The Welsh NHS Confederation response to the Health, Social Care and Sport Committee inquiry into primary care.

Contact: Nesta Lloyd – Jones, Policy and Public Affairs Manager, the Welsh NHS Confederation.

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Date: 29 January 2017

Introduction

1. We welcome the opportunity to contribute to the Health, Social Care and Sport Committee inquiry into primary care. Primary care is vitally important to our national health service and we must recognise the range of professionals who are part of the primary care service. Primary and community care encompasses a range of services including, but not exclusively, GPs, general practice nurses, pharmacy, dentistry, specialty clinics, optometry, community and district nurses, midwives, health visitors, mental health teams, health promotion teams, physiotherapists, occupational therapists, dietitians, speech and language therapists, podiatrists, phlebotomists, paramedics, public health teams, rehabilitation teams, social workers, other local authority staff and all those people working and volunteering in voluntary organisations which help meet the health and well-being needs of people in our communities. This inquiry is timely to highlight the significant work that is being done and the developments in primary care sector across Wales.

2. The Welsh NHS Confederation represents the seven Health Boards and three NHS Trusts in Wales. The Welsh NHS Confederation supports our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work. The Welsh NHS Confederation and our members would be more than happy to provide further information to Members of the Committee.

Overview

3. As changes in demographics and our lifestyles have resulted in a dramatic rise in demand on the health and care services, it has become increasingly clear that a transformation in the way treatment is delivered is required if the NHS is to meet the needs of a future population.

4. We know the demand for primary care services continues to increase, with about 19 million patient contacts a year. Primary care continues to represent the significant majority of NHS patient contact and primary care acts as a gateway to a range of other services, especially referring patients to acute services. The development of primary and community services is a fundamental part of the Health Boards’ clinical service strategy, “Changing for the Better”, and the National Primary Care Plan for Wales has created a welcome catalyst to accelerate the changes needed to create a more sustainable health and social care system across Health Boards.

5. As highlighted, primary care encompasses a range of professions and GPs themselves increasingly recognise that they need and want to be part of that wider primary care team. That will mean the role of primary care changing, where they will be providing services for the more complex patients and co-ordinating the wider primary care team. Over the years there has been greater integrated and multi-professional services across communities in Wales, and they have been created around the 64 Clusters.

6. The multi-professional service that primary care encompasses is clearly highlighted in the “Our Community: Ten actions to support primary care in Wales”[i] document that the Welsh NHS Confederation’s Policy Forum has developed. The document, submitted as part of our evidence and endorsed by over 30 health and social care organisations in Wales, highlights what is required to ensure a sustainable primary and community care sector. This includes encouraging the development of a long-term vision for primary and community care services, with social services and cross-sector organisations working in partnership to deliver integrated, person-centred care closer to home and the investment required to achieve this.

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)

7. A range of Cluster models are emerging across Wales to suit different geographic, professional and patient populations, ranging from GP led Clusters to multi-disciplinary teams. Allowing different models to evolve, whilst ensuring standardised outcomes and governance frameworks, appears to be effective in reducing demand on primary care services. The Clusters, and the more formal Cluster models e.g. federations, have led to stronger practitioner commitment to transformative change and new ways of working across Wales.

8. While a there are a number of developments and initiatives, demand on primary care continues to be high. Clusters have a key role to play in re-shaping the response to demand through identifying training needs and opportunities at a very local level and identifying local gaps in the service. Most gaps in the health service ultimately lead to problems “falling through” to primary care and the first response usually comes from the GP practice or community team. Clusters should have the local knowledge and “intelligence” to identify these problems and find local solutions. As Clusters develop they need further opportunities to have the levers to effect change e.g. financial, management responsibility and power and, probably most importantly, the profile and ability to influence other areas of the service.

9. The following projects and initiatives have been introduced recently across Health Boards to reduce demand on GPs:

Pacesetter projects

10. The Pacesetter Programme, funded by Welsh Government, promotes innovation across primary care and delivered through Health Boards and primary care Clusters in Wales. The Pacesetter projects have provided an important step forward in supporting innovation in primary care across Wales, and provided an opportunity to learn lessons across Health Board boundaries and work at scales within Clusters. The aim of this pacesetter is to avoid people from going into hospital unnecessarily and avoiding care home placements.

