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 09:30.
The meeting began at 09:30.
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Cyflwyniad,
Ymddiheuriadau, Dirprwyon a Datgan Buddiannau
Introductions, Apologies, Substitutions and Declarations of
Interest
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[1]
Dai Lloyd: Bore da i chi gyd a
chroeso i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol
a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. O dan eitem 1 y
bore yma, a allaf estyn croeso i fy nghyd-Aelodau?
Rydym wedi derbyn ymddiheuriadau oddi
wrth Jayne Bryant a hefyd oddi wrth Angela Burns, ac mae
Mohammad Asghar yma yn dirprwyo dros
Angela Burns, ac mae Julie Morgan yn rhedeg ychydig bach yn hwyr y
bore yma ond mi fydd hi yma cyn bo hir.
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Dai Lloyd: Good morning, everyone, and
welcome to this latest meeting of the Health, Social Care and Sport
Committee here in the National Assembly for Wales. Under item 1
this morning, may I extend a welcome to my fellow Members? We have
received apologies from Jayne Bryant and also from Angela Burns,
and Mohammad Asghar is here substituting
for Angela Burns, and also Julie Morgan is running a little late
this morning, but she will be joining us soon.
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[2]
Yn bellach, gallaf gyhoeddi fod y
cyfarfod yma, yn naturiol, 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 atgoffa pobl i naill ai
ddiffodd eu ffonau symudol ac unrhyw gyfarpar electronig arall neu
eu rhoi ar dawel? Nid ydym ni’n disgwyl larwm tân y
bore yma, felly os bydd tân neu larwm, neu’r ddau, bydd
angen dilyn cyfarwyddiadau’r tywyswyr wrth adael.
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May I further announce that this meeting is,
of course, bilingual, so you can use headphones to hear
simultaneous translation from Welsh to English on channel 1, or for
amplification of the verbatim on channel 2? May I remind everyone
either to turn off their mobile phones and any other electronic
equipment, or put them on silent? We are not expecting a fire alarm
to sound this morning, so if there’s a fire or an alarm, or
both, we will then need to follow the ushers’ instructions as
we leave.
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[3]
A ydy’r clustffonau’n
gweithio? Nid yw clustffonau Caroline yn gweithio. Mi wnawn ni eu
newid y nawr.
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Are the headphones working? Caroline’s
headphones do not seem to be working, but we will change those
now.
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09:31
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Ymchwiliad i Ofal
Sylfaenol: Sesiwn Dystiolaeth 8—Coleg Brenhinol y
Seiciatryddion
Inquiry into Primary Care: Evidence Session 8—Royal College
of Psychiatrists
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[4]
Dai Lloyd:
Symudwn ymlaen i eitem 2 a pharhad
efo’n hymchwiliad i ofal sylfaenol a chlystyrau meddygon
teulu. Sesiwn bore yma yw sesiwn dystiolaeth rhif 8 yn y gyfres, ac
o’n blaenau ni y mae Coleg Brenhinol y Seiciatryddion, ac yn
benodol, felly, yr Athro Keith Lloyd o Goleg Brenhinol y
Seiciatryddion. Rydym ni wedi derbyn eich papur gerbron, ac yn unol
â’n harfer nawr—ac rydych wedi dod i arfer bod
yma fel tyst hefyd—awn ni’n syth i gwestiynau.
Mae’r cwestiwn cyntaf gan Caroline Jones.
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Dai
Lloyd: We move on to item 2, which is a continuation of our
inquiry into primary care and general practitioner clusters. This
morning is the eighth evidence session in the series, and before us
we have the Royal College of Psychiatrists and representing them,
Professor Keith Lloyd. We’ve received your paper, and as per
usual—and you will know this having been a witness—we
will move immediately to questions. The first question is from
Caroline Jones.
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[5]
Caroline Jones: Diolch, Chair. Good morning. Could you tell
me, please, regarding the increased workloads in mental
health—we’ve been taking evidence to that
fact—whether there has been parity in terms of prioritising
cluster funding between mental health and physical health?
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[6]
Professor Lloyd: Okay. So, according to the Royal College of
General Practitioners—their data from 2014—out of every
1,000 people who go to see their GP, about 300 have a mental health
problem: 230 will be seen, 24 will be referred on to secondary
mental health services and six will eventually be admitted to
either psychiatric hospitals or crisis teams. So, the vast burden
of that workload falls on the primary care team. That
notwithstanding, increasing amounts of that work are now being
referred into secondary care.
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[7]
So, I think your question was about how the clusters have helped
with that. The honest answer is: I really don’t know. I can
talk to the workload and I can speak to the fact that the
challenge, given that workload, in primary care is that even though
things have improved greatly, only about just under half of general
practitioners have done any postgraduate experience in psychiatry
or mental health—I think the Chair of this committee was one
of that trailblazers in that respect—but there remains both a
workload and a skills issue and it’s difficult to know how
clustering will address that. There is a general parity of esteem
point about how clusters might prioritise mental health within
their workload.
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[8]
Caroline Jones: Okay, thank you.
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[9]
Dai Lloyd: Mae’r
cwestiynau nesaf o dan law Oscar.
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Dai Lloyd: The next questions will be
from Oscar.
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[10]
Mohammad Asghar:
Thank you very much, Chair, and thank
you, Professor. My question is regarding reducing demand on GPs in
the same area that you just answered on to Caroline. There seems to
be limited hard evidence on the impact of clusters. What is your
view on the quantifiable effect the various cluster initiatives are
having in terms of improving access to psychological therapies and
reducing demand for GPs?
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[11]
Professor Lloyd:
This relates to other questions that will
come up later, I suspect, about social prescribing and other forms
of intervention, but have clusters made a difference to that?
It’s difficult to say. At the moment, I guess clusters
don’t have that much influence on, as far as I can tell, the
types of services that they provide. If it’s possible for a
cluster to work collectively to deliver alternatives to
medication, so psychological therapies, then that would be a good
thing. If we work backwards at your question—what’s
missing and how clusters could play a role in providing
it—then we might be able to approach it from that
direction.
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[12]
In England, they had a scheme a few years ago called IAPT, which
stands for improving access to psychological therapies, and that
was rolled out in primary care there with some success. We
don’t have an equivalent scheme here. Similarly, although on
the plus side, we do have something called primary care mental
health liaison nurses—people who are generally psychiatric
nurses who are based in secondary care who work, primarily, in
primary care, effectively triaging mental health referrals from
GPs. They’re able to deal with a large number of the
referrals that they get and they refer only a small proportion on
to those of us who work in secondary care, such as myself, who
works in a community mental health team.
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[13]
Now, where clustering could play a part is if the cluster decided
to prioritise investing in psychological therapies and alternatives
to medication, but so far, I’m not aware of any evidence that
says that that’s happening, which isn’t to say that
they’re not—there just isn’t any evidence that it
is happening.
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[14]
Mohammad Asghar:
Right, thank you. What should be done to
ensure that there is robust evaluation of their work and that good
practice and effective service models are being rolled out in
Wales?
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[15]
Professor Lloyd:
Evidence-based policy making—there
should always be a robust evaluation of the roll-out of policies.
There are a number of reasons why that doesn’t always happen.
I guess, in medicine, we’re fairly used to the idea of using
a particular type of evidence, and evidence means different things
to different people. To lawyers, it means what the person in front
of them is saying, often. To us, it’s about types of research
evidence and audit evidence, as well as the things that our
patients say. So, at the moment, there isn’t the evidence for
it, so, yes, the short answer to your question: clearly, there
should be an evaluation of this. The important thing would be to
decide what the question was that you were asking and what a good
outcome would look like.
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[16]
Mohammad Asghar:
Right, thank you again. In an earlier
question, you mentioned the psychological
therapies—there’s some sort of difference in England
and in Wales. Have any lessons been learned from that side of any
improved service providing to the public?
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[17]
Professor Lloyd:
Generally speaking, I think, probably,
primary care is in better shape here than in England, overall. IAPT
is something that they have done quite well, and what they did was
to take graduate psychologists, so people who’ve just
graduated from university with a psychology degree, and trained
them in the delivery of psychological therapies. That work seems to
work best—there’s a very good centre in Manchester that
studied this in quite some detail—when people enter the care
pathway for mental health services right at the beginning and
don’t leap-frog around it, because there’s an
assumption that a lot of people need to access more complicated
therapies, but if everybody starts with the simplest, except where
the need is very obvious, then the results tend to be
better.
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[18]
Mohammad Asghar:
Okay, thank you.
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[19]
Dai
Lloyd: Rhun, mae gennyt ti gwestiwn fan hyn hefyd.
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Dai
Lloyd: Rhun, you have a
question on this, too.
