The proceedings are
reported in the language in which they were spoken in the
committee. In addition, a transcription of the simultaneous
interpretation is included. Where contributors have supplied
corrections to their evidence, these are noted in the
transcript.
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Dechreuodd y cyfarfod am 10:15.
The meeting began at 10:15.
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Cyflwyniad,
Ymddiheuriadau, Dirprwyon a Datgan Buddiannau
Introductions, Apologies, Substitutions and Declarations of
Interest
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[1]
Dai Lloyd: Croeso i gyfarfod diweddaraf y Pwyllgor Iechyd,
Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol
Cymru. O dan eitem 1, a allaf i estyn croeso i’m cyd-Aelodau
i’r cyfarfod yma o’r pwyllgor iechyd, a hefyd egluro
bod y cyfarfod yma yn ddwyieithog? Gellir defnyddio clustffonau i
glywed cyfieithu ar y pryd o’r Gymraeg i’r Saesneg ar
sianel 1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar
sianel 2. A allaf i hefyd atgoffa pobl i naill ai diffodd eu ffonau
symudol ac unrhyw gyfarpar electronig arall, neu eu rhoi ar y dewis
tawel? Nid ydym yn disgwyl larwm tân y bore yma, so os bydd
un o’r rheini yn canu, mae disgwyl i ni ddilyn y tywyswyr
allan o’r adeilad.
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Dai Lloyd: Welcome to the latest
meeting of the Health, Social Care and Sport Committee here at the
National Assembly for Wales. Under item 1, can I welcome my fellow
Members to this meeting of the committee, and also explain that
this is a bilingual meeting? You can use headphones to hear
interpretation from Welsh to English on channel 1, or for
amplification on channel 2. Can I also remind you either to switch
off your mobile phones and any other electronic equipment, or to
switch them to silent? We aren’t expecting a fire alarm this
morning, so if you do hear an alarm, then we’ll have to
follow the ushers out of the building.
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10:16
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Ymchwiliad i Ofal
Sylfaenol—Sesiwn Dystiolaeth 1: Iechyd Cyhoeddus Cymru a
Byrddau Iechyd Lleol
Inquiry into Primary
Care—Evidence Session 1: Public Health Wales and Local Health
Boards
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[2]
Dai Lloyd: Gyda chymaint â hynny o ragymadrodd,
felly, fe wnawn ni symud ymlaen i eitem 2, ac ein hymchwiliad i
ofal sylfaenol, clystyrau ac ati. Hwn ydy sesiwn dystiolaeth rhif 1
ar y pwnc yma, ac o’n blaenau heddiw yn y sesiwn dystiolaeth
gyntaf yma mae Iechyd Cyhoeddus Cymru a byrddau iechyd lleol.
Felly, a gaf i groesawu Rosemary Fletcher, cyfarwyddwr rhaglen,
datblygu ac arloesi mewn gofal sylfaenol a chymunedol Hwb, Iechyd
Cyhoeddus Cymru? Bore da. Alan Lawrie, dirprwy brif weithredwr a
chyfarwyddwr gofal sylfaenol a chymunedol, bwrdd iechyd addysgu
Powys—croeso. A hefyd John Palmer, cyfarwyddwr gwasanaethau
sylfaenol, cymunedol ac iechyd meddwl, bwrdd iechyd prifysgol Cwm
Taf. Croeso i chithau hefyd. Mae Aelodau wedi derbyn tystiolaeth o
bob man, yn cynnwys o’r byrddau iechyd lleol ac Iechyd
Cyhoeddus Cymru. Felly mae gennym ni gwestiynau gerbron, ac felly,
gyda’ch caniatâd, fe awn ni’n syth i mewn
i’r cwestiynau hynny. Mae gennym ni awr fach, felly
cwestiynau byr; atebion byr. Angela.
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Dai
Lloyd: With that
introduction, we’ll move on to item 2, which is our inquiry
into primary care, clusters and so forth. This is the first
evidence session, and before us today in this evidence session is
Public Health Wales and local health boards. So, can I welcome
Rosemary Fletcher, programme director for the primary and community
care development and innovation hub from Public Health Wales? Good
morning. Alan Lawrie, deputy chief executive and director of
primary and community care, Powys teaching health board, welcome to
you. And also John Palmer, director of primary, community and
mental health, Cwm Taf university health board. Members have
received evidence from many sources, including local health boards
and Public Health Wales. So, we do have questions, and so with your
permission we’ll go straight into those question. We have an
hour, so succinct questions and succinct answers. Angela.
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[3]
Angela Burns: Diolch, Chair. Good morning. Thank you
very much for coming along to see us. I’d just like to dive
straight into where you see the evidence gathering taking place,
and what evidence do you have that would indicate that clusters are
being successful?
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[4]
Mr Palmer: Bore da. Good morning. I think, in terms of
evidence base, we’ve got to just start with saying it is
early days for what we’re learning about these new changes
around clusters and what each project is achieving within those.
But we have, from the very beginning, I think, had a bit of a view
about gathering evidence. There are probably two things that
we’ve done that are important. We’ve commissioned from
work from Bangor University, which is helping us to understand the
maturity of our clusters, and it sort of builds on initial work
that we did to just try and understand how soon we would be seeing
results from clusters. How would they mature or shape up? How would
they accrue other professions into the system and start working
effectively? So, that’s a helpful piece of work to have in
train.
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[5]
Attached to that, as well, we’ve had Pacesetters running for
the last two years, which I suppose are slightly a level up from
clusters but very much connected to clusters, where we’ve
again gone out to tender to ask for support. But over the last two
years, we’ve had a team working through the hub, and probably
in earlier stages with some of the professionals from 1,000 Lives,
and they’ve been working very hard to share peer learning
across the health boards. We’ve had a number of all-Wales
national days, where there have been exchanges about pharmacy
developments that come from the Pacesetter work and from the
cluster work, and that has been a very healthy exchange, and I
think that’s got to be at the best practice sharing, going at
an early stage. So, those two pieces are probably the things that
are going to help us get some on-the-record evaluation in place.
But Rosemary is probably a little closer to it than Alan and I at
the moment.
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[6]
Angela Burns: May I ask another question before you answer,
Rosemary? Because perhaps you can flex your answer. That all sounds
wonderfully positive. There are 64 clusters out there. We’ve
talked to a fair number of them, both on rapporteur visits into
north Wales and into west Wales, and indeed we’ve had a
session with local clusters for the Cardiff and Valleys areas. They
don’t have quite such a rosy view. There’s a lot of
confusion as to how this is going to be evaluated. There’s,
and I’m quoting, ‘not always a shared understanding of
how evaluation and data would be collected, managed and
delivered.’ I’ve got—well in fact there’s
just so much I will have fingers in all sorts of papers if I try to
read every single quote—but there seems to be quite a
difference of opinion as to how the effectiveness and how the
objective, which is to relieve the stresses on primary care
delivery, are being collated, understood, fed back and, ultimately,
evaluated for us to decide whether clusters should go forward or
not. So, I just wondered what your take is, because my observation
would be: 64 clusters—if you can’t get that message out
to 64 people, or 64 heads, to disseminate through their
organisation, there’s a bit of a communication gap.
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[7]
Ms Fletcher: Just to follow on John’s point in terms
of the work that’s being commissioned from Bangor,
we’re engaging with cluster leads in terms of the development
of the tool. So, the tool is in pilot stage. That’s being
informed by research elsewhere, through Bangor University.
They’re actually running—well, there’s a workshop
later today, and there’s another one being run in north
Wales. That invitation has been issued to all cluster leads because
we want to engage them in that tool. It’s really for them to
test and validate the tool to be able to provide exactly what you
say to assess the maturity of the clusters, and the potential for
clusters going forward.
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[8]
Mr Lawrie: Perhaps if I could just add in to that, I think
there are probably two dynamics going on there. There’s
clusters as coming together, across a patch—not just about
GPs, but the wider social work: voluntary sector, locality managers
and so on and so forth—and I think I picked up there the
demand for GP services. So, I think what clusters are helping us to
do is get practices working together, which they probably
didn’t do in the past as well, looking at shared areas of
risk and sustainability, and, in terms of some practical examples,
they’ve now started to develop a whole series of new sorts of
roles that can work at both practice and cluster level, which is
relieving pressure from general practitioners.
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[9]
A very specific example for myself up in Powys is that we’ve
identified a new role called an urgent care practitioner, and they
have proved to be very effective. We’ve now got seven of
those urgent care practitioners working across five practices in
Powys. I was just seeing some stats yesterday that showed that in
one of the practices in Newtown, the UCP—the urgent care
practitioner—is now doing 65 per cent of the home visits that
were previously being 100 per cent done by GPs. So, I think what
we’re seeing with these new roles that are being developed,
both at practice level and within clusters, is that they are coming
in, they’re supporting, they’re augmenting general
medical services with their own skill sets, and they are most
certainly helping to manage workload at that kind of level. But
clusters aren’t just interested in managing demand at GP
level, they’ve got a wider involvement as well.
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[10]
Dai Lloyd: Okay. John.
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[11]
Mr Palmer: Just to come back to your point, I wouldn’t
at all want to suggest that everything is rosy in the garden. I
think we’ve got some good initiatives in place that are going
to help us understand and evaluate clusters nationally, and those
two pieces of work that I referenced, I think, will be really
helpful. But we’re two years into quite a different way of
working, and I think it shows real promise, but you’ve got to
make sure, as well, that you’re looking to individual health
boards to deliver on the promise to clusters, if you like. I think
what I do see after two years is if you look at this round of
integrated medium term plans for the organisations that have got
them over a three-year cycle, and for the one-year plans that are
coming through for other organisations that haven’t, you do
see clusters, I think almost universally now, properly referenced
in each document, and in a plan system, it’s really important
that the clusters are represented. I wouldn’t pretend for a
moment there isn’t complexity and some dynamics around that
because these are new into the system, but I would also say, as
Alan has just laid out with a couple of examples, there are some
really promising developments that are definitely going to scale up
in terms of three-year plans.
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[12]
Angela Burns: And I perfectly accept the principle behind
your observations. I think, from our viewpoint, what we want to
see, or what we want to ensure, is that there has been proper
monitoring of both the effectiveness of the initiatives in terms of
outcome, and the effectiveness of the use of the money, and whether
or not that’s created the time excess that we need in order
to develop or deliver better primary healthcare. What we
don’t want to do is run a system for, say, three or five
years, and then start monitoring and evaluating it, and that is
what has happened with some of these initiatives in the past. So,
we’re very keen to understand from you exactly how this is
going to be monitored, what you’re going to be measuring,
when you want to see your first set of measurements, and do you
have any benchmarks against which you will level those
measurements. That’s what we’re seeking to see.
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[13]
Dai Lloyd: Okay. Moving on, Julie.
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[14]
Julie Morgan: Thanks very much and good morning. I wanted to
ask you about the multidisciplinary teams and how they are
developing. What are the advantages and the disadvantages? Are
there any themes emerging of the multidisciplinary working?
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[15]
Mr Lawrie: I suppose I answered a little bit of that in the
first question.
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[16]
Julie Morgan: You’ve already said a bit about it,
yes.
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[17]
Mr Lawrie: I think that, through cluster working,
we’re now seeing that all clusters and the practices within
them are beginning to see that multidisciplinary working is the way
to go. Some have been more advanced than others in terms of that.
We’re seeing a range of professionals now working at practice
level: advanced nurse practitioners, physiotherapists working in
practice, pharmacists working as practice pharmacists, triage of a
variety of sorts—now probably being referred to a telephone
first, but nurse triage and so on and so forth. Therefore, coming
together and working as a MDT within a practice—. If you
probably went back four or five years ago, you would have had a GP,
maybe a practice nurse, and a healthcare support worker. You walk
into many practices now, you’ll see that range of
professionals.