11. The Pacesetter Programme is still developing however initial results have been extremely positive, with good feedback on relationship building across the interface and up-skilling of GPs and the acute nursing team and the saving of bed days through providing care in the community as opposed to a hospital admission. The outcomes of individual projects inform an emerging model for primary care with the potential to drive transformational change across the NHS in Wales.

Multi-disciplinary Cluster Teams

12. There are significant opportunities to manage primary care demand through a Multi-disciplinary Team (MDT) approach, matching Cluster workforce expertise with the needs and demands of the local population.

13. Cluster teams are well placed to provide holistic care because they understand the motivations, clinical history, social situations, personal backgrounds and families of their patients. A wide range of professional skillsets, with each team member spending most of their time on activities that add greatest value, ensures that patients receive appropriate care without unnecessary delays. Pacesetter projects indicate that Cluster MDTs cope better with the practice workload and report higher morale and motivation within the workforce. Through developing and promoting new roles within primary care (pharmacy, paramedics, social workers etc.) it will help reduce demand. Clusters need to consider how best to educate both professionals and the public of the importance of these roles so that the first point of call is not necessarily the GP.

Clinical Triage

14. In some Clusters, a clinical triage system directs patients to the most appropriate professional within the Cluster team at the point of contact, greatly reducing the day-to-day workload of GPs and improving access to the right care. High quality clinical triage promotes patient safety through facilitating early assessment and assisting speedier identification of sick people and opportunities for early intervention. The further introduction of national standards and guidance for the NHS would promote safe and effective systems for clinical triage.

Primary Care Out-of-Hours (OOH) Services

15. Newly redesigned OOH services offer multi-professional assessment and seamless patient care across the in-hours / out-of-hours interface in some Clusters. This is particularly important for complex patients, the elderly and those receiving palliative care, to ensure an understanding of individual needs and continuity of care.

Infrastructure for Clusters

16. A strong governance framework, with clear accountabilities and indemnity, is an essential foundation for new Cluster models. Pacesetter teams report the importance of robust, user-friendly primary care IMT systems to support redesign, communication, joint-working, bench-marking and automated data capture on a Cluster basis. HR processes and financial systems must be aligned to change with pace. Increasingly, the design of estates needs to support MDTs working on a Cluster basis.

Access to Mental Health Services

17. Providing timely and person-centred mental health services is becoming a strong theme in emergent Cluster plans around Wales. The second year of Cluster plans show evidence of Clusters commissioning MIND, and other providers, for in practice mental health clinics.

The emerging multi-disciplinary team (how health and care professionals fit into the new Cluster model and how their contribution can be measured)

18. There is a strong desire from our members for Clusters to have multi-disciplinary workforce model and future collaboration between practices depending on local need and geography because one size does not fit all. Examples of workforce redesign and the redistribution of work and roles can have are already being seen across the Clusters. There have been opportunities to change the skill mix across the whole care spectrum both to address the core General Medical Services work as well as addressing some of the demand factors, such as complexity, increasing number of frail older people, and the need to addressthe widening health inequalities gap.

19. The national investment into Clusters and the pathfinder/pace setter and Primary Care Integrated Medium Term Plan (IMTP) and Workforce Funding from Welsh Government has been essential in supporting plans to diversify the workforce and develop more sustainable models of care within Cluster networks.

Team working

20. Across Wales Health Boards are redesigning the workforce, working with primary care, social care and third sector providers, to ensure that they have the right level of staff with the appropriate skills to deliver services in the most appropriate setting. The Cluster workforce is being developed to support prudent healthcare principles, service developments and overcome recruitment difficulties for certain staff groups. Ownership of new Cluster roles by the existing primary care team is essential to success. Teams that use assessment of local health needs and patient demand to recruit professionals with the appropriate skills realise the greatest benefits.

Extended roles

21. The Pacesetter projects extended roles for paramedics, nurse practitioners, pharmacists, physiotherapists, technicians, occupational therapists, mental health counsellors and Local Authority professionals within a Cluster setting. Evaluation of these new roles and services includes their impact on patient satisfaction, reduction in face-to-face GP consultations and avoidance of hospital admissions. There is evidence from other research of the benefits of Cluster roles for physician’s associates, healthcare support workers, dietitians, optometrist, speech and language therapists, behaviour change consultants and dental hygienists.

