Response from Cardiff Third Sector Council to the National Assembly for Wales, Health, Social Care and Sport Committee consultation on Primary Care
Introduction
1. Cardiff Third Sector Council (C3SC) is a registered charity and umbrella body working to support, develop and represent Cardiff’s third sector at local, regional and national level. We have over 1,000 members, and are in touch with many more organisations through a wide range of national and local networks. We are a part of Third Sector Support Wales (TSSW) – a body of membership organisations constituting WCVA and Wales’ CVC’s; our mission is to provide excellent support, leadership and an influential voice for the third sector and volunteering in Cardiff.
2. C3SC is committed to a strong and active third sector building resilient, cohesive, active and inclusive communities, giving people a voice, creating a strong, healthy and fair society and demonstrating the value of volunteering and community action.
3. We welcome the opportunity to respond to the National Assembly for Wales, Health, Social Care and Sport Committee consultation on Primary Care. This response is structured in accordance with the eight points raised in the consultation.
4. This response is drawn together by C3SC’s Health and Social Care Facilitator from experience and knowledge of related issues through their working role, and contributions from C3SC’s Senior Management Team. C3SC promoted the consultation to members; we will confirm through Network meetings if member organisations, as is very likely, have contributed via other avenues.
Point 1. How GP cluster networks in Wales can assist in reducing demand on GPs and the extent to which clusters can provide a more accessible route to care (including mental health support in primary care)?
5. The GP clusters hold a lot of potential for reducing the demand on individual GPs and as they are maturing they appear to be responding appropriately to the needs of the local populations in Cardiff.
6. One of the Cardiff GP cluster’s held 2 health fairs in two of the GP Practices within the cluster. They overcame the issues to enable anyone from within the cluster to be able to access their flu vaccinations on the 2 days no matter which Practice they were registered with. The importance of having a nurse who covered the whole cluster was pivotal in the success due to limitations on the nurses being able to give flu vaccinations to patients from other practices, due to liability insurance. Along with flu vaccinations Health Checks were carried out and health information provided with the involvement of Public Health and the Third Sector. Information from the events and lessons learnt are being collected for sharing with the other clusters in Cardiff.
7. Sharing of more resources, such as frailty, mental health and diabetes nurses who can work across the cluster and support patients in primary care rather than accessing secondary care services. Some of the surgeries have limited space whilst others have rooms which may be available which could be used for a cluster wide service. This would involve patients registered in one Practice being able to access other Practice surgeries in the cluster. There are 2 key issues with this from a patient perspective, the first is the availability of transport to the surgery and the second is that there are different patient record systems being used in the GP surgeries. Sharing information can be more complicated as the systems do not communicate easily, having a common system used by all GPs in Wales would solve this problem and should be a national priority.
8. GP cluster networks can help in sharing expertise across the GPs, developing areas of specialism within clusters and reducing the need for GPs to have specialist knowledge in every health area. This along with sharing resources could have a positive impact for patients.
9. The GP clusters working together in partnership with the third sector can enhance the offer and prevent patients from needing to access the GP or to reduce the number of times that they need to see the GP. The third sector can complement the services and support healthy lifestyle choices.
10.There should also be an opportunity to promote health literacy through the GP clusters and local community groups that engages with the wider community and reduces the health inequalities that are dependent on where someone lives.
11.In Cardiff, the Neighbourhood areas which are Local Authority areas are almost identical to the GP Clusters. This enables more joined up and partnership working and engagement between the cluster, public health, local authority and local third sector organisations to the benefit of those who live in the areas.
Point 2. The emerging multi-disciplinary team (how health and care professionals fit into the new cluster model and how their contribution can be measured)?
12.It is important for multi-disciplinary teams to include a range of staff from all sectors, health, local authority and the third sector. There are many examples of how well this can work. In Cardiff, third sector organisations are co-located with the Community Resource Teams. This has worked well and third sector staff attend team meetings, take referrals and develop good working relationships with a range of health and social care staff. It helps to speed up referral processes and people are therefore provided with support in the community more quickly than they might be if there was no co-location.
