Cluster Fund 2015-16

Needs and assetsDo you really know your population and the assets in your communities? Can you explain this to others? See Paper 1 Summary of population health information

Paper 2 Quick guide to need and assets

What can Clusters do?Can you separate out what the contribution of Clusters (and Locality Leadership teams) could be? It helps to think what is in your control and what is in your sphere of influence, as these can be put in your Plan and become ideas for local delivery that could attract funding and resources. These do not need to be led or delivered by GP Practices as the Cluster acts as a mechanism to identify needs and solutions for their community.

Source: Professor Chris Bentley

For example: Increasing referrals to CAHMS service with long waiting times Area of concern: increase across UK in number of children and adolescents referred with mental health and

behavioural problems Area of influence: raise concerns with Health board and actively engage with service providers to find better

solutions Area of control: review root causes of increased referrals, share ideas with partners, explore alternative local

solutions and assets, set up local services e.g. parenting support groups with Third Sector

Priorities1. National

a. Improving access and qualityb. equitable accessc. skilled local workforce

2. BCUHB Operational Plan All Cluster Plans to have actions to address population health needs All Clusters to have measurable improvements in at least two health improvement areas Increase access to LARCs in primary care and improve numbers of women in vulnerable groups

accessing LARCs

Achieve all immunisation targets Achieve smoking cessation targets

3. LSBa. What is in your local authority LSB Plan?

4. Public Health See Paper 3 BCUHB Prevention and health improvement priorities

a. Early years (LARCs to reduce unwanted pregnancies, healthy pregnancy with reduced smoking/

alcohol and improved mental health, breastfeeding and parenting support, childhood vaccination programs

b. Risk factors (Shared decision-making, smoking cessation, staying in good work, alcohol brief intervention, falls prevention, obesity and physical activity)

c. Inequalities in health outcomes (strategic population approach to tailor mainstream services to need, income maximisation support, population approach to vascular risk identification and management,

d. Enablers Connecting NHS with community assets, partnership with LAs and Third Sector, all frontline health and social care workers to use “teachable moments” for health and well being interventions, social prescribing to wellness services and community assets, shared decision-making with motivational skills

What are we trying to achieve?The funding application asks you to define your outputs and outcomes:OutputsOutputs are descriptions of change as an immediate result of your activities e.g. increasing the knowledge and skills of practice nurses in the Cluster in identifying patients at high risk of falls through a training program. OutcomesThe outcome statements also indicate a change which should follow from the change specified in the output statements. Several outputs may contribute to an outcome. E.g. practice nurses in all Cluster practices correctly identifying patients at high risk of falls and referring to a falls prevention service.

It may be helpful to also define what your overall goal is, although the form does not ask for this:GoalThe goal refers to the overall change to which your project will contribute e.g. a reduction in falls in the target group of patients with maintained health, well being and independence. The goal is usually achieved by contributions from more than one partner and enables everyone to see what the common goal is and what their particular contribution to it could be.

Menu of some ideas

Inequalities in health outcomes1. Vascular risk identification and management - Assessing and managing CVD risk is important, as CVD is a

major cause of mortality and morbidity across Wales. Health services can make an important contribution to the reduction of health inequalities through the identification and effective management of CVD risk factors. A plan to stratify and prioritise those likely to be at higher risk is the most cost effective way to address CVD risk management and is essential to reduce health inequalities. There is new guidance on how to develop a systematic approach to identify and manage unmet need and establish agreed pathways for future risk management. See Paper 4 CVD Management Cluster Guide and

Paper 5 risk management flow chart

Early years2. Immunisation: childhood and adult Plan across one or more Clusters to increase uptake of all vaccinations

through innovative delivery e.g. employ nurses on sessional basis to vaccinate at home/ community venues, explore technology for reminders and marketing etc. There are Action Plans for Clusters and Practices, so if any Cluster would like to invest in innovative approaches to go above and beyond these, we can develop pilots in consultation with the Immunisation Coordinator and Public Health team

3. Teenage pregnancy. Set up a project to coordinate access to sexual health advice, and contraception for all young people in area to ensure all primary and community teams are participating in the C Card scheme, giving out condoms and raising awareness. All young people to have access to LARCs quickly and easily and locally ( e.g. some Practices providing for all). See Papers 6 and 7 examples for Conwy and Flintshire as separate docs under GPOne Betsi Cadwaladr HB Cluster Fund Support April 2015

