Our plan for a primary care service for Wales up to March 2018 Annual Report Appendices

Our plan for a primary care service for Wales up to March 2018 Annual Report 2015 2016 Appendices Planning care locally Strong leadership Improving access and quality A skilled workforce Equitable access DPCMH June 2016 1

Contents Appendices Page Appendix 1. Additional examples of good practice/innovations 3-10 Appendix 2. Cluster governance and accountability progression 11-20 Appendix 3. OOH driver diagram 21 Appendix 4 Strategic Workforce Planning and Development 22-24 Appendix 5. RAG rating of local progress 25-31 Appendix 6 PCCDI Hub Purpose and Structure 32-36 Appendix 7 Pacesetter Report May 2016 37-44 Appendix 8 Primary care contribution to USC 45-51 Appendix 9 Primary care overview of priorities diagram 52 Appendix 10 Portfolio of activities 53 2

Appendix 1 Additional Examples of developments in Primary Care services Cardiff and Vale - Primary Care cluster development Going into 2016/17 a number of cluster Community Directors have met with Dental, Optometry and Pharmacy leads to explore service developments and pathways going forward to encompass all primary care independent contractor professionals. Work on referral guidelines is being pursued to ensure practices sign-post patients to the most appropriate independent primary care contractor first time. Cwm Taf - Cluster Hub Developments The development of Cluster Hubs is a new concept designed to provide a vehicle for interfacing and integrating primary and secondary care services at a Locality level. Each of the four localities will have a Cluster Hub which will serve as a focus to develop a range of out-of-hospital services aiming to: make best use of skills in an equitable way across all practice populations; provide opportunities for Independent Contractors to develop specialist services, according to community need and in conjunction with the Health Board, at no detriment to the core primary care function they must deliver; provide new portfolio career opportunities for Doctors, Nurses and AHPs across primary and secondary care; create a system which will reduce unnecessary hospital admissions; facilitate direct access to a greater range of diagnostics; enable protocol-driven access to inpatient waiting lists reducing overall RTT; reduce outpatient follow-ups; improve patient experience; and Four schemes have been identified, one across each Locality and these are Cardiology in Merthyr Tydfil, Diabetes in Cynon, Respiratory in Rhondda and MSK in Taff Ely. 3

Cardiff and Vale - Healthcare planned and delivered locally Clinicians from primary and secondary care are collaborating on the development and implementation of a number of evidence based pathways identified by the clusters that will support patients more safely and closer to home (supporting USC improvements and shifting services from hospital to community based settings). Powys teaching Health Board Patient Forums Patient forums now operate in five areas of North Powys, with a local medical practice affiliation in two of these areas. In one, the patient forum has supported the influenza vaccine campaign, running a local coffee morning to promote immunisation uptake. Another has worked with its local medical practice to improve palliative care provision in the local community hospital, while in another the patient forum supported Powys Teaching Health Board to communicate to patients a local development involving the health board taking responsibility for the running of the local medical practice and the expanded range of clinical services available there as a result. Cardiff and Vale - Well-being Co-ordinators Wellbeing Co-ordinators have been appointed in Cardiff and Vale to work at a cluster level with practices on cluster priorities, working to bridge the gap between practice and the communities. These Wellbeing Co-ordinators will help sign post to nonstatutory services to improve patients wellbeing and promote the social model of care. Some of the priority areas identified have been: improvements in seasonal flu uptake for targeted groups, improvements in screening uptake for hard to reach groups, increased use of community activities. 4

Cwm Taf - Primary Care Support Unit Cwm Taf is fortunate in that it has had a Primary Care Support Unit since 2002 but additional investment has been given to extend this team to wider multi-professional establishment to support Primary Care in Cwm Taf in its widest sense. It is designed to address the needs and demands of contemporary general practice and primary care. The PCSU is a multi-professional team with an administrative support structure The achievements to date are: Supporting individual GP practices who are facing difficulties in recruitment of staff, GPs, Nursing, medical secretaries, admin and practice management Supporting 4 directly managed practices and bringing them up to a standard and size where they will be viable and therefore attractive to revert back to independent status. A support mechanism in all of the 4 locality cluster plans to progress local developments as well as delivery of core service. It is facilitating the release of GPs from their day to day practice commitments to delivery the new community hub developments i.e. cardiology, respiratory, diabetes and MSK. Appointment of dieticians, medical receptionists, administrators, a PCSU support manager and a GP focusing on academic research They support the buddying of stable practices and less sustainable practices together within cluster areas. Cwm Taf - Early Diagnosis of Cancer As part of the Cluster programme the Rhondda Cluster has developed and planned educational sessions for GPs and practice nurses to reflect on best practice in relation to early detection of lung cancer. 2 events have taken place in 2015/16. They also plan to work with local pharmacists to ensure the appropriate patients are signposted to their GP when presenting with symptoms. In addition to this a reminder tool has been developed and discussions are taking place with MacMillan in respect of how this tool can be rolled out to Cwm Taf and beyond. 5