13.It would be useful to build on this model of third sector co-location by more integration of the third sector into teams working in and out of GP surgeries. This has started in Cardiff and the Vale through a project delivered by United Welsh called Wellbeing4U, whereby Wellbeing Co-ordinators are located in GP surgeries and focus on priority areas identify by the GPs, eg increasing the uptake of flu vaccinations and screening, and signposting people to services. However, their capacity is limited and they are unable to have a presence in all surgeries, this model also requires engagement from the GPs themselves making relevant referrals.
14.The City of Cardiff Council are currently running a pilot project on a small area of the City within one of the GP clusters. They are developing a different model, engaging with the local GP Practices, Housing Associations, Care Providers and other third sector organisations and groups. If this pilot is successful then it could provide additional opportunities for the GP clusters working in partnership together and with other local services in multi-disciplinary teams and in co-location. The Council are engaged with the Cardiff and Vale University Health Board around the ‘Perfect Locality’ work and will feed in the results from the pilot to the working group.
15.All these third sector services are providing monitoring and evaluation reports which have indicated that they are effective models and are delivering real change. However, they are funded on a short term basis, some from the Intermediate Care Fund, and as such there is no guarantee about their long term sustainability.
Point 3. The current and future workforce challenges
16.Increased delivery in primary and community care especially in general practice will be dependent on capacity and will need a variety of staff, with a range of skills who have time to support patients and the public. Given the current pressures on general practice it is difficult to see how further development of primary care can happen unless there is additional resource. There is the challenge of their being enough qualified or specialist staff, whether they are nurses, therapists or GPs. The GP clusters are often competing for the same workforce with secondary care, there is an opportunity to enable personal development for staff if they are able to smoothly move between primary and secondary care or to work across both.
17.Cardiff is due to be the fastest growing ‘Core City’ of any in the UK, with an increase in population of 20% between 2015 and 2035. This means that 41,100 homes need to be built by the Local Authority in the next 10 years, these homes will require additional primary care services at a local level (Draft Cardiff Liveable City Report 2017). Additional primary care services will require additional workforce. This is a challenge that is already being discussed by the GP clusters where the developments are due to take place. The existing surgeries may have to take on additional patients until the developments are at a level where a new GP Practice or surgery is sustainable within the developments; putting more pressure on existing services and demands on the workforce.
Point 4. The funding allocated directly to clusters to enable GP practices to try out new ways of working; how monies are being used to reduce the pressure on GP practices, improve services and access available to patients.
18.The monies provide opportunities for new ways of working, some of these involve the third sector, such as the health fairs run by one cluster, or the development of wider patient engagement and participation to improve services and access to patients in another. The challenge is where the funding comes from long term. If the monies are to try out new ways of working, how can that be sustainable in the long term? Unless there is long term funding available for the proven ways of working which do not provide any savings in the first instance then they are not sustainable. This is a challenge that is faced not just by Primary Care but by Secondary Care, Local Authorities and the Third sector.
19.More could be achieved through the funding if the barriers caused by the current workforce challenges were resolved. At present time is often wasted on trying to recruit to posts.
20.There needs to be longer term funding available to enable the infrastructure change which should result in savings. The monitoring of this funding should be robust and consistent across the whole of Wales.
Point 5. Workload challenges and the shift to primary prevention in general practice to improve population health outcomes and target health inequalities.
21.Greater primary prevention in general practice will be dependent on capacity and will need a variety of staff, with a range of skills who have time to support patients and the public. Given the current pressures on general practice it is difficult to see how further development of primary prevention can happen unless there is additional resource.
22.However, primary prevention in general practice does not necessarily need to be dependent on increased GP capacity. The third sector services mentioned earlier help to relieve pressure not just on general practice, but also on other health and social care services. They need to be adequately resourced, but have proved to be cost effective and successful and are able to provide the in depth support which some people need.
