The Directors of Primary Community and Mental Health (DPCMH) come together on an All Wales basis every month to work collectively on matters that affect each Health Board within the spheres of primary, community and mental health services. This collaborative work considers both tactical and business as usual matters as well as the delivery of the ambitions set out in the Primary Care Plan for Wales. A report on that activity for 2015/16 demonstrates the breadth and depth of the work undertaken as well as the work programme, as agreed with Welsh Government, for the current year. A similar report will be forthcoming for the work undertaken during 2016/17 and the proposed work plan for the coming year. In addition we have outlined to Health Board Chief Executives the work that we intend to pursue in 2017/18 set against a number of key drivers on strategic change for NHS Wales. As such, the DPCMH feel well placed to provide a detailed response to the questions set by the Inquiry, as well as demonstrating the significant work that has been undertaken, and will continue to be undertaken, on Primary Care services across Wales and providing that leadership both to national programmes and at Health Board level

Several of the questions are better responded to on a national basis through the DPCMH, than they would be at a local Health Board level. Responding to the Inquiry in this way we would hope to provide full answers to the work that has been undertaken in the domains outlined. Individual Health Boards will undoubtedly wish to respond to specific elements and in particular elements of question 3 (workforce), question 4 (use of cluster funds) and question 6 (the maturity of local clusters). Public Health Wales (PHW) will have submitted a related but individual response.

This specific response is set in the context of the Pacesetter Programme, funded by Welsh Government to promote innovation across primary care and delivered through health boards and primary care clusters in Wales. This funding (£4m) was part of the 2015/16 recurrent investment made by Welsh Government in Primary Care services. The development of this programme has been a key part of the work of the DPCMH and the Primary and Community Care Development and Innovation Hub (the Primary Care Hub) which was established in 2016 by PHW, with an accountability to the DPCMH.

PHW via the Hub was commissioned to support the Pacesetter Programme and facilitate evaluation of the 24 projects that focus on the Ministerial priorities of service sustainability, improved patient access and moving care into the community. The outcomes of individual projects inform an emerging model for primary care with the potential to drive transformational change across the NHS in Wales.

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, e.g. federations, include stronger practitioner commitment to transformative change and new ways of working.

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 clinical history, social situations, personal backgrounds and families of their patients. A wide range of professional skill-sets, 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.

1.2 Clinical Triage

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; 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.

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.

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

Newly redesigned OOH services offer multi-professional assessment and 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 information management technology (IMT) systems to support redesign, communication, joint-working, bench-marking and automated data capture on a cluster basis. Human resource 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.

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 shows evidence of clusters commissioning MIND and other providers for in-practice mental health clinics. The Valleys Steps model in Cwm Taf and other tier 0 Cognitive Behavioural Therapy (CBT) models are also in their early phases and showing strong evidence of working well with primary care to avoid escalations.

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 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 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 associates, healthcare support workers, dietician, optometrist, speech and language therapists, behaviour change consultants and dental hygienists. Outlined below are the findings from the research. Further information is available on an emerging model that could be in place across Wales to deliver transformational change from recruitment through to reduced reliance on secondary care services.

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.

2.2 Extended roles

· 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 musculoskeletal (MSK) services within cluster teams, leading to reductions in GP consultations for MSK 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 coordination.

· 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.

· Practice-based Social Worker roles have proved successful, not only in subsuming the many social problems and issues which GPs have to deal with every day but also in “tracking” practice patients who are admitted to hospital and facilitating timely discharge. The role has also been effective working in partnership with the practice pharmacist and visiting house bound patients.

2.3 Collaborative arrangements

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

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

3. The current and future workforce challenges

The fragility of many practices across Wales has a range of causes including increased volume and 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 an urgent 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.

3.1 Primary Care Sustainability

Detailed statistics on practice sustainability assist in the assessment of resilience and risk. The Pacesetter Programme indicates the value of standardised measures for sustainability and the use of dashboards to inform a national view of primary care resilience and workforce planning.

3.2 Health Board Support Teams

Methodologies to increase the resilience of practices and facilitate recruitment are under evaluation. A collaborative approach across adjacent health boards helps 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.

3.3 Multidisciplinary Approach

The enhanced cluster team offers flexibility and responsiveness to changing conditions and demand, promoting sustainability, resilience and improved economies of scale.

3.4 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 Health Board 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. The development of more forensic workforce planning in primary care will support better Integrated Medium Term Planning (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

Whilst this response largely refers to Pacesetter activities, the DPCMH would observe that in broad terms the direct funding of clusters has been a success. 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 Service Level Agreements (SLAs) for social worker support or mental health clinic provision.

Activities commissioned at local level have ranged across several areas:

Future years should see some 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. 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 research conducted on the Predictive Risk Stratification Model (PRISM) should be further considered for its potential to support anticipatory care models; and the work already conducted through the Inverse Care Law Health checks (between Aneurin Bevan and Cwm Taf University Health Boards), 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.

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

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.

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.

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

In overall terms the DPCMH 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. There are now several programmes providing leadership development in support of cluster working being accessed regularly by cluster leads across Wales.

Locally, significant efforts have been made by Health Boards to support Clusters in their development and cluster plans are being prioritised in this round of IMTPs.

The Pacesetter programme 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 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.

7.2 Innovation Networks

Workshops facilitated by PHW 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 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

Pacesetter project evaluations are based on success in finding solutions to the three ministerial priorities for primary care. 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, 1000 Lives Improvement Service (PHW) and Health Board DPCMH. There has been assessment and dissemination of the shared learning from the programme and national learning events held. The Pacesetter Programme is tendering for a partner to evaluate activities undertaken thus far and further activities to follow.

Documentation referred to in this response and available on request:

· DPCMH Annual Report 2015/16

· DPCMH work plan

· Role of PHW Primary & Community Care Development & Innovation Hub

· Pacesetter Programme – an emerging model for primary and community care in NHS Wales

Produced for and on behalf of the All Wales DPCMH.