Health, Social Care and Sport Committee

Inquiry into Primary Care

RESPONSE FROM POWYS TEACHING HEALTH BOARD

Powys Teaching Health Board (PTHB) has both the ambition and track record of delivering high quality primary and community care services. It has a strong primary care infrastructure and already provides extended primary care practice linked with a network of GP led community hospitals which provide access to diagnostic and treatment services and are a key part of the Health Boards unscheduled care and planned care delivery.

These strengths make a significant contribution to the development of the local collaborative model and needs based service planning. Recruitment difficulties in General Medical Services from both GPs and other traditional primary care staff such as Practice Nurses, had not previously been significant drivers for change however, recently these challenges are emerging across several parts of the county and are a clear and present risk for small services distributed over a large geographical area.

Access to specialist advice is complex and challenging in Powys due to the numerous provider relationships. It is therefore a particular priority for the Board to ensure that we develop local skills, enable technology and encourage professional networks to support local pathways that maximise community provision. This is an area where Powys has and can continue to lead on innovative models that will be of value right across NHS Wales.

Recruitment and retention will be enhanced by ensuring that Powys is seen as a centre of excellence for teaching, training and research in the community model of care. Experience in Powys will provide confidence in the extended skills required for a fully developed community model. Strong professional networks will support clinical pathways to specialist centres and provide seamless training opportunities that reflect patient experience and focus on improved outcomes. 

This ambition, specific context and track record of delivery set the scene for PTHB and its associated primary care practitioners to lead the way across Wales and the content below looks to outline where we are currently as a Board and our three associated Clusters.

PTHB plays an important role in a number of all Wales groups and in particular the Directors of Primary Community and Mental Health where our Deputy CEO chairs this group and alongside the newly established HUB. An overarching response has been provided by this group to the Inquiry focussing on the Pacesetter Programme and looks to highlight the emerging models for primary care delivery , much of which now exists and is being delivered in many parts of Powys, although perhaps not yet at full strength.

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)

A range of cluster models is emerging across Wales to suit different geographic, professional and patient populations. Allowing different models to evolve, whilst ensuring standardised outcomes and governance frameworks, appears to be effective. The benefits of more formal cluster models and the developing GP federations, include more stable services, stronger practitioner commitment to transformative change, and new ways of working. Across Powys the clusters are at slightly different stages of development, however, in each and every case they have elements of the following features in place.

1.1 Multi-disciplinary Cluster Team (MDT)

There are significant opportunities to manage primary care demand through an MDT approach, matching cluster workforce expertise with the needs and demands of the local population. 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.

1.2 Clinical Triage

A clinical triage system directs patients to the most appropriate professional within the cluster team at the point of contact, minimising waste and increasing the efficiency of the practice such that there is improving access to the right care. High quality clinical triage promotes patient safety through facilitating early assessment; less ‘noise’ in the system assists speedier identification of sick people and opportunities for early intervention. National standards and guidance would promote safe and effective systems for clinical triage. Within Powys there are examples of clinical triage provided remotely via our Out Of Hours provider (Shropdoc) and also in a dedicated manner within a practice (our Pacesetter project). Both examples have showed a demonstrable improvement in efficiency and significant improvement in access, alongside an important element of practice sustainability. 

1.3 Integration with Specialist Care

Specialist staff, such as Care of the Elderly consultants and specialist nurses, working alongside cluster teams can make a significant impact by supporting community-based care and providing educational opportunities for primary care professionals.  Specialist expertise available in the community setting can support the delivery care for chronic conditions, including the routine management of the majority of care for diabetes, dermatology and cardiovascular diseases.

1.4 Primary Care Out-of-Hours (OOH) Services

Within Powys, OOH services are provided by Shropdoc which is a not for profit Community Interest Company. Over the past two years this service has transformed from a traditional doctor led services into a multi-professional assessment and delivery team. Shropdoc now provides remote clinical triage to several GP Practices on an in hours basis and as such provides seamless patient care across the in-hours / out-of-hours interface. 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.

1.5 Infrastructure for Clusters

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. Work has recently been undertaken in Powys to ensure that the clusters are working symbiotically with the locality management teams that support them. It is anticipated that clusters across Wales will begin to have a greater level responsibility and accountability for resources that have been devolved which are over and above the resources that have most recently been allocated by Welsh Government. PTHB will be working closely with its clusters to ensure that such developments in governance and accountability are built into their ongoing development .  

1.6       Access to Mental Health Services

It is clear that rapid access to appropriate and locally driven mental health provision is becoming a strong theme in emergent cluster plans around Wales.  The second year of cluster plans across Wales show evidence of clusters commissioning MIND and other providers for in practice mental health clinics.  Such an approach has been developed by the South Powys Cluster and this illustrates a needs based approach to service development, enabling frontline clinicians to identify and address the issues faced in local communities with appropriate solutions.