23.The engagement between the neighbourhood partner members and the GP clusters in Cardiff is a key element for improving health outcomes and targeting health inequalities. Developing this relationship further may be an important element to enable the GP Practices to deal with the workload challenges caused by an increasing population and the shift to primary prevention.
24.The sustainability of GP Practices appears to be an issue across Wales, with a number of GP Practices being handed back to the Local Health Boards. Whilst currently this has not happened in Cardiff, this is something that could happen. There are also some Practices who are operating out of buildings that are not fit for purpose and therefore add to the challenges for the GPs. There are some examples of multiple Practices combining resources and sharing a new or updated building but it is unclear how the success of these is being measured, especially when there are two reception areas that cause confusion to patients and who are working as two separate entities.
Point 6.The maturity of the clusters and the progress of cluster working in different Local Health Boards, identifying examples of best practice.
25.We can only comment on the Cardiff element of the Cardiff and Vale University Health Board. There are six GP clusters and they are all at different stages of maturity, though all have made significant progress. The Local Health Board and the Public Health Team are engaged with the GP clusters and increasingly the GPs are looking at the wider communities and local services. The maturity of the clusters appears to depend on one or two key individuals, often the leads for a cluster, there is a risk that if the cluster relies too heavily on these individuals that if they move or are unable to continue in the role that the cluster will slip backwards instead of progressing.
26.City and South Cardiff GP Cluster have run the two health fairs, engaged with Wellbeing4U and developed diabetes services for the cluster to meet the needs of the diverse population who live within it.
27.North Cardiff GP Cluster are involved in the pilot being run by the City of Cardiff Council and are engaging with the local community groups to develop closer links and reach people in different ways.
28.There was a fact finding trip arranged to visit Bromley by Bow in London to see what they were doing and what could be learnt. The trip involved the Cardiff and Vale University Health Board, Cardiff and Vale Public Health Team, Cardiff GP cluster leads (or designated persons), City of Cardiff Council and the Third Sector. The group that travelled remain in contact and meet as regularly as they can to discuss options for developments and learning from best practice.
Point 7. Local and national leadership supporting the development of the cluster infrastructure; how the actions being taken complement those in the Welsh Government’s primary care plan and 2010 vision, Setting the Direction
29.The Cardiff and Vale University Health Board through its Shaping Our Future Wellbeing ten year strategy and through the ‘Perfect Locality’ work are supporting the shift in service delivery models. The sustainability and different models for GP Practices are being explored. The integration of health and social care and involvement of the third sector are all part of this development and whilst the strategy is in its infancy the involvement in Cardiff of the Local Authority and the Third Sector appear to show a desire for real partnership.
Point 8. Greater detail on the aspects being evaluated, the support being supplied centrally and the criteria in place to determine the success or otherwise of clusters, including how input from local communities is being incorporated into the development and testing being undertaken.
30.There is very little information available on how the work being carried out by clusters is being evaluated. This is an opportunity for the Welsh Government along with the Universities to ensure consistent evaluation of the different models that are being trialled across the clusters. The current short term funding system means that something that needs longer to provide results but provides better results would be overlooked for something that provides almost instant responses but in the long term has limited benefit. This could lead to waste within the system at a time of limited resources.
Additional information from C3SC
31.The GP Clusters in Cardiff are showing signs of maturity and a willingness to work in partnership with the Local Health Board, Local Authority and the Third Sector. There are many benefits to working in partnership, especially for patients and the public. There is a need for improved health literacy to help reduce health inequalities which is delivered better together than individually. In addition, different service delivery models require different approaches which working in partnership and engaging more with the local communities are able to achieve.
Contact details
If you require any further information in regards to the responses to the questions please contact Sarah Capstick, Health and Social Care Facilitator at C3SC directly via email: XXXXXXXXXXXXXXXXXXXXXX telephone: XXXXXXXXXXXX or by post to:
Cardiff Third Sector Council
Baltic House
Mount Stuart Square
Cardiff CF10 5FH