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[18]
Julie Morgan: Is it most practices?
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[19]
Mr Lawrie: Many.
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[20]
Julie Morgan: Many.
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[21]
Mr Lawrie: Not all. You’ve still got some places where
it’s very traditional, very GP, and maybe some practice
nurses, through to places where you’d get every healthcare
professional under the sun, nearly, working under the roof. I think
that’s about size, and that’s why cluster working is
really important. We’ve got smallish practices actually
having some of those resources at practice level—so your
individual pharmacist or your individual physio—it’s
just not going to be as cost-effective or viable, and therefore
doing it at a cluster-wide level, it becomes much more effective.
In a larger practice, maybe 14,000 patients or 20,000 patients,
actually employing ones and twos of those is much more effective.
So, in terms of advantages, there’s certainly better care
co-ordination for the patient, certainly freeing up GP time to work
on the more complex patients, and certainly, I think, for us, it is
about delivering the prudent healthcare principles. It’s
providing prudent healthcare—only doing what you can do and
so on and so forth.
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[22]
I think there are some disadvantages. I think we have got issues in
terms of being clear about the scope of professional practice
between these individuals. We’re growing these people quite
fast: what’s their scope of professional practice? I think we
have some issues just in terms of role overlap. Where does a UCP
start and stop? Where does an ANP start and stop? And I think
we’re beginning to get, in some of the larger practices, some
issues with GPs in terms of having manage this growing
multidisciplinary team and feeling confident to be able to manage a
growing number of healthcare professionals when they’re used
to working kind of on their own. Having a large team is, for some
people, very natural; for others, we’re going to have to put
some training and some skill around that. I think, on the whole,
it’s a very advantageous way of working, but we’ve got
some challenges that we know we’re going to have to work
through.
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[23]
Dai Lloyd: Okay. John.
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[24]
Mr Palmer: I’m just going to give a small, specific
example. One of the things I think that’s important about
clusters is that they have allowed a number of smaller initiatives
to get running, and there was very strong steer from Ministers at
the very outset: let’s be creative, let’s be
experimental, and allow some things to happen, and, in some senses,
make sure that health boards get out of the way and facilitate as
much as possible for delivery.
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[25]
So, a nice example: St John’s, Aberdare—one of our
practices in the Cynon. We’ve got an interesting mix of young
GPs and older GPs in that practice. They have some really strong
debates about what they want to do. Coming into this year’s
cycle of winter planning, they had a whole discussion about—.
We had a number of acute exacerbations that have happened in the
system, people who we pretty much knew would get unwell during a
cold snap, and we know that, in other years, they have definitely
come through into the acute hospital system—they’ve
been a presentation at accident and emergency, and then
they’ve had a slightly unmanaged length of stay and
could’ve been treated much earlier in the system if
we’d been alive to that.
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[26]
Now, we’ve had a number of initiatives over the years that
have been trying to get more upstream, but they’ve run with
the Welsh Ambulance Service NHS Trust this year—a community
paramedic scheme. That’s been a small group—it’s
just a team of four that have been working across the region but
focusing most of their energies on this practice, and so the whole
aim has been to predict the people who are going to get unwell when
there’s a cold snap, and to get to them early and have a
discussion about, ‘How do we wrap around you and support you
so you don’t need to come into the acute system?’ That
has probably saved, after the initial evaluation that’s been
done locally—it’s looking like it’s saved five
admissions a week during the winter period. Now, if you scale that
up and we were running that kind of model out of every practice in
Cwm Taf, you could be looking at either an avoidance or a delay in
about 11,000 admissions a year. So, it really is the case, I think,
that in micro, some of these things look really promising. The
challenge to us now in a planned system—we’re in a
three-year planning cycle—is now to say, ‘Okay, we can
scale that up in partnership with other partners to make a bigger
dividend from the investment.’
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10:30
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[27]
Dai Lloyd: Okay, Jayne—
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[28]
Julie Morgan: I just—
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[29]
Dai Lloyd: Sorry, Jayne has a small point.
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[30]
Julie Morgan: That’s fine.
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[31]
Jayne Bryant: On your point about that example that
you’ve given, which is a really good example and showing how
creative they can be, but we had evidence from Cardiff and Vale
University Local Health Board who were talking about the cluster
agenda becoming so demanding that there’s limited time to
develop networks and generate ideas. Do you think there’s
enough time to find these ideas and run with it, or—?
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[32]
Mr Palmer: It’s an interesting question. I mean, I
don’t know exactly where the observation came from, so
I’d probably need to know a bit more about it to give you a
decent answer, but, again, we kind of need to flip this on its
head. If clusters believe that they need to make time, and they can
make time to invest in joint working, then I think it’s then
the responsibility of the health boards to respond and support. So,
in terms of team working and team development, if you look across a
number of the health boards, what you’re starting to see now
are appointed clinical leads who have got a locality focus;
you’re starting to see development managers, who are there to
support primary care projects and primary care spend; and
you’re seeing a mixture of clinical leads coming out of
clusters or clinical leads coming from the practice management
community—or, sorry, managerial leads from the practice
management community, who are appointed to drive this agenda. So,
then, I think what you try to get is a mix between drive and energy
coming voluntarily from the system, with the support of a
contractual incentive, and then health boards investing to make
sure that these projects can deliver. Where that’s happening,
you’re seeing pace, and you’re getting connection
between core funding for primary care, Pacesetter funding
that’s been trying to push the agenda, and then cluster
funding that’s seeding lots of interesting changes.
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[33]
Dai Lloyd: Okay. Julie.
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[34]
Julie Morgan: I just wanted to know whether you’ve
made any assessment of what has been the response of the patients
to these changes. It is something we discussed when we visited
Pembrokeshire, to discuss it with the clusters there, and how
accepting people were now, generally—maybe of not going in,
and where in the past they expected to have seen a GP, they now see
someone else. Have you made any assessment of this?
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[35]
Mr Lawrie: We’ve done a couple of pieces of work
around that, around the triage side of things. We implemented the
clinical triage model through our Shropdoc provider into the
Newtown practice about a year and a half ago. We thought we’d
done quite a good communications plan, but you can never
over-communicate, can you? We involved the local community in that,
and then I’ve run a number of patient surveys, and they have
been generally positive—generally positive. Similar sort of
exercises in the south of Powys where they implemented a different
sort of triage system, and, again, I’ve done some patient
experience through our patient participation groups at practice
level, and also through the community health council.
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[36]
I think there is a real question about increasing the amount of
public education around this, though, because moving away from,
‘You’re going to see the doctor’, through to,
‘You’re going to see the appropriate healthcare
professional’ and getting that message out there. So, when
people do access it, it appears as though what they get is a very
positive response, but there’s a concern if they
haven’t accessed it, ‘Why am I not getting to see the
doctor?’ So, I think we’ve got more work to do both at
practice, cluster and health board level in terms of that public
message in relation to—. Things are changing; they’re
changing for the better, but you might not be seeing the
doctor—you will have to do some of these things. And where
it’s working, it appears to be working very, very effectively
around that.
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[37]
Julie Morgan: Thank you.
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[38]
Dai Lloyd: Ocê. Rhun
nesaf.
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Dai Lloyd: Okay. Rhun next.
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[39]
Rhun ap Iorwerth: Bore da i
chi i gyd. A allaf i sôn ychydig bach am weithlu? Rydym ni
fel pwyllgor, rwy’n meddwl, wedi adnabod cynllunio gweithlu
fel un o’r problemau mawr sy’n ein hwynebu ni yn y
gwasanaeth iechyd yng Nghymru. A allwch chi sôn rhywfaint am
faint o her ydy sicrhau gweithlu priodol er mwyn i glystyrau allu
gweithio’n effeithiol? Ac yn benodol, a ydych chi’n
credu bod y rhagdybiaeth yma yn gywir: bod y ffaith bod yna
drefniadau i rannu staff ar draws clwstwr eang, ar draws y
gweithlu amlddisgyblaethol
ehangach, yn ffordd ynddi’i hun i fynd i’r afael
â rhai o’r heriau gweithlu yna?
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Rhun ap Iorwerth: Good morning to you
all. May I mention the workforce a little? We, as a committee, I
think, have recognised workforce planning as one of the major
problems facing us within the health service in Wales. Could you
talk a little bit about how much of a challenge ensuring an
appropriate workforce is for clusters to be able to work
effectively? And specifically, do you think that this perception is
correct: that the fact that there are arrangements in place to
share staff across clusters, across the multidisciplinary team more
widely, is a way in itself of getting to grips with some of those
workforce challenges?
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[40]
Mr Palmer: I think this is one of the areas where
we’ve got some of the greatest challenges, so I think
it’s just worth being honest about that. The Minister has put
a taskforce in place for Wales to look seriously at the workforce
issues we have around primary care, and there have been some
incentive packages recently that have come out that have been very
positive. So, in the areas that have been targeted, we’ve
seen something like a 16 per cent improvement in GP take-up, so
that’s good news, but I think one of the things we’ve
been challenging ourselves as a network of primary care directors
with is: how do we get clarity on long-term modelling around
workforce needs, against the need that’s expressed in our
population? So, we’re in the middle of some really serious
modelling work with workforce and OD directors, and the workforce,
education and development services, who are giving us data and
statistics as well. We’ve done an initial piece of work
around that for the taskforce, but I would say it needs a lot more
work. So, I think, cards on the table, we’ve got some
challenges to name exactly what the demand profile is going to be
over the next five to 10 years.
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[41]
However, having said that, I also think there’s, again, some
real promise in the system. Alan’s already laid out a couple
of examples around multidisciplinary teams developing. On my own
patch in out-of-hours at the moment, I just seem to be experiencing
a turn where we’re starting to develop a much more mixed
approach to out-of-hours. GPs are in the lead, but working with
community paramedics, who have started to come on stream as a
workforce, and working with advanced nurse practitioners, and we
just seem to have hit a seam, a bit of a tipping point, where
we’re getting these people in to work together
collectively.
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[42]
In terms of a day-to-day sustainability, one of the absolute clear
priorities that’s come out of the Pacesetter funding has been
investment in things like primary care support units. So, in Cwm
Taf, we have a well-established model of having a multiprofessional
team that’s available to support practices that really need
us to support them and to provide salaried professionals.
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[43]
When you look across Wales, certainly over the last two years,
we’ve seen investments in similar sorts of things: very
focused, professional, available posts that can go in at short
notice to provide sustainability support. So, there’s been an
immediate response in the system, and I think that’s just
helped to provide a bit of stability over the last couple of years,
but we’ve got to bridge from that. I think the ambition has
to be that we’re not in a constant wrestle of sustainability.
What we want are the right number of facilities on each patch
around Wales, that have really good estate, that bring in a
multiple group of professionals who can work together effectively
for patients. And I think we’re laying foundations for that
at the moment, and then, as I said earlier, we’ve got to push
ourselves to really get the workforce modelling right over the next
five to 10 years.
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[44]
Mr Lawrie: Just to add to that, I think on the one hand we
can look at the work that has been done across a number of health
boards and say there are some really innovative roles in there,
some big changes, really, that have been over the last couple of
years. That’s very positive, but there is the same quantum of
physiotherapists, pharmacists, nurses and so on and so forth. The
jobs that we’re creating are interesting and exciting jobs,
so therefore people are attracted to those. That’s going to
create potential recruitment problems elsewhere in our system,
whether that’s in our community hospitals or in our district
and general hospitals, potentially, et cetera, because they see an
exciting job working in a practice or at cluster level. So, I think
there’s a big job, linking to the work that John was talking
about in terms of modelling. So what should the supply look like
coming into the pipeline as you move forward? This isn’t just
about solving a problem for now. It is about how we continue to
work on that problem over the next five to 10 years, so the supply
chain into those professions is really crucial for us, and in terms
of an absolute number for that, I’m not sure we’re
there yet, but the modelling work will help us get to that.