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[20]
Rhun ap Iorwerth:
Just picking up on what you’ve said
and what a number of others have told us during this inquiry about
it being difficult to measure whether clusters have worked. Is that
a concern of yours that we aren’t able to evaluate if
they’re working or not?
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[21]
Professor Lloyd:
I’m not saying we aren’t able
to evaluate whether they’re working. I’m saying we
haven’t done it yet, that I know of. If that were seen as a
priority for funding, then people would be able to evaluate it. And
I guess there would be a range of outcomes that could be looked
at—I mean, from what the end users of it thought, what the
patients using the service thought, through to what it does for
recruitment, retention and things like that for primary care. I
suspect that, for the last one, there are probably other things
that’ll have more impact, such as the recent upturn in the
recruitment of GP training slots, which seems to be down to a
variety of measures, of which I’m not sure clustering is
necessarily one. So, it’s quite difficult to tease out
those different effects, but if the patients like it and the
professionals like it, then it must be doing something right. So,
that would be a place to start.
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[22]
Rhun ap Iorwerth:
We’ve picked up quite clearly on
there being more than a little ambiguity about what it is exactly
that clusters are meant to be delivering that wasn’t being
delivered before. Are you clear in your mind, in terms of
psychiatry and mental health, what we should be getting out of
clusters as opposed to the previous situation?
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[23]
Professor Lloyd:
I would think it would be helpful if
clusters could organise the delivery of psychological therapies and
other things that are not currently available as a group for their
patients, because sometimes there are economies of scale in doing
that.
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[24]
Rhun ap Iorwerth:
Okay, we’ll come back to those
issues, I’m sure.
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[25]
Dai Lloyd: Mae’r cwestiynau nesaf o dan ofal
Lynne
Neagle.
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Dai Lloyd: The next questions are from
Lynne Neagle.
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[26]
Lynne Neagle: Thanks, Chair. We know that some of the clusters have
invested in mental health services—some of them third sector,
others primary mental health care services. To what extent is it
possible to ensure that these roles are well aligned?
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[27]
Professor Lloyd:
Are you thinking about the third
sector?
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[28]
Lynne Neagle: Well, I suppose, all the investment, really, that is
going from the clusters into mental health services, but, yes, with
third sector and the statutory sector.
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[29]
Professor Lloyd:
Okay, so some of the stuff that’s
being provided from the third sector is very good. I hope
it’s not just being used as a cost-shifting exercise, so that
care that was previously provided from the NHS or from primary care
is being provided from the third sector, but some of that stuff is
very good. I guess what would help clusters in making informed
choices about which of those services to go with would be clear
guidance on the type of provision that is helpful and beneficial to
people. I think, at the moment, there are some very good
initiatives in some clusters and some third sector organisations
are doing fantastic work—Hafal and Mind come up frequently in
this. I guess the answer to your question would be that clusters
would probably be aided in this if they were given explicit
guidance on what works for who and who can provide it.
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[30]
Lynne Neagle: From Welsh Government.
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[31]
Professor Lloyd:
From somewhere—from people with the
appropriate expertise. I think the RCGP and the RCPsych are
probably both well placed to inform that debate.
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[32]
Lynne Neagle: Okay. If primary mental health services are patchy,
is cluster funding being used to reduce the gaps in provision as
far as you’re aware?
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[33]
Professor Lloyd:
I think it is in some places. It’s
hard to generalise about that. Speaking as a clinician, I
haven’t seen much happen in that respect so far in the patch
where I work, but I’m aware there are GPs who are looking to
do that in other areas. It’s kind of quite early days as well
for clustering, I think.
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[34]
Lynne Neagle: Okay, thank you. We’ve heard about the need, in
cluster and practice teams, for clarity in the scope of
professional skills and practices and avoiding overlap in new
clinical roles. What are the challenges here and what needs to be
done?
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[35]
Professor Lloyd:
I think that’s very important and
that touches on the prudent healthcare agenda as well. You want the
right person doing the right job with the right set of skills,
neither too much nor too little. That’s why I think the IAPT
scheme that I mentioned before for graduate psychologists is quite
a good example of people coming in with the right level of skills
and the right skill set to deliver what’s needed in primary
care. We haven’t really done that yet. That would be a good
example of something that we could roll out more extensively if
there were a will to do so.
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[36]
Lynne Neagle: Okay, thank you.
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[37]
Dai Lloyd: Diolch, Lynne. Yn nhermau heriau y gweithlu, mae
cwestiynau gan Rhun.
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Dai Lloyd: Thank you, Lynne. In terms
of workforce challenges, Rhun has some questions.
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[38]
Rhun ap Iorwerth:
Continuing from that, really, we know
that getting the people in the right places with the right skills
is one of the biggest problems that we face in the NHS. You talk
about the potential economics of scale that clusters bring you. Is
the assumption perhaps correct that we also have economies of
workforce, if you like, whereby bringing different elements of
primary care together, we can use the limited personnel resource
that we have in a better way, spreading that workforce across a
wider area and being able to treat more patients and so on? Is that
part of the workforce planning answer?
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[39]
Professor Lloyd:
I think it is part of the workforce
planning answer, and that really touches on a broader set of issues
around the workforce that we’re training.
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09:45
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[40]
I’ve been to this committee previously in another role, as
dean of the medical school in Swansea, and I’m very aware of
the issues around the need to train a workforce with the right
skills that we can retain and keep in Wales, and who will then
continue to develop as they go on. Because I think the challenge,
certainly for primary mental health care, and I guess in other
areas of primary care as well, is that the nature of the work
that’s done in primary care is changing. We’re seeing a
move away from hospital-based care increasingly towards
intermediate and ambulatory care and more being done in the
community. So, there will be a need to refresh people’s
skills, if they’re able to keep ahead of the workload and the
changing population that we face, with an increasing number of
older adults. So, it’s going to be more people with memory
problems and dementia and that will require a rethink about how we
deliver those services. So, we’re going to need to train that
workforce right from when they first start in medical school, or
train as nurses or psychologists or physician associates, or
whatever, right the way through to maintaining and refreshing their
skills later.
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[41]
Rhun ap Iorwerth:
There seems to be a blurring of lines
that, as far as I can see, is welcome, between primary care and
secondary care, and elements of secondary care need to be involved
in the delivery of primary care and vice versa. Is there evidence
that clustering is making that easier in the development of
multidisciplinary teams across primary care clusters—that
that makes the interaction somehow with secondary care better or
easier?
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[42]
Professor Lloyd:
At face value, it would be very
reasonable to think it was. I’m not aware of any evidence
that it’s making it harder. I think it’s too early to
say whether it’s helping, but it seems like a good
idea.
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[43]
Rhun ap Iorwerth:
Is there potential to develop that?
Because one thing we’ve seen is that there’s not a
formula for the development of clusters—clusters are
developed in different ways in different parts of Wales. Have you
identified some areas where there’s a particularly good model
of clustering that facilitates that working with secondary
care?
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[44]
Professor Lloyd:
The variation in—to answer that
with respect to mental health care—the ability of practices
to support the people who are on their lists with mental health
problems seems to be affected more by the skill set of the people
in the practice than it does by whether or not they’re in
clusters. I can think of practices where the level of care that
they deliver is superb and others who seek advice from us much
earlier in managing, say, depression than they would if they were
managing diabetes or hypertension—it’s just a skills
gap really. So far, I think that has a bigger impact. I guess that
if I follow that through, logically, what I would be saying is that
clustering could make a big difference if it helps to skill up the
people within the cluster to feel able to deliver mental health
services. One of the things that can be quite difficult for mental
health care, and where I think there isn’t parity of esteem,
is where cost shifting happens and practices are reluctant to
prescribe drugs that are slightly more expensive than things that
have been around since the 1950s, in a way that they aren’t
with other specialties. That’s a slightly different point,
but—
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[45]
Rhun ap Iorwerth:
Yes, but I guess that’s about the
sharing of good practice: if you have a practice that is
particularly strong on mental health within a cluster,
there’s more of an opportunity for that best practice to
be—
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[46]
Professor Lloyd:
And there are some practices that are
absolutely superb at delivering mental health care that I work
with, and some that are less comfortable with it.
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[47]
Rhun ap Iorwerth:
Going back to our other inquiry on
workforce planning, is it clear who’s taking the lead on
making sure that proper skills are there and available for
developing clusters? Is it down to the clusters themselves or is
there a clear lead at Government or health board level?
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[48]
Professor Lloyd:
With regard to the general skilling up of
clusters, I don’t know. In terms of mental health care, we do
work with local clusters around where I am to do skills and
education sessions with the GPs. So, that’s happening on the
ground; I’m not aware of how it’s organised
centrally.
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[49]
Rhun ap Iorwerth:
Okay, thank you.