Aneurin Bevan University Health Board Direct Access to Physiotherapy The Direct Access Physiotherapy Service was funded by, and piloted across, the 2 Blaenau Gwent NCN/Cluster areas in Ysbyty Aneurin Bevan. The service is aligned with the Planned Primary Care Workforce for Wales (NHS Wales, 2015) which aims to improve access for patients to health services whilst supporting the continuity planning for Primary Care services. Following evaluation, this Band 6 Physiotherapy service, which was rated by 84% of patients as excellent and the rest as good, has recorded the following outcomes and benefits: Potential saving of 9,306 when compared to traditional referral via GP: 282 patients seen by the service in its first 3 months, of which 265 did not need to subsequently see their GP Savings acquired from fewer x-rays and scans: 4.6% of patients returned to their GP with a Physiotherapy request for further investigation, creating a potential saving of up to 33 per patient with further savings to be made from lower levels of prescribing Faster access to injury assessment by Musculoskeletal (MSK) Clinician: Up to 12 patients access the service on any day, of which the highest demand is in the early part of the week (Monday and Tuesday) Better treatment outcomes: Produced regarding long term pain, disability and absenteeism from work Health-focused behaviour promoted by enabling patients to make their own choices: 10.2% of patients were discharged from all services to self-manage Aneurin Bevan University Health Board - Access Improvement Scheme As part of a Pacesetter project, the Primary Care & Community Services Division were successful in securing funding to support an Access Quality Improvement scheme, the scheme has been developed in two phases: Phase 1 enables practices to look at their access and demand as well as their existing workforce, using recognised quality improvement methodologies, patient questionnaires etc; 6

Phase 2 enables practices to apply for funds to enable purchase of equipment or services that they have identified would improve access. Examples include new telephony systems, extra lines for patients to dial into. 44 practices engaged in Phase 1 in 2015/16 39 participated fully in the baseline capacity and demand assessment 14 practices submitted 27 bids of which 13 bids were approved as part of Phase 2 Further roll out of Phase 1 and continuation of Phase 2 in 2016/17 In addition the Health Board in conjunction with the LMC and CHC has developed guidance to practices on the principles of reasonable access; Cardiff and Vale - Modernising the Workforce As part of the Primary Care workforce investment, Cardiff & Vale have invested in workforce expertise to review and plan a skilled workforce for our population needs. This will consider new models of care and the required skill mix. To support this work, an OD practitioner has also been recruited. The key themes arising from the GP Support Team will inform the new models of care. Cwm Taf - Pharmacists in General Practice Pharmacists have been employed by Cwm Taf UHB and sub contracted to the cluster to improve access and increase G.P. capacity. These individuals are also further supported to gain additional skills via the participation in Independent Prescribing training. The GPs within the cluster are providing the mentorship support to enable them to do this valuable training. Use of Pharmacists in the clinical priority areas of polypharmacy. 5 Pharmacists recruited by Cwm Taf Health Board in line with the individual requirements of each cluster. 2 of the clusters have pharmacists in place and working to an agreed plan. Another cluster has approached the pharmacy team about further recruitment in 2016/2017. 7

Aneurin Bevan University Health Board The Aneurin Bevan University Health Board has worked with the Gwent Branch of the NHS Retirement Fellowship (NHSRF) to develop a volunteering service. Funded through NHS Charitable Funds, the Care Home Ask and Talk (CHAaT) volunteer service operates across all nursing homes in the Neighbourhood Care Networks (CCN) / Cluster areas and is made up 23 retired NHS staff who in reach into care homes and offer a confidential ear to older people and relatives. This aim of the service is to: An opportunity to speak in confidence about their care experiences Give older people and relatives a voice Care Homes/interested parties use feedback to improve services for ALL older people in residential care Collective celebration and sharing of best practice across the sector Rapid identification of potential safeguarding issues A role profile for the volunteers has been developed based on Age Cymru s quality of life standards for a good experience for those living in residential care. A communication prompt allows volunteers to engage older people and relatives in discussions around the key themes of: They are treated with dignity and respect They still feel part of a community They are involved in decisions about care and home life They are able to make decisions about their own health They enjoy living in the home They have confidence in the staff caring for them The CHAaT model has been adopted by the Royal Voluntary Service who provides the same service in residential care homes. 8