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[45]
Rhun ap Iorwerth:
Have you got any thoughts on
this?
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[46]
Ms Fletcher: You commented specifically on whether the perception
is correct about sharing staff across clusters, and I would say we
have to consider that new model, because some of the staff—.
You have to have that critical mass. A practice, in isolation, may
not be able to fund, or resource, or have the demand for that
particular professional, but by looking across a cluster, you can,
then, get a better range of professionals who can serve the needs
of the whole cluster. So, that’s why, personally, I think it
is correct that, where it is appropriate, it is considered at a
cluster level.
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[47]
Rhun ap Iorwerth:
And both, certainly the two of you from
the health boards, admit that we’re currently probably
still at a position where you’re trying to recruit from a
fairly small pool of people who have the right skills. What is the
key, do you think, as a national lead, to making sure that, in the
long term, that’s not going to be the case? Is that the work
of the taskforce that’s going to be at the heart of that?
|
|
[48]
Mr Palmer: I wouldn’t say it was just the taskforce.
The taskforce has a number of things that it’s trying to do,
but, really, fundamentally, attracting the workforce is about
reputation. Do practitioners feel that they’re coming to a
place that is stable and safe? For me, over the last couple of
years, that’s probably been the biggest part of the
agenda—making sure that our core functions feel stable and
safe. Once you start that, you start to generate a reputation for
being a place where people want to work, because they’ve got
that environment. Then, next what you’re looking for is a
sense that you’re going to be able to express yourself
clinically. So, there are opportunities for innovation and redesign
and clever service design. Again, because I think the cluster space
has been a bit more innovative—it’s a bit more pacey,
it’s a bit more exciting—I think we are seeing some of
those expressions. So, I pretty much feel that clusters have
certainly pulled us into a pharmacy space at much greater, rapid
steps than we would’ve expected otherwise, and a lot of the
cluster funding, without a big hand of organisation, has tracked
towards pharmacy.
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|
[49]
The other thing that’s happened is that information and
communications technology has become a feature of the landscape,
bottom up. You’re seeing models like webGP that triage using
online systems and are definitely helping some practices, and
you’re seeing Vision and other online services being put in
place to co-ordinate medical records viewing and taking of the
record in someone’s house, building on some of the
interesting stuff we’ve seen in district nursing, for
instance. I think we’re seeing pace in a different way, and I
think what that does is it creates a dynamic that asks us a
question in our leadership roles, within our own health boards and
at the national level: can we match that sense of ambition? Can we
respond in a planning cycle to scale some of these things up
actively? That’s on us. That’s our responsibility and
accountability as leaders in NHS Wales.
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|
[50]
Rhun Ap Iorwerth: I think the reputation point, in
particular, is very important.
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[51]
Dai Lloyd: Symud ymlaen i faterion cyllidol, ac mae gan
Caroline Jones gwestiwn.
|
Dai Lloyd: Moving on to financial
issues, and Caroline Jones has a question.
|
|
[52]
Caroline Jones: Diolch, Chair. Good morning. I’d like
to ask a couple of questions, please, about funding, particularly
regarding cluster development moneys. We’ve heard that the
allocation process is unclear. We’ve also been told that the
moneys are not targeted effectively and that they should go
directly to clusters. Could you tell me if these concerns are
justified, and, if they are, how do you think the moneys may be
deployed effectively in the future?
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|
[53]
Mr Palmer: Again, I think we’ll continue with the
theme of honesty this morning. So, I think we all know that, over
the last two years, there’s been some variation across the
system, and certainly we’ve got mixed feedback about how
clusters feel about how allocations have been handled. But, I take
you right back to the beginning, when the previous Minister, before
we had Cabinet Secretaries, came out to us very, very clearly, as a
whole system, and it was, ‘Look, we are sending out £6
million directly to clusters. You must keep out of the way, health
boards, and we want experimentation. We want to see pace and
experimentation. Let a thousand flowers bloom.’ I think
that’s been a real challenge for a number of health boards.
We do tend to like our orthodox planning approaches. We do like to
be in our IMTP cycle, because there’s an expectation of us
delivering against that plan. So, it’s a different ask, and I
think what I’ve seen over the last two years is a number of
health boards grapple with that challenge of moving from
controlling funding to facilitating the delivery of funding and
supporting clusters to do what they feel they need to do at a
population health level.
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10:45
|
|
[54]
I would say that, over the last six months, we’ve probably
really worked that through in the system. There have been some
really important conversations over the last six months that have
made it very clear to everyone that the expectations, going
forward, are that all the funding goes out absolutely directly.
There is an absolute expectation that we facilitate and support,
and if we can join up funding, all the better. I would like to say
that I am seeing some progressive work now, where health boards are
facilitating and making connections between the dots. So, think
about the funding packages: we had £30 million out for core
funding for primary care, which has been a really important lever
overall; we had £4 million for Pacesetter work, to be a bit
more radical; and we had £6 million directly out to the
clusters. In an integrated system, I think the challenge—and
a challenge that I think a lot of organisations are stepping up to
now—is to connect the dots so that there is balanced,
integrated funding across the whole of the patient pathway.
|
|
[55]
Caroline Jones: Okay, thank you.
|
|
[56]
Mr Lawrie: Can I just add to that? I think we can’t
get away from the fact that the funding for clusters has been
positive. It has been a positive thing. The fact that it is
recurrent has allowed people to plan a little bit more. I think it
has also provided a real focus at clusters and it has surfaced some
of the issues between various groups. Actually having to make
decisions between four and five practices and other professionals
has surfaced some of the issues that they have got to work through.
I think, sometimes, that has probably slowed the process down a wee
bit. We recognise, I think, that some health board systems and
processes have got in the way—so, recruitment, procurement
rules and so on and so forth. We probably haven’t been as
good as we could have been, in terms of trying to work that through
with the clusters.
|
|
[57]
I think we talked a little bit more previously about the support
that is required to be provided to clusters. So, I think it is
about health boards getting in there, and, if they are getting
difficulties in relation to getting a job advertised or matched, or
whatever it may be, helping and facilitating that, as opposed to
just letting it languish. I think, often at cluster level, they are
used to things happening very immediately. In a practice, you could
appoint someone tomorrow, really. In a health board, you
can’t do that because of the various checks and balances that
are in the system. So, I think that helping clusters navigate that
is really important. Where we have got those identified at health
boards where there are some of those difficulties, as directors
across the piece, we have been trying to work with those areas to
try and say, ‘This is what we do in this area. That might be
an approach that they could use.’ You don’t want to be
reinventing the wheel across the seven health boards.
|
|
[58]
Caroline Jones: No, but when there’s a success story,
you wish to share it.
|
|
[59]
Mr Lawrie: Yes, you want to share it.
|
|
[60]
Dai Lloyd: Okay, John, you had an additional point.
|
|
[61]
Mr Palmer: Just very quickly. Just to give you further
reassurance, I think that one of the things that typified the
approach in year 1 was that everyone just worked hard to get the
money out—very much directed by the clusters. If you looked
at the spending patterns, you therefore saw a lot of in-year spend
on equipment, for instance, which was needed but probably
wasn’t ambitious in terms of really pushing the agenda around
different types of care models. What we have seen in year 2, I
think, with a bit of maturity and a bit of everyone understanding
the challenge, has been a bit of excitement around clinical service
design. So, we have seen clusters coming forward and saying,
‘We really want to negotiate some service-level agreements
with the local authority to provide social workers in the system,
or we would like to do something around pharmacy and commission
that on an SLA’, and, most importantly perhaps, SLAs for
mental health services. So, MIND is popping up in a number of
cluster areas, providing mental health counselling in practice. So,
one of the areas where health boards have been able to help is to
give a bit of support on commissioning. So, again, it is moving us
from a position of regulating to facilitating and supporting, to
help organisations that aren’t used to doing multi-year
service level agreements.
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[62]
Caroline Jones: Finally, we have heard that the funding is
short term in duration and is limited, and that 90 per cent of the
money is spent on salaries. I wonder if you could tell me if this
gets in the way of real innovation and testing.
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|
[63]
Mr Lawrie: Certainly, the cluster money is being—. We
have had it for the last two years, and I think the understanding
that we have with colleagues in the Welsh Government is that that
money will continue. So, we have been working on the basis that
people can plan over a longer period of time, so, doing, as I think
John was describing, some fairly short-term things in the first
year, but actually getting into the service redesign and
interesting spaces in subsequent years. So, we have just received
our year 3’s worth of funding, with the expectation that that
is going to be there in year 4, year 5 and year 6. I think we have
to work on that basis. So, it’s not short-termism. I think we
are now starting to see people thinking very differently about it.
But, it is a relatively small element of the total amount of spend
that happens in primary care in a particular patch, and, I think,
seeing it in the round, that element can actually be the lever to
change something, using it that way. If it all gets spent on lots
of staff in year 2, then you haven’t got any area for
innovation and development as you move forward into year 3. So, I
think that one temptation that we’ve had to date is to spend
a little bit of it recurrently, but to have some headroom to allow
you to use that money creatively as you move into year 3, year 4
and so on.
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[64]
Caroline Jones: So, is the 90 per cent incorrect, then?
|
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[65]
Mr Lawrie: It wouldn’t be 90 per cent from a Powys
perspective.
|
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[66]
Caroline Jones: Okay.
|
|
[67]
Ms Fletcher: Could I just comment on the Pacesetter funding
as well, because the Pacesetter funding is there to promote
innovation? There are 24 projects operating across health boards,
but the attention then is where those Pacesetters are demonstrating
real value, therefore, looking to the health boards then in terms
of how they may be mainstreamed so that the funding can be released
to test out other ways of working. So, I think that’s part of
that process in terms of investing and trialling things that are
working well—to roll-out and share that practice as well
across clusters and across health boards, but then reinvest in new
areas of innovation to test those out, going forward.
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|
[68]
Dai Lloyd: Okay. Angela’s got a brief point on
this.
|
|
[69]
Angela Burns: Just a really quick one. John, you were
talking about the fact that the trust was supposed to be innovative
and dynamic—you know, ‘Health boards, get out of the
way’. You hold the money, therefore do the health boards also
decide whether or not a trust can go ahead with a particular
initiative, because some of the feedback that we’ve had is
that that’s the blockage and, therefore, that’s
stopping that innovation and dynamism. So, where, if a cluster has
10 per cent of all of the primary care health funding that goes
into primary care from the Government, do you just say,
‘There you are, sure, whenever you want it, just apply for
it’ or do you make them jump through hoops? A direct quote
that I’ve just read was that clusters are overregulated and
cannot breathe.
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|
[70]
Mr Palmer: I can’t, I guess, answer on the specifics,
but what I know is that every health board, through their chairs,
through their vice chairs, through their chief executives, through
their directors of primary care and mental health, have received a
very, very strong message, which is that the funding goes out
directly to the clusters and that we must support and facilitate.
So, I appreciate that there’s been some variation in that,
and I think I referred to that in my previous question, but it is
very clear that that is the way that this must be approached.
|
|
[71]
I’ve been, very recently, out with the confident leaders
programme, where I had a full representation of clusters from
across Wales and we talked though a number of these dynamics. I
would say that it’s definitely getting better and that the
concerns that might have been in health boards about regulation and
financial regulation have probably been allayed because we’ve
seen a bit of trust develop over the last two years between health
board finance and HR teams and local clusters. It’s up to us,
again as leaders in the system, to make sure that this is done
properly and well and that clusters are able to express themselves
at the local level.
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[72]
Angela Burns: To be absolutely clear, and you can obviously
only speak for your health board, in your health board, does a
cluster have to have a project signed off by the health board
before they go ahead and do it?
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|
[73]
Mr Palmer: No.