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[50]
Dai Lloyd: Symudwn ymlaen ac y mae’r
cwestiynau olaf o dan ofal Dawn Bowden.
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Dai
Lloyd: We will move on now and
the final questions will come from Dawn Bowden.
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[51]
Dawn Bowden: Thank you, Chair. You touched on this in your earlier
answers and this is a chance to enlarge a little bit now on the
issue around social prescribing, because you touched on that
earlier. And, certainly, I was having a discussion only recently in
my constituency with a third sector organisation that had been set
up to deliver well-being projects and services, and they’re
very keen to interact with the GPs in the area, but that
hasn’t happened yet. You were saying that there isn’t
actually any evidence that these alternative therapists are being
used to any great degree. But can you tell us what you think the
potential benefits of social prescribing would be, given that
preventative mental health treatments are obviously the way
forward, really?
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[52]
Professor Lloyd: So, yes, I noticed this in the
question, that social prescribing and prevention are elided, kind
of put together, in the question there. I think they’re
separate. I think they overlap, but they’re separate. So,
taking the social prescribing bit first, I looked around for the
evidence for social prescribing, because at face value it’s a
great idea. So far, the evidence base to underpin social
prescribing hasn’t been fleshed out. It seems like a good
idea, but we really need to evaluate it, particularly for mental
health care. I found some stuff—. I found two studies that
looked at who was likely to take up initiatives in social
prescribing. They’re very recent, from 2017, these two
studies. And one of them found, from a small study of about 100
people, of qualitative design, that people with anxiety and
depression were less likely to take up social prescribing options
than people with some physical conditions—so, arthritis pain
and so on. Exercise programmes seem to work better for people with
physical health problems than they do for mental health
problems.
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[53]
Dawn Bowden: Because we generally associate well-being with
mental health, don’t we?
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[54]
Professor Lloyd: Yes. It needs working through. Hafal do
some very good things; the Samaritans do some very good things;
Mind Cymru have some very good initiatives in this respect; and, on
the face of it, they really ought to help be part of the picture.
As long as they’re properly evaluated, then I think they
could help. The prevention agenda is broader than the social
prescribing agenda. There’s a full range of public health
initiatives that could play a part in promoting wellness and
well-being in the population, from promoting resilience and
well-being in schoolchildren, for which there seems to be some
evidence, through to supporting people who are recovering from a
more severe mental illness. So, there does seem to be evidence for
that, which I would tend to separate out from the social
prescribing agenda slightly.
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[55]
Dawn Bowden: So, would you be suggesting that the
preventative measures, given the evidence base, should be
prioritised for clusters, but that they could work with other
social prescribing therapies, if you like, as a separate kind of
service delivery, really?
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[56]
Professor Lloyd: There’s been a debate over the years
about the role of primary care in prevention. There was a big
debate about cardiovascular prevention, for example, and asthma. I
personally think that there is a significant role for primary care
to play in raising awareness about, promoting help-seeking for, and
reducing stigma around mental health. That goes with the parity of
esteem agenda and will help people to feel empowered to seek help.
It’s then important that we have a range of options for them,
which is where the social prescribing stuff might come in, except
we don’t yet know how well it works.
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[57]
Dawn Bowden: Sure. Okay. Yes, I understand that. Can I just
ask you one further question? This is around leadership, and
whether you feel that your members have had any specific
involvement in cluster work. Do you feel as though you’ve had
an involvement in terms of how they might develop, or are you
coming late to the party?
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[58]
Professor Lloyd: I think it’s been very
much—. You have to be on the guest list to get into the
party, and it’s been very much a primary care party. We have
been invited. We are involved a bit. People do seek our advice
about mental health services. The Royal College of General
Practitioners works quite closely with the Royal College of
Psychiatrists around this, so that’s the level at which
we’ve engaged really.
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[59]
Dawn Bowden: Sure. Okay. That’s fine. Thank you.
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[60]
Dai Lloyd: Just a question to—. A general one,
really. There’s a general tension, certainly in GP circles,
between what happens in the normal general practice and what
happens at the cluster level and, obviously, the financing of both.
Obviously, recent increases in primary care funding have all gone
to the clusters, none of which have come to the ordinary GP
practice on the ground. In terms of, say, people—even though
you’re on the guest list to the party, but possibly not
intimately involved in that sort of tension—can you think of
a way of trying to defuse any such tension, do you think?
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[61]
Professor Lloyd: Possibly the provision of things like
psychological therapies, which could be dealt with at a cluster
level, would help, because it would be a tangible example of
something where there would be trickle-down to the practices, and
if the service were provided by the cluster then the practices
would benefit from it, and it would be a way of getting individual
businesses to work more closely together.
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[62]
Dai Lloyd: That’s good. But the counter to that would
be—because I’ve heard this debate as well—in
terms of clusters being expected to use their moneys to actually do
things that the health board should already be doing. How would you
value that sort of—? Or the clusters being expected to plug
current gaps in provision, and letting the health board off
scot-free.
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[63]
Professor Lloyd: I guess that’s the same argument
about cost shifting as I was making about the third sector. We are
going to have to see a move of money over time—which is very
difficult given where many of our health boards are at the
moment—from secondary and tertiary care towards primary care.
So, as long as the clusters are adequately funded to deliver these
services, I think that could be a positive thing.
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[64]
Dai Lloyd: Good. And just a final one from me. As Rhun
pointed out earlier, there is this general shift and it’s
recognised generally that, actually, we should be doing more stuff
in the community and secondary care practitioners need to be in
intermediate or even primary care, and vice versa. How can you see
that being helped or actually hindered by the development of
clusters?
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[65]
Professor Lloyd: I think if the clusters take on and engage
with the training and staff development role, they can play a role
both in recruitment and retention and staff development going
forward. So, that could be a positive force around the use of
clusters. From a mental health point of view, the Royal College of
Psychiatrists would be very keen to engage with them on that
training.
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[66]
Dai Lloyd: Great.
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[67]
Dyna ni. Diolch yn fawr iawn i chi.
Unrhyw gwestiynau eraill? Pawb yn hapus? Reit, dyna ni; dyna
ddiwedd y sesiwn. Diolch yn fawr iawn i chi am eich tystiolaeth ac
hefyd am y dystiolaeth ysgrifenedig. Fe fyddwch chi, fel rydych
chi’n gwybod nawr, yn derbyn trawsgrifiad o’r
drafodaeth er mwyn i chi allu ei wirio. Ond dyna ni; diolch yn fawr
i chi am eich presenoldeb. Ac wrth fy nghyd-Aelodau, fe wnawn ni
dorri am egwyl nawr o chwarter awr a dod yn ôl am 10:15.
Diolch yn fawr iawn i chi.
|
Thank you very much. Any further questions?
Everyone happy? Okay, that’s the end of the session. Thank
you very much for your evidence and also the written evidence you
gave us. As you’ll know, you will receive a transcript of the
discussion so that you can check that for accuracy. Thank you very
much for coming today. And to my fellow Members, we will have a
break now for 15 minutes and come back at 10:15. Thank
you.
|
|
[68]
Professor Lloyd:
Diolch.
|
|
Gohiriwyd y cyfarfod rhwng 09:58 a
10:17.
The meeting adjourned between 09:58 and 10:17.
|
|
Ymchwiliad i Ofal
Sylfaenol—Sesiwn Dystiolaeth 9—Pen-y-bont
Health
Inquiry into Primary Care—Evidence Session 9—Pen-y-bont
Health
|
|
[69]
Dai Lloyd: Croeso nôl, bawb, i sesiwn ddiweddaraf y
Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad
Cenedlaethol Cymru. Rydym ni’n cario ymlaen rŵan dan
eitem 3 efo’n hymchwiliad ni i ofal sylfaenol, a’n
hymchwiliad ni i sut mae clystyrau meddygon teulu yn gweithio. Hwn
ydy sesiwn dystiolaeth rhif 9, y nawfed yn y gyfres, ac mae
meddygfa gyfunol Pen-y-bont o’n blaenau ni. Efallai, cyn i fi
gyflwyno, y byddai’n well imi ddatgan rhyw fath o fuddiant.
