Health, Social Care and Sport Committee - Inquiry into primary care

Introduction

This document provides a Cardiff and Vale UHB response to the inquiry into Primary Care being carried out by the Health, Social Care and Sports Committee.

Question 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).

 

Clusters working together can support individual practices, through peer support and addressing key practice issues collectively, thus enabling them to be more sustainable for the future.

 

Clusters provide the opportunity to enable individual practices to be sustainable yet work more collaboratively across natural geographical areas, enabling coordination of services rather than competition between them. Clusters can enable bidding for provision of a wider range of enhanced services across a patient population and consistency in delivery of those services provided at cluster level, all of which helps manage demand.

 

Specifically in Cardiff & the Vale of Glamorgan, cluster working has allowed practices the ability to invest collectively in enhanced service provision to support the management of patients that might require additional practice input and better manage demand.  For example, in Cardiff a number of clusters have invested in cluster Primary Care Nurses for Older People who work for the cluster practices to help support the most frail, elderly and vulnerable cluster patients.  This streamlined delivery of care at a cluster level benefits from the economies of scale brought about from working across a cluster population rather than individual practice population. 

 

Clusters have also been able to assist in reducing demand on GPs via working with secondary care hospital directorates and specialities via developing new pathways, challenging traditional models and designing more integrated primary/secondary care pathways. The South West Cardiff Cluster has developed an integrated paediatric outpatient care model, which has challenged the traditional paediatric outpatient model and introduced the following:

·         GPs communicating with consultant paediatrician using eAdvice (robust email system)

·         booking coordinated by primary care team

·         patients seen in their own or neighbouring practice rather than in a hospital setting

·         paediatrician delivers clinic 1-2 monthly with input from primary care team, plans are made jointly with paediatrician & GP

·         whole-practice multi-disciplinary team (MDT) meeting with feedback after every clinic.

As well as improving patient access and their experience, it also provides the opportunity to manage the demand on GPs.

Likewise, clusters have been able to assist in reducing demand on GPs via working more effectively with Third Sector, Social Care and other community providers. In Cardiff and Vale this has been seen via the introduction of Well-being Co-ordiantors who work at the interface between GPs and the community, with a focus on delivering public health priorities for the cluster population, and enhance the social model of care (social prescribing), through their use of community networks. Early indications suggest this resource has helped reduce GP appointments where alternative Third Sector and non-statutory input has been able to be utilised through the use of local community activities e.g. referral to leisure/ housing/welfare/ community wellbeing activities.

 

Access to care including Primary Mental Health has been demonstrated in the Central Vale cluster through collaboration with Mind (Third Sector provider) who have been commissioned by the cluster (using cluster investment) to deliver psychological therapies for mild to moderate mental health problems.  The Cardiff South East cluster has taken this learning and now also working with Mind to deliver low level mental health services.  The Cardiff East cluster is working with the UHB Mental Health Services to develop a new model of cluster based CPN resource.  All three models will be evaluated to inform the future of mental health services delivered at cluster level.

 

 

Question 2: The emerging multi-disciplinary team (how health and care professionals fit into the new cluster model and how their contribution can be measured).

 

There is a clear understanding that cluster working must benefit the health and wellbeing of the local population and the clusters in Cardiff and Vale are keen to work with the Third Sector, Social Care and wider stakeholders to support this. 

 

Whilst the protected GP time is important there needs to be consideration of the incentives for the wider primary care contractors. Going into 2016/17 a number of cluster Community Directors (cluster leads) in Cardiff and Vale have met with Dental, Optometry and Pharmacy leads to explore service developments and pathways going forward to encompass all primary care independent contractor professionals. Work on referral guidelines is being pursued to ensure practices sign-post patients to the most appropriate independent primary care contractor first time. Impact can be measured in terms of where contacts are undertaken and by whom (eg the post cataract scheme to shift from secondary care to primary and those seen by an optometrist).

 

In addition to the previously mentioned roles (primary care nurses for older people, cluster CPNs), clusters in Cardiff and Vale have also developed cluster pharmacists, specialist nurses and community paramedic roles.  Alongside the broadening of roles into the cluster model in Cardiff and Vale we are keen to measure the impact.  This takes the form of the shift in activity – either away from secondary into primary care or away from the GP into the wider cluster model.  Early indications show that this can be evidenced however a longer period of measurement is required before conclusions can be made.

 

Where cluster based initiatives have been facilitated via WG cluster investment, there is an emphasis locally to ensure evaluation and impact can be measured. However, the main mechanism for measuring the cluster model in its broadest sense has been via implementation of cluster plans. The Primary Care Information Portal has also allowed clusters to review and measure impact at a cluster level, for example the impact of working with the Third Sector to improve screening uptake in certain clusters can be monitored via the Primary Care Information Portal.