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[74]
Angela Burns: They can just decide to do that.
|
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[75]
Mr Palmer: They can, but what I’d want to say to you
is that that should be the least of our expectations. Where I know
that our system is, because we have two monthly meetings with our
cluster leads and my senior team attends all of those, we’re
beyond that discussion. That’s my strong view. So, what
we’re talking about is how we join up funding. So,
we’re doing a piece of work, for instance, on early stage
cancer diagnosis at the moment, where we’re importing a model
from Denmark. In that, there’s going to be a contribution
from the clusters—it’ll probably be more about
engagement and drive than them putting finance into the model.
I’m putting investment from radiology on the secondary care
side of the business and I’m putting investment into new
roles that are in the interface, and I’m investing sessional
time in both GPs and acute physicians. So, from my point of view,
everything from here has to be about knowing that we’ve got
the fundamentals sorted and that we’re putting investment
into the integrated pathway so that everyone pulls together and
benefits. Because it is when we get the multidisciplinary team not
just working locally, but across the whole system that we drive
real value for the patient. So, I’m very confident that
we’re going in the right direction. I very strongly feel that
on my own health board patch, of course, but I do see it in the
other six as well.
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[76]
Dai Lloyd: Okay. Jayne.
|
|
[77]
Jayne Bryant: Thank you, Chair. We know how important it is
to have a workforce based on population health needs and focused on
early intervention. I think, John, you mentioned that earlier in
one of your answers. And I know from my own health board, in
Aneurin Bevan, in Newport, that there’s excellent work going
on with the older people’s pathway and work with pharmacists.
How effective do you feel that the clusters are generally in
tackling health inequalities?
|
|
[78]
Mr Palmer: Again, it’s early days, but, in policy
terms, what’s been made very clear is that we’re
expecting clusters to operate in a population health environment,
and I see some good, developing opportunities around all of this.
Clusters have been well engaged and effective in, for instance, the
inverse care law work that we’ve been doing on cardiovascular
risk that has started in Aneurin Bevan and Cwm Taf. So, in some
senses, this is a behavioural management intervention. What
we’re doing is we’re working off our general practice
lists, we’re trying to stratify our lists and target people
that we know are vulnerable, particularly to issues around
cardiovascular risk. And then we’re running a programme of
health checks where we welcome people into that environment, and we
do some very simple things. We give people a view of their risks,
in terms of smoking, alcohol, their lifestyle. We show them their
likelihood of having a major cardiac incident in the next three to
five years, and we tell people what their heart age is roughly. And
that very simply expressed, very health-literate kind of model has
had a really big impact both in Aneurin Bevan and in Cwm Taf,
working with quite deprived communities, and the clusters have been
helpful in engaging with that. I’d say, at early stages,
because this started just at the beginning of the cluster cycle,
the model was probably a little bit too health board dominated and
therefore a little bit too far away from the patient, perhaps.
Clusters have been able to engage with our work and help us to get
much more into local people’s behaviour, community behaviour,
and so on. So, that model’s now rolling out across Wales. I
think that’s very positive and it’s helping us to think
about closing gaps.
|
|
[79]
Jayne Bryant: So, you think clusters are flexible enough to
be able to react quickly to those things.
|
|
[80]
Mr Palmer: I referred to the early-stage cancer diagnosis
stuff earlier. So, the opportunity there, for us, is to remove
gatekeeping culture from the system and to trust GPs’ gut
instinct about whether the person in front of them has got cancer
or not, and to look for a much earlier diagnosis as a result by
really driving that referral through radiology. You can make that
system work as well as you want, but if you haven’t got the
community with you, then you’re not going to make a massive
difference. So, I think, in the Cynon, where we’re going to
pilot this from 1 June, we’ve got 40 GPs that have come
through the cluster, that have massively engaged in the project and
have really brought it energy and excitement, and they’re
there, actively looking for referrals that they can make in when
they have a gut instinct that someone’s got cancer.
|
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[81]
They now need to help us, not just do that bit, but reach out into
the community, talk to people about, ‘Why are you so
frightened? What’s happened to you through the life of your
family that means that you feel so frightened about presenting with
a query around cancer? What can we do to help?’ So, for me,
that is the next step. We can talk all the technical improvements,
but I really think that clusters now, with a multi-professional
team and people working from social work, people working from a
mental health angle, have got to help us reach out, and reach out
and in, to our communities, express their voice, and help us to
really fundamentally change behaviour so that we can get to grips
with outcomes that haven’t shifted for a long time.
|
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[82]
Dai Lloyd: Okay. Alan.
|
|
[83]
Mr Lawrie: Perhaps it’s a little less sophisticated, I
think, in Powys, in that identifying health inequalities across the
patch is a little harder, but the issues of rural isolation are
certainly an issue for us in mid Wales. And I’ve seen
clusters actually being very proactive in relation to bringing
people into their cluster meetings—so, the community
connectors, for example, that are employed through the voluntary
sector organisations, the investment that they’ve made in
Mind and working with some of those elements, and also some frailty
healthcare support workers who are going out there proactively,
engaging with over-85s in distant communities. And they picked that
up as an issue that they saw absolutely for their population. So, I
do think they’ve got a mindset now that is around where
they’ve got the most vulnerable people, what they can do at
cluster level to support that, which they may be not be able to do
just at individual practice level. So, I feel quite confident,
really, that they have that in their sights, because that whole
emphasis should be about looking at the health needs of the local
population, and it’ll be different, depending on where you
are across Wales.
|
|
11:00
|
|
[84]
Ms Fletcher: Just to comment on that, obviously the
relationship of the local public health teams with their clusters
is really important—having the information base in terms of
understanding health inequalities and how it applies locally and
then, what the evidence is in terms of how those may be addressed.
So, again, as part of that wider cluster team, the local public
health teams are very important in those relationships.
|
|
[85]
Dai Lloyd: Mae’r adran
olaf o gwestiynau o dan law Dawn Bowden.
|
Dai Lloyd: The last questions are from
Dawn Bowden.
|
|
[86]
Dawn Bowden: On the answer to the first question from
Angela, when you were talking about perhaps mixed views about how
well the clusters are working, I know John is in my area in Cwm Taf
and I’ve met with the cluster leads there and the chief
executive and the chair and there seems to be a very positive view,
but that may not necessarily be the same everywhere, and I accept
that. Where there is not such positivity—because obviously,
what we want to do is roll out good practice—where there is
not such positivity around the clusters, has that been, do you
think, partly about the involvement of other professionals and the
consultation and involvement of them in setting up the
clusters—that it’s been too GP-focused?
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|
[87]
Mr Palmer: It’s complex, isn’t it? When you
think about how you get something up and running and established,
you’re going to have a lot of stakeholders involved and so, I
think, at the two-year point, we’re broadly seeing a system
that’s maturing faster than we would have expected it to.
There’s loads of variation, because we set out to experiment
and that means that we’ve seen lots of different things
happen from community to community. So, one of the issues for my
own patch, and I know for others, has been that some clusters grew
too big, too quickly. So, what they ended up with was loads of
stakeholders around the table and then an almost completely
unmanageable agenda because, just like we have big meetings with
lots of stakeholders around the table at Government level, health
board level and delivery level, clusters were sort of entering into
that space and trying to get consensus.
|
|
[88]
What we’re seeing now is a number of cluster organisations
finding ways of having both a core conversation about what
they’re trying to do now, but also developing space for broad
discussions across the contractor professions and then
they’re bringing that boiled conversation into their main
governance space, if you like. Again, I wouldn’t want to say
that any one part of the system is far away from another.
It’s just that we’re all on a slightly different
journey. But, I would re-emphasise the point: I think that on the
areas where we have concerns, or where the Minister has had
concerns, there have been direct conversations and interventions at
chair level and vice-chair level to make sure that the expectations
are understood and that there’s really good peer discussions
about how everyone supports clusters. It’s very clear that
there’s a long-term commitment to clusters. So, I do see the
system maturing.
|
|
[89]
Ms Fletcher: Can I just comment in terms of investing in
cluster leadership? The confident leaders programme, which John had
mentioned, has taken in excess of 40 of the cluster leads through a
development programme in two cohorts. There are nine modules and
they’ve been meeting on a monthly basis. That’s
providing a networking opportunity for the cluster leads so that
they can share and also they’re learning and developing
together. So, there have been a number of modules in terms of
governance, legal and value-based healthcare. So, there’s
been a variety of modules to help them in terms of undertaking
their roles and progressing the clusters and there is huge
enthusiasm coming from those cluster leads.
|
|
[90]
Mr Lawrie: I think, again, I take the view that, linked to
that—. I think we probably did start two years ago with a
very strong emphasis around it being GP driven, and I still think
that there is a role for those GP networks within a cluster domain
to actually work together, because there is some business that is
very specific to GPs. They need to be able to get together and
thrash that out. And, I think, if we—‘water it
down’ is probably not the right word—but if we involve
too many people in that, then they won’t have those
conversations. There is something about them having that higher
layer of primary care cluster, to which GPs are a very, very
important part, but you have actually got the right level of
stakeholders around it. I think what we’re seeing across the
health boards is those two functions that are starting to work more
effectively together, so it’s GPs absolutely coming together
where they need to, being supported by the health board, but
actually, the cluster being much wider. I think one of the key
issues for us though is about making sure that clusters have got an
influence at health board level. If a cluster does what a cluster
does, and, actually, at health board level, no-one takes any notice
of their development plan, or their aspirations, and they’re
not able to input into clinical strategies, service redesign, and
so on and so forth, then I think people become a little bit
disenfranchised. So, I think it’s a really important point
for us to make sure that the work of clusters is providing the
bedrock and is providing that bottom-up approach, even into things
like IMTPs, so that you expect the IMPT to feature a lot of the
things that are happening under the development issues at cluster
level. I think there’s a responsibility on health boards to
ensure that that connection’s there, or we’ll find
ourselves in a few years’ time with clusters sitting over
here somewhere disjointed from the health board.
|
|
[91]
Dai Lloyd: Okay. John.
|
|
[92]
Mr Palmer: Just very quickly. I think there’s a
developmental opportunity that we’re just scraping the
surface of at the moment. But, we’ve got to remember that
we’ve got a prevailing legislative context around the future
generations Act and the social services and well-being Act, that I
think give clusters a real opportunity. So, again, we’re just
beginning to see now clusters starting to come into the space more
formally in social services and well-being arrangements, and on the
edges of public service boards. So, they’re coming forward
with their cluster plans and saying, ‘Look, we’ve got
two or three major things here that we’re trying to do, would
the board want to support us?’ So, then, you see the
opportunity for us to start to bring together blocks of primary
care funding and the integrated care funds, and in that way getting
another opportunity to build more mature, stronger projects. So, I
expect that to gather pace over the next 12 to 24 months as well,
and then we can really start to get clusters into the space about,
‘What do our communities look like? What’s the shape of
our communities over the next five, 10, 15 years?’ And I
think, then, they can start to live the population health challenge
that’s been put to them.
|
|
[93]
Dawn Bowden: So, as the clusters mature, then, do you see
there being less of a role for the health boards, and this being
more driven by the clusters with the health boards being the
funders, and maybe the facilitators—I think that’s a
word you used earlier—and that it’s actually the
clusters that will drive this forward?
|
|
[94]
Mr Palmer: I would say it’s about—. This is a
really sort of official answer, so maybe you’ll have to talk
to me about it afterwards, but I think it’s about balance
across the system. So, the example I gave you earlier about early
stage cancer diagnosis, that needs investment in every part of the
system to be effective. So, I need to get investment into the local
community to promote awareness. I need to get investment into our
GPs and our other professions, so they feel that they’ve got
time to make an assessment based on their gut about cancer
presentation. I need to invest in radiology, because if I increase
the demand, and I’m after increasing the pick-up rates, I
need to invest there, and I need to make sure that there’s
acute physician and oncology sessions available to then service
that demand. Then, hopefully, I get through the bump, and
I’ll be seeing the same people, just earlier, and
they’ll be coming to us at stage 1 and 2 rather than stage 3
and 4. That’s a blended investment at every stage of the
pathway. If we’re going to be a mature system that changes
outcomes, I really feel that’s the way that we’ve got
to tackle it, and I would say that clusters are an absolutely
essential part of that patient journey. So, of course we’d
want to invest in that.
|
|
[95]
Dai Lloyd: Dyna ni. Diolch yn fawr. Dyna ddiwedd y sesiwn,
dyna ddiwedd y cwestiynau. Diolch yn fawr iawn i’r tri
ohonoch chi am eich tystiolaeth y bore yma. Gallaf hefyd roi
gwybodaeth pellach i chi y byddwch chi yn derbyn trawsgrifiad
o’r cyfarfod yma i gadarnhau bod beth rydych yn ei ddweud yn
ffeithiol gywir. Felly, gydag ychydig eiriau fel hynny, a allaf
ddiolch yn fawr i chi am eich presenoldeb? Rwy’n cyhoeddi i
Aelodau y bydd egwyl nawr am 10 munud—ac i ddod yn ôl i
fan hyn am 11.20. Diolch yn fawr.
|
Dai Lloyd: There we are. Thank you very
much. That’s the end of this session and the end of the
questions. Thank you very much to the three of you for your
evidence this morning. Could I also give you further information
that you will receive a transcript of this morning to check for
factual accuracy? So, again, thank you for your attendance.