Cyn i chi i gyd gael eich geni, roeddwn i yn feddyg teulu ym
Mhen-y-bont. Fe wnes i dderbyn hyfforddiant ym meddygfa Oldcastle,
sydd nawr yn feddygfa Oak Tree; pobl fel Dr Steve Madelin a Huw
Mason oedd fy nghyfoedion i. Byddai’n well i gael hynny ar y
record, neu fe fydd pobl efallai yn dweud rhai pethau.
|
Dai Lloyd: Welcome back to everyone to
this latest session of the Health, Social Care and Sport Committee
here at the National Assembly for Wales. We are continuing now
under item 3 with our inquiry into primary care and how GP clusters
work. This is evidence session 9, the ninth in the series, and
Pen-y-bont Health are before us. Before I make some introductions,
can I declare an interest, please? Before you were all born, I was
a GP in Bridgend. I was trained in Oldcastle surgery, which is now
Oak Tree surgery. People like Dr Steve Madelin and Huw Mason were
my compatriots. But I should put that on the record, I think,
otherwise people will have some things to say.
|
|
[70]
Ond gyda chymaint â hynny o
ragarweiniad, a allaf i groesawu, felly, Joanne Carter, practice
manager o feddygfa Pencoed, Dr Alison Craven o feddygfa
Riversdale, dros y ffordd o lle roedd Oldcastle arfer bod, Dr Ian
O’Connor o Oak Tree, a hefyd Dr Gail Price, hefyd o feddygfa
Pencoed? Bore da i chi i gyd.
|
But following that introduction, can I welcome
Joanne Carter, practice manager for Pencoed medical centre, Dr
Alison Craven from Riversdale, over the road from where Oldcastle
used to be, Dr Ian O’Connor from Oak Tree, and Dr Gail Price,
also from Pencoed medical centre? Good morning to you all.
|
|
[71]
Ein ffordd traddodiadol ni o ddelio
efo hyn ydy: yn sylfaenol, rydym ni’n gofyn cyfres o
gwestiynau, a theimlwch yn rhydd i’w hateb, un ai bob un
ohonoch chi, neu—. Nid oes rhaid i bob un ohonoch chi ateb
pob cwestiwn. So, nid oes yna ddim pwysau, felly. Ond rydym
ni’n dechrau gyda chwestiynau cyffredinol o dan law Caroline
Jones. Caroline.
|
Our traditional modus operandi is to ask a
series of questions. Feel free to answer them individually,
although you don’t all have to answer every question, of
course. So, there’s no pressure to do that if you don’t
want to. So, can we begin with some general questions from Caroline
Jones, please?
|
|
[72]
Caroline Jones: Diolch, Chair. I’d like to ask you,
please—good morning—regarding the profile of the
federation itself. For Pen-y-bont Health, could you tell me what
the population profile is, and the numbers of staff employed?
|
|
[73]
Mrs Carter: Right. Well, we cover six practices on the east
side of Bridgend and we are just over 70,000 between the six.
We’ve got 30 GP principals, a mixture, then, of salaried GPs,
and five of the six are training practices as well.
|
|
[74]
Caroline Jones: Right, okay. Thank you. That’s quite
large. Does anyone else want to elaborate on that?
|
|
[75]
Dr Craven: That’s the profile of our individual
practices all added together.
|
|
[76]
Caroline Jones: All added together. Okay. So, my second
question is: could you tell me, please, what motivated you to set
up—the reasons for setting up the federation? Were some of
these reasons influenced by workforce, finance, capacity to improve
services or sustainability? Could you—?
|
|
[77]
Dr O’Connor: Well, I think it’s a combination of
all of those things. When the decision was to have networks and
funding attached to the networks, we felt that there needed to be a
better way of deciding, with clarity, what you’re going to
spend your money on. The way that networks were set up in many
areas was that there’d be representatives from all walks of
social and health care, but it was chiefly the GPs or the GP
practices that would be seen as the main drivers of any change and
implementation. Because of that, it was at the behest of the GP
practices, to have a unified decision on what they were doing. We
didn’t think that we had that capacity; there was no
governance structure in place for us to make decisions that would
be fair and democratic. Therefore, we wanted to look at a way of
solidifying that and cementing that in our network, and then, as a
consequence of that, that led us down the road of looking into the
means of doing that and taking that a bit further.
|
|
[78]
Dr Craven: I think we all felt that networks had got bogged
down, really. Everything was very slow, there was no mechanism for
it to be fair. We’re six practices, but two of us are very
large, two medium and two very small. We’re all individual
businesses. So, you had to be fair—that the decisions you
were making were going to apply to all, and there was no mechanism
for that in the cluster. It all depended who turned up to the
meeting, which we didn’t feel was very fair, really.
|
|
[79]
Dr Price: There was quite a bit of disengagement,
wasn’t there?
|
|
[80]
Dr Craven: Yes.
|
|
[81]
Dr Price: The cluster working was becoming a bit stale.
There was a lack of progress, really, and that was frustrating.
That led to a bit of disengagement. So, we then decided to take it
forward and looked at various models, with the help of the Bridgend
Association of Voluntary Organisations. We had discussions with
BAVO. Then we went back from our cluster leads to all our GPs
within the six practices. We had a protected learning time session
to discuss, really, ways forward, to look at different models of
companies, and it was decided then that we would look at a
non-profit special purpose vehicle. Then we became engaged with
mutual ventures that took us through the feasibility study and then
the business planning, which took, really, the best part of 18
months. It was quite arduous, with twice-monthly meetings taking us
out of our practice time.
|
|
[82]
Caroline Jones: Could I ask you to elaborate on when you
said the clusters were becoming stale? Do you mean because of
patient outcomes or—what do you mean by
‘stale’?
|
|
[83]
Mrs Carter: No, it was that the ideas that we came up
with—. We looked at numerous ideas. We started off as
networks, many years ago, and then, obviously, went on to clusters,
and we came up with projects at the very outset of the networks,
and they never came to fruition. We could never really—we
tried to move services out of secondary care and bring them into
primary care, but we could never actually drill down the budgets to
try and find out where we could move with these projects. We looked
at contraceptive services to take the pressure off family planning,
and we looked at the wound care and the dressings with district
nurses, and we always hit a brick wall. So, we just felt that by
having a more cohesive working situation and a business, we
could—
|
|
[84]
Caroline Jones: So, there’s more flexibility.
|
|
[85]
Mrs Carter: Yes, very much so.
|
|
[86]
Dai Lloyd: Julie.
|
|
[87]
Julie Morgan: Can I just ask: do you remain as individual
businesses?
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|
[88]
Mrs Carter: Yes.
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|
[89]
Julie Morgan: Right. Thank you.
|
|
[90]
Dr O’Connor: We are six practices, and each practice
is an independent business, but each practice has agreed that they
will send a nominated representative to attend the network meetings
on a regular basis. But it’s also transpired now that those
six have taken on a role on the new federation board as well. So,
we have the voice, if you like. We have to report that back to the
board from each practice. So, my view might be to spend the money
in this way, but if my partners are saying, ‘We think it
ought to be spent in this way’, then that’s the message
I have to bring to the board.
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|
[91]
Julie Morgan: And then the board reaches a decision.
|
|
[92]
Dr O’Connor: Yes. We’ve decided, no matter what
the population size of the practice, that each practice has one
vote and that vote is equal amongst us. We have a decision, then,
made on voting, as to what we do. So, a majority vote will carry
the day.
|
|
[93]
Dr Price: The six practices have a GP principal as one of
the directors on the board, assisted by two practice managers, and
we’ve just employed an administrative assistant as well. We
have to be quorate to make a decision. Then, we feed back to our
practices what’s happening in our board meetings and vice
versa—what we discuss as projects, we then bring the voice of
our practices back to the board.
|
|
[94]
Dai Lloyd: Rhun, ar y pwynt yma.
|
Dai Lloyd: Rhun, on this point.
|
|
[95]
Rhun ap Iorwerth:
Just on another point of clarification, I
assume that, although you have made this arrangement, which is a
voluntary arrangement, you are viewed as a cluster in the eyes of
Welsh Government and the local health board.
|
|
[96]
Dr O’Connor:
We’re two things, now. That’s
one of the things—. We were lucky enough to receive
Pathfinder moneys to develop the federation, and it’s through
those moneys that we’ve been able to have protected time to
have discussions and meetings and all the rest of it and take
things forward. But, where we’ve got to, essentially, is that
we’ve got two entities now. We’ve got the network and
we’ve got the federation. They are separate but they overlap,
because the voice of the federation is what we would bring to the
network.
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|
[97]
So, if there’s a discussion
around—. The wound care LES is a good example. If
there’s a discussion over how that should be funded, we carry
the voice of our six practices to the network discussion, and then
other members of the network, whether that be the district nurses,
the local health board, or whatever, will have the discussion with
us. But, unfortunately, within each network, we haven’t got a
constitution or a voting system in place to say, ‘Okay, well,
we’ll take a vote on this now’, it’s just whoever
happens to be there, and some of those people who will be there
might have no interest in wound care services, yet they—. I
recognise that, in other networks, they would still be able to have
a vote.
|
|
[98]
Rhun ap Iorwerth:
By ‘network’ you mean
cluster.
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|
[99]
Dr O’Connor:
Cluster network, sorry, yes.
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|
[100]
Rhun ap Iorwerth:
We’re very simple people around
here.
|
|
[101]
Dr O’Connor:
Part of the problem, all along, has been
the terminology of these things.
