March 12, 2017
The Welsh Health Cabinet Secretary (Minister) Vaughan Gething AM has identified three major priorities for primary care in Wales
* maintaining the sustainability of the sector,
* improving access to services and
* delivering more care in a community setting.
Central to delivering these are objectives are the emerging GP Clusters / Primary Care Networks. There are 64 networks or clusters in Wales with a population base of 30- 60,000 patients. It is based on promoting partnership and collaborative working.
The networks allow general practices and a range of other primary and community care practitioners to get together with their local health boards to shape community based services for their populations. However, unlike CCGs model in England, they are not involved in the commissioning of secondary care.
The Health, Social Care and Sport Committee of the National Assembly for Wales is undertaking an enquiry to obtain a better understanding of how the cluster model is working in Wales. The evidence submitted to the enquiry provides an interesting barometer of the progress that is being made.
Where things are going well, a wide range of new services are bring provided, often using new models of care. Many of these more advanced areas areas want to move towards more formal structures. In the Bridgend area of the ABMU Health Board a social enterprise has been established to look a providing services. Elsewhere a number of networks see the formation of “federations” as the next obvious step.
There is not a single operational model for the networks with varying levels of professional engagement and breath of wider organisational involvement. Some networks are more active than others in their efforts to involve social care organisations, third sector bodies and the wider patient / user / public voice.
Clinical representative bodies (e.g. GPC Wales, RCN, RCSLT, Royal College of Physicians, Royal Pharmaceutical Society, Care Council ) highlight that involvement in the networks is time intensive with some concern about an over-focus on GPs and the lack of parity of esteem for other professional health and social care groups. But management evidence ( e.g various health boards, NHS Confederation, Directors of Primary, Community and Mental Health) suggests an awareness of these problems and that they are working to address them.
An important factor in improving the status of the networks and facilitating their work has been the Welsh Government’s decision to directly allocate funds to them. While most primary care funding still goes through health boards, £16 million of recent allocations have been directly earmarked for the clinical networks. This has been welcomed though some concern has been expressed that some health boards might dip into these resources in areas where the networks are making less progress.
The fragility of primary care overall and general practice in particular is a consistent feature of much of the evidence. This is in line with recent BMA survey evidence that 80% of GP respondents had concerns about the sustainability of their practices. The efforts of the Welsh Government to promote recruitment and the status of general practice were widely supported. But the factors under-pinning this fragility – patient need and expectation, system pressures and supply side issues such as resourcing and staffing levels must all be acknowledged and addressed ( Bevan Foundation).
While some individual submissions suggest that independent contractor status of general practice needs to be enhanced, overall most submissions acknowledge that this traditional model is no longer adequate on its own. Some sort of salaried GP service is required to supplement struggling practices, to staff directly managed practices and to provide out of hours care. As well the Bridgend social enterprise is looking at the option of directly employing GPs as a form of new service delivery. This is a welcome development as up to now, most Welsh health boards only saw salaried GPs being employed by independent contractors and regarded their own reluctant involvement in directly managed practices some sort of transitional safety net.
The need to relocate services to a community setting and to improve access is widely acknowledged across many submissions. Many illustrative examples are given. Some such as the use of pharmacists, better home physio and OT services and community re-ablement for respiratory and cardiac conditions builds on well established practice. But other initiatives such as Predictive Risk Stratification Model (PRISM) are being developed to support anticipatory care models while the Inverse Care Law Health checks (which was developed in the Aneurin Bevan and Cwm Taf University Health Boards) are being promoted for national roll-out in Wales.
Social prescribing is also gaining attention as a means for primary care to engage with primary prevention, health promotion and other activities to reduce the chance of becoming ill though the better use of non-medical community assets and to influence social determinants of health locally. Public Health Wales is working to create an evidence base to support this work.
While there is wide-spread support for the development of primary care networks, there are obvious issues that need to be addressed. There is uneven development and engagement both within networks and across networks and health boards. Hard pressed clinicians in areas of high need are most likely to find it most difficult to be fully engaged in these additional areas of work. Local Medical Committees, health boards and Public Health Wales need to carefully monitor the situation to ensure than this does not lead to an inadvertent widening of the health inequalities by ensuring that the areas with the greatest need are not left behind.
With some exceptions (e.g. ABMU HB, Care Council, College of Occupational Therapists) it is of concern that social care has not figured more prominently in the submissions. Social care is crucial to promoting and maintaining the independence and dignity of the most vulnerable in our community. However there are few submissions from the social care sector and there seems little awareness of the need to include social care as a key player in the management of people with multiple and complex problems.
But while there is little specific reference to social care, many of the submissions acknowledge the key role that multi-disciplinary teams (MDTs) will play in the evolution of primary care networks… both in terms of policy formation and delivery. These teams must not only embrace a wide range of primary care clinicians but also include social care. They should also explore ways to have a much more fluid interface with secondary care – as the RCP describes it, we need “hospitals without walls”. By implication, though it has not emerged in the submitted evidence, this would involve some primary care network participation in the wider planning of secondary health care services for their localities.
The absence of a rigid model for networks has many advantages as it allows clusters to develop at their own pace and in line with their own priorities. However the lack of an overall governance framework must create risks that will inevitably emerge as networks evolve and become more directly involved in care delivery.
The submissions to the Health, Social Care and Sports Committee shows there is widespread support and good will for the emerging primary care networks. The evidence suggests that they are evolving in a positive way. However there a are differing levels of maturity with differing levels of impact at a local level. The Committee will publish its own conclusions in time and hopefully its report will provide a further opportunity to consider how things should develop.