I’d like to announce to the Members that we will now have a
break for 10 minutes. Please be back here for 11.20. Thank you.
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Gohiriwyd y cyfarfod rhwng 11:09 a
11:23.
The meeting adjourned between 11:09 and 11:23.
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Ymchwiliad i Ofal
Sylfaenol—Sesiwn Dystiolaeth 2: BMA Cymru a Choleg Brenhinol
yr Ymarferwyr Cyffredinol
Inquiry into Primary Care—Evidence Session 2: BMA Cymru Wales and Royal
College of General Practitioners
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[96]
Dai Lloyd: Croeso i adran
ddiweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon
wedi’r toriad. Rydym yn
symud i mewn i eitem 3 a pharhad efo’r ymchwiliad i ofal
sylfaenol ynglŷn â chlystyrau. Hon yw sesiwn dystiolaeth 2. Fe gawsom ni sesiwn
dystiolaeth 1 cyn y toriad. Yn y sesiwn dystiolaeth yma mae BMA
Cymru a choleg brenhinol y meddygon teulu o’n blaenau ni.
Felly, a allaf i groesawu i’r bwrdd Dr Charlotte Jones,
cadeirydd pwyllgor meddygon teulu Cymru y BMA; Dr Ian Harris, aelod
o bwyllgor meddygon teulu Cymru a phwyllgor meddygol lleol
Morgannwg; Dr Isolde Shore-Nye, coleg brenhinol y meddygon
teulu; ac hefyd Jane Fenton-May, hefyd o’r coleg brenhinol
meddygon teulu? Croeso i’r pedwar ohonoch chi. Rydym wedi
derbyn tystiolaeth ysgrifenedig helaeth ynglŷn â
chlystyrau ac ati, felly fe awn ni’n syth i mewn i
gwestiynau. Mae gennym ni rhyw dri chwarter awr; fe awn ni’n
syth i mewn i gwestiynau. Fe fydd yna ddigon o amser i fynd i
mewn i fanylion, ac ati. Felly, fe wnawn ni ddechrau efo
Angela.
|
Dai Lloyd: Welcome to the latest
section of the Health, Social Care and Sport Committee after the
break. We are moving into item 3 and continuing the inquiry into
primary care regarding clusters. This is the second evidence
session. We had the first session before the break. In this session
we have BMA Cymru and the Royal College of General Practitioners
before us. So, I’d like to welcome Dr Charlotte Jones, chair
of BMA Cymru’s general practitioners committee; Dr Ian
Harris, member of the general practitioners committee Wales and the
Morgannwg local medical committee; Dr Isolde Shore-Nye, Royal
College of General Practitioners; and also Jane Fenton-May, who is
also from the Royal College of General Practitioners. Welcome to
all of you. We have received extensive evidence regarding clusters,
so we’ll go into questions. We have about three quarters of
an hour; we’ll go straight into questions. We will have
plenty of time to go into detail. So, we’ll start with
Angela.
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[97]
Angela Burns: Thank you, Chair. Good morning. I’ve
just got a couple of series of questions that are about the
evidence and the data collection to evidence how successful cluster
working is being in terms of reducing demand on GP services in
particular, and making a better transition through primary care.
I’d also like to tie my questioning to evaluation and how
it’s going to be evaluated in the end, and if I skip neatly
to the BMA evidence, there’s a comment in here that says:
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[98]
‘Thus far the benefits of cluster working, in terms of
transforming primary care for the benefit of the patient and GP
across Wales, are not as tangible as we would expect at this stage
of their existence’.
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[99]
We’ve just seen representatives from local health boards and
Public Health Wales to talk about this, and we’re really
struggling to get an understanding of how this is going to be
evaluated, monitored and benchmarked.
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[100] Dr Jones:
Okay. I’ll start off, then, if I may. The clusters obviously
devise a cluster development plan, so for each of the 64 clusters
across Wales, they have a cluster development plan, within which
there should be ideas for service transformation as well as the
sustainability of services for patients across their geographical
footprint. How that is actually reviewed by the health board in
terms of actually monitoring momentum and delivery against those
action plans is variable, I would say, and it’s not quite
clear, so we need transparency around that.
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[101] But you also
need to triangulate that feedback against what’s happening on
the ground. So, from patients, have they seen a change in service
provision? Have they seen the benefits of this with wider
healthcare professionals and access to social care to meet their
needs? We need to triangulate with patient feedback, and we also
need to triangulate it with practices and with our community
team—so, our district nurses, our pharmacy and optometry
providers—to look at where it’s working well, why
it’s working well, and when it’s not working well, why
is that, what are the barriers, and what are the reasons, and
address those. Because it seems to me that we have a national
strategic policy that we’re all signed up to, and we can see
the benefit of it—there’s lot of evidence to support
working in this way from within the UK and outside of the
UK—but that’s not translating into real, transformative
change on the ground level for patients, and that’s what
we’re all here to do. They were designed to improve service
delivery for patients. They were designed to provide sustainability
for practices and to start that collaborative working wider than
just at practice level. That’s working very well in some
places and not in others, and we need to work out why that is.
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[102] I don’t
think there is enough scrutiny, enough transparency of how these
plans are delivering, and where they’re not delivering, why
is that? We have a survey with a number of outcomes and a number of
points from GP practices and from cluster leads, and it is
disappointing to say that there’s not been significant
progress despite the significant additional resource that’s
been provided to these. I would also say that the evaluation of the
pathfinder projects are those projects that were designed to
transform and innovate across Wales—we haven’t really
seen the outcomes from that in terms of tangible change.
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[103] Angela
Burns: But who’s responsible for doing that
evaluation?
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[104] Dr Jones:
Well, I would say it’s twofold. I would say it’s Welsh
Government because these are public funds, they should be
scrutinised, and that scrutiny needs to be in a way that is clear
and transparent, not just a form of a report—I don’t
think that helps us; it needs to be me measureable—and also
from the health board and from the clusters themselves. So, we need
to make them—. They need to be more transparent in terms of
giving the outcomes that we would hope to see.
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[105] I think that one
of the key areas that we should be asking about is not just to look
at the resource that’s gone into clusters, but also look at
the wider want of Welsh Government to transfer resource from
secondary into primary care to deliver enhanced care in the primary
community sector. There is a key performance indicator that
I’ve been very keen to see brought in for health boards about
the percentage resource that has moved and the monetary resource
that that equates to. Certainly, when we’ve asked this
question before, we’ve only had evidence of one pathway being
transferred into the community with moneys, and when we explored
that further, it turned out it wasn’t secondary care money,
this was charitable money for a service delivery. So, again, we
need to see that, because that’s not to say it’s not
happening, but it’s not clear, it’s not transparent,
and we’re all here to try and make the services better for
the patient at the end of the day. My colleague Ian may well have
something further to say, because he’s part of a federation
in Bridgend as well that is part of the transformative pathfinder
work.
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[106] Angela
Burns: Okay, but can I just quickly ask, Charlotte, because I
think I picked out that what you said was that the 10 per cent of
the funds that has gone into clusters, obviously that needs to be
monitored, but you’re also saying that you’re not
seeing any monitoring of the 90 per cent that’s being kept by
LHBs in order to enhance and improve primary care delivery?
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[107] Dr Jones:
Exactly, and it’s not to say that that monitoring isn’t
going on somewhere, but we’re not seeing it, it’s not
transformative, and I think there is a sense out there that the
cluster moneys themselves are not being enabled for use by the
individual clusters, and the pathfinder moneys, the tangible change
that they’ve brought, it’s not clear—
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[108] Angela
Burns: Sorry, but can I just stop you there again, because of
the evidence we’ve just received earlier? When you say
they’re not being enabled for use by clusters, the message
that we’d received fairly loud and clear was that, across all
health boards, if the clusters wanted to spend their money in a
particular way, the health boards do not have the veto to say,
‘No, they cannot do it.’ Is that not what is happening
on the ground?
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[109] Dr Jones:
Absolutely not. In some health board areas they are utilising that
money for what the cluster has asked them for. In others not. There
are other barriers to enabling change: for example, procurement of
equipment to deliver a service; and, for example, recruiting staff,
because at the minute the clusters are not legally autonomous
entities and we need to change that. So, therefore, the moneys are
held by the health board and the way in which they recruit to posts
asked for by the clusters means that, actually, there can be
significantly long delays in getting job descriptions, advertising
them and putting someone in place.
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11:30
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[110] Of course, at
the moment, there is no ability or allowance for the cluster moneys
to be carried over year on year, which was our understanding from
previously—if something was badged for a project and there
was a delay in delivering that, for whatever reason it was, that it
could still be kept by the health board to be used by the cluster,
but that’s not actually what we’ve seen in reality.
I’m thinking specifically here of Hywel Dda, and we’re
very happy to give you evidence on that—
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[111] Angela
Burns: Can I just stop you there, because I know that Caroline
is going ask a lot more questions on funding? So, I just want to
translate that back though to the whole—. My concern is that
in two years’ time, we’ll sit here and go, ‘Oh,
clusters, weren’t they a good idea?’ and we won’t
actually know how to evaluate them. That’s what I’m
really trying to get to grips with, because it’s great to
have a warm, fuzzy feeling—we’re all very positive
about it, we all think that this has got real potential—but
what we actually need to know is: is there value for money? Have we
monitored an improvement in outcomes? I want to know who is doing
that. I’m trying to understand who is doing that. The
previous people said that there was a set of qualitative research,
I think, coming out of Bangor University. Has anybody heard of that
one? No, okay, I didn’t think so. To find out how they were
working. What I really want to be able to walk away from this
evidence session with is understanding whether this is being
monitored. Because I hate the thought that we’re not
following the money to an outcome.
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[112] Dr Jones:
The problem is, because of the delays in getting that money to do
what the clusters have identified as being needed to be done, that
you cannot monitor it very easily at the moment. Practices are,
through the ways in which we work, very fleet of foot. We’re
very agile. If we want to make a change, we can make it. If I
decide today, come Monday, it’s in place. For example, around
the warfarin enhanced service, we’ve identified we want to do
it, the practice is drawing up a project plan, it will be done, and
it will be in place very quickly whereas, when we have to involve
the health boards, either because the person supporting the
clusters isn’t a decision maker or because of the request
that’s being made, it’s not always driven by the
cluster. Sometimes, it’s the health board agenda, and we need
to be truly looking at what the barriers are and how we can change
those to enable us then to monitor it properly and see where those
moneys are going. My colleague Ian Harris, to my left, will
probably be able to give some further comments on this.