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|
[102]
Dai
Lloyd: Iawn, Rhun?
|
Dai
Lloyd: Okay, Rhun?
|
|
[103]
Oscar, you have the next two
questions.
|
|
[104] Mohammad Asghar: Thank you very much,
Chair, and good morning, panel. My question to you is
straightforward: what are the advantages and disadvantages of the
federation model and the major challenges you face?
|
|
[105]
Mrs Carter: I think the advantages are—. When we started
out, each practice was individual, we all had our own business.
When you went to these meetings, you always came away with what was
best for your individual practice. I think, working very closely
for nearly two and a half years now, we all work very cohesively
and we’ve all got the same thought process when we take that
back to our practices. So, it’s made collaborative working a
lot easier and we all communicate a lot better as well, as
individual practices working together.
|
|
[106]
Dr Craven: I think we’ve started to think of the bigger
picture, in that there are things we can share even though we are
individual practices. We’re much more amenable to
that—sharing staff and expertise, and the website. So,
we’re all involved in that.
|
|
[107]
Dr Price: Sharing premises as well.
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|
[108]
Dr Craven: Sharing premises for various services—you
don’t go to the practice that you’re registered with,
necessarily; you go to the one where the person is delivering the
service. That would never have happened before. It’s much
more sensible and much more efficient.
|
|
[109]
Dr Price: And I think, also, safety in numbers. Projects that
we’ve been looking at, we’ve been able to undertake
because we are a six-practice organisation, rather than a smaller,
individual attempt on some of the services we’ve already put
in place.
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[110]
Mohammad Asghar:
I’ve heard a couple of times that
you run individual businesses. So, basically, there are two
elements involved in this: one is profitability and the second one,
in your case, should be the customer or patient satisfaction. So,
which is your priority in this area?
|
|
10:30
|
|
[111]
Mrs Carter: There’s no profitability in either because
we’re not—
|
|
[112]
Mohammad Asghar:
You said it’s a
business.
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|
[113]
Mrs Carter: It is a business.
|
|
[114]
Dr O’Connor:
It’s not for profit.
|
|
[115]
Mrs Carter: It’s not for profit. It’s a special
purpose vehicle that was set up not for profit. So, obviously,
we’ve got two tranches. Looking at services, we’ve got
ones that we have to do to generate profit that goes back into the
business to be able to provide services that—. For instance,
Dr Price is looking at a healthy children initiative at the moment,
tackling obesity in our area. That doesn’t generate any
profit or anything to our business, so we have to then look at
another stream of income, because eventually we have to be a
stand-alone, because the Pacesetter moneys were only guaranteed for
three years. At the end of that three years, we have to be able to
move forward, support the business, but then put the money back
into other services that will benefit the patient
population.
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|
[116]
Mohammad Asghar:
Okay. And you share best practice also, I
hope.
|
|
[117]
Mrs Carter: Yes.
|
|
[118]
Mohammad Asghar:
Okay, fair enough. The second question:
what are the governance, planning, and decision-making structures,
including the publication of federation plans, and are there any
difficulties in establishing priorities and leadership?
|
|
[119]
Mrs Carter: Well, we have a chair. We elected a chair when we
formed the federation. So, obviously, you’ve got six GP
directors, but Dr O’Connor is our chair. As we say, we are
quorate, so we always have to have four board members present at
each meeting to be able to make a decision to move forward. If the
board isn’t quorate, then we can’t make any
decisions.
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|
[120]
Dr Craven: And we’re listed with Companies House and the
accounts are listed and public, as they would be for anybody
else.
|
|
[121]
Mohammad Asghar:
Okay, thank you.
|
|
[122]
Dai Lloyd: Could I just flesh out some potential challenges in
terms of patients at one practice obviously being seen by somebody
from another practice? Could you just flesh out the data protection
and patient confidentiality challenges inherent in that, and also
if there are any indemnity issues in terms of people, not
necessarily other GPs, but from other organisations that you might
have contracted with? How does the indemnity situation—how is
that covered?
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|
[123]
Mrs Carter: Patients don’t see other GPs in other
practices; your registered patient is with your registered
practice. But, to date, we have developed a tier 1 mental health
counselling service, where we’ve got a contractor to do that
for us and she is covered by her own indemnity registration. We use
three of the practices because some patients don’t want to be
seen in their own practice for mental health issues, they’d
prefer anonymity, to be seen in another practice, so we have a room
there, and we use three of them to rotate. But, if you’re
registered, say, with Pencoed Medical Centre, you would only be
seen by the GPs for your primary care. And there’s a
vasectomy service that’s hosted by one of the practices, so
patients from all six practices go there, but, again, that’s
a separate contract and all the indemnities are in
place.
|
|
[124]
Dai Lloyd: So, that operates, effectively, as if it was mini
secondary care, is what you’re saying.
|
|
[125]
Mrs Carter: Yes, very much.
|
|
[126]
Dai Lloyd: And that any GPs with a special interest operate on
that same—rather than being other practitioners in the
same—
|
|
[127]
Mrs Carter: No, we don’t—they stay with their own
practice.
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|
[128]
Dr O’Connor:
One of the issues we’ve had when
we’ve gone through it is the funding stream for those sorts
of things. So, if we wanted to engage in any new project, we would
have to have agreement from our health board that they would pay us
through an SLA arrangement rather than directly into practices. So,
that took quite a lot of discussion and clarity around the section
50/51 moneys, because it wasn’t clear as to whether the type
of company that we’d set up would be allowed to receive those
sort of moneys. We couldn’t get answers very quickly to that
and it took quite a long time to eventually nail down that if we
wanted to deliver a service on behalf of the health board then we
would have to enter a SLA arrangement.
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[129] Dai Lloyd: Just
one other question from me in terms of potential challenges,
because we’ve heard evidence from other witnesses in terms of
tensions between what clusters—just normal
clusters—are expected to do vis-à-vis what
health boards should have been doing anyway. There’s a sort
of feeling in some parts of Wales that actually some cluster moneys
have been used to plug the gap where it should have been health
board provision anyway.
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[130] Now, with that
as a backdrop, if you are now instituting new services for your
federation, are there potential difficulties for neighbouring
clusters, who would think that, say, the vasectomy service should
actually have been provided anyway? Obviously, they will not have
access to your federated vasectomy service. So, what happens
to—that was just an example—any service that your
neighbouring clusters would feel they ought to have, or feel that
the health board should be providing, but now you’re
providing in your particular part of Bridgend? How does that help
the wider Bridgend general population?
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[131] Dr
O’Connor: I think there are two issues, really. Each
cluster network across Wales has taken on different projects that
they feel are going to be worthwhile to their population, and
they’ve had recurring funding to support those issues. Now,
we’re two or three years into that. Certainly, from a GP
perspective, the way we read this at the beginning—. The
majority of GPs, I think, read this as being, ‘Okay, well, if
you can prove your concept and you can prove your value, then it
should be the health board’s decision to mainstream
that’.
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[132] At the moment,
there’s no evaluation process. We’ve not had a protocol
or an evaluation form that we’ve had to fill in to
demonstrate things. Each federation—sorry, each cluster
network—across Wales will have done things, but not
necessarily recorded it in a way that the health board’s
going to say, ‘Yes, we can see that that’s been
beneficial, therefore, we’re going to fund it’.
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[133] In our
particular case, we’ve had a couple of projects that we feel
have been very well received by patients, GPs, and our community at
large. We believe that we’ve collected evidence and
demonstrated their value, but we’re still awaiting our health
board to decide whether they’re going to say, ‘Right,
you’ve proven your point. We will fund this now.’
Because what will happen is that the money is going to stagnate,
isn’t it? You’ve got this money for your project,
you’re doing your three projects, there’s no new money
coming in, so how can you progress things further?
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|
[134] So, if the
project isn’t successful or it’s too costly or
whatever, scrap that, do something different. But if you’ve
proven something is, then there ought to be a decision by the
health board to say, ‘Right, that’s it, you have the
same amount of money coming in, now you can invest it in a
different programme.’ That process hasn’t happened at
all yet.
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|
[135] The second issue
then was around the effect on the surrounding networks and things.
I think that goes back a little bit to what services you choose to
deliver and the funding of that. At the moment, and I suppose for
any new way of delivering a service, it would be up to the health
board to set criteria as to who that’s to cover and the
standards that they would expect that organisation to meet. So, I
think that comes down to negotiating your contract at the time,
really.
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|
[136] But, from our
perspective, if, for example, there was an enhanced service, as a
federation, we wouldn’t be able to engage with an enhanced
service. That would have to go back to individual practices to
deliver that enhanced service. As a federation, we would have to
ask our health board, ‘Could you come up with an SLA
provision for us to deliver that enhanced service?’ So, it
does mean more work for the health board. That’s one of the
things they’ve got to get their heads around, and work with
us to find solutions, I think.
