National Primary Care Conference - Clusters: past, present and future: Cluster ‘Yearbook’

Cluster background:

South Pembrokeshire Cluster Network serves a population of approximately 54,000 in a mainly rural environment with 99.1% of the Cluster population living in an area classified as rural, with high deprivation in one urban area (Pembroke Dock). The Locality is a busy tourist destination where the population of some towns can double in size during the holiday periods and also has a steady influx of visitors throughout the year. The area is a popular retirement location, which contributes to the higher than average number of over 65’s and 85,s. The Locality hosts many popular sporting events all year around e.g. Iron Man, and the county is home to Pembrokeshire Coast National Park.

Cluster contact details: GP Lead: Dr Mackintosh:

Primary Care Locality Development Manager: Lucie – Jane Whelan,

Who are we and where did we come from?

The South Pembrokeshire Cluster was formed 7 years ago and originally consisted of 6 practices, now 5. In 2016 the two Narberth Practices merged together, and there is one Health Board managed practice (Tenby Surgery). The Cluster consists of representatives from all 5 GP Practices, Local Authority, Public Health Wales, the Health Board, third sector, WAST, Community Pharmacy, Optom, and Dental.

What we have done. Our key achievements. Why we are great!

Cluster Occupational Therapists (OT) – The Cluster has invested in 2WTE occupational therapists since 2016. These OT’s have tailored provision in response to the Cluster population needs and utilize aspects of the Anticipatory Care Plans (ACP) approach, a process designed to support individuals living with a chronic long-term condition, to help plan for an expected future change in their condition. Patients are receiving a timely ‘one stop assessment’ at home, alongside proactive early intervention supporting self-management and making referrals for ongoing rehabilitation with the Community Team where appropriate. Patients and their families, who have been previously assessed by OT’s, are appropriately requesting to follow-up with the OT’s, rather than a GP. The project was nominated for an NHS Wales Award 2019 and has been presented at the National Primary Care Event. The next step is for the project to be extended into the North Pembrokeshire Cluster as part of Hywel Dda’s Transforming Clinical Services.

OT Fit Note Project – The successful deployment of OTs in the Locality has been a factor in the selection of South Pembrokeshire GP Cluster for a high-profile Department of Work and Pensions Research project in partnership with Royal College of Occupational Therapists (RCOT) and University of Nottingham. This project will examine the effectiveness of an OT vocational clinic in primary care setting (OTVoc) to support people to return to and stay in work and improve health and wellbeing.

Outreach Nurse for the Elderly (ONE) - This project seeks to identify those patients in care homes and the community at the greatest risk of inappropriate/avoidable admission, using baseline health checks at home provided by a nurse practitioner. The role has been instrumental in engaging with care homes and the community. The ONE links in with the multi- disciplinary working, and is trained to provide flu vaccinations, Advance Care Plans and DNACPR.

Healthy Lifestyle Advisor - The role of the Healthy Lifestyle Advisor is to manage a caseload of clients who require support to make changes their lifestyle to improve their health. The Healthy Lifestyle Advisors have targeted community settings, such as businesses and school settings with staff. The project has been well received and has empowered clients. The Healthy Lifestyle Advisors have been linking in and signposting clients to third sector organisations and Community Connectors.

Social Worker - This is a joint project with the Local Authority and is funded on a 50/50 share basis between the South Pembrokeshire Cluster and Pembrokeshire County Council. A practice-based Social Worker links in with the MDT working and to joint work with the embedded Cluster OT. The project has been well received so far and is part of the vision of Transforming Clinical Services roll out across the whole Pembrokeshire Locality.

Advance Care Planning –The Cluster has continued to fund Advance Care Plans via the third sector, the Paul Sartori Foundation. In 2019/2020 this project was joint funded as a whole Locality approach with North and South Pembrokeshire Clusters, County Team and Secondary Care.

Pembrokeshire Counselling Service- the service will provide confidential, short term (6 sessions) of one-to-one counselling to adults, aged 16 upwards, with mild to moderate mental health issues. PCS is an early intervention and preventative service.

Cluster Physiotherapist - The Cluster is investing in a MSK Physiotherapist, due to start September 2019. The physiotherapist will work alongside the GP as a first point contact practitioner for their MSK patients. The potential value and impact of extending this approach to service delivery is significant. Physiotherapists seeing patients at an earlier stage when they first present with a problem, enables prompt treatment for the patient. This is the next step for the Locality, with a multi-disciplinary team approach across the 5 practices.

What’s next?

The Cluster is considering a number of projects, including
• A Youth Mental Health resilience service.
• Long Term Conditions Assistant Practitioner working with Advanced Nurse Practitioners to reduce demand on the ANP / CNS team, and reduce the risk of increased GP and OOH attendances. The South Pembrokeshire Cluster is working with the HDUHB “a Healthier Mid and West Wales” Programme and working in partnership with the Locality to ensure the County’s Transformation proposal.





My Health Online

My Health Online is a service provided by National Wales Health Informatics Service that allows you to access your practice online. My Health Online includes a number of optional features, including:

  • Checking, booking and cancelling appointments.
  • Checking your medication and ordering repeat medication.
  • Updating your contact information, including mobile phone number and email address.
  • Sending messages to your practice, so avoiding the need for a phone call for routine enquiries.

Your practice may not offer all these features. Ask your practice which ones are available.