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

The cluster approach has enabled the development of a collaborative, needs based approach built around the list based model of general practice. New workforce roles recruited at Cluster level have enabled local teams to test new models without risk to small local independent practices. This has been pump primed by PTHB to provide an opportunity for practices and clusters to pilot and evaluate such models before making a long term changes.  This shared endeavour has also promoted the value of the collaborative model and highlighted the potential of other community based resources such as third sector provision. The Pacesetter projects researched 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 included 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 Physicians Associates, Healthcare Support Workers, dietician, optometrist, Speech and Language Therapists, Behaviour Change consultants and dental hygienists. Within Powys very many of these other healthcare professionals were already in place and this has grown considerably over the past two years. Numerous PTHB practices now have such working embedded within their routine operation, this is not without challenge however in particular the need for GPs to develop new skills in terms of managing large multi skilled teams.

2.1 Team working

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. The personal characteristics of cluster staff, especially being a team player, are important to success.

2.2 Extended roles within Powys

· 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.  Within Powys there are approximately 8 highly qualified specialists undertaking this work at cluster and dedicated practice level. They have been a key element in terms of sustainability and improving access.

· Extended scope physiotherapists are leading successful MSK services within cluster teams, leading to reductions in GP consultations for musculoskeletal conditions. There have been three pilots of this working in Powys all with very positive benefits realisation and now being employed by practices in a shared manner with PTHB

· 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 coordination.

· Mental health counsellors manage a range of MH problems in patients who return frequently and offer brief intervention techniques when appropriate.  The South Powys Cluster has used some of its funding to engage MIND to provide this service across the cluster.

· Across North Powys and in conjunction with our OOH service provider we have introduced Urgent Care Practitioners (UCPs) at practice level in a network across the North Cluster. These clinicians with a advanced practice skills and often from a paramedics background are trained in a wide range of clinical assessment and decision-making skills, treating patients close to home, undertaking point of care testing, reducing unnecessary hospital visits and acting as a further resource to aid sustainability. 

2.3 Collaborative arrangements

· 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. Within Powys senior social work staff now attend cluster meetings and are an integral part of the Virtual Ward MDTs. In addition working with Powys County Council and PAVO there are now 9 community connectors in place who also work with our Practices and Virtual Ward MDTs. During 2017 they will begin to become a part of the Community Hospital MDTs as well.

3. The current and future workforce challenges

Across Powys over the past two years, there has been a growing level of fragility within some practices. This has been due in the main to recruitment challenges even in some of the less rural areas. In addition all practices through the clusters and cluster plans have raised concerns about increased volume and complexity of workload. PTHB has used the Welsh Government Sustainability Framework to make judgements in regard to the relative risks that are being faced across Powys and has worked with 3 High Risk and 4 Medium Risk practices to date in regard to their ongoing sustainability . The HB has looked to invest in new workforce models as described in Section 2 above and has pump primed such development at practice level by funding practices to explore the new models and funding this exploration and innovation.

PTHB has also used the allocation of funding for the primary care workforce to develop a programme for the introduction of Physician Associates from both Birmingham University (in conjunction with HDUHB) and more recently from Swansea University.

Across Powys we now have a raft of new workforce operating at both cluster and practice level, including; Urgent Care Practitioners, Advanced Nurse Practitioners (including remote clinical triage), Advanced Physiotherapists, Pharmacists and Pharmacy Technicians, Physicians Associates and a training programme for a seam of such from University 

Health Board Support Teams

Ways to increase the resilience of practices and facilitate recruitment are under evaluation across Wales. A collaborative approach across adjacent health boards would help to maximise resources and attract new professionals. Flexible career schemes offer interesting GP jobs whilst providing locum cover for practices across a cluster or health board area. This work will require a significant organisational development focus and may not be wholly applicable in Powys given our geography. Within PTHB we are looking to develop such support and development teams at Cluster level and in conjunction with Shropdoc.

Ministerial Taskforce on Workforce

The Minister’s taskforce 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 HB activities (this focus is now moving out across the primary care professions).  It is also seeking to accelerate the development of primary care workforce projections, which have not been well developed previously.  The development of more forensic workforce planning in primary care- as part of a whole system approach,  will support better IMTP representation of the recruitment challenge and necessary activities to address it.

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

From a PTHB perspective it would be our clear view that in broad terms the direct funding of clusters (with £6m of central funding) has been a success.  For each of the three clusters the HB has adopted a clear light touch approach and only looked to ensure that the funding was being deployed either against the issues of sustainability and access or to the top priorities within the cluster development plans.

Within Powys and across all three clusters there has been a focus to provide the services that are needed to meet patient need as close to home as possible. In many cases this has been used to address long standing development issues, in other cases it is being used to tackle emerging challenges and often on a match funded basis with the HB.  PTHB has been complemented by the LMC on it approach. This will be an ongoing feature of the manner in which PTHB works with its associated Clusters.

Activities commissioned at local level have ranged across several areas including; Frailty HCAs, MIND counselling services; GP eConsult; Practice based Pharmacists, point of care testing, the development of UCPs, appointment of Physicians Associates, data outcomes analyst and establishing a Community Interest Company.

