1.1 Role and ways of working
The Primary & Community Care Development & Innovation Hub (Primary Care Hub) coordinates support for health boards and clusters, at a national level, in the delivery of the national plan for primary and community care in Wales; facilitates coordinated delivery on a range of primary care projects; and provides support to other projects within the overall work programme for Directors of Primary, Community and Mental Health Services (DPCMH). Colleagues within other Public Health Wales (PHW) national teams work in partnership with Primary Care Hub staff to deliver these projects. Local public health teams (LPHTs) also work closely with the Primary Care Hub, playing a key role in supporting primary care clusters directly within health board areas, and in contributing local knowledge and skills to the national work programme.
1.2 Work programme
The work programme for the Primary Care Hub is agreed and overseen by a Programme Board and currently focuses on four themes: cluster development; access to information and health intelligence; quality improvement and safety; and innovations in healthcare.
1.3 Pacesetter Programme
The Pacesetter Programme has provided funding from Welsh Government to health boards/ clusters to explore new ways of working in relation to Ministerial priorities for primary care of service sustainability, improved patient access and moving care into the community. PHW was commissioned to support this programme and to facilitate its evaluation. A separate response has been prepared by DPCMH, in liaison with PHW, that focuses on the contribution of the programme to an emerging model of primary and community care with the potential to drive transformational change across the NHS in Wales; that document should be read in conjunction with this response.
2.1 Cluster development and wider professional involvement
Primary care clusters (also known as neighbourhood care or cluster networks) were intended to involve the wider primary care professions, but we are aware of variation ranging from inclusive arrangements to clusters that have a general medical practice focus. We highlight the need for wider professional involvement (reflected in consistent use of inclusive cluster-related terms) at greater pace.
2.2 Innovation and demand management
Evaluation of the Pacesetter Programme has and will examine the contribution that clinical triage systems can make to management of primary care workload; the bespoke professional services and/ or resources that can moderate the use of acute services by persons with complex care needs; and systems-level integration of out-of-hours services to ensure continuity of care.
3.1 Cluster development and role description informed by needs
Development and description of new roles will need to be in line with identified cluster needs, supported by the availability and funding of tailored training for existing staff who are changing roles and for staff newly recruited to primary care. Clusters will need expert support to identify their staffing needs and the resources available to meet them.
3.2 Quality/ safety and assessment of MDT impact
The contribution of multi-disciplinary team (MDT) approaches to service delivery would be broadly reflected in outcome-related measures (such as number of injuries resulting from falls in the home); process-related measures (such as rates of referral to secondary care); and measures related to patient experience (such as survey-derived levels of satisfaction). In the context of other transformation-related changes, accurate assessment of the specific MDT contribution will be challenging. Pragmatic evaluation approaches exist (such as contribution analysis) and there is an existing evidence base on effective MDT working in the scientific literature. How successful MDT pilots are supported to transform into sustainable business-as-usual services requires attention.
3.3 Innovation and the MDT contribution
Evaluation of the Pacesetter Programme has and will examine the contribution that MDTs can make to management of primary care workload.
4.1 Cluster development and workforce issues
Feedback from clusters, local public health teams and others attests to the pressures that many GPs face to maintain levels of service. Feedback also indicates that this imperative can conflict with engagement in the full extent of primary care cluster ambitions. Some Primary Care Hub staff have had input into primary care workforce strategy. Their involvement indicates that challenges include assurance of attractive career pathways (such as new cluster consultant nurse roles); retention of knowledge and experience; barriers around recruitment process; provision of peer support to those in new roles (such as mentorship); appropriate training; and development of cultures based on inclusivity and mutual respect between all cluster roles.
4.2 Cluster development and evolving professional roles
Well-supported public awareness campaigns will be needed to ensure a prudent public understand that supplementing (not substituting) GPs with wider multidisciplinary roles frees GPs to focus on what only they can bring to primary care; new roles are not intended to replace GPs.