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[137] Dr Price:
An example of that is the Karuna counselling that we’ve had,
which is tier 1 counselling where, basically, patients that
don’t need to be referred to the primary mental health team,
they come back—come back for a dose of the doctor—but
we’re not counsellors at the end of the day, and it’s
taking up valuable appointment time. So, having this counselling
service has (a) lifted the pressure on appointments for returning
patients, the patients are happy that they’ve got contact
with a counsellor, but also we’ve looked at this with our
cluster pharmacists and it’s significantly reduced our
antidepressant prescribing as well. But, obviously, a lot of these
patients are not then being referred on into primary mental health
services within secondary care. But we’re waiting on whether
that can be facilitated.
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|
[138] Dai
Lloyd: Dr Craven.
|
|
[139] Dr
Craven: And we also didn’t see a problem in the
federation. We were talking about fairness to other people who
didn’t have it. As a federation, we hope we’ll grow,
and there’s no reason why we couldn’t provide that
service for a neighbouring cluster if they so desired. That would
be our vision, ultimately.
|
|
[140] Dai
Lloyd: Good.
|
|
[141]
Mae cwestiynau eraill o dan law Dawn
Bowden.
|
Other questions will now be coming from Dawn
Bowden.
|
|
[142] Dawn
Bowden: To a degree, you’ve dealt with some of the
questions I was going to ask around evaluation, but that’s
from a health board perspective. But can you tell us a bit more
about how you have evaluated internally, if you like, in terms of
what you’re doing, and whether you’ve been able to
identify what the quantifiable impact has been on the services that
you’re delivering?
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|
[143] Mrs
Carter: When we started, the first year, by the time it was
registered at Companies House, we were obviously going through the
feasibility process, so there wasn’t a great deal of activity
in the company. The best part of the second year we went through a
five-year business planning process with Mutual Ventures, and we
have now got our five-year plan. Year 4 was always scheduled to be
our stand-alone year where we could go forward and be able to be
financially stable to support the business without any Pacesetter
moneys.
|
|
[144] We’re just
coming into year 3, and we’ve evaluated it by the projects
that we have got off the ground in a very short amount of
time—obviously, the counselling, but there’s no profit
coming back into the company to reinvest. But we have been very
successful in tendering for GP provision in Parc prison, and we
have won that contract, which is to deliver GP services for three
years. The element of profit in that will be reinvested back into
the company to be able to pay our administrative assistant and look
at other projects that will benefit patients. So, we evaluate every
time we have a board meeting. We’ve got very strict criteria
and we go through every project on the agenda—where we are,
what challenges we’re facing, what we need to move those
forward—and we’ve also then got our five-year business
plan, which has identified services that we’d eventually like
to be able to provide, which will again take the pressure off
primary care and, essentially, secondary care. Because we can
deliver a lot of services in secondary care in primary care.
|
|
[145] Dawn
Bowden: So, how have you been able to evaluate the impact on
patients? You talked about the counselling services, and there
seemed to be some clear evidence that you’re prescribing
fewer antidepressants and so on and so forth, and that’s
obviously taken the pressure off you. Have you been able to
evaluate that in terms of the other services that you’re
delivering, and in terms of the impact on your time generally, from
patient feedback?
|
|
[146] Dr
O’Connor: One of the other projects that we engaged with
was that by being a federation we were able to apply for grants and
awards, if you like, that you wouldn’t be able to do
necessarily as an independent contractor in GP land, and you
wouldn’t be able to do as a cluster network. So, we’ve
had a 10-week turnaround to try and secure some funds from the
stroke implementation group. They had already demonstrated in
Cardiff and Vale that, basically, if you paid practices to look at
their patients who had atrial fibrillation, who were at risk of
having a stroke but weren’t on an anticoagulant agent, then
you got a better uptake of patients who would go on those sort of
agents, and the cost benefits, then, on their working module were
that you would end up saving a patient from having a stroke, which
would have enormous cost savings to the NHS, but also to the
patient as an individual and their families.
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10:45
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[147] So, there were
funds available for that, and as a federation we felt that we would
be able to mobilise our support services to deliver that in a very
short time frame of 10 weeks. We were successful in engaging with
our cluster network pharmacist and with outside third sector
agencies as well to come in and help support and deliver this
programme to our patients. As a consequence, we’ve monitored
those patients who were at risk who weren’t on an agent at
the start of the programme and compared it to the end of the
programme, and we’ve had to deliver that as part of our award
that we had—we had to provide the outcomes and evaluation, at
the end of it anyway.
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[148] Dawn
Bowden: And do you think you’ve been able to quantify how
many patients this different type of service delivery may have kept
out of secondary care, or is that too difficult to quantify, or is
it impossible to quantify, I don’t know?
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[149] Dr
O’Connor: Well, I think, with that particular example,
over our 70,000 population, we worked out that we prevented two
strokes in that 12-month period. So, whilst that’s a small
number—it’s on a population-wide basis—that can
make a difference, and certainly, to the individuals, that’s
a huge blessing.
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[150] Dawn
Bowden: Absolutely. Okay, that’s fine. Thank you.
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[151]
Dai Lloyd: Grêt, diolch. Mae’r cwestiynau nesaf
o dan ofal Julie Morgan.
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Dai Lloyd: Great, thank you. The next
questions will come from Julie Morgan.
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[152] Julie
Morgan: Diolch. I wanted to go on on the theme of
multidisciplinary working, which you’ve already referred to,
and really to ask you how the multidisciplinary team works in the
federation and whether you could highlight to us any issues.
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[153] Dr Price:
I think, looking at the projects that we’ve individually
looked at so far, for example the prison contract, obviously, the
work-up for the tender process for that was a lot of work, which we
did as directors of the company, to put a business plan forward and
then win the contract. And we had to go to a presentation, a bit
like Dragon’s Den, which was alien to us as
clinicians. So, it’s been a big learning curve in that way.
But also, to look at the workforce that we would like to pull on to
work in that setting—we’ve now looked within our own
teams within our practices for people who’ve got any special
interests or special expertise who could work within that
environment. Likewise, with a physio pilot that we’re about
to embark on, we’ve got partners who’ve got particular
interests and have also got expertise and have worked in the
muscular skeletal services and diabetic injectable services, and
we’ve picked on our practice nurse specialists who are our
diabetic leads, as well as the GPs, to go for training with regard
to that. So, that’s from the point of view of the clinicians
and the nurse support team that’s there as well.
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[154] With regard to
the project that we’re embarking on now with obesity and
inactivity in children, obviously, linking in and augmenting with
public health, who sit within our clusters, but also within our
local Bridgend County Borough Council, with the recreational
team—the teams that are going into schools—we’ve
had meetings there. So, each project—sometimes it is just
very clinically led, or very administratively led, but there are
other pockets that we would pick on then, as and when needed, to
come into certain specified projects.
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[155] Julie
Morgan: So, in your own individual teams, you would have a
multidisciplinary team within your own individual practice.
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[156] Dr Price:
Yes.
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[157] Julie
Morgan: And you would use some of those people to go to the
wider projects.
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[158] Dr Price:
Yes.
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[159] Dr
Craven: It does demonstrate one of the challenges that
we’ve had in that as a federation, we cannot employ anybody
within the—. Obviously, the people we want are going to be
largely employed by the NHS. We cannot give them an NHS pension and
we cannot employ them within the NHS. So, that is a great
disadvantage that has not been solved, and we are
waiting—
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[160] Julie
Morgan: So, did you say at the beginning that you have
employed—?
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[161] Dr Price:
An administrative assistant, but that’s hosted via one of our
practices. We have to host them.
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[162] Julie
Morgan: So, it comes under the NHS in that way, does it?
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[163] Dr
Craven: Yes.
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[164] Mrs
Carter: Yes. We have to hold the contract. We have to rely on
individual practices to say, yes, they’ll hold the contract
for this employee and that’s how we get around it at the
moment. I know that there have been some inroads in other health
boards with regard to pension arrangements, but it is a massive
stumbling block for us at the moment.
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[165]
Julie Morgan: Right.
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[166] Mrs Carter: We
have got an advert out at the moment for salaried GPs to come and
work with us to help us deliver the services that we’re
currently providing, and the services we want to provide.
But, again, we haven’t got that ability to offer them a
pension, which is something that is attractive to anybody working
within the NHS.
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[167] Dr Price:
And also we’re now hosting—. Our practice will host one
of the schemes, and sometimes, then, the financial drawdown from
the local health board isn’t there either. So, that’s
sort of incumbent on the practice, then, to subsidise that until
those moneys come in. So, that’s been a big problem for us as
well.