22. As the Policy Forum “Our Community”: Ten actions to support primary care in Wales” briefing highlights, there are a range of professionals working within primary care who play a significant role in supporting patients within the primary and community care setting. Specific roles include:

• Clinical pharmacists; contributing to clinical work relating to medicines in GP practices, supporting safe and effective medicines use. The Cluster pharmacist can work in a specialist clinical area or a more generic role, addressing a range of medication issues. Experienced pharmacists identify high-risk patients from a medication perspective and support patients to manage their own health, offering alternatives to medication through advice and social prescribing.

• Greater understanding by the Cluster team of the in-house occupational therapist role assists in identifying people who would benefit from these services, with potential to link directly with social services and third sector services.

• Extended scope physiotherapists are leading successful MSK services within Cluster teams. This is leading to the reduction in GP consultations for musculoskeletal conditions.

• Advanced nurse practitioners assist with more complex patients and can undertake clinical triage within Clusters. Practices indicate the importance of aligning new nursing roles with existing services to ensure good planning and co-ordination.

• Counsellors are ensuring an increase in access to mental health and emotional well-being services. Mental health counsellors manage a range of mental health problems in patients who return frequently and offer brief intervention techniques when appropriate.

• The GP with Special Interest (GPwSI) brings specific clinical expertise and is well placed to be a ‘Cluster champion’ in a specialist area, offering support and clinical advice to colleagues and forging closer links with acute clinical teams. GPwSI posts are proving successful in attracting GPs into an area.

• Advanced practice paramedics are trained in a wide range of clinical assessment and decision-making skills, treating patients close to home and reducing unnecessary hospital visits.

• Integration with local authority and voluntary sector staff on a Cluster basis can reduce A&E attendance and hospital stays. Regular MDT meetings support individuals to live independently at home, steering many away from residential or nursing home care.

• Chronic conditions nurses for housebound patients in order to provide a person-centred, holistic approach to the management and education of patients with chronic morbidities.

• Joint rotas, shared learning opportunities and co-location of Cluster staff with other agencies, e.g. Welsh Ambulance Service Trust and Local Authority, improves integration.

23. While there are significant developments engaging with a wide range of health and social care professionals within the Cluster model, it can be challenging for Health Boards. There is a need for a change in culture to break down the old silo way of thinking. In addition, every professional group is extremely busy with demanding case-loads, long waiting lists and lots to do. Professional’s interest depends upon finding solutions to their problems so only a minority of people will actively engage in strategic planning and visions of future models of care. We would recommend that each Cluster needs to identify problems from discussion with the professionals, develop solutions through small management teams composed of senior staff who have the authority to make changes and then work with local professionals.

The current and future workforce challenges

24. The enhanced Cluster team offers flexibility and responsiveness to changing conditions and demand, promoting sustainability, resilience and improved economies of scale. However the fragility of many practices across Wales has a range of causes, including increased volume/ complexity of workload, and difficulties in recruitment. The rapidly shrinking GP workforce is one of the most challenging aspects of primary care, with increased workforce pressures, unstable practices and risks to the quality of patient care. There is a need to increase capacity in the system, with new workforce roles and alternative models that do not simply move existing resources around the healthcare system.

25. There are a number of workforce challenges that continue. Many Health Board are experiencing sustainability issues in both primary and community services. While there continues to be challenges around GP recruitment, these challenges are not unique to Wales. The Cabinet Secretary’s Taskforce on Workforce has brought a welcome focus to workforce activities with a strong initial focus on GP recruitment and retention in the form of a national recruitment campaign supported by local Health Board activities (this focus is now moving out across the primary care professions). We hope that the national and international campaign launched by the Welsh Government in October 2016, making it clear that Wales is an attractive place for doctors, including GPs, to train, work and live, will have an impact. The changing demographics of the GP workforce and poor condition of some of the primary care estate has also affected the ability of practices to provide sustainable services. The development of more forensic workforce planning in primary care will support better IMTP representation of the recruitment challenge and necessary activities to address it.

26. Sustainable primary care services rely on stable and sustainable general practice and therefore there has been the need for short-term work to help stabilise practices to deliver on high workload and workforce pressures. This has included:

• Opportunities for career development through portfolio careers for GPs to support future recruitment and retention.