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[113] Dr
Harris: Hopefully. I think we have to remember the environment
when clusters were set up. They were very much set up on the hoof,
in some respects. They weren’t organic structures that
developed because GP practices felt that they were necessary. They
were centrally, not imposed, if you like, but developed, and, as a
result, I don’t think clusters are at that level of maturity
where evaluation and analysis of their cluster initiatives are
necessarily part of their daily workload.
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[114] So, I think,
very much, clusters are developing in that area. I’ve seen
evidence of a few initiatives in my own cluster that have had an
evaluation, and the results are largely qualitative. I think
it’s fair to say that the data are not fantastic. Where there
are data, they support the fact that certainly there are some
cluster initiatives that are valuable to some extent, but if
you’re looking at value for money, often they don’t
reduce GP workload as much as you’d like to think they would,
and they cost significantly more than, maybe, employing another GP
would.
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[115] Angela
Burns: Right. That’s interesting.
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[116] Dr
Harris: So, in the current climate where workforce pressures
are quite significant and trying to attract GPs into the profession
is very difficult, using allied professionals is something
we’re having to do, and we’re all on board with that.
But where you are using allied professionals to save GP time, the
results can be a little disappointing at times, I think.
We’re also not looking at a huge amount of resource in each
cluster that’s being devoted to reducing that workload in
each GP practice, if you like.
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[117] For instance, in
my cluster, we have six practices and we have one full-time
equivalent pharmacist who comes and does sessions in each practice.
Now, if you share that resource out across all six practices, it
doesn’t amount to a huge amount of resource to offload us. If
you’re talking then actually—. You know, one sixth of a
pharmacist maybe saves you one eighteenth or one twenty-fourth of a
GP, then you’re not looking at a huge dent in the workload
pressures that we see every day with the cluster initiatives. So, I
think we certainly need to have more robust evaluation of these
initiatives and I think that should be something we should look
at.
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[118] Dai
Lloyd: The RCGP view, Isolde.
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[119] Dr
Shore-Nye: I’d like to come in on this, in a way, with
two roles. I have to admit I’m actually cluster clinical lead
in Blaenau Gwent east as well as being a GP in Abertillery. So,
having the experience first hand—a lot of the issues I know
you’ve probably talked about already—particularly
regarding evaluation, it can be very difficult to quantitatively
evaluate a project that is designed to maybe alleviate pressure on
the GP workforce when, actually, we know that the demand out there
is certainly far and above what we may be putting in place.
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[120] Ian mentioned
pharmacists. My cluster is a cluster of five practices, maybe soon
to be four, and we have 0.8 of a pharmacist, which took me seven
months to employ through the employment process and recruitment.
During that time, that money was being accrued and, as Charlotte
eloquently put across, I cannot carry that money forward. So, you
end up with having to put money into projects that you can’t
either fully evaluate or maybe are difficult to evaluate because
they have that fluffy feeling that you mention—you know,
what’s improving the quality of care may not be easy to
evaluate quantitatively.
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[121] Dr
Fenton-May: Can I just say, I don’t think anybody has put
any money into actually producing evidence about care for the
patient and whether that is improving or not improving, using
potentially wider teams and cluster working? And it would be quite
useful if we could have some sort of support for that kind of
research thing that is about quality rather than the quantity,
which maybe where the money goes, which is what the LHBs may be
looking at.
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[122] Dr Jones:
Certainly, for this committee, one of the areas I’ve often
thought might be worth exploring is the three-year health board
plans. If they’ve got three-year health board
plans—and, okay, they’ve got to audit at year end, but
if something is badged, carried over, you know, you can make that
allowance—why is that not the case for clusters? Because,
actually, that would enable the sustainability of some of these
initiatives. Where we know that, actually, although we might not
have enough of the pharmacists, or we might not have enough of
something, where we know that actually, when they’re there,
they are making a difference, why can’t we expand that and
look at what’s stopping us from expanding that? And actually,
our ‘Responsive, safe and sustainable: urgent prescription
for general practice’ calls for a pharmacist in each
practice, because we know they’re such experts in medicines
that they can make a significant difference to us, day to day.
Having access to an occupational therapist for our frail elderly
who are falling can make a significant difference, but it’s
not easy to access. Why isn’t that? So, there’s other
evidence that says, ‘Actually, the clusters need this to
support them as well’, rather than the cluster having to say,
‘Please could I have—?’
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[123] Angela
Burns: One last little question on this, if I may—
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[124] Dai
Lloyd: Short. You’re really using up brownie points,
Angela.
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[125] Angela
Burns: —which is: have you had, during the two years that
this has been in existence, anybody write to you or inform you of a
benchmark that you can measure yourself against? So, does anybody
say to you, ‘Wow, these couple of initiatives have gone
incredibly well—hey, the rest of you, the rest of the 64,
have a look at it’?
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[126] Dr Jones:
Not with respect to individual cluster plans, but there is lots of
evidence out there for benchmarking the input that physiotherapists
can bring, and that pharmacists can bring, particularly, because,
probably, they’ve been working in these ways for longer. I
think that evidence will come out, but until we’re
transparent about how the resource is flowing into the clusters to
make the changes, I think we’re a little way off that,
personally.
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[127] Dai
Lloyd: Speaking of fleet of foot and agility, that’s
required in the management of the rest of this committee, now.
Going on to Julie, now, with the next question.
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[128] Julie
Morgan: Thank you very much. I wanted to ask about the
multidisciplinary teams and, obviously, you’ve covered that a
bit in the responses already. You can see the advantages, but could
you spell out, in a general way, what are the advantages and
disadvantages of working in multidisciplinary teams?
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[129] Dr
Harris: I think there are certainly advantages to it. They
bring a different approach—we can be sometimes a bit
entrenched as GPs, so I think there are certain benefits to having
allied professionals within your team. They’ve got different
skill sets. We mentioned that maybe the pharmacists didn’t
save quite as much GP time as we were hoping they would in our
cluster, but certainly, there’s a definite feeling that the
quality of the input they can give perhaps is maybe even slightly
better than that I can give in a medicines review. So, you’re
looking to get the right person treating the right person in the
right time, if you like. So, there are certainly advantages to
that.
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[130] There are
significant barriers and disadvantages to it, though. Currently,
the allied professionals within that team are employed by the
health board. Now, you’ve heard about the delays and the
barriers we’ve got to recruitment as a result and the lead-in
time to getting those feet on the ground, if you like. There are
also other indemnity issues and risk issues with practices allowing
other professionals to look after their patients, if you like,
without having that insurance cover, and that’s something
that hasn’t really been bottomed out fully yet. A lot of the
allied professionals have their own insurance but they don’t
necessarily dovetail with ours and, as a result, clusters and
practices are taking on significant risk to themselves when they
allow their allied professionals to deal with their patients,
because they’re still ultimately vicariously responsible.
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[131] So, there are
specific challenges, I think, around getting the numbers up,
because I think, as we’ve said, there are small numbers of
resource in every cluster and I think there has to come a time
when, if there’s a proof of concept that these
multidisciplinary teams are aiding us and improving patient care,
then there needs to be a little bit of bravery on a health board
level to be able to make that entrenched and a normal part of
practice life, if you like.
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[132] I’m quite
sure that if you look at where patients access healthcare, they
access it through their GP and they access it through the emergency
department. The various initiatives we have about trying to
signpost patients to here, there and everywhere don’t tend to
work because we’ve got two very fantastic brands, if you
like, in the Welsh NHS, which are general practice and casualty,
for accessing healthcare. What we need to do is make sure that we
design services that sit behind those front doors. There is a
degree of resource locked within health boards, if you like. If
you’re talking about employing physiotherapists or employing
pharmacists directly to manage patients in primary care, then there
is a resource locked into those health boards that they could
release to clusters, but that requires a degree of bravery and a
bit of organisational gumption, if you like, and, at present, I
don’t think we’re seeing an awful lot of that.
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[133]
Julie Morgan: Do you think that will happen?
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[134]
Dr Harris: That’s a very good question. We’ve not
seen any evidence of it to date. And I think the worry we have is
that you’ll have 60-odd clusters developing initiatives,
which appear to be very valuable, but that innovation never becomes
reality on a grander scale. I’m not entirely sure that health
boards have twigged that that’s exactly what needs to happen
and, you know, time will tell.
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[135]
Julie Morgan: You’ve mentioned a number of different allied
professionals, I just wanted to ask about speech and language
therapists. Are they involved in any of these teams?
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[136]
Dr Jones: They will be involved with the care home enhanced
service and they have been in some health boards for some time.
But, certainly, they’ll be integral to the delivery of the
new care home direct enhanced service, which will be all health
boards across Wales, and they are very important. But, again, all
of these allied healthcare professionals are under pressure
themselves because there aren’t adequate numbers of
them.
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[137]
So, where we have multidisciplinary team
working, it’s great in principle, sometimes it works,
sometimes it doesn’t: we’ve only got to look at our
palliative care patients in the community and the strains on the
district nurse teams, the clinical nurse specialist
teams—there is just no capacity for doing it maybe as
holistically as they would like. The multidisciplinary team-working
principles are absolutely right, but what we need, though, is the
actual mass of professionals to deliver it to make it work. It fits
with the prudent healthcare agenda but, again, I think a lot of
these problems lie at health board levels, either in terms of
releasing the staff, recruiting the staff, and actually wanting to
make that change. It does often make us beg the question: we have
all the right evidence, we have all the right principles, we have
all the right strategies at a national level—there’s
lots of evidence outside of Wales supporting these national
strategies—why is it failing at a health board level and why
is it not working, and, actually, where are the blockages, and is
that actually because there’s been too much power devolved to
health boards to deliver these national strategies and
they’re not delivering? It’s a question I ask often.
It’s a question I don’t always get the answer
for—
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[138]
Dai Lloyd: You’re not going to get it here, now, this
morning [Laughter]. Lynne, you’ve got a related
question here.
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[139]
Lynne Neagle: Yes. You’ve mentioned some of the challenges
already, but are there any other challenges you want the committee
to be aware of in terms of making the multidisciplinary teams work,
and what do you think needs to happen to overcome those
challenges?
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11:45
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[140] Dr Fenton-May: One of the issues is there aren’t enough of
those other health professionals there, and the biggest problem is
that most of them are trained in secondary care and, actually, the
transition into primary care can be really difficult. If you take a
ward nurse, for example—we’ve had practice nurses for
30 years now—and put her into a GP practice, she needs to be
completely retrained; she hasn’t got the skills to manage the
kind of things that a practice nurse would do. Also, working in a
more isolated—although GPs work in teams, we’re sitting
very often doing one-to-ones with patients. So, the practice
nurses or the physios are doing that. They haven’t got a
whole kind of team of people behind a screen that they can refer to
if I’ve got a problem in the same way. So, you need to teach
them how to interact in a one-to-one way with the patients. There
aren’t enough clinical pharmacists either to be employed. The
ones that are working in practices are not all fit for the kind of
work that is going on. So, there’s an element of training.
Surprisingly, if you want to pull all these services together, any
multidisciplinary team needs time in order to talk, which is why
you’re actually taking—. If you employ somebody else to
work in a practice, you’re taking time away from the GP
because they’ve got to have that communication time with that
other health professional. If you’re not careful, the patient
becomes 20 different bits—you know, drugs, big toes, physio,
backs, whatever—and you need somebody to provide that
holistic pulling-together service for the patient, and I see that
as the GP and the leader of the team, who is able to deal with all
bits of the patient, from cradle to grave.