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[168] Julie
Morgan: Right. And these sorts of issues that are
emerging—where are you able to take those? Is there anywhere?
To the health board or do you—?
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[169] Dr
O’Connor: Throughout the whole process, there’s
been a degree of dysfunctional communication from the health board.
So, you’ve got the people at the very top who are generally
very supportive and are keen to try and work with us to work
through problems and make things happen. Middle management and
below we’ve had all sorts of difficulties with. They’ve
not been singing from the same hymn sheet, and it’s made it
very, very difficult to progress things. So, we end up having to go
back to the very important people at the top, who are equally busy
and stressed with their own issues, and say, ‘By the way, we
still haven’t got a resolution on the pension situation, or
procurement issues, or indemnity issues. Can we have a meeting to
push this forward?’ Even getting the sort of financial
aspect, so that we can plan when we can have access to moneys to
draw down to deliver and pay for the services we want to
deliver—we’ve not had a free flow of money in that
way.
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[170] But those at the
top have generally tried to find ways, so they have brought in
their chief procurement officer and their chief legal person to
have meetings with us, and that has been helpful and enabled us to
move things forward. So, that’s been good. But it’s
been a real battle from our perspective. When you’ve got your
day job, and you’re meeting periodically, it’s very
difficult then to keep chasing other things that you feel should
just happen and they don’t. That’s been a big issue for
us, I think.
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[171] Julie
Morgan: So, it’s been a struggle.
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[172] Dr
O’Connor: I think we all feel that it’s been good
generally. We’ve come much closer together as practices.
We’ve got a similar vision now that we all want to find ways
of working smarter together to make our lives easier and make
better services for patients, and to encourage younger GPs into our
environment. It’s very difficult in lots of areas, as
you’re well aware, to get new GPs coming in, and we’ve
got to find a way of working slightly differently to ensure that
GPs are going to come in and they’re going to fill our shoes
and want to carry on looking after our patients, really.
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[173] Dr Price:
I think it’s been a frustration rather than a struggle.
You’re just frustrated sometimes at the lack of momentum,
because, obviously, we take time out twice a month for our board
meetings, out of clinical practice, and you’re wanting to get
the projects moving, and then we’re coming up against
stumbling blocks, waiting on information from the health board,
really. I think, basically, the ethos for us becoming very
interested in having the enthusiasm for this project is, obviously,
we want to improve primary care, and the provision for primary care
for our patients, but also the workload of GPs, because we’re
very aware of retainment and recruitment of GPs in our area. So, I
suppose, our prime objective there is providing for our patients,
and the improving of GP workload, but also looking at secondary
care services that we can bring out into the community. But then
that has to be worked through so that—potentially, what we
would really like is that the funding follows the
patient.
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[174] The other prong
to our working ethos is looking at business opportunities so that
we can then plough money back in to look at other opportunities
there, and then also augment public health agendas as well. So,
there are four areas for each of our projects—that would fit
into that area, and that there—so it’s not just sort of
one service provision; we’re looking at those four areas on
the projects that we’re embarking upon.
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[175] Julie
Morgan: Thank you.
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[176]
Dai Lloyd: Mae’r cwestiynau olaf o dan ofal
Rhun ap
Iorwerth.
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Dai Lloyd: The final questions are from
Rhun ap Iorwerth.
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[177]
Rhun ap
Iorwerth: Cwestiynau ynglŷn â’r gweithlu sydd gen i.
Rydych chi wedi sôn yn barod am rai elfennau o’r hyn
rydych yn gorfod delio efo fo efo’r gweithlu, ond a oes
enghreifftiau lle mae cydweithio a rhannu adnoddau staffio yn helpu
i ddatrys y broblem fawr yna sydd gennym ni yn yr NHS o ran sicrhau
bod gennym ni’r bobl iawn i wneud y swyddi iawn efo’r
sgiliau cywir?
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Rhun ap
Iorwerth: My questions are in relation to the workforce.
You have already talked about some of the elements that you have to
deal with on the workforce, but are there any examples where
collaboration and sharing staffing resources help to solve this
great problem that we have in terms of the NHS, which is to ensure
that we’ve got the right people to do the right jobs with the
right skills?
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[178] Dr
O’Connor: This is following prudent healthcare
initiatives and that sort of things, isn’t it, really? I
think that’s how we’ve tried to set up things, as Gail
just mentioned, really. We’re trying to use our staff at
whatever level to do stuff that they can do safely, but in a more
streamlined way, so that there’s fewer knocks on our door as
GP to sort out things where we think, ‘Well, surely, someone
else could have done this bit?’, or, ‘If they’d
only seen a physio before seeing me.’ To tell them to go and
see the physio would have taken a step out and I could have seen
Mrs Jones with her bad leg or something. It’s those sorts of
things that we’ve looked at with all our projects.
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[179] Dr Price:
That’s a pilot with us at the moment. We’re just about
to embark upon that with physio where, basically, at the point of
contact with the patient at the surgery, they would be triaged
following a set of protocols and an algorithm. The receptionist
they would speak to would see if they could be directly sent to a
physiotherapist without actually having a GP appointment. Similarly
now with our cluster pharmacists, we’re utilising them to do
some of the medication reviews that don’t need to come
through to a GP. So, in those areas, we’ve started utilising
that.
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[180]
Rhun ap Iorwerth:
You could assume that the same issues
would be true of successful and effective clusters too, that they
could share responsibilities across clusters. Is this something
that you looked at and then decided that a federation was a more
effective way of maximising the bang you get out of your buck with
your staff, as opposed to going down simply a cluster
route?
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[181]
Mrs Carter: I think we’ve got a lot of GP principals who
are very experienced and have a lot of special interests. The
projects that we are looking at at the moment—. Take Parc
prison, for instance: you have to have substance misuse
qualifications, and we have quite a number of GPs who have those
and want to work within the Parc setting. But, obviously, you have
to be careful that you’re not diluting what you’ve got
in practice as well to see your everyday patients. So, a lot of
practices are now looking at employing a salaried GP and employing
them for more sessions than they actually need in practice, which
will then allow the partners to be released. They can back-fill
them and they can go on to do other projects, using their expertise
and their specialist skills. So, I think that’s the way that
we’re looking at it. The fact that we’re working as six
practices, instead of one practice looking at delivering a
contract, means that we can utilise the expertise across the 30 GP
partners and salaried GPs as well.
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[182]
Rhun ap Iorwerth:
Yes, which combats the shortage of GPs
coming through the system.
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[183]
Mrs Carter: Yes.
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[184]
Dr Craven: One of the reasons we chose the federation model was
the fact we could have a proper constitution. There is no
constitution in clusters. That was why—one of the primary
reasons. We had a bit of a disagreement, shall we say, and it
highlighted the fact that there was no constitution to resolve
anything like that. I don’t sit on the local medical
committee anymore, but when I did, what I learnt was that not all
practices get on like the six of us do. Without that constitution,
I don’t know how they ever reach any agreement, to be quite
honest—they spend more time fighting than anything else.
Well, you’re not going to achieve anything with that. One of
the things it’s done is we’ve had to work together.
We’ve all appreciated each other’s differences and
we’ve moved on hugely in that respect. We are not now six
individual practices—‘What’s he earning over
there?’, and, ‘Why are they earning that?’, and,
‘Why can’t we do that?’ We do it together
now.
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[185]
Rhun ap Iorwerth:
There is still that because of the
overlap that you mention with the cluster, and they’re
presumably looking over their shoulders at what you’re doing.
What is that relationship like with the rest of the cluster, seeing
as you’re a big, powerful group among them?
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11:00
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[186] Mrs Carter: We
don’t have a lot of interaction, really, with the other
clusters in our area. We’ve got west, north and east,
and we are east. We’re aware of what projects they’re
doing, and they could very well look at projects that we’re
doing and think, ‘Well, that would work in our area.’
It works both ways. The cluster leads come together very
regularly.
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[187] Dr
O’Connor: There are regular cluster lead meetings across
our health board. I attend those, and we have feedback from each
area on the projects and what the difficulties are. But I suspect
that the long and short of it is that they’ve all done their
individual projects, and they will want those projects to be funded
centrally from the health board. At the moment, there’s no
light at the end of the tunnel there; there doesn’t seem to
be anyone about to make a decision today or tomorrow to say,
‘Yes, we can see that that’s useful; we’ll take
over that now; you go and do something different.’ I think
all networks would be in the same boat there.
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[188] Whilst the main
implementers are the GPs within each cluster network, the people
who seem to have most authority in driving what is actually
delivered will often be LHB managers. And so there is a feeling
within our own network that we’ve stood up to them and said,
‘Actually, we don’t want to do this; we don’t
feel that that’s value for money; that’s not going to
work for our area; we want to do things differently.’ And
because the six practices are unified in doing that, it’s
ruffled a few feathers within our own cluster network.