Future years will see an ever increasing positive alignment between Health Board, Pacesetters and Cluster plan service priorities.

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

The MDT approach to cluster working, with a workforce based on population health needs, offers opportunities to focus on prevention and early intervention. The alignment with the list based GP model maximises the potential of a public health approach using information such as QOF data to inform service plans and target unmet need. 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 wellbeing outside the traditional medical model. The work already conducted through the Inverse Care Law Health checks (between ABUHB and CTUHB), which is now rolling out nationally should be interrogated 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. The development of planning and public health skills at cluster level has great potential to maximise the efficiency and effectiveness of services.

The research conducted on the PRISM model should be further considered for its potential to support anticipatory care models

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

The responses made by PTHB to the questions above would in our view demonstrate that within Powys the clusters are maturing, are working well and have the potential to grow further. This is especially true in regard to the development of new workforce models and the clear involvement of a multitude of new stakeholders having a direct influence on cluster development.

Within PTHB the Clusters are supported and work alongside dedicated Management Teams who are responsible for the delivery of community services, the commissioning of secondary care and the ongoing partnership with local primary care services. Work over the past three years has seen the clusters and local team in many ways merge together on many aspects of both planning and occasionally delivery.

A set of revised arrangements will be introduced during 2017 that will further define the roles, purpose, accountability and inherent governance at locality cluster level. It will also make clear where the clear blue water lies between planning of services based upon population need and the delivery of such in the primary care environment.

There are frequent references in many documents and papers across Wales that suggest that clusters and federations are interchangeable. From a PTHB perspective we wish take this opportunity in responding to the Inquiry to set out our belief and the way we intend to operate.

In essence;

· GP Federations are and will be essential, for delivery of greater sustainability, economies of scale and robust future delivery models. GPs will need to become more collegiate as a  professional group across a specific geography and in this way, it should be possible to improve access and provide an extended range of services.

· Clusters are the local planning and delivery areas for Health Boards with all partners and making use of all local resources

The Cluster definition has been debated however the definition adopted locally is:

‘A grouping of GPs working with other health and care professionals to plan and provide services locally. GPs in the Clusters play a key role in supporting the ongoing work of a Locality Network. Locality Network is a term often used to describe this collaborative approach.’

In the Cluster: -

· Other health and social care professionals will have an equal role in developing local plans

· All local resources will be considered to maximise the effectiveness and efficiency of locals services- including third sector and programme budgets for conditions that can be delivered in the community

· PTHB will have a key role in appointing and developing Cluster leads and there will be clear clinical leadership structures linking to the Executive Team such that we are functioning as ‘integrated organisations’ regardless of contracts.

· Cluster leads will be appointed on the basis of their knowledge, skills and commitment- and should reflect the range professional communities-

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

Powys has been central to the work undertaken by the Directors of PCMH who have prioritised cluster development.  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 several programmes providing leadership development in support of cluster working being accessed regularly by cluster leads across Wales. 

Locally, significant efforts have been made to support Clusters in their development and cluster plans have always been prioritised for inclusion in the IMTP.

The Pacesetter programme alongside local OD work highlights the importance of clinical and managerial leadership in successful innovation and service redesign within clusters.

7.1 Clinical Leadership

Clinical leaders are essential to educate, advise, support  lead innovation and be accountable. 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. The emerging networks of assistant medical directors and primary care clinical directors should play a key role in enabling the full potential of integrated organisations.

7.2 Innovation Networks

Workshops facilitated by Public Health Wales have provided project leads with opportunities to share ideas, experiences and outcomes and enabled colleagues to envisage large-scale development for the future of primary care in Wales.

7.3 Business Development Managers

Pacesetters have proved the value of experienced practice managers in driving cluster innovation. There is potential for economies of scale in back-office/support functions of clusters through developing practice manager teams, led by experienced Business Development Managers on a cluster basis.

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

This is an area where whilst there is work ongoing nationally, PTHB has only begun to really work on the evaluation of its various schemes, concepts, deployments and so forth.

PTHB is linked to the Pacesetter programme and as such has therefore benefited from evaluation of the triage work. However, further work and national / regional support will be needed to test out whether the deployments and our strategic intent is delivering benefit.

It is clear that a strong primary and community care delivery function means that we have the lowest emergency admissions to secondary care, that we have maintained access to all 17 GP practices, that we have positive feedback from patients, the CHC and our Health Focus Groups on the work being undertaken and that we have dramatically improved patient experience by delivering care (both planned and emergency) much closer to home.

a rigorous evaluation framework is necessary to help us continue to plot the right course for our services and to better inform our emerging Health and Care Long Term Strategy.

AUTHOR : ALAN LAWRIE , DEPUTY CHIEF EXECUTIVE , POWYS TEACHING HEALTH BOARD

DATE : 1^st FEBRUARY 2017