Feedback around the information and support needed at the point of transition has led to the development of a trip advisor for care homes accessible through the following link: www.goodcareguide.co.uk. This site allows older people/relatives to rate their care home experience and leave real time feedback. C.H.A.aT volunteers are now supporting older people and relatives on hospital wards, enabling them to become more informed when faced with transition and needing to choose a care home. In the past year, the volunteers have engaged with over 600 residents living in nursing homes and their relatives. Aneurin Bevan University Health Board ABUHB has secured funding from the Health Technology Challenge (Wales) Scheme to pilot a Prescription for Loneliness befriending scheme. These monies will allow the ABUHB to work with its partners and the local population to research the issues that people from different vulnerable groups face, focussing primarily on older people and veterans. Additional monies have been secured from Public Health Wales to extend the scope of this work to include other vulnerable groups and extend the pilot across all NCN areas. To date discussions have been held with: Older and younger veterans Parents who have lost children in combat LGBT community Carers Older People Migrant Workers A video has been produced and is available to view at: https://www.youtube.com/watch?v=y5sf82bbzge&feature=youtu.be An engagement event was held on the 27 th of May and following a local competition, the service has been named as FFrind I mi (Friend of Mine). A #countmein challenge was sent to ABUHB staff asking if they had one hour a week to spare to support a lonely person. To date, 142 people have signed up to this initiative. Next steps will ensure the scoping of all volunteering befriending services across the area and recruiting other volunteers to support intergenerational befriending for those who are 9

lonely/isolated (e.g. police cadets, college students) and recruiting others from our community who wish to volunteer to support this agenda. Discussions have taken place with retired police officers, veterans forums etc to progress this activity. Cwm Taf Patient Forums Focus on Choose Well Each year Cwm Taf hold a series of Public Forums in each of the four Localities. In 2015/16 the focus was on Access and traditionally it would have undertaken a session/update on GP Access. Last year however the focused was on Choose Well and raising awareness of the services provided by not just GPs but all the Primary Care contractor professions. The event was interactive and consisted of a panel of experts, which included a GP, Dentist, Optometrist and a Pharmacist. The audience were give a series of scenarios and asked to choose which person they thought they should see for a described condition. After each scenario the relevant professional gave a brief explanation of why it was appropriate that they should be chosen. The event was aimed at giving out the following key messages; access to Primary care is not just about GP surgeries or how easy or hard it is to get a GP/Nurse appointment; that primary care workforce is made up of a range of skilled professionals who are more skilled and have the equipment to treat certain conditions (it is not all just about the GP), who each have a role to play in a patient s care; educate and to discourage inappropriate use of GP time and which will release appointments for those that do need to see a GP. This event helped all the Cluster multi-professionals to engage with their patient and stakeholder populations and is something that they all wish to build upon and in some cases has helped to start or improve joint working between the different professions. Further engagement events will take place in 2016/17. 10

Appendix 2 ORGANISATIONAL AND GOVERNANCE MODELS FOR CLUSTERS DIRECTORS OF PRIMARY, COMMUNITY AND MENTAL HEALTH SERVICES 1. Introduction Directors of Primary, Community and Mental Health have been tasked with developing organisational arrangements and governance models to support cluster working. The attached document sets out a menu of governance arrangements and considerations for primary care networks that has been produced by the Heads of Primary Care for discussion at the Directors meeting on 4 December. It should be noted that this is still work in progress and will continue to evolve as clusters develop. The purpose of this covering document is to discuss how this applies to clusters within the NHS Wales context and to set out some suggestions about how we could take the work forward. 2. Definition of Primary Care Primary Care is complex and Our Plan for a Primary Care Service for Wales sets out a vision for the development of Primary Care services to March 2018 and it defines Primary Care as : those services which provide the first point of care, day and night for more than 90% of peoples contact with the NHS in Wales. General Practice is a core element of primary care; it is not the only element primary care encompasses many more health services, including pharmacy, dentistry, and optometry. It is also importantly about coordinating access for people to the wide range of services in the local community to help meet their health and well being needs. These community services include a very wide range of staff, such as community and district nurses, midwives, health visitors, mental health teams, health promotion teams, physiotherapists, occupational therapists, podiatrists, phlebotomists, paramedics, social services, other local authority staff and all those people working and volunteering in the wealth of voluntary organisations which support people in our communities. The cluster networks are the lead agents for change in the delivery of the Welsh Government strategic aims and therefore the governance arrangements must reflect the complexity of this. 11

3. December 2015 - Where are we now? Clusters GP practices in all Health Boards are already grouped in geographical clusters. There are 64 across Wales. The GMS contract has facilitated the development of clusters in the following ways 14/15 15/16 Required practice plans and cluster plans Supported by some non recurrent monies Emerging priorities started to influence planning cycle Building on progress, requirement for multi agency working Clearer links with Health Board planning cycle Cluster investment distributed across 64 Clusters The WG has allocated recurrent investment monies directly to Primary Care Clusters, but financially managed via Health Boards, on a population share basis. A number of clusters in some UHB areas have moved beyond just groups of GPs practices and include representations from community teams, other independent primary care contractors, social services, third sector and mental health. The development of multidisciplinary cluster groups on this basis will be the focus going forward. There is a requirement for Health boards to have a light touch approach in terms of how the money is invested, however it is important that each Health Board complies with it s Standing Financial Instructions (SFI) when procuring equipment and employing staff and this can be bureaucratic and time consuming. In addition Health Boards have invested in cluster schemes aimed at service improvement through other pots of the available investment. 4. The Function of Clusters is very clear in 2015/16: Further develop 2014/15 cluster network actions where appropriate To develop local plans based on assessment of local need Ensure the sustainability of core services with appropriate risk management and actions to address local needs, including improved access to services. Provide mutual support and peer review, e.g. to reduce variation or to address sustainability challenges 12

