | P a g e

QCancer has been validated as a tool to help healthcare professionals try to improve the earlier detection of cancer and should

only be used in conjunction with clinical judgement based on history and examination. It has been validated for use in improving

detection of 6 cancers: lung, kidney, gastro-oesophageal, colo-rectal, pancreatic and ovarian.

2. Should we routinely use cancer markers e.g. CA125, CEA, CA199, although these are screening tests would they help to

inform GP’s along with symptoms and other blood investigations.

The use and usefulness of these tests in terms of predictive value in a primary care setting remains to be validated in many cases.

However, this would open up a useful discussion with secondary care colleagues regarding development of potential pathways for

earlier cancer identification.

3. Careful history taking and disease pattern recognition is important in those with multiple co-morbidities and mental health

problems.

4. Timely review of patients presenting with non-classical or vague symptoms is important, to review natural history of the

presenting complaint.

5. Regular case-based practice meetings should be held to discuss difficult cases so that consensus can be reached on which

investigations are required.

6. Regular practice reviews and discussion of all patients newly diagnosed with cancer is good practice to identify learning

points.

41 | P a g e

7. It is important that patients should be educated on red flag symptoms.

8. Improving screening uptake within the population must be addressed and variation at practice level of screening rates should

occur to try to reduce the variation

42 | P a g e

Action plan

Objective

no.

Date Action Responsible Status

1a November

2014

Review the needs of the population using public

health data

Local public health

team

1b March

2017

Implement health promotion signposting and

support mechanisms utilising the NUMED

information system, cluster communications

officer, 3rd sector and Public Health.

Practices

UHB

3rd Sector

Public Health

1e March

2016

Improve upon the flu uptake in patients throughout

Rhondda through flu champion training

Practice

Jane Williams Imms

lead

2a March

2017

Work on developing a plan to devise solutions for

the GP recruitement and retention issues facing

Rhondda practices

Dr. David Miller

leading for Rhondda

Cluster

2b March

2017

To review demand and capacity and review DNA

rates across the cluster

Practices

2d March

2017

To ensure high quality sustainability of local

services through implementing the plan devised in

2a. By using the comms officer to promote the

Rhondda

Upskilling staff

Practices

UHB

2e August

2016

Through actions already demonstrated for 2a & 2d Practices

UHB

2f March2016 Implement the use of Vision Anywhere throughout Practices

43 | P a g e

the cluster

3 March

2017

Develop a proposal on Nursing homes/care

homes . LES currently under review by UHB

Practices

UHB

4a January

2017

Faster access to information to aid diagnostics

and treatment. Work with acute UHB dept to

consider alternative

Practices

UHB

4b July 2016 Fund 8 AED’s and training in their use throughout

the Rhondda

Welsh Hearts

Cluster

4c March

2016

Organise educational meetings to educate the

practice team and local pharmacists in early

Detection of lung cancer

Dr. Gaynor Thomas

March

2017

Complete review of prevention and early detection

of cancers and include actions in practice

development plan

Practices

5a March

2016

Complete review of end of life care and include

actions in practice development plan

Practices

5b March

2016

Analyse are at practice level for end of life care

and palliative care registers

Practices

District nurses

Macmillan nurse

Third sector

Local authority

5c March

2016

Individual practices to undertake case reviews and

feed into practice development plan

practices

6a March

2016

All practices to feedback into cluster plan lessons

learnt at practice level

Practices

7a March

2016

Complete review of minimising risk of

polypharmacy and include actions in practice

development plan

Practices

44 | P a g e

8a March

2016

Complete CGPSAT tool at practice level and

include actions in practice development plan

Practices

9a August

2016

Continue to take part and feedback into the pilot

project that is currently ongoing

Public health

Practice managers

9c March

2016

Immunise elderly and at risk housebound patients District Nurses

Practices

9d September

2016

Take part in Inverse Care Law programme Practices

9e November

2016

Monitor Physiotherapy services. Invite Physio to

feedback to cluster on new model for delivering

physiotherapy.

Practices

9f March

2016

Build relationships with consultants who are willing

to run clinics in primary care and consider how

this can link in with the proposed cluster hub work

GPs

UHB

rhondda gp cluster network action plan 2014-17 · • promoting integration/better use of health,...

Documents