National Primary Care Cluster Event ABMU Health Board 13 th October 2016 1
National Primary Care Cluster Event - ABMU Health Board Introduction The development of primary and community services is a fundamental plank of the Health Board s clinical service strategy Changing for the Better, and the National Primary Care Plan for Wales has created a welcome catalyst to accelerate the changes needed to create a more sustainable health and social care system. This document provides a brief synopsis of the work being undertaken by ABMU Health Board. Developing Cluster Networks in ABMU Health Board There are eleven cluster networks within the ABMU Health Board area and the populations vary from about 30,000 to over 75,000 (see map at Appendix A) There is clear leadership within the networks from GPs in particular; and, the networks have been developed on a multi professional and multi agency basis. They now form the basis for organising and delivering many community health and social care services, and have developed strong links with the third sector. A Primary and Community Services Unit has been established to lead on this agenda, as one of six Operational Units covering all of the clinical services provided by the Health Board. Changes are now being made to organisational arrangements within the Unit to provide support for the accelerated development of clusters as outlined below: Health Board Support to Cluster Networks Head of Primary Care Head of Nursing and Community Services Area Clinical Lead GPs Community Services Manager (8b) Cluster support Manager (6) Cluster GP Cluster Network Lead Cluster Development Manager (8a) Lead Nurse (8a) Primary Care Manager (8a) NB: Whilst not all posts will be part of this consultation the diagram demonstrates the health board support which will be available to cluster networks Nursing staff (6&7) Bridgend East, Bridgend North, Bridgend West, Neath, Afan, Upper Valleys, Bay, Penderi, City, Llwchwr, Cwmtawe 2
One of the national pacesetter projects hosted within the Health Board - the development of a Federation in Bridgend East - is also testing out a new organisational form (social enterprise) for the future development of networks. This model requires a step change in how practices work together and has the potential to be an effective vehicle to redesign pathways between primary and secondary care, using the pooled skills and resources of its members. As a limited company this concept will challenge the current ways in which the Health Board commissions and contracts for services. Each Cluster is in the process of finalising its third cluster network plan, informed by cluster health needs profiles. To date clusters in ABMU have received 1,742,000 through their direct allocation from WG. This investment has supported a range of innovative projects including for example: Significant Workforce diversification: Network Based Pharmacists, Prescribing Technician and Physiotherapists, Mental Health Counselling Continued partnership with the third sector such as the Healthy Partnership Project, extension of Citizens Advice Bureau scheme Focus on self care and co production through leaflets and radio campaigns Five patient carer forums established for cluster networks in Swansea under Big Lottery Community Voice Programme Four bowel screening pilot sites to increase early detection of bowel cancer Various health promotion initiatives including, alcohol screening pre diabetic work, community weight management, promotion of the Healthy City Directory Development of local Mental Health Services through increased counselling and CBT provision, mental health drop in clinics and mental health guide Training and information on issues such as Falls Prevention information, Dementia, prescribing call handling and customer care Extending opportunities to improve access use of Primary Care Foundation to review demand management and access, increased use of telephone triage, Development of a new women s refuge service Improving the delivery of end of life care In June 2016 a Cluster Development Workshop was held within the Health Board to showcase the pacesetter projects and new service developments. This reinforced the importance of cluster networks as a key vehicle for addressing sustainability and service development, with some excellent examples of new models of care already underway. However, the workshop also identified the need to do more work to address some of the frustrations identified by clusters to date e.g. the importance of estates and IT infrastructure, the constraints of bureaucracy on innovation, particularly in relation to workforce and procurement, and a lack of time and capacity to support the work. Delivering the shift of services, with resources, to out of hospital setting, focussed around the needs of our public. Primary care investment has also supported a range of other service developments including: Cardiology: GPWSI triaging all cardiology referrals to cardiac consultants via community based clinics. The scheme has reduced waiting times for patients and can assist in getting a rapid diagnosis and earlier treatment for 3,500 patients. 3
INR: establishing a safe high quality atrial fibrillation and anticoagulation service based within the community. Diabetes: Prompt access within primary care to a choice of structured diabetes education for newly diagnosed patients. Nutrition and dietetic support to provide lifestyle interventions in GP clusters. Provision of a nutrition and dietetic service to the frail elderly living in nursing homes, staff and carer education, support for menu and meal planning. Respiratory: Upscaling and enhancing the Pulmonary Rehabilitation Service to reduce waiting times. This community based work will identify and proactive management to support patients with COPD and Asthma to better manage their condition. Outcome will slow the progression of the disease, prevent exacerbations and keep people fit and healthy. Dermatology: Equipment including webcams and digital cameras purchased to expedite feedback from the consultant dermatologist for skin lesions e.g., whether an outpatient appointment is required. These examples of service redesign hold the key to the development of a more sustainable model of care if they are implemented on a comprehensive basis. The Health Board is holding a follow up workshop on 22 September to explore how to build on this progress and transfer lessons learned from community cardiology to other chronic condition areas such as diabetes and respiratory medicine. The aim is to set out the potential scope of a cluster based service in these areas, and to assess the benefits of this for patients, professionals and the secondary care system. This will inform service redesign plans for the next IMTP and the associated workforce and financial frameworks. GP leads are also playing a key role within the new commissioning arrangements within the Health Board. Building the workforce of the future through the implementation of the Primary Care Workforce Plan A critical challenge for primary care in ABMU relates to the workforce, and in particular, the availability of GPs. In ABMU approximately 30% of the 73 practices have identified a sustainability risk, and workforce features highly as a reason. The national investment into primary care workforce of 627K (non recurrent investment in 2015/16) has been essential in supporting plans to diversify the workforce in General Practice and develop a more sustainable model as outlined below: Developing a clear plan for portfolio careers for GPs in ABMU to support future recruitment and retention for example, in cardiology where we now have a number of GPs with specialist interests, or opportunities to work within the Clinical Support Hub in the 111 service Supporting new models of care with targeted training for a range of professions in skills such as telephone triage, call handling, advanced nursing roles, nutritional skills, health promotion interventions, dementia awareness etc Establishment of a Primary Care Support Team for practice sustainability, overseen by a Clinical Director, in response to sustainability issues 4