Strengthen the multidisciplinary team working and inform local workforce strategies Further develop horizontal integration to support sustainable general practice and new models of care led by local teams (for example developments may include cross referral for clinical care; federations of GP practices; shared administrative support; full practice mergers Further develop local needs assessment working closely with colleagues in public health and developing a shared understanding of priorities across health and social care services Develop more effective collaborative working with community services (including nursing, local authority and third sector) to improve the communication, coordination and quality of care and to optimise the availability of professional skills. Develop more effective engagement with the population to strengthen the arrangements to respond to the views of patients and service users Prioritise signposting to the most appropriate professional or self care As a collective influence the Health Boards priorities identified in the IMTPs. 5. Roles and Responsibilities It is recognised that Primary Care Cluster development will evolve and will essentially differ within Health Boards and between Health Boards. However, when considering the organisational and governance arrangements to support each cluster at this level it is important that the following arrangements are secured and agreed as a basic requirement: 5.1 Health Board Role/Responsibilities Health Boards will support cluster development programme by; Setting out the Welsh Government s strategic vision and the aims and objectives for the clusters. Under the cluster programme, Health Boards remain accountable for all the funds allocated to them by the Welsh Minister for Health and Social Services and for ensuring fair access to high quality services for their populations, within the resources made available to them. Work with Clusters to agree priorities in relation to local and national targets Supporting the development of Practice Based Plans and Cluster Development Plans ensuring that they fit with local and nationally identified priorities and that the plans address the needs of the populations Develop an agreed understanding of the approach to light touch for the spending of the indicative budgets on procurement of equipment and appointment of staff within the restraints of the Standing Financial Instructions of Health Boards. 13

Health Boards are committed to supporting the implementation of cluster development and whilst management costs will not form part of the cluster funding, support and advice will be provided. A designated management link/lead from the Health Board, e.g. a Locality / Network Clinical Director, Locality/Network Manager/ Development Manager etc. This role will be vary depending on the structures and resources available and in place within each Health Board. Produce a plan on how it intends to support the development needs of the cluster leadership and OD perspective of each Cluster. This plan will vary depending on the structure and autonomy of each cluster. Support clinical and managerial leadership through the development of incentive payments (backfill or sessional remuneration) or Health Board employment contracts to cluster members to encourage innovation and service redesign. To provide clusters with the tools and support they need to effectively discharge their responsibilities. This is to include finance, information, analysis, public health expertise and support Advise, co-ordinate and inform clusters of the wider implications of proposed service redesign or improvement schemes. Ensure robust systems are in place for the assessment and agreement of cluster plans and cases for change throughout the year. Recognition that each group is different and in the focus will not be on how the work is to be undertaken, but be more about the outcomes. Ensuring robust systems are in place for ensuring value for money and clinical and corporate governance arrangements and improved patient services are established for any proposed service change Ensure guidance on public consultation, avoiding conflicts of interest and tendering requirements as a result of any proposed service change are followed Ensure equity of provision for patients reducing impact of Inverse Care Law 5.2 Cluster Role/Responsibilities To form a clearly defined leadership team, which has been nominated and agreed by the cluster members. It should be recognised that this team may vary from Clusters to cluster within Health Boards and between Health Boards. A leadership team should be broad and include all or some of the following; I. A nominated clinical lead(s), usually but not always a GP, could be nurse or pharmacist etc II. III. A Practice Manager(s) or alternative management lead Other Stakeholders, not just General Medical Services (GMS), and can include other primary care professionals, e.g. Dentist, Optometrist, Community Pharmacist, third sector and social care representatives etc Regular cluster meetings involving all stakeholders and relevant partners/agencies. Supported by agenda and minutes of discussions and actions agreed. It is expected that Clusters members will reach consensus decisions where possible. All significant decisions relating to cluster priorities will be documented and a fair and democratic approach to decision making will be undertaken. These Cluster plans will be shared with 14

