Primary Care Consultation Feedback
Views of the North Cardiff Cluster established from the Cluster Development Session held on Tuesday 7th February 2017.
Participants from all 11 practices included GP’s, Nurse Practitioners, Practice Nurses, Health Care Assistants, Practice Managers, Cluster Pharmacists, Primary Care Nurses for Older People and others.
There were a number of positive comments in relation to the two main initiatives funded through the Cluster Development monies i.e. Cluster Pharmacists and Primary Care Nurses for Older People (PCNOP) – both being regarded as “incredibly valuable” although regarded as a limited and insufficient resource. This is now recognised as a challenge to the system as to how these developments can be brought to scale and “development monies” freed up for that purpose.
There were mixed feelings about the wider purpose of the cluster with some feeling that the cluster generates more work whilst others recognised benefits of “sharing good practice”, “planning”, “dealing with local population needs” and “meeting un-met need”. It was felt that GP services remain the “first port of call” and that demand continues to rise with schemes allegedly developed to reduce GP workload (e.g. NHS Direct, Community Pharmacy schemes) having little if any impact.
Direct access to a number of other practitioners could certainly reduce demand on GPs particularly to mental health services such as PMHSS and it was suggested that a “self-referral hub” could be created to include mental health; counselling; physiotherapy; nutrition; audiology; podiatry; health education; social services and others - in some respects then removing the “gatekeeper” role of GPs.
2. The emerging multi-disciplinary team
This remains embryonic and challenging outside of the existing practice based multi-disciplinary teams. However engagement with Cluster Pharmacists and Primary Care Nurses for Older People has provided an initial base from which to develop. The greatest challenge for GP practices and practitioners is creating sufficient “head-room” to learn about and take advantage of the collaborative opportunities.
The Cluster has engaged in some developmental preventative services work with third sector and local authority organisations in the form of “Citizen Driven Health” and “Independent Living Services” respectively. Both have the potential to address wider social needs of individuals and through utilising existing community assets improve general wellbeing and importantly impact upon both demand for GP appointments and reduce call on secondary care services. Whilst potential has been recognised from early local work and an evolving evidence base further afield resource allocation to these developments is limited.
The Cluster has engaged with specialist colleagues to
Recognised constraints include the need for comprehensive IT solutions with appropriate levels of resource for equipment, software and training. The need for a structured Practice Nursing training programme and career path is essential.
3. The current and future workforce challenges
The increasing pressures on GPs through a multitude of factors including increasing demand, expectation and the ageing population is widely recognised. This has been having an impact upon both recruitment and retention for a number of years and is now becoming acute. This when combined with perceived instability of the system, increasing risk for GPs as both professionals and employers and yet with falling GP remuneration leads to a negative spiral in all respects. The changing profile of the workforce toward salaried, locum, part-time female GPs is having a major de-stabilising impact on the independent contractor model. Fewer GPs and wider multi-professional teams means that the system has to flex and respond quickly - for example maternity and paternity support has to be provided to practices for all team members and not just GP performers. Greater support is urgently needed to help practices move to properly funded larger organisations to ensure future stability.
Infrastructure has to be developed and appropriately funded - increased service provision in the community with larger multi-disciplinary teams need appropriate accommodation.
4. The funding allocated to clusters to enable GP practices to try out new ways of working
“Cluster Development Monies” (CDM) in the North Cardiff Cluster have principally been utilised to develop and implement the Cluster Pharmacist and PCNOP roles and services (see section 1). GP leads have been identified in each practice for both services and both schemes have been widely appreciated by patients and practitioners with opportunity to provide more GP resource to complex and often housebound patients.
The bulk (>95%) of the CDM are now committed through salaries so in the forthcoming year the Cluster will have less than ten thousand pounds for any future development work. The challenge then is then how to move from development to increased scale with for example pharmacists and frailty nurses in each practice? Further investment in community service provision is essential. The sharing of cluster developments from across the nation is welcomed though of little benefit if they cannot be adopted through lack of resource.
