Locality GP Clinical Lead Working

1. Locality GP Clinical Lead Working Steve MacVicar A personal view of the first 7 months

2. AngleseyLocality • 66,829 residents • Above average elderly and deprivation • 11 GP practices • 11 NHS Dental practices • 13 Pharmacies 6 Opticians • 2 Community Hosptials

3. Getting to know what is involved • Listening, meeting, and reading • Visiting GP practices • Meeting members of the Locality Team, other Localities, old LHB, and BCUHB • Understanding the evolving organisational structure of BCUHB • Joining a CPG • Others

5. Well Being Activity Grant Health and Social Care and Wellbeing Strategies Health Challenge Wales Corporate Health Improvement Groups Health Challenge Anglesey Newsletter After school clubs Telecare Change for Life Keep Warm Keep Well this Winter Dragon Sports Home Fire Safety Checks Teen total Project Alcohol Resources Substance Misuse Action Team Calorific Wheels Alcohol Brief Intervention Pack for Pharmacies Year 7 Parents information Packs Alcohol Training events for Care Home carers, Home Carers, Support staff Alcohol Awareness Week Anglesey Show Healthy Challenge Wales Goody Bags Healthy Living Week Marathon Mon Cookery Classes Healthy Aging Centres Youth Clubs Change for Life resources Young People Mental Health Conference Student Assistance Programme Friends for Life Seasons for Growth Educational Plays for schools Focus on Food for Kids Workshops Amlwch Outdoor Partnership in Paddle Sports Simple but Healthy Meals on a Budget Course Capacitar in Action Carers Outreach Service Amlwch Safe Schools Cycling Sports Development Unit Brynsiencyn Community Garden and Allotment Age Concern Age Well on Anglesey Project Strategy for Older People Integrated Play Activities and Healthy Eating Programme Specialist Children Services After Schools Clubs for Disabled Children

6. No smoking awareness sessions in primary schools Smokebugs Anglesey Health Alliance Bygiau Baco Community Safety Partnership Children and Young People Partnership Continuing Health Care Dementia support Carers Support Falls Prevention Services Equipment Allocation Complementary Purchasing Reablement Intermediate Care Single Point of Access Health and Social Care Generic Support Worker Physiotherapy Occupational therapy Rapid Response Spot Purchasing Maturity Matrix PRISM EARLI Risk stratification Service Gap Mapping Local Enhanced Services MET Office weather Alerts COPD Rescue Medication Designed for Competence Ffynnon Tool Promoting Independence Health Lifestyles Chronic Conditions Stop Smoking Wales ASSIST Smoking in Public Places Legislation Telehealth CCM Community Campus Project Health and Social Care Co-ordinators Group Integrated Care Pathways Unified Assessment Document Patch MDT Advanced Nurse Practioners Heart Failure Service Exercise Referral Expert Patient Groups Look after me (LAM) programmes Self care bundles Practice Pharmacists Special Nurses Review Community Nursing Strategy Long Term Conditions Alliance Voluntary Sector Older People NSF Annual Operation Frameworks Patient stories C-card scheme Targeted outreach service for homeless Digartref Ynys Mon Community Hospitals Information kiosks Mental health Service User and Carer Involvement Strategy Salt awareness campaign MEND programme Immunisations

7. Challenges • Integration into and development of Model Mon Locality Lead Team • Engagement with Primary Care • “Improving engagement and communication at all levels and in all sectors” - across localities - with CPGs • Risk stratification, robust statistics and focusing resources • Where can I make a difference in 1 day a week?

8. Support • Model Mon / Locality Lead Team • BCUHB team: Corporate and Clinical • Old Anglesey LHB team • Practice Team, other GPs, and LMC • Other Localities • Pharmaceutical • Other sectors

10. Learning from others • Demonstrator sites - Excel spreadsheet of projects - GwionRhysManyeyes / QOF statistics - Mini-LOG / MMM / mini-LLT - MDT working • Other leads including Learning Forum, Secondary Care perspective, Mental Health, Child Health • Sharing learning through Sharepoint / Internet

13. Delivering results • Providing GP input into ongoing service delivery and development through working with colleagues in Model Mon / LLT particularly those representing therapies, pharmacy, and nurses who also input into CPGs • Piloting developments in one’s own practice (MDT meetings, Unified Assessment Form, Patient Participation group, Information booth) • Working with colleagues in CPGs, e.g. to produce care pathways or identify priority areas to work closer together

14. Delivering results: GP engagement • Annual practice visits • GP Modernisation Group - meets every 6 weeks - rotates round practices 6.30-8.30pm - one GP from each practice - Practice manager involvement • Locality meetings (QOF) • Medical Society meetings

15. GP Modernisation Group Jan-July Presentations Forum for discussion Tertiary cardiology referrals New QOF indicators Care Home enhanced service Outpatient appointments review GP involvement in MDTs Updates • Podiatry • Midwifery • District Nursing • Health Visiting • Hip / knee scoring • Gastroenterology • GUM • Other services

16. Now and the near future • Spread out proven good practice • Find out what works and what doesn’t • Develop care pathways and projects • COMMUNICATE within locality and beyond • Huge importance of linking across all sectors • Web site • Robust statistics • Risk stratification tool • Remove any constraints where possible • Focus on what is achievable