and agreed by primary care teams within the Health Board and fed into the Health Board IMTP process by helping to identify how improvements in the population health can be achieved and identifying the priorities. Cluster investment plans shared with and agreed via light touch approach by primary care teams within the Health Board, and evaluated at regular intervals to demonstrate cost effectiveness and patient focused outcomes. The Cluster financial allocation is managed nominally by the cluster leadership team with support from nominated health board staff. The cluster plan does not have to be restricted to the actions which have an investment attached or related to QOF as the cluster priorities should be more holistic in approach but can be broad depending on the priorities identified by them. Clusters are accountable for achieving best value within their budget and to achieve financial balance with funds allocated. Each Cluster should recognise that practices are different and should facilitate smaller practices, particularly single-handers, being able to engage with the Cluster work programme. Professionals are directly accountable to their patients and to their regulatory body (such as GMC or Nursing and Midwifery Council etc) and the Health Boards for their standards of clinical practice. 5.3 Cluster Leadership Team Role/Responsibilities The nominated representatives will: Provide clinical and management leadership for practices within their cluster Provide clinical input and focus for wider pathway redesign or delegate/assign this and other specific tasks and work to other cluster members. Represent the Cluster at Health Board level and Welsh Government meetings Feedback to the Health Boards on Cluster progress Attend cross cluster meetings, representing the views of the cluster and working with the PCT on promoting the development of cross cluster service redesign initiatives Co-ordinate along with the Health Board identified support the activities of the Cluster Co-ordinate the development and completion of the Cluster Plan To encourage and improve practice engagement in the Cluster Programme To encourage and improve patient engagement at individual practice level To encourage and improve stakeholder engagement in the Cluster Programme Contribute to the review of current services and undertake cost benefit analysis and recommendations for service improvements Drive continuous improvement and innovation from within the Cluster across the whole system Ensure that the Cluster plans are outcome focused following SMART principles 15

6. Accountability Framework for reporting and monitoring progress of cluster programmes Each Health Board should ensure that there are robust governance and monitoring arrangements in place to regularly report and monitor the effectiveness of cluster programmes. It is difficult to be prescriptive with regard to what this should be as each Health Board has different reporting structures. It is therefore essential that the reporting and monitoring should be incorporated into the accountability framework which already exists and this should be clearly described to all clusters. This will ensure that the Cluster plans and service developments meet both clinical and corporate governance requirements and scrutiny, and will provide assurance to the Executive Team and Board. Each Health Board should also consider and identify an Executive Lead for the Cluster Programme. At present this varies from Health Board to Health Board and this may be due to historic arrangements/portfolios, Clusters should be informed of the named Executive Lead for each Health Board. 6.1 Decision Making Clusters should seek to reach consensus decisions wherever possible. For transparency all significant decisions should be documented and a fair and democratic approach to decision making be exercised. All decisions should be clearly documented and minutes/notes made. Clusters may seek advice and support from the Health Board in order to facilitate decision making where a consensus cannot be reached. Declarations of interest should be openly recorded and considered when decisions are made. Individual members may be asked to abstain from particular decisions where appropriate. 6.2 Quality Assurance It is advised that Clusters use Clinical guidelines and clinical audit to inform and to improve quality of care when redesigning clinical pathways. As part of good clinical governance Clusters should support significant event reporting, reflection and identify learning. 7. Fast forward 2018 - Where do we want to be? A Cluster Plus model The Primary Care Plan for Wales sets out the context and vision for the future development of clusters.. Recognises that clusters (geographical grouping of several adjacent GP practices) are already in existence but focused largely on collaboration between GP practices and are relatively immature structures Highlights that planning and provision of care should be done at a small population level and refers to the Kings Fund recommendation of an optimum size of 25 100,000. (planning function) 16

Recommends that Health Boards should develop clusters to include all planners, coordinators and providers of local services and other community resources and local people becoming directly accountable for the health and well being of the communities they service and the use of available financial, workforce and other resources (integration function) Emphasises that each cluster needs a leadership team with the capacity and capability to fulfil that function, to agree action plans and key milestones, including the devolved management of services (direct management/ service delivery function). This may have to involve combined management teams supporting several clusters where necessary if the capacity is not available within Clusters or UHBs. Suggests that clusters will also play a significant role in planning the transfer of services and resources out of hospitals into local communities (expanded delivery function or commissioning function) Proposes that clusters will be the basis for innovation in terms of new funding models, new service models and workforce roles, new ways of contracting and new partnerships Vision for Clusters It is important to stick to the principle of form follows function when considering future organisational forms. The first step is therefore to confirm and clarify the functions that we expect Clusters to be able to deliver as outlined below: Planning - Local assessment of need and planning Integration - Communication and coordination between agencies, stakeholders and local people Quality improvement- Sustaining core primary care services through peer support and pooled expertise. Service delivery - Expanded delivery of primary and community services through direct management of resources for the cluster (staff and budgets) eg enhanced services commissioned at cluster level, direct management of community teams Extended service delivery -A vehicle to deliver extended services through a transfer from secondary care eg securing and delivering non GMS services It is assumed at this stage that it is not the policy intention to give clusters commissioning powers and commissioning budgets in relation to secondary care. At the basic level the clusters will be delivering the first 3 functions outlined above. However, some indicative budget setting will enable clusters to best utilise resources, and this may stimulate innovation and further investment. It is therefore the intention by 2018 all clusters should be ready to deliver all of these functions. 17