Developing models of care that can be delivered through extending the multi-disciplinary team around clusters, as well as tapping into wider community assets through third sector. Examples already include therapists, mental health workers, pharmacists, audiology, community dieticians Plans to roll out service and quality improvement skills and training to cluster leads as per recent Kings Fund report, and through participation in the Confident Leaders Programme. Exploration of a primary care academy with Swansea University to reinforce local recruitment and longer term retention Participation in national development of more innovative recruitment campaigns including social media, primary care careers fairs, introduction of rural fellows, Post CCT Fellowships with a mixture of acute and primary care job plans Continued development of the Out of Hours service by using an extended range of professionals for example, pharmacy triage In 15/16 an additional 67.8 wte staff have been recruited with an additional 49.6 wte staff to be recruited in the current year (across all Primary Care funding schemes). Making linkages across the different parts of health and care system work better and more integration of services The most significant programme of work to create and strengthen integration is being undertaken through the implementation of the What Matters to Me model. This work has been driven through the Western Bay Partnership and describes the development of a coherent whole system model to address the challenge of ageing, as outlined on the following diagram: 5
There has been a particular focus on developing a single model for the integrated intermediate care team, supported by the ICF investment in Community Resource Teams. Key features include a multi-disciplinary single access point including the third sector, an acute clinical response service to avoid hospital admissions and promote timely discharge, reshaping re-ablement services to promote independence, provision of step up and down facilities for community based re-ablement. A more recent development is anticipatory care planning which is cluster network based, trialled so far in 3 clusters with plans to roll out to the remaining clusters by the end of the year. Anticipatory care involves professionals working together to identify those older people in their population most at risk of losing their independence and working closely between GPs, social services, mental health and community nursing to put in place anticipatory care plans supported by a care navigators. It is anticipated that this will have a positive impact on reducing unplanned admissions to hospital and supporting GPs in managing vulnerable individuals. In parallel with the above work is underway to link an innovative programme of local area co-ordination with cluster networks to ensure that local community assets are utilised to combat social isolation and loneliness and promote independence. Reducing variation, improving consistency and embedding innovation that s worked at pace The Pacesetter projects have provided an important step forward in supporting innovation in primary care and providing an opportunity to learn lessons across Health Board boundaries. ABMU Health Board is hosting 8 of the national pacesetters as outlined below: Acute Clinical Outreach Team in Swansea A team of GP s led by a community based Care of the Elderly Consultant explores a model of hospital at home at the interface of primary and secondary care providing a 4 hour response on an outreach basis. It will inform future models of care in the community and help to avoid unplanned admissions. Neath Primary Care Hub Pacesetter The aim of the pacesetter is to channel patient demand for primary care through telephone triage and to more appropriately manage demand by direct access to a wider range of share professionals attached to the cluster ie physiotherapists, pharmacists, mental health support worker. 111 Pathfinder this includes a range of schemes such as incorporating a pharmacist in the OOH team, establishing a clinical support team to provide better assessment of complex patients, and improving communication about complex patients between GPs in hours and out of hours. Pharmacy Roles - ABMU is at the forefront of testing out new models for pharmacy roles. These include The role of the Pharmacists in preventing Acute Kidney Injury in the community through improving the prevention, detection and management of community acquired acute kidney injury ( AKI) 6
Community Pharmacy domiciliary visits Pharmacist led medication reviews for housebound patients in their home. Aims to support housebound patients to manage their medicines at home and focuses on patients without a package of care. Tackling high rates of antibiotic prescribing Specialist antimicrobial pharmacists review and advise on practice prescribing. Improves the quality of antibiotic prescribing and minimises the risks of antibiotic resistance through increased awareness of the risks associated with antibiotic use. Palliative Care Pharmacists to support the GP workforce to improve care for palliative patients and deliver better outcomes for both cancer and non-cancer palliative patients. Federated working A social enterprise of 6 GP practices to support pooling of funds and services (as referred to earlier) Deliverables for 16/17 Continue to support and learn from local and national pacesetters by end of 2016/17 to map out what a sustainable model of primary care looks like, to inform service, workforce, estates and financial plans Facilitate an accelerated programme of cluster network development, supporting GP cluster leads and others to participate in the Confident Leaders Programme first cohort now under way Complete implementation of the new management arrangements within the Health Board so that there is appropriate support for the development of clusters Agree further system shift priorities for diabetes and respiratory medicine as part of IMTP process, maximising contribution of cluster networks to a new and ambitious model of care To roll out the community cardiology service across the whole Health Board Continue to develop and implement the existing workforce plan based on the extended multi-disciplinary team Establish the Primary Care Support Service to help address sustainability issues Following the recent launch of the Primary Care Portal, ensure that this is used proactively to identify areas for improvement Establish a local Primary Care Delivery Board to mirror national arrangements, to maintain focus, visibility and direction within the Health Board 7
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