 

 

Question 3: The current and future workforce challenges.

 

The fragility of the GP workforce is the most challenging issues faced at present.  The establishment of the Cardiff and Vale General Practice Support Team (GPST), through Welsh Government Primary Care investment, is a key enabler to addressing the current and future workforce challenges, including cluster development. The GPST are a dedicated multi-professional team with a focus on supporting and delivering long term primary care sustainability. Through the GPST, Cardiff and Vale UHB have put in place the foundations for a more robust approach to workforce planning recognising the sustainability issues, combined with the aspirations of the Primary Care Plan for Wales. Workforce Planning and OD posts have been recruited to, working with the GPST to:

•       Support the continuing development of primary care clusters and the sharing of best practice

•       Investing in the development of the wider primary care workforce

•       Stabilising key sections of the current workforce

•       Developing a culture of integrated working seamlessly across organisational boundaries

•       Significant review of skills and development of new or extended roles has taken place

•       Develop workforce plans for each practice / cluster and ensure access to better primary care workforce information.

 

The appointment of Optometry and Dental Advisors in Cardiff and Vale has ensured support to the independent contractors on governance and developments as well as links to GP practices and clusters to promote services and service improvement including addressing workforce issues and challenges.

 

Going forward, the new cluster roles being implemented are trail-blazing and therefore require an increased level of support as clusters move into this unchartered territory.  In addition, whilst evaluation of these roles is at an early stage, there is a risk from a workforce planning perspective (eg 70 cluster pharmacists across Wales now compared to none 18 months ago).

 

Question 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.

 

Recurrent cluster financial investment introduced in 2015/16 and increased for 2016/17 has incentivised clusters to accelerate collaboration and agree collectively on the best use of this investment. This has increased the speed at which clusters have matured as a result. Cluster investment to date has highlighted numerous new ways of working to reduce pressure on GP practices, and improve services and access available to patients, examples include:

·         Primary Care Nurses for Older People - in the North Cardiff cluster where there are high numbers of older people, there are growing health needs associated with general frailty and dementia, the cluster has invested in the development of specialist nurses who can provide additional support to this patient group.  These nurses will work across practices and be linked into the local Community Resource Team (CRT), where they will be able to access resources such as therapists, Consultant Gerontologists and the voluntary sector so as to enable patients to maintain their independence and health for as long as possible in the community.

·         Cluster Pharmacists – clusters in Cardiff and Vale have invested in Cluster Pharmacists, whose key role is to ensure patients receive thorough medication reviews so as to maximise their treatment plans and to provide additional specialist support to patients with complex medication regimes.

 

 

Question 5: Workload challenges and the shift to primary prevention in general practice to improve population health outcomes and target health inequalities. 

 

The Cluster Network Development Domain requires clusters to collaborate to:

 

•       Understand local health needs and priorities.

•       Develop an agreed Cluster Network Action Plan linked to elements of the individual Practice Development Plans.

•       Work with partners to improve the coordination of care and the integration of health and social care.

•       Work with local communities and networks to reduce health inequalities.

 

This has ensured that Cluster Plans are in place for each cluster with a clear focus on primary prevention and population health, recognising local priorities and need.

 

As stated earlier clusters have provided a vehicle to also work with secondary care hospital directorates and specialities on developing new pathways, challenging traditional models and designing more integrated primary/secondary care pathways.

 

Clusters have a significant role to play in planning the transfer of services out of hospitals and into local communities, and this has taken place in Cardiff and Vale, to date, on an organic basis, the cluster (and wider WG Primary Care) investment has helped facilitate this. Having said this, a more formal role in this process, may need to be considered, for example how clusters influence Health Board IMTP priorities in relation to the shift to primary prevention. Clusters have enabled natural communities become entities, from a health and care perspective that have a clear and united voice at Health Board level that is able to inform and influence.

 

An important consideration of cluster working is the time that clusters have together to work through ‘cluster’ business.  There are only five mandated cluster meetings (five per year).  The agendas for these meetings are becoming increasing pressured to work through existing issues and also consider new issues.  In addition, as the cluster model is starting to embed, there are increasing numbers of interested parties wanting to meet with the cluster group.  This is leading to limited time to network and generate ideas outside of these meetings.  On one hand this is an indication that cluster working is embedding but on the other it is providing a pressure and will impact on cluster responsiveness.

 

 

Question 6: The maturity of clusters and the progress of cluster working in different Local Health Boards, identifying examples of best practice. 