• Development of more innovative recruitment campaigns, including social media, recruitment videos and website http://www.wales.nhs.uk/sitesplus/863/page/87351

• Contribution of primary care nursing considered at Cluster level, providing opportunities to develop new skills.

• Cluster specific solutions e.g. GP fellowship scheme to encourage recently-qualified GPs to practice in areas that has been difficult to recruit, Cluster Salaried GPs and the establishment of a Practice Support Team and alternative portfolios for GPs.

• Joint work with the Wales Deanery to improve recruitment and retention of dentists within South Wales through the Postgraduate Dental Training Unit [PGDTU]. In September 2014 the training programme was changed to include greater variety in the training placements, ranging through primary, community, secondary and tertiary care aiming to broaden skills, and encourage local workforce retention. September 2016 saw a further change with a tightening in UK-wide requirements that Satisfactory Completion of Training be demonstrated with students exposed to the full range of dentistry that could be expected in practice. As a consequence the service profile of the PGDTU has been remodelled to include its operation as a ‘normal’ general dental practice, and to become part of the rota of dentists providing urgent dental care in-hours.

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

27. The Funding allocation to GP Clusters is very welcome and some innovative projects are being rolled out as a result. Overall our members believe the direct funding of Clusters (with £6m of central funding) has delivered real progress. Whilst year one of the funding was generally focused on set up arrangements for various activities and some one off spends for equipment, year two has seen the development of service related activities with SLAs for social worker support or mental health clinic provision.

28. While overall the funding allocated has been welcomed, the sums are relatively small and the financial rules and regulations limit Cluster’s ability to use them most effectively. The inability to “roll over” money into the next financial year means money has to be spent before end of year, which can lead to short term spending decisions and lower value for money than could be achieved with longer timeframes. If we want to re-design a service, recruit, train and make real change, flexibility and sufficient lead time is required.

Workload challenges and the shift to primary prevention in general practice to improve population health outcomes and target health inequalities

29. The MDT approach to Cluster working, with a workforce based on population health needs, offers opportunities to focus on prevention and early intervention. In planning for future services, it will be essential to factor in services that support self-care, social prescribing and the promotion of health and well-being outside the traditional medical model.

30. The research conducted on the PRISM model should be further considered for its potential to support anticipatory care models; and the work already conducted through the Inverse Care Law Healthchecks (between Aneurin Bevan UHB and Cwm Taf UHB), which is now rolling out nationally should be evaluated for its impact on outcomes following earlier intervention. In the future list analysis and segmentation of the list to better manage risk in the population should be considered.

31. Public engagement is also vital in relation to improving population health outcomes and ensuring people access the right treatment and professional advice when they need it. The Choose Well campaign is one important addition which gives people more information and helps them make the right decision on which services they choose based on their symptoms.

The maturity of Clusters and the progress of Cluster working in different Local Health Boards, identifying examples of best practice

32. Cluster networks do bring about greater liaison/interaction between various professional groups within the network which improves collaborative working. Cluster working and its funding has resulted in the trial of various initiatives to reduce demand on GPs which would not have otherwise been possible. This is a new way of working that would have been inconceivable prior to Cluster working/funding. The mature Cluster provides holistic care for the community, moving from a collection of GP-based services into fully functioning organisations that draw in the full range of agencies to support co-ordinated care for the entire population. Referrals are made only when necessary and people return to care of the primary care team as soon as possible.

33. The Pacesetter projects demonstrate:

· Integrated care can only be achieved through significant investment in IMT systems to ensure secure communications between professionals and agencies.

· Building flexibility and patient choice into new service delivery models helps to secure the trust and co-operation of patients and professionals in whole system redesign.

· A review of clinical pathways for ambulatory care sensitive conditions and other common conditions helps to inform planners where professionals should be located to deliver effective patient-centred care outside the hospital setting.

34. Each Cluster has now finalised its third Cluster network plan, informed by Cluster health needs profiles. Annual reports and risk registers have been published on progress in year two and will shortly be completed for the third year. Progress on moving forward with Cluster network priorities has been good across Wales and this has included:

• Diversification of the workforce;

• Supporting public health priorities, self-care and choose well programmes;

• Piloting new models of collaborative working;

• Investing in modern technology and equipment to support improved patient care;

• Peer review and support for improved patient pathways;

• Considerably strengthening relationships with the third sector and access to an increased range of services.