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[141] Dr Jones:
When we go back to the prudent healthcare principle of only doing
what you should be doing and using the team approach, it all fits
with that, but we don’t have the numbers of professionals
under that. So, we need to look at what resource is there in the
health board—is it being used in the right way, is there a
way that we can get more into the community separately through
other recruitment measures, and also making sure that the
educational frameworks and support that they need are in place as
well, which, actually, are not for some elements of the workforce.
So, we need to address that before they’re likely to want to
start moving into these community and primary care roles.
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[142]
Dai Lloyd: Ocê. I ddatblygu’r syniad yna, Rhun
sydd nesaf.
|
Dai Lloyd: To develop that idea, Rhun
is next.
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[143]
Rhun ap
Iorwerth: Mae hynny yn sicr yn ein harwain ni ymlaen at gwpl o
gwestiynau gennyf i ynglŷn â chynllunio gweithlu, sydd,
fel rydym ni’n gwybod, yn un o’r problemau mwyaf
sy’n wynebu yr NHS yng Nghymru. Mi fyddwn yn gwerthfawrogi
eich sylwadau chi ymhellach, os liciwch chi, ynglŷn â
phroblemau cynllunio gweithlu. Ond hefyd, mae yna ragdybiaeth bod y
ffaith bod clystyrau yn annog rhannu staff, o bosib, ar draws
ardaloedd eang neu ar draws disgyblaethau ynddo fo’i hun yn
fodd i ymateb i her y gweithlu. A ydyw hynny yn realistig, ynteu a
ydyw pethau ychydig bach yn fwy cymhleth na hynny?
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Rhun ap
Iorwerth: That certainly leads
us on to the few questions that I have about workforce planning,
which, as we know, is one of the major problems facing the NHS in
Wales. I would appreciate hearing your comments with regard to
problems with workforce planning. But also, there is an assumption
that the fact that clusters encourage the sharing of staff,
potentially, across a wide area or across disciplines in itself is
a way of responding to the workforce challenge. Is that realistic,
or are things slightly more complex than that?
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[144]
Dr Harris: Fe wnaf i ateb hynny achos fy mod yn siarad
Cymraeg, so rwyf tamaid bach yn glouach na gweddill y panel.
[Chwerthin.]
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Dr Harris: I’ll answer that
because I speak Welsh, so I’m a little bit quicker than
everyone else on the panel. [Laughter.]
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[145] I won’t
answer it in Welsh, Rhun, because my Welsh isn’t that good,
but I do think that, at present, if you’re looking at the
degree of workforce that’s there, sharing it across clusters
is a bit of a pipe dream at present because there isn’t
probably enough resource to go within clusters, let alone across
cluster boundaries. The idea is fine. Like I said, the critical
mass isn’t there at present. I think we heard, with Isolde
earlier, around the agility and the ability of clusters to be set
free to set their own agendas is still in question, I think, in a
lot of places. There is certainly work being done around structures
of clusters that would allow them, if you like, to take on
management of their own workforce and budgets and these sorts of
things, but I don’t think any of those have been addressed
fully yet because we have federations and Pacesetter projects that
currently have lovely structures, but they don’t seem to be
able to do anything with that structure as yet. I think
that’s the concern we have: (a) there is a fixed resource
around bringing people into clusters because you are moving the
resource—moving the deck chairs around the Titanic, if you
like. There are also finite levels of resource that the amount of
cluster funding can offer you, which doesn’t really fill the
gap in the workforce that’s already within practices. We have
areas of general practice within Wales at present that are becoming
deserts almost, and I think that’s a concern for us at the
minute, in that I don’t think clusters are going—.
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[146] There’s a
cluster local to me, in Morgannwg local medical committee, that has
really tried to develop initiatives that look at recruiting GPs
into clusters to share the resource around practices where there
are gaps. They view the fact that GPs are not working
independently. If your neighbouring practice is in trouble,
it’s going to become your problem very shortly. Certainly,
there have been attempts to address that workforce gap within
clusters—the problem is that there isn’t a workforce to
fill the cluster gap, if you like. I think we’re all battling
for the same people to employ within that. I think having the
clusters agile and autonomous enough to go and fish for those
people would help, because having the health board as an extra
layer of bureaucracy in there certainly doesn’t seem to be
fostering collaborative working and autonomy within clusters at
present.
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[147] Rhun ap
Iorwerth: And that confirms, I think, what we fear: that you
just feel that you’re fishing around in a pool with a limited
number of people. The key is getting more people into that pool
that you can choose from. Are you confident that things are in
track now that there seems to be a recognition, at last, that
workforce planning and training is a real issue?
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[148] Dr Jones:
Certainly, the ministerial taskforce, and the fact that the
Minister chairs that, has made a difference with respect to looking
at general practice recruitment specifically, and the initiatives
around paying for the examination for GP specialty trainees across
Wales, and the additional moneys for those going into
hard-to-recruit areas, is showing benefits this year in terms of
increased applications for those areas, and to Wales. However, that
said, we do need more training places, but it’s a bit of a
chicken and the egg: you can offer 1,000 places, but if
you’ve only got a 150 candidates, you’re not going to
fill them. So, you’re almost setting yourself up to fail with
respect to that. But we should have some flexibility that, where we
get more applicants for an area and they’re good quality
applicants, they should be allowed to take up a training place, or
have the funding to support that.
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[149] There are lots
of initiatives that are going on around widening access to
medicine, thinking about shortage specialties outside of just
general practice, but it’s not all about the GPs either. So,
we need to, yes, have more coming through, but they're not going to
come into, essentially, bums on seats for some time. So, it's not
going to solve the here and now. So, we need to be looking at what
we can do with respect to retaining the workforce we have, which is
a challenge, and also how can we have those other allied healthcare
professionals supporting us whilst the other initiatives come
through.
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[150] I'm not sure
that enough focus is being spent with our nursing colleagues,
looking at what’s happening within district nursing and the
wider primary community teams; I'm not sure enough is happening
around healthcare support workers to allow nurses to work to the
top of their area of specialty and professionalism and be able to
delegate downwards appropriately; I'm not sure enough is being done
around that either. And, again, we’ve got very good ideas
around where pharmacists may well make a difference; we
haven’t got enough of them coming through. So, it's a
challenge, but we need to accept that, at the moment, we’re
in the perfect storm: that things are starting to make a difference
for the longer term—but, actually, will there be a general
practice and primary community care to deliver it effectively until
then? We have to be realistic and say, ‘Okay, that's great,
carry on working along that line and we welcome all of that
work’, but we need to be also doing more now as to how we can
retain our current staff across the workforce and enable more to
come in now. I'm interested in the recruitment campaign to see how
that is actually translated into people working in Wales.
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[151] Dr
Shore-Nye: I think my answer encompasses the question about the
multidisciplinary team as well. In the cluster where I'm currently
leading, we've seen a halving in GP numbers within the last two
years. So, I really would welcome the opportunity to work more with
the multidisciplinary team, but I don't have enough of that
opportunity within my cluster to do that because—as
Charlotte’s just mentioned—yes, I would like another
physiotherapist, a pharmacist, an occupational therapist, some
mental health nurses, to come and work with me in my cluster, but
that isn't within my remit or my opportunity. At the moment, the
funding that I receive as part of the cluster moneys would in no
way at all address the need to recruit those specialties, even if I
could.
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[152] Rhun ap
Iorwerth: And we come back to a point raised earlier about
you’re not entities in yourselves that can build up a team;
you’re dependent on the health board to do that for you.
That's something that could, if you were able as an entity to build
up, you know, all those members of a multidisciplinary team as
employees of your own—that would help.
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[153] Dr Jones:
Certainly that was in our urgent prescription for general practice,
our strategy document, which is now some two years old.
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[154] Dr
Harris: I think it depends what you think clusters are there
for, really. Because if you think they’re there to prove
concepts and allow health boards then to make the major investment
further down the line, then I think that's what they're kind of set
up to do. They have very small budgets. It may be a large amount of
money from the public purse across the piste, but, if you look at
individual clusters, a couple of hundred thousand pounds doesn't
buy you many boots on the ground to deliver workforce change and
workload change for GPs day to day. If they're there to prove the
concept and to innovate and show initiatives that, then, health
boards can pick up and run with and put in place across the piste,
then I think that's what they're currently set up to do. I don't
think they’re set up to be entities with huge budgets that
can deliver a lot of input for patients with the budgets they
have.
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[155] Rhun ap
Iorwerth: And that's really interesting. I think that's
something that's come across clearly to us, that different people
have different interpretations of what clusters are actually meant
to do, and if, to me, as a layman, looking from the outside, what
I'd like to see is clusters being greater than the sum of their
parts—you see the entirety of the budgets of all those
surgeries and other elements of primary care that are part of that
cluster, and somehow they come together, and are able to pool
resources—it doesn’t work like that.
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[156] Dr Jones:
No. It was designed that you would get the practices working
collaboratively and start looking at service provision across its
geographical area and, in time, they would then take on community
budgets, community staffing, but they haven’t been enabled to
do that, unfortunately.
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[157]
Rhun ap Iorwerth:
Is that one of the big
barriers?
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[158]
Dr Jones: Yes.
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[159]
Dai Lloyd: Okay, moving on. Funding next. Caroline.
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[160]
Caroline Jones:
Diolch, Chair. I’d like to ask you
a couple of questions on funding, particularly with regard to the
cluster development moneys, because we’ve heard that the
allocation process is unclear, and also that it’s not
targeted effectively, that it should go directly to clusters. Are
these concerns justified, and how do you think, if they are, that
the funding may be deployed more effectively in the
future?
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[161]
Dr Shore-Nye: Do you want me to speak from personal experience,
rather than from the royal college experience?
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[162]
Dai Lloyd: Any number of experiences you have, as long as you
carry on.
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[163]
Caroline Jones:
Whichever—whatever you want to
say.
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[164]
Dr Shore-Nye: The opportunities I’ve had in my cluster
are—. I have met with quite a few cluster leads, and what I
have noticed is that the way funds are utilised within the cluster
varies considerably within health boards, and it can almost vary
within health boards, about how the cluster money is able to be
spent. Going—. Oh, I’ve lost my train of thought about
allocation of money. So, I—.
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[165]
Dr Jones: The allocations are known every year, and
they’ve been known for the last few years. The actual ability
to use it is difficult and, actually, our BMA survey that
we’ve done recently, to both cluster leads and to individual
GP practices, has shown that there is a difficulty in actually
mobilising that resource into tangibly putting in place the service
you want to deliver, and that’s not just for recruiting
people; it’s actually for equipment to deliver a service.
It’s for seemingly quite trivial little things, but
that’s not translating into enablement to use the resource.
And also, we’ve had feedback that, for some clusters and some
practices, they feel that where the cluster, as I’ve already
said, comes up with an idea, because that might not fit with the
health board’s idea of what should be done, that
they’re not enabled to use the resource. Does that bring you
back?
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[166]
Dr Shore-Nye: Yes, thank you, Charlotte. Sorry, I completely lost
my train of thought. I believe the original allocation letter
doesn’t state about innovation. So, what we find is we may
have an idea, or an idea might come through my cluster, but it may
not fit the idea of the original letter that was apparently outwith
of some of the GMS things that we should be providing within our
contract. So, we reach barriers where we might have an idea—.
I’ll give an example. I talked about flu when I was here
before. We wanted to provide something different for flu in my
cluster, but I was put up against a barrier that that was something
that the GP surgeries were already funded to provide. So, it
wasn’t something that we could do within the cluster, yet
other clusters in different health boards were providing a similar
service. So, there is variability, and it gets very frustrating
when you try and share your ideas with different cluster leads and
find that, actually, each health board is interpreting it slightly
differently. It may work out to some advantage in some health
boards and against other health boards, and it varies between
them.