In order for this to happen further discussion is required on provider / commissioner roles and there will need to be the appropriate contractual changes / levers to enable clusters to do this. Health Boards will also need to be prepared and organised in readiness to support and facilitate this development from a leadership and operational level. 8. Organisational Forms and Models for Cluster Plus The challenges of considering the organisational and governance arrangements starts with recognising that some examples relate specifically and exclusively to primary care and others involve a broader range of partners. The latter is more aligned with the broad range of functions outlined in the Primary Care Plan and the definition of Primary Care. The Primary Care Plan refers to the potential for a number of different models for delivering the work of clusters, albeit recognising that the GMS Contract model/ GP practice will remain the principal model in Wales: Contracting for care at a community level (assume this means cluster level). Developing a greater range of integrated services in community settings, designed around the needs of patients Secure greater investment in upstream interventions that keep people healthy for longer, prevent ill health and reduce inequalities Drive continuous quality improvement and innovation Direct employment of GPs and other health professionals with services commissioned through use of alternative provider services contract model Practice mergers Development of federations We already have some examples of new organisational models and governance arrangements supporting cluster working, for example, the development of the Federation in Bridgend East. These examples will provide important learning and a source of advice in taking clusters forward. Federations can enable improved patient care through more being available in the community and support struggling practices as well as sharing back office functions, education and networking. Federations are independent practices forming the foundation block and thus retain ability to respond to their unique population. It could be argued that GPs coming together enable the preservations of the best features of the traditional GP and encourage collaboration and a collective voice. The recent publication by the RCGP and Nuffield Trust identified a number of interesting and relevant findings regarding collaborations in primary care that are worth considering in NHS Wales. Some of the findings included; 18

a strengthened trend towards collaboration amongst GPs with the majority of respondents reporting being part of a formal or informal collaboration the main motivators were encouragement from CCGs, financial pressure in primary care and a desire to expand services offered in primary care the most common organisational form for formal collaborations was reported to be a federated model rather than a super practice the main challenges were building trust and engagement with member practices the report noted a confusion of language and terminology about organisational forms and legal structures In addition we need to take stock of some of the themes that will be reported from the Regional Cluster Development Workshops that have been held in recent weeks. For example, there was a clear sense of positive momentum and belief in the importance of clusters to the future development and delivery of primary and community services from participants and hence enthusiasm for developing them. In addition there were some clear messages from many cluster leads and development leads that frustrating and bureaucratic HR and procurement processes were encouraging clusters to consider how to develop more formal models of collaboration in order to take on direct management of staff and budgets. In addition to this the other main themes to come out of the workshop were: The need to share good practice and experience across Health Boards in Wales Specific areas that were highlighted as a priority for development were leadership, management and finance. Awareness of clusters and the primary care plan needs to be raised across the healthcare system. It is still a niche area. It was felt that little support was being given from outside the primary care bubble to cluster development. Data was generally regarded as useful and important but the reality was there is no time, space and often ability to properly understand and analyse at the front line. Support for cluster leads was requested in this area. Cluster leads reported very little time to anything else other than attend meetings. There was little time to plan, network and develop. It was felt that current funding arrangements in primary care didn t really support true cluster working. This needs to change. There is a need to integrate third sector into the cluster agenda. Other Welsh Government strategies and delivery plans are often not aligned to the primary care plan and clusters which makes delivery (and priority setting within LHBs) difficult. The over whelming feedback from GP practices though throughout the last year is one of concern around capabilities and capacity. Including Current limitations on GPs time due to workloads 19

Lack of core skills (including leadership) An urgency to spend allocated budget within tight timescale whilst having comply with restrictions of internal processes within Health Board 9. Interim Recommendations Several steps have been taken by Health Boards to increase the engagement of a range of clinicians and Primary Care Professionals, Practice Managers, Third Sector, and Social Care in cluster development and to encourage more involvement into wider strategic planning/issues for their populations. Primary Care clusters have come a long way since the introduction of cluster working 2 years ago and on the whole many practices within clusters, across Wales are making significant progress in terms of collaborative working; exploring innovative ideas regarding service provision; providing mutual support to one another; and started to open up lines of communications with each other, Health Boards and other Stakeholders who are providers of health and social care. It is the recommendation of the Heads of Primary Care that the clusters be given the flexibility to further evolve, with the light touch guidance and support of Health Boards, over the next 2 years and not be forced to develop into one way or the other into a specific model. It is believed that this will happen through a light touch and encouragement and supportive structured OD programme. 20