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[189] Rhun ap
Iorwerth: So, your influence as a group is greater than the sum
of the parts when it comes to your relationship.
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[190] Dr
O’Connor: I think so. Definitely.
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[191] Rhun ap
Iorwerth: This isn’t a criticism of the way you’ve
gone about doing things, but do you think that if things pan out as
you hope they will—and you seem confident that they
will—that the success of your federation will undermine the
principle of clusters?
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[192] Dr
O’Connor: Yes, I think that is the—
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[193]
Rhun ap Iorwerth:
Not that I’m saying you’re
wishing that, but, you know— [Laughter.]
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[194]
Dr O’Connor:
I think that is the dichotomy, because
you’ve got networks that haven’t got a constitution and
governance structure in place, and don’t seem to have the
capacity to continue to roll out and to develop projects. Whereas
we believe, even if networks fell apart tomorrow, I think we would
keep our federation company going because there are other areas
that we can tap into that are feasible for us to tap into as a
separate not-for-profit organisation. We don’t need to rely
on the local health board’s moneys, if you like, in order to
deliver those services, and that’s the advantage that
we’ve got as a federation.
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[195]
Rhun ap Iorwerth:
The sense I get, Wales wide, is that the
bringing together of surgeries and other parts of primary health
delivery in groups is a good thing. There’s ambiguity about
how clusters can work. You’ve gone for a particular model. Do
you think that as the notion and the principle of clusters develops
that what you’ve put together could actually become a model
that replaces the looser cluster arrangements in other parts of
Wales?
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[196]
Dr Price: It could do. I think we’re very fortunate that
we all get on as practices, and within our local area you know that
there are practices, I should probably say, that can be a little
bit more awkward than others, and you think, ‘Well, I
couldn’t work with them.’ So, it’s not one thing
suits all. I think we’ve been very fortunate that we’ve
been able to take this forward because of the way we’ve
jelled together in the way we think, but that wouldn’t
necessarily run out across all practices in each cluster
area.
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[197]
Rhun ap Iorwerth:
Are there looser arrangements? It’s
clear that you’ve got a good working relationship. The Welsh
Government could decide to force GP surgeries to come together in
federation, or there could be a halfway house that is firmer than
the cluster and looser than your arrangement. Is that something
that you would advocate?
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[198] Dr Price: And I
think that’s where we said originally that the staleness of
the cluster scenario was there. Obviously, we sit around a table
where we’ve got district nursing and public health and we all
have our own agendas. We had our own individual agendas as GP
practices. Now we’ve got a GP voice, if you like, on the
cluster. The district nurses will come, public health will
come with their projects, the dietetics will come, but I think
what’s overwhelming is that because we’ve formed this
together, we’re now driving momentum forward and things are
happening where it wasn’t happening at a cluster level.
Perhaps that does cause a little bit of, maybe disharmony, not that
we’ve heard it directly, but the fact that we’re moving
ahead with projects—‘Oh, it’s the GPs doing
this.’ Well, somebody’s got to do it and this is the
way we’ve moved forward.
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[199] Mrs
Carter: There’s a lot of interest in moving to a
federated model from other health boards. We’ve had a lot of
requests to go and speak about our journey. And when we first
looked into it, part of the process and the funding was to develop
a toolkit to help other clusters move to a federated model. Because
I think we, in essence, were the guinea pigs, and we’ve
ironed out a lot of the issues that became apparent as we worked
through it. So, other clusters moving towards that model would,
perhaps, find it a little bit easier than we did initially.
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[200]
Rhun ap Iorwerth:
Have we got time for one more, which is a
little bit more nebulous, perhaps? But there is a potential—.
Say we went down a federated model, there’s a danger that
what you would be seeing is the development of large private
healthcare providers—you could all merge in future;
it’s a possibility. Are there alarm bells there for the
delivery of the NHS along the principles that are important to us
here?
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[201]
Dr Price: Well, as part of our development, we actually went on
a trip to Northern Ireland because, over in Northern Ireland,
they’d already set up 17 federated companies. So, we went
along with local health board representatives, GPs and practice
managers to visit them on a day trip, and, basically, very little
is happening with those federated companies. They’ve
federated 17, and when we came back from that visit, what we were
doing as a cluster was more advanced than what they were doing as
their federated companies. So, obviously, it hasn’t worked
out there by federating a large number. I think that’s
perhaps a difficult call to say that, carte blanche, it would have
to be all federated.
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[202]
Rhun ap Iorwerth:
In terms of the growth of the private
sector in the delivery of NHS services, any other thoughts on
that?
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[203]
Mrs Carter: No. I think, day to day, it’s still our
practices that are our priorities. It’s dealing with the
patient demand, which is increasing on a daily basis. Part of the
process was we set up our website, Pen Y Bont Health, to try and
help patients to self-treat, self-medicate, to stop them coming to
the doctors for simple things like hay fever, things like that. I
think we’re just looking to take the pressure off what is
coming to the door, and looking at making things better for
practices and patients. I think that’s the most important
point that we were trying to achieve. We share best practice as
well now. Whereas every practice had their own appointment system,
nursing system, we now share best practice around the table to look
at it, and if something works in my practice that’s not
working in another practice, then we’ll share that to try and
streamline our services across the board a bit better.
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[204]
Dr Craven: And the whole premise when we originally asked for
support from our partners, their agreement was on the condition
that it was for the patients and for their working lives, and
that’s our mission for the business. It’s not to make
large amounts of money on private medicine—we haven’t
got time for that—but to reinvest it in projects for our
patients.
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[205]
Mrs Carter: I think it’s important to note that none of the
money comes into the practice. It stays within Pen Y Bont Health to
be reinvested into other projects.
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[206]
Dr Craven: Yes.
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[207]
Rhun ap Iorwerth:
Diolch.
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[208]
Dai Lloyd: Diolch yn fawr. Excellent evidence session, thank you
very much indeed. It’s been a very valuable contribution to
this hopefully comprehensive review on clusters.
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[209]
Felly, diolch yn
fawr iawn ichi. Diolch i’r tystion i gyd. Joanne Carter, Dr
Alison Craven, Dr Ian O’Connor a Dr Gail Price, diolch yn
fawr ichi am eich presenoldeb. Fe fyddwch chi’n derbyn
trawsgrifiad o’r cyfarfod yma er mwyn i chi ei wirio fo a
chadarnhau ei fod o’n ffeithiol gywir. Felly, diolch yn fawr
iawn i chi am eich presenoldeb.
|
Thank you very much.
Thanks to all the witnesses. Joanne Carter, Dr Alison Craven, Dr
Ian O’Connor and Dr Gail Price, thank you very much for being
here today. You will receive a transcript of this meeting to check
for accuracy. Thank you very much for being here today.
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11:09
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Papurau
i’w Nodi
Papers to Note
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[210]
Dai
Lloyd: Symud ymlaen i eitem 4, papurau i’w nodi, a’r unig
bapur i’w nodi yn fanna ydy’r papur bendigedig gan Sian
Gwenllian, Aelod Cynulliad Arfon, ‘Delio â’r
Argyfwng: ysgol feddygol newydd i Gymru’. Dyna eitem
4.
|
Dai
Lloyd: We move on to item 4,
papers to note, and the only paper to note is an excellent paper
from Sian Gwenllian, the Assembly Member for Arfon, on
‘Tackling the Crisis: a new medical school for Wales’.
That’s item 4.
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Cynnig o dan Reol
Sefydlog 17.42 i Benderfynu Gwahardd y Cyhoedd
Motion under Standing Order 17.42 to Resolve to Exclude the
Public
|
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Cynnig:
|
Motion:
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bod y pwyllgor yn penderfynu gwahardd y cyhoedd o
weddill y cyfarfod yn unol â Rheol Sefydlog
17.42(vi).
|
that the committee
resolves to exclude the public from the remainder of the meeting in
accordance with Standing Order 17.42(vi).
|
|
Cynigiwyd y cynnig.
Motion
moved.
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[211]
Dai Lloyd: Eitem 5: cynnig o dan Reol Sefydlog 17.42 i benderfynu
gwahardd y cyhoedd o weddill y cyfarfod. Pawb yn cytuno? Ydych,
diolch yn fawr. Felly, awn ni i sesiwn breifat. Diolch yn
fawr.
|
Dai Lloyd: Item 5: motion under
Standing Order 17.42 to resolve to exclude the public for the
remainder of the meeting. Everyone in agreement? Thank you very
much. So, we will move now into private session.
|
|
Derbyniwyd y cynnig.
Motion
agreed.
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Daeth rhan gyhoeddus y cyfarfod i ben am
11:10.
The public part of the meeting ended at 11:10.
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