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[167]
Dr Harris: Don’t underestimate the fact that there is not
clear decision-making processes within clusters at times. Clusters
are at different levels of maturity and organisational levels
across the piste. Certainly, we’ve had Pacesetter moneys to
set up a federation with a constitution, with a limited liability
company behind it, with voting rights and all these sorts of
things. But that federation isn’t the cluster, and we can
make decisions as a federation, but the cluster, which involves the
wider health economy, doesn’t always have to agree with that.
We’re almost sort of hoisted by our own petard a little bit
by the decision-making process that we have internally. And then,
when you then make a decision and it’s bounced back to you by
a health board, that’s incredibly frustrating. We are such
agile, innovative people as GPs, because we run our own businesses,
that we’ve only got a certain degree of patience with these
initiatives, I think, and the danger, if we don’t see quick
wins and meaningful change through clusters over the next year or
two, is that GPs will disengage from that cluster
process.
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[168] There have been tangible benefits, I think, around
how GPs interact with one another. It may well be that 10, 15 years
ago, you didn’t speak to your neighbour down the road. He was
your competition, if you like. Now, that certainly has changed, and
that’s by necessity, given the workload pressures as well.
So, I think the conversation within clusters has improved.
The funding is not enough to deliver any meaningful change, even if
we were set free, I think, but setting us free would help that.
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12:00
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[169] Dai
Lloyd: We have got the Pen-Y-Bont Health federation coming in
in a couple of weeks’ time to give evidence. Have you got
another question there, Caroline?
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[170] Caroline
Jones: Okay. It’s just about the salaries. We have been
told that the funding is limited, short term in nature and is
largely tied up with salaries—90 per cent is the percentage
figure we’ve been given. Can you elaborate on this? Also,
with regard to Angela’s questions, Charlotte wanted to say
something on Hywel Dda health board, to recap, and I wondered if
you could tie it all in, please.
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[171] Dr Jones:
The issue about the Hywel Dda health board was around a transfer of
resource from secondary to primary care, which didn’t turn
out to be secondary care resource—it turned out to be a
charitable resource. That was a few years ago; I think I brought it
to this committee then. The issue around salaries is a huge
challenge. Not only do you have to go through the recruitment
process, they have to be employed and then we have to add the
indemnity on top and the other terms and conditions. Because the
moneys aren’t huge to each individual cluster, you can see
how it can get taken up by one or two pharmacists or one
physiotherapist, or something like that. But, if that is what the
cluster needs and is determined it needs, that’s great.
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[172] The moneys have
been recurring for four years, so they are not really short term.
But the problem is that they are short term if they are not allowed
to be carried over because they haven’t been used. So,
that’s a difficulty. But, yes, we have to make sure that
these moneys are used for sustainable change. It is no good having
something in for a year—where you have got funding for a
speech and language therapist to come and help you with your frail
elderly for a year, but then, actually, after that they don’t
know. So, why would a healthcare professional leave a stable job to
come to a cluster job if there’s no stability of employment?
It’s a difficult conundrum to marry up.
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[173] The issue about
indemnity is one I can wax lyrical on forever, but you really
don’t want me to do that today. But there are issues in terms
of indemnity for the individual and the risks to the practice
around vicarious liability, and our BMA advice, largely written by
myself, is clear on that. But that is again a constraint, or
something that practices aren’t aware that they are leaving
themselves open to risk about. The other problem we’ve got
around the cluster moneys isn’t so much about it being tied
up with salaries. But, if it’s not used, or the health board
suddenly say, ‘Well, you can’t do that with it’,
it then suddenly has to go into short termism, and then, you know,
practices and clusters are struggling to think of what they can
use. They don’t want to lose it—‘The health board
won’t say yes to this’—so they might invest in
iPads for staff to do remote visiting or for educational purposes:
things that, actually, I’m not sure deliver the
transformative change I would want to see. Although the moneys are
small, they’re small enough to have fired a flame of
enthusiasm among the practices and the staff involved in the
clusters. But, because they are not having any momentum of change,
that enthusiasm is disappearing rapidly, I would say.
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[174] Dai
Lloyd: Ian?
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[175] Dr
Harris: The other thing to say is that, if a cluster sets up
and employs two pharmacists and finds that it is fantastic, unless
the funding to that cluster increases exponentially, there is no
more innovation in that cluster because you’re tied. There
has to be a process whereby the innovation within a cluster becomes
practice across the health economy, and I’ve not seen any
evidence of health boards showing an appetite for that, let alone a
mechanism for releasing it.
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[176] Dai
Lloyd: Good. Time is against us; we’re down to the last
two questions now, team. So, Jayne next, then Dawn.
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[177] Jayne
Bryant: I shall be brief, Chair. I’m very interested to
have your views and perspective on how effective clusters are,
generally, in tackling health inequalities and responding to
population health needs.
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[178] Dr Jones:
Okay, well, I’m going to take this from my national
perspective. I do all the cluster plans for my own practice, by the
way, and take them to my colleagues to review. We have very good
reports from the Public Health Wales Observatory. They give us
individual statistics in our practice around, for example, chronic
obstructive pulmonary disease, cardiac disease, and they benchmark
us against other practices in the area and across Wales. They are
actually publicised on the My Local Health Service website. At a
cluster level, I know that we have interactions with Public Health
Wales around some of the screening programmes—bowel
screening, cervical screening, breast screening—and about the
vaccinations and immunisations of your population, and having
discussions around how you can improve uptake of that, which leads
you into looking at your vulnerable and more hard-to-reach areas.
How that has translated into meaningful change, though, from
cluster reviews of this—I haven’t seen any evidence to
say that, actually, having that in a cluster report and a cluster
discussion has led to a real change in uptake rate. I would argue
that it’s not always the responsibility of the cluster and
the practices; I think it needs to be part of a wider scale piece
of work to look at how we can harness social media for teenagers
who might not access these services, and through to tv and
advertising to enable uptake of all the screening services.
I’m thinking back to what happened with cervical
screening—it went up massively after a celebrity sadly died
from cervical cancer and now it’s dropped back off. People
don’t like the idea of bowel screening, but, when you explain
to them, they do understand it. So, it’s not just the cluster
responsibility, but there is a role for the clusters in terms of
looking at how services can be improved in terms of uptake and are
there any gaps in what people are thinking about. But I don’t
think it should be solely the responsibility of the clusters to
look at that. And different clusters cover different types of
areas, so the challenges are different.
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[179] Dr
Shore-Nye: I have to confess up here that I think I am cluster
lead in the cluster with the worst uptake for flu vaccine and the
worst uptake for bowel screening and the worst uptake
for—well, I don’t think we’re worse for cervical
screening or breast screening; I believe that’s a different
cluster. I think there may be a role in clusters for addressing
health inequalities. I think the issue is wider than just within
the cluster team. I also think that it may also reflect on the
maturity of the cluster and the stability and the sustainability of
the services—healthcare, social care and other
care—within that cluster area. If you look at Blaenau Gwent
East, for an example, we are massively struggling with general
practice recruitment. We have difficulty with nursing recruitment,
there is a high level of social deprivation, and all of that cannot
be entirely addressed by cluster working. We can address certain
issues. We can look at concerted efforts and how these are promoted
within the area, but I think that the issue is, as you say, a wider
issue. It is looking at other ways of empowering that local
community, the citizens from the community and the population
rather than just the cluster.
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[180] Dr Jones:
I think the clusters, through sharing information and sharing how
they go about delivering certain services, have helped with health
inequalities generally. But, again, if that’s measurable or
not, it’s very difficult to say. The cluster plans, though,
are available for viewing, so the quality of that discussion should
be captured there, but, as I say, I think it’s a more
wide-scale issue for addressing in different ways. Of course, some
of these hard-to-reach groups are very, very small in numbers, so
you need a critical mass, and I think, again, that fits a more
health board/national approach sometimes for some of them.
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[181] Dai
Lloyd: Okay, on the [Inaudible.] issue, Dawn.
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[182] Dawn
Bowden: Thank you. A simple question, and I think I probably
know the answer given the evidence that you’ve given so far:
do you think that there is a case for less health board involvement
and more clinical leadership directly from the clusters, going
forward?
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[183] Dr
Harris: I’ll answer that: yes [Laughter.]
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[184] Dawn
Bowden: I thought that would be a simple one.
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[185] Dr Jones:
It might be a unanimous ‘yes’ and ‘yes’.
And more resource—yes, yes, yes. And more—
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[186] Dawn
Bowden: But that point in terms of the resource, because there
has to be a link, doesn’t there, because the resource comes
from the health board, so it can’t be complete autonomy?
There has to be some accountability, doesn’t there?
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[187] Dr Jones:
Well, the resource could come—if they were legal entities set
up, as we’ve previously suggested—direct to the
clusters, and you might get more meaningful, measurable change if
it were to come to those. And it might be an idea to pilot that in
those clusters that are of a maturity where they wish to try just
to prove the concept. We all know there are always unintended
consequences of some of these actions and, sometimes, the solution
becomes a problem in itself when you’re putting it together,
but I certainly think that we should now be at a stage where we
know which are the mature clusters, and let’s give it a shot.
You know, we’ve got nothing to lose by it, have we?
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[188] Dr
Fenton-May: The evidence that we’ve had from talking to
different clusters is that, very often, the agendas of the meetings
are set by the LHB, and the GP bits of the agenda very often fall
off the end because there is so much push from the LHB rather than
from the GPs, who may have five different agendas from the five
different practices. So, we need to work in a different way, and
the maturity of the cluster enables that voice of the GP to be
heard better.
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[189] Dr Jones:
I think we need to go back to basics and re-establish the knowledge
and awareness of what the clusters are, because they’re not
just the GP practices. But actually raise that, as well, and get
some enthusiasm and excitement about what they could deliver,
because I think we’re all under such pressure that it’s
very difficult to engage in that.
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[190] We actually have
done a survey—I’m afraid of just the practices,
though—within the last month and we shall e-mail that through
to the committee if that’s of help to you, because there are
some useful free-text comments within that, which might, again, be
food for thought.
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[191] Dawn
Bowden: Okay, thank you.
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[192]
Dai Lloyd: Diolch yn fawr. Mae’r amser ar ben, felly,
diolch yn fawr iawn. Tystiolaeth arbennig y bore yma. Diolch yn
fawr iawn i chi am eich presenoldeb. Diolch arbennig, felly, i Dr
Charlotte Jones, Dr Ian Harris, Dr Isolde Shore-Nye a Dr Jane
Fenton-May. Fel rŷch
chi’n gwybod erbyn nawr, byddwch chi’n derbyn
trawsgrifiad o’r cyfarfod yma i wirio’r ffeithiau.
Fedrwch chi ddim newid eich meddwl ynglŷn â gwahanol
agweddau, ond o leiaf fedrwch chi wneud yn siŵr bod y
ffeithiau yn gywir. Felly,
gyda hynny o eiriau, diolch yn fawr iawn i chi am eich
presenoldeb.
|
Dai Lloyd: Thank you very much. Our
time is at an end, so thank you for your great evidence this
morning. Thank you for your attendance, especially to Dr Charlotte
Jones, Dr Ian Harris, Dr Isolde Shore-Nye and Dr Jane Fenton-May.
As you know by now, you will receive a transcript of the meeting to
check for factual accuracy. You can’t change your minds about
different aspects, but at least you can ensure that the facts are
correct. So, thank you very much for your attendance.
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12:10
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Papurau i’w
Nodi
Papers to Note
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[193]
Dai Lloyd: Eitem 4 i Aelodau yw’r papurau i’w
nodi. Mae yna bum wahanol lythyr yn fanna os ydych chi eisiau codi
rhywbeth, neu, yn absenoldeb hynny, fe wnawn ni symud ymlaen i
eitem 5.
|
Dai Lloyd: Item 4 for Members, papers
to note. There are five different letters there if there’s
anything you want to mention, otherwise we’ll move on to item
5.
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