 

The Welsh Government Primary Care Plan and associated funding has provided a real opportunity to address the sustainability of core primary care.  In Cardiff & Vale, dedicated resource has been put in place to look at new workforce / operating models and develop workforce plans.  Whilst this will take time (next financial year), new cluster roles are already in place. There would be benefits in providing a greater infrastructure (at national and local level) to cluster working for example business support, HR, IM&T, and Information Governance. The consideration of the requirements of implementing and then managing new roles at cluster level cannot be under-estimated.

 

The evolution of clusters in Cardiff and Vale has led to a different emphasis and way of working across the clusters.  This has been encouraged as it supports a more locally responsive approach. 

 

Examples are:

·         The Central Vale cluster has developed a scheme with MIND with their cluster funding. 

·         Cardiff North cluster has led on the Citizen Driven Health project.

·         Locality based working initiatives with the Local Authority and Third sector in two clusters looking at locally based homecare, co-ordination of day care opportunities and housing strategies.

 

The cluster investment has increased the pace at which clusters have matured, through collaboration and collective agreement on the use of this funding.

 

Information at a cluster level is also more readily available and being used in Cardiff and Vale on a cluster basis via the NWIS Primary Care Information Portal. This information is helping to drive quality improvement through tackling cluster variation relating to the Primary Care Measures for Wales. However Information Governance considerations when putting in place new models of care at a cluster level has been a key consideration and can sometimes provide a barrier or challenge to overcome in relation to cluster working.

 

Cardiff and Vale UHB has recently established three priorities to drive the Ten Year Strategy (Shaping Our Future Wellbeing). Cluster development has been identified as a core component of the BIG 2 Perfect Locality priority area. As part of this work, clusters have been vital in driving forward a number of proposed new models of care delivered through developments, clinically led by the Community Directors and with strong stakeholder and partner input. 

 

Whilst the protected GP is important there needs to be consideration of the incentives for the wider primary care contractors, if continued cluster development and maturity is to move towards a more holistic wider Primary Care and Partnership approach.

 

Recruitment has been a particular frustration for clusters (in Cardiff & Vale and across Wales).  Given that cluster roles are new roles, the job matching process together with the recruitment process has led to protracted timeframes for recruitment. The recruitment process is further complicated by the governance arrangements for appointing staff to work at a cluster level but be managed by the relevant health board operational team because clusters are not statutory bodies in their own right. Addressing these recruitment issues will speed up the maturity of cluster working.

 

Some areas that need attention on an All Wales basis in order to embed cluster working include:

-          All Wales compendium of job descriptions for cluster roles and other new roles

-          Clear parameters to work within when developing job descriptions for ‘integrated’ job roles (with Local Authority, Third Sector etc)

-          The Information Governance framework required to work in an ‘integrated’ manner.

-          Consideration of the IM&T required for cluster working

 

 

Question 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 [Opens in a new browser window].

 

An organisational development programme for Cardiff and Vale clusters has been put in place to work alongside the cluster GP leads (Community Directors) to define function and direction, and identify the steps required to achieve this. A key priority within this has been to ensure clarity of purpose at a cluster level.

 

Cluster Community Directors (lead GPs) have been appointed to provide clinical leadership for each of the nine Cardiff and Vale clusters, the CDs are supported by the locality network. Cluster meetings take place to manage cluster business, service developments and monitor the cluster plans in place.

 

A Community Directors Forum (Clinical Reference Group) has been set up in Cardiff and Vale and provides a Forum for Community Directors to share experiences and lessons as well as agree collective priorities and clarity of purpose at a strategic level.

 

Cardiff & Vale are also taking part in the national clinical leadership programmes.

 

 

Question 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.

 

Clusters in Cardiff and Vale are making significant progress in terms of collaborative working; exploring innovative ideas regarding service provision; providing mutual support to one another; and starting to open up lines of communications with each other. As stated earlier more is required to further develop clusters to ensure they play a central role in transferring services from secondary care into primary/community care.

 

Light touch input from health boards has been essential to ensure that priorities are driven by local cluster population need. Cluster investment, although challenging as a new way of working, has incentivised clusters to work together to agree priorities reflecting local need and led to innovative models and roles. Evaluation of cluster initiatives facilitated via Welsh Government investment has been subject to local evaluation, and quarterly updates provided to Welsh Government ensuring progress is closely monitored has been important.

 

Clusters also monitor their progress against cluster Plans including input from local communities, for example a number of cluster based Health Fairs have been held with outputs from the Fairs captured (eg the number of immunisations and vaccinations, BP and BMI taken) and considered by clusters.

 

Cluster maturity and development is overseen and evaluated locally by the Community Directors Forum, and national oversight and discussion via the Directors of Primary, Community and Mental Health monthly meeting.  For further information please see the submission by the All Wales Directors of Primary, Community and Mental Health.