Risk factors4. Smoking cessation See Paper 8 Smoking Cessation

GP Cluster funding could be utilised to support the development of further Intermediary Smoking Cessation Capacity via a specific training package which would include the following steps:

o Commitment to access and pass online training modules via the free National Centre for Smoking Cessation and Training (NCSCT) programme. This requires approximately a whole day to complete, and can be done in sections.

o Following completion of the modules, commitment to release staff for a 1 day face to face training which would include familiarity with cessation clinical governance, data collation and reporting, CO monitoring, Brief Intervention scenario practice, NRT product overview etc

o Commitment to purchase CO monitors and calibration equipment, if not already available (monitors approx £120 each)

o Commitment to collate and report data on smokers supported to quit, including regular follow up and CO monitoring – in line with standards.

5. Falls preventionThere is good evidence that falls are preventable in older people. The NICE Guidelines for Falls (2014) recommend Multifactorial Risk Assessments (MRA) and subsequent Multifactorial interventions, with a particular focus on exercise which improves balance, strength and confidence. The North Wales Falls prevention project, which started in 2012, has developed evidence based multiagency service models for preventing falls and related injuries in 3 main settings, namely older people living in their own homes, in care

homes, and those in hospital. There are gaps in each county in implementing this model, and also extending to nursing homes and follow on from the formal falls exercise classes. (see Paper 9 summary with information by county)

5. Social prescribing is defined as “a means of enabling primary care services to refer patients with social, emotional or practical needs to a range of local, non-clinical services, often provided by the voluntary and community sector.” Social prescribing is usually delivered via primary care – for example, through exercise on referral or the book prescription scheme. Other opportunities could be for physical activity, weight management, learning new skills, volunteering, mutual aid, befriending and self-help, arts and creativity, as well as support with, for example, employment, benefits, housing, debt, legal advice, or parenting problems. The public health team is interested in setting up a pilots for an information/ referral Hub, linked to a SPOA, in particular for social isolation. Please contact us if you are interested and we can work together

6. Atrial fibrillation case findingThe Specialist Medicine CPG has put this in the BCUHB 1 Year Plan: “Screening for AF in Primary Care, to establish workstream , establish clear Task and Finish Groups, business Case for North Wales Arrhythmia Service and submit full business case to HB PMO” In case any of you are thinking of doing similar and we are in danger of duplication

7. Primary care mental health. Mental health issues take up a high proportion of GP workload and are very common in people with long term conditions: mental health and physical health are deeply entwined. Access to talking therapies is evidence based but we are not sure how good, or equitable, access is across North Wales, for instance via the Primary Mental Health workers or Third Sector services such as Parabl. If anyone is interested in a model based within GP Practices, there are examples see Paper 10 example from Cwm Taf (that was not implemented)

Enablers1. Lifestyle Behaviour Change

There are different levels of Brief Intervention (BI) that could be available for different staff groups, depending on their roles and levels of contact with patients within Primary and Community Care. Brief Intervention and MECC training packages See Paper 11GP Cluster MECC

2. Shared learning pilot with secondary care. Evidence on effective referral management methods is strongest for formal managed shared learning between primary and secondary care clinicians. See Paper 12 Torfaen pilot and

Paper 13 shared learning proposal for COPD

3. Community Health Workers embedded in primary care team. This model has been developed in North Wales by a group including Bangor University, the London School of Hygiene and BCUHB and several GP Practices have expressed an interest. The concept has not really been tried in the UK : a lay health workers is embedded within a GP Practice and serves a neighbourhood rather than a target group with particular condition or age group. WG Communties First proposed funding but this has not been agreed and the proposal has not progressed but the idea is there if anyone wants to try. See Paper 14 CHW Pilot Summary

4. GP Cluster Health Intelligence Unit: recruitment of additional staff to create a small unit whose job it would be to work with other staff in the Health Board, Public Health Wales, Local Authorities and Third Sector to provide health needs assessment support to the 14 clusters across North Wales and to assist them in pulling together their cluster level action plans to tackle healthy inequalities etc

6. Sharing service provision Extended role pharmacist: medication reviews for polypharmacy, smoking cessation, social prescribing for health improvement HCA smoking cessation, social prescribing for health improvement