Appendix 3: OOH diagram 21

Appendix 4: Strategic Workforce Planning and Development Workforce & OD Directors Collaborative Work Programme PURPOSE The purpose of this paper is to provide Directors of Primary Community and Mental Health with a summary of the collaborative W&OD work programme and how key elements of the work programme support the delivery of the Primary Care workforce plan. The Team Wales event in November 2015 focused on addressing NHS Wales challenges through a focus on the workforce and considered what the key prevailing issues were and how they could be tackled. Following this event a number of work streams were identified which were subsequently agreed with Chief Executives. A 60 Second Briefing was developed to support each work stream, available on request. A briefing was also developed for Integration which was not developed into a separate work stream but was agreed as needing to underpin the work, in particular work relating to planning, shape of the workforce, primary care. The collaborative work programme work steams are: Temporary Staffing Capacity Recruitment Primary Care Workforce Shape of the workforce ESR Enhance / Hire to Retire Retention Workforce Performance Measurement Health and Wellbeing / Sickness Absence Workforce Planning / Education Policy / Pay / Terms & Conditions Senior Succession Planning & Leadership Medical Staffing (Locum & Agency Costs) 22

IMPACT ON DELIVERY OF PRIMARY CARE WORKORCE PLAN Examples of the links between the collaborative work programme and the DPCMH agenda are set out below and include: Shape of Workforce CEs have asked for work to be undertaken to consider the configuration of registered to unregistered workforce and potential for roles at band 4. There is a work stream for HCSWs relating to integration and initial discussions have taken place with Care Council for Wales. A workshop to support workforce redesign is being piloted in Powys but could also potentially be adapted for primary care. Recruitment Currently focussed on overseas nurse recruitment, however, discussions have taken place with WG as to how a central marketing approach for Wales can be developed and sustained which can support local recruitment initiatives. Feedback from Cluster events regarding HR processes relating to job evaluation was relayed to WODDs at their peer group meeting. It has been agreed that work will be undertaken to develop a new approach for Wales. Workforce Performance Measurement This work stream has been developing a workforce performance dashboard for the employed workforce which is nearing completion. It is proposed that with the agreement of DPCMH this group is reformed to focus on the development of workforce measures for primary care. Workforce Planning / Education This work stream is delivered mainly via the Wales Workforce Planning network (which is being expanded to include W&OD primary care business partner posts) and the All Wales Strategic Medical Workforce Group (ASMWG) which has a standing GP sub group. Key work includes exploration and development of population based workforce planning approaches, making links between work streams to support join up of intelligence regarding developing workforce models and prioritisation of Wales modelling work to supplement and support information derived from IMTPs e.g.: 23

o Links via WEDS to Wales Pharmacy Workforce Group via WEDS. Facilitating 111 lead to brief the group on impact of developing workforce model. Discussions with group about commissioning specific modelling for Pharmacy to map impact for Wales of additional pharmacy posts. o Discussions with Director of Workforce & OD, WAST about modelling workforce implications of additional paramedic posts in primary care as part of workforce model. Work is also being undertaken via this work stream to develop a Medical Workforce Strategy. The first of 3 Medical Workforce Strategy engagement events took place in Cardiff on 22 nd April with over 80 attendees and a high degree of participation and input. Participants have specifically been targeted from primary care to ensure that this is key part of the developing strategy. Work is also taking place between Welsh Government, the Wales Deanery, Shared Services, WEDS and the chairs of the All Wales Strategic Medical Group to agree an interim process for consideration of medical training numbers for Wales. It is currently envisaged that a paper will be received at the July CEOs meeting of the group with the aim of that being submitted to CEOs/Welsh Government for consideration via the National Executive Board. This paper will include General Practice. Primary Care workforce Aim is for this group to pick up any other elements not covered in the rest of the work programme that will specifically support the Primary Care workforce agenda. 24

Appendix 5: RAG rating of local progress OUR PLAN FOR A PRIMARY CARE SERVICE FOR WALES UP TO MARCH 2018 2016 UPDATE LOCAL HEALTH BOARD ACTIONS WITH CLUSTERS AB ABMU CV CT HD PtLHB BC Each year, from 2014-15, health boards will support GP practices to collaborate at cluster level to develop and deliver an action plan with specific goals and actions for developing and improving GP services and local solutions to help deliver sustainable and improved local health and well being, reduced health inequalities and improved service quality and performance. Each year, from 2015-16, health boards will support their primary care clusters to: Implement actions and key milestones to support their sustainable rapid ongoing development. Undertake an assessment of local health and wellbeing needs, drawing on a wide range of sources of information; Map all available clinical, workforce and other resources and communicate this to both the local population and those providing these services, particularly those services responsible for coordinating people s access to services; Agree protocols for access to all available services; Use an assessment of how clinical, workforce, financial and other resources can be used more efficiently, flexibly and innovatively and identify what gaps in services and workforce numbers and skills remain to direct the better use of all available resources; Put in place local pathways of care and referral protocols for accessing these services, workforce and other resources G G G G G G A G G A G G A A 25