35. The main Cluster development needs are:

• Leadership and support to develop;

• Financial and governance accountabilities – as role expands further increased business and financial support;

• Time to identify and implement new models of working; and

• Pace of response from ABM for service change / development.

36. Some of the barriers to progress that have been identified, and are being considered, include;

• Pressures on core primary care services: recruitment, staff retention; solutions and suggestions being developed with primary care leads;

• Ability to recruit to posts – availability of pharmacy technicians, medicines management professionals, advanced nurse practitioners, to recruit into networks with the investment that has been released;

• Investment in challenging financial climate;

• Capacity/ time constraints linked to pressures; and

• Cross border issues for patients straddling network boundaries.

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 [Opens in a new browser window]

37. Health Boards recognises that good quality leadership and management of staff/contractors is critical to improving retention rates. Health Boards are therefore providing a wide range of development programmes to support and develop leaders and managers at all levels, both inside and outside of the Health Boards, to improve their skills and improve staff experience. The Pacesetter programme highlights the importance of clinical and managerial leadership in successful innovation and service redesign within Clusters.

38. In overall terms the Directors of Primary Community have prioritised Cluster development very strongly. Early work on models for understanding Cluster maturity and matching supporting resources has given way to a deliberate programme of Cluster support activities being delivered through the Primary Care Hub in Public Health Wales. There are now several programmes providing leadership development in support of Cluster working being accessed regularly by Cluster leads across Wales.

39. Clinical leaders are essential to educate, advise, support and lead innovation. Cluster Champions promote new services and cascade key skills amongst the primary care team. Educational sessions to demonstrate improved clinical outcomes help to engage and assure professionals.

40. Following the Cluster Lead Survey conducted in 2015, the Confident Primary Care Leaders Course has been commissioned by Public Health Wales, It is aimed at Cluster leads and aspiring Cluster leads across NHS Wales. Sessions are led by qualified coaches and expert facilitators and include: Population Health and Maximising Patient Experience; Business Planning and Finance; Building a Culture; Influencing, Negotiating and Chairing Skills; Understanding Leadership Styles. The programme commenced in September 2016, with a second cohort commencing in November, the Programmes run on a monthly basis.

41. The Cluster networks have a protected learning time programme that allows practices within a Cluster network to regularly meet and consider service pathways and related issues. Topics that have featured in the programme recently include equality, diversity and human rights, cardiology service updates, gastroenterology, dermatology, child protection, national exercise referral programme, diabetes, respiratory, diagnosis of lung cancer domestic abuse and support services. The Health Boards supports this by providing cover for the practices that take part on the protected learning time programme. In addition to the protected learning time scheme some Cluster networks have now decided to meet on a more frequent basis than the GMS contract stipulates in order to progress their action plan priorities on an accelerated basis.

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

42. Pacesetter project evaluations are based on success in finding solutions to the three ministerial priorities for primary care – increase in sustainability, improved patient access to services and moving care into the community. Individual projects have been delivered and evaluated by each health board, with co-ordination and support provided through a partnership approach between the Primary Care Hub (Public Health Wales), 1000 Lives Team and health board Directors of Primary Community and Mental Health Services. There has been assessment and dissemination of the shared learning from the programme and national learning events held. The Pacesetter programme is currently tendering for a research/evaluation partner to evaluate activities undertaken thus far and further activities to follow.

43. In addition, Public Health Wales have been providing support, guidance and oversight of the evaluation of the pathfinders / pacesetters to date. A further external evaluation into the benefits and outcomes of this pacesetter investment across Wales is also due to be commissioned by Welsh Government in the next month or so and will we understand, take 9-12 months to evaluate and produce the final report.

44. Regular monitoring reports are submitted to Welsh Government on a quarterly basis for all of Health Board funded pathfinder/pacesetter projects, the IMTP / workforce delivery agreements and the Cluster level funding grants. To inform Cluster network plans each general medical practice produces a practice development plan which sets out how the practice population has been involved in developing their priorities.

Conclusion

45. As highlighted in our submission there has been significant developments across Wales. The Clusters are supporting greater integration between GP practices and also across professional groups, depending on local need. The funding provided by the Welsh Government for Clusters has helped but future flexible funding would be welcomed. Finally while the main source of primary health care are GPs other professional groups provide a vital role in ensuring patients receive the right care at the right time and in the right place.