4.3 Innovation and planning in support of sustainable transformation
Evaluation of the Pacesetter Programme has and will examine the central role of workforce planning across primary and community care in facilitating transformation and in ensuring the medium- to long-term sustainability of primary care services. Experience suggests that addressing sustainability must precede implementation of new workforce models and new work they support.
5.1 Cluster development and systems working
General practices operate within a primary care context, and primary care within a whole system context (including secondary care and communities). It follows that funding streams to explore new ways of working should reflect this inter-dependence. Although clusters continue to evolve towards wider primary care involvement, in some cases decisions on spending these monies do not reflect this. We encourage equitable access to funding opportunities based on assessment of population needs.
5.2 Quality/safety and primary care service improvement
Our 1000 Lives Improvement team is leading development of a primary care safety and quality programme supported by the Primary Care Hub. This will incorporate several projects that make use of technology to identify and manage risk, with the aim of improving outcomes for patients. The development of clusters provides an opportunity to take a fresh look at strengthening leadership around quality improvement across primary care networks.
6.1 Cluster development and social prescribing
Social prescribing is gaining increasing attention as a means for primary care to engage with primary prevention (health promotion and other activities to reduce the chance of becoming ill), better utilise non-medical community assets and influence social determinants of health locally. To support primary care in this, we are coordinating a map of the evidence, gathering social prescribing activity and organising events to share and promote this learning across Wales to inform decisions on current and future projects.
6.2 Information/ intelligence and population health
The Primary Care Hub is working with others to improve access to relevant and timely health intelligence. We encourage clusters to take a broad view of data describing population needs and to integrate intelligence arising from professions other than general practice. As well as reflecting population needs, cluster plans should be informed by evidence on effective interventions, and we intend to strengthen our support for this. Local public health teams play a vital role in helping clusters interpret population health status, prioritise action and select best value interventions—but tailoring this for 64 clusters challenges capacity.
7.1 Cluster development and maturity status
We anticipate that individual health boards will comment on the current maturity of their clusters and nominate best practice examples in their responses.
7.2 Innovation and cluster configuration
Evaluation of the Pacesetter Programme has and will examine approaches to internal configuration of clusters that drive transformation.
8.1 Cluster development and support for leadership and skills
We have supported or brokered several initiatives to develop leadership and other skills. These are the Confident Leaders Programme (for cluster leads); coaching and action learning (initially in North Wales and also aimed at cluster leads); and a series of workshops aimed at anyone working in or with clusters (initially on health needs assessment, project management and co-production). A follow-on programme is in development and will be informed by evaluation of events to date.
8.2 Innovation and the role of primary care support units
Evaluation of the Pacesetter Programme has and will examine the organisation and function of primary care support units (PCSUs), particularly their role in relation to the short-term sustainability of primary care services.
9.1 Cluster development and academic evaluation of the cluster model
PHW has commissioned an academic partner to survey the functions and maturity of clusters in Wales; review measurement tools designed for comparing primary care maturity and quality; tailor an existing tool for within Wales comparisons; and measure the ‘strength’ of primary care clusters in relation to maturity.
9.2 Information/ intelligence and support for collaborative working
The Primary Care One website promotes collaborative working in Wales and aims to support cluster development at a national level. It aspires to be a central source of information relevant to clusters and promotes mutual support to share learning, cluster-led projects and achievements.
9.3 Quality/ safety and measures of primary care effectiveness
The Primary Care Hub supports the development and implementation of Primary Care Measures being led by the DPCMH. These measures are intended to reflect quality improvements in the primary care contribution to better health outcomes (or proxies thereof).
9.4 Innovation and support for outcomes assessment
New ways of working necessitate some form of outcomes assessment to identify change that has merit and potential for adoption elsewhere through the sharing of learning. We are exploring how we can strengthen our support to clusters through coordinating access to research and evaluation expertise within and without the organisation.