5. Workload challenges and the shift to primary prevention in general practice to improve population health outcomes and target health inequalities
The current challenges facing General Practice in terms of rising demand, expectation, ageing and complexity detract from the inherent capability within primary care teams to provide broad based primary preventative activities. This can be overcome by significant investment in primary care teams to allow further skill mix development particularly within nursing team and co-ordinator or navigator roles. The latter are suitable for delivery in collaboration with local authority and voluntary sector partners - the North Cardiff Cluster is engaged in “Social Prescribing” and community development and support through “Citizen Driven Health” and the Independent Living Services Locality Project with Cardiff City Council. Getting to scale through collaboration and developing appropriate systems will require further time and additional resource.
Opportunity has to be made and taken to provide enhanced public health information and support to primary care teams. Progress has been made though there needs to be a streamlining of data sources and improvements in quality and presentation of material in simplified user friendly dashboard format.
There are extensive opportunities emerging to improve patient education through technology - examples include “Pocket Medic” education videos in diabetes and heart failure (secondary prevention education) which can be used for primary prevention to tackle obesity, improve health screening and some wider social issues.
6. Maturity of Clusters and progress of cluster working
Clusters are heterogeneous both in terms of their individual mix and number of GP practices and their wider population socio-economic profile. The North Cardiff Cluster is the largest cluster in Wales with 11 practices and a current population of 107,000 patients - with population growth as part of the Cardiff Council Local Development Plan it is expected to rise to almost 120,000 by 2026.
Engagement has been driven via a contractual model rather than an organic “common purpose” & the challenge to change from a loose unstructured and informal entity with consensus decision making to a formal body continues to hamper progress. The Cluster Development Monies have provided something of a catalyst for closer working and tangible progress through the developments stated earlier however developments across the nation are diverse and even if communication of best practice became widespread the capture and implementation of success is perceived to be limited through resource and capability. More has to be done to support this sharing of information both locally both within UHB clusters and across UHBs.
7. Local and national leadership supporting the development of cluster infrastructure
Feedback from cluster level indicates a mix between recognition and need for skilled and well trained leaders and antipathy suggesting a disconnect possibly as a consequence of poor morale, falling income, helplessness and lack of belief in the current system. Local attempts to understand and provide support and solutions to disenchanted practitioners has been slow to develop although recent workforce and organisational development resources are being utilised though will need time to have significant impact. They will not bring value or success without Health Board recognition and practical delivery of resource shift from secondary to primary care.
The population expansion of Cardiff is an enormous challenge and practices are fearful of the perceived lack of planned resourcing of workforce, services and infrastructure.
There is widespread recognition that we quickly need integrated IT solutions across the Cluster and Health Board.
8. Evaluation, central support, development of success criteria and involvement of local communities
There is continuous concern about the long-term future of clusters and the resourcing of them - this has been described above (6.). Practices struggle with the contracting cycle that perpetuates uncertainty - as of February 2017 there is no contractual agreement for the forthcoming year 2017/18. Continued erosion of core funding at practice level is perceived to be undermining any benefit of cluster activity.
Practices are engaged, in varying degrees of commitment, in developing their own Practice Development Plans and from these into the Cluster Annual Development Plan. There has been little support and facilitation into that process and with limited feedback their full value and potential is not realised.
There has been an evolving level of central (UHB) support through the current financial year although given the history of cluster development this has taken far too long to materialise. This is mirrored by the enormous delays in human resource and procurement delays. The main cluster developments have been slow to progress to evaluation as a consequence. However there is a continued desire to focus on improving quality of care and recognising that all hospital admissions cannot be avoided - “hospital admission is not always a failure!” - and in establishing outcomes we also have to agree on “what is valuable?”
Dr Haydn Mayo
North Cardiff Cluster Lead
Community Director, Cardiff and Vale UHB
February 2017