appropriately; Ensure that these local pathways of care and referral protocols are capture in a robustly managed, maintained and up to date directory of service to ensure that local clinicians and the public know what is available and how they can access it easily, and this is made available to the national 111 services as it is rolled out across Wales; Develop and deliver a three year plan, informed by the cluster level plan for GP services with specific goals and actions for developing and improving primary care services to deliver improved local health and wellbeing, reduced health inequalities and improved service quality and performance. LOCAL HEALTH BOARD ACTIONS WITH CLUSTERS AB ABMU CV CT HD PtLHB BC From 2015-16, health boards will support their primary care clusters to draw in all local partners, such as the third sector and local government to deliver local solutions and strategies to improve health and wellbeing of the local community, help prevent avoidable ill health and provide ongoing care for people living with long term conditions or who are frail and elderly. From 2015-16, health boards will support primary care clusters to establish patient participation mechanisms and to demonstrate how they are actively seeking and responding to people s experience of all aspects of primary care to drive and report on continuous improvement in the quality of care for their communities. G G A G G A A G A A G A G A 26

LOCAL HEALTH BOARD ACTIONS WITH CLUSTERS AB ABMU CV CT HD PtLHB BC From 2016-17, health boards will support their primary care clusters, to introduce a rolling programme of peer review for primary care, based on a set of nationally agreed core principles which health board directors of primary, community and mental health help develop to drive and report on continuous improvement in the quality of care. A A A A G G R Each January, health boards, through their annual refresh of their threeyear A A A A A A A integrated medium term plans, informed by cluster level plans will set specific goals and actions at cluster level to: Identify local solutions and use primary care to meet local need, tackling the inverse care law and reduce inequalities in health outcomes; Improve access to primary care for people with Welsh language or other language and cultural needs, people with physical and learning disabilities, people with sensory loss, people with low health literacy, frail older people and those who do not routinely seek help from the NHS. FOR LHBS BY 2017 18 AB ABMU CV CT HD PtLHB BC Health boards to support full participation of its primary care service in the National Clinical Audit Programme. Currently only 10% of the Audits included in the National Clinical Audit Programme cover services delivered by primary care services. We have good participation in the National Diabetes Audit. Work is also underway to develop the COPD audit and Chronic Kidney Disease. From 2015-16, health boards will publish their performance against the agreed national set of primary care quality and delivery requirements and G G A G G A A A A R/A R A R R 27

measures and Welsh Government will publish this information on My Local Health Service. Through 2015-16 new ways of improving transparency of reporting of primary care quality outcomes will be developed and implemented. From April 2016, health boards will demonstrate more people are routinely reporting they are able to communicate in Welsh when seeking care and support from primary care. From April 2015, health boards will consider reports at their regular board meetings and report to Welsh Government on the agreed set of primary care quality and delivery requirements and measures to provide a clear line of sight from practice to health board to national level. G A A A A A A A A A/R R G R R/A A A A A A A/G R/A FOR LHBS BY 2017 18 AB ABMU CV CT HD PtLHB BC By April 2017, health boards will provide people with on line access to their GP held health record. A R A R R/A By March 2018, health boards will demonstrate the routine use By the public of: A wide range of e health services; A range of options to access local care; Text reminders for appointments; By the wider primary care service of: Email via the NHS Wales email system to communicate with each other; Electronic referral to local services and hospital services; Electronic discharge and reporting information; A A A A R A 28

Online appointment booking, ordering of repeat prescriptions and access to their GP held health record, care plan and outpatient and hospital discharge information; Telehealth remote monitoring equipment and a range of diagnostic tests available at or close to home. Shared patient episode information on integrated IT systems; Specialist advice via telephone, e mail and telemedicine equipment. LOCAL HEALTH BOARD ACTIONS AB ABMU CV CT HD PtLHB BC With immediate effect, health boards will work with primary care to identify people at increased risk of poor health or exacerbations of existing conditions and manage that risk through an agreed individual care plan, with a named care co-ordinator where appropriate and agreed with the individual to oversee that care. Each January, health boards will, explicitly reflect their primary care clusters three-year plans in the annual refresh of health board level three year integrated medium term plans. Health boards should consider and develop joint contracting arrangements with multiple service providers, including local authorities, the third and independent sectors From October 2015, health boards will work with local authorities, the third sector and others to begin to phase in a national online and telephone service called 111 to provide access to a wide range of G A A A A A A G G G G G G A G G A G A R G A A A A A R A 29

reliable health and wellbeing information, advice and assistance. From 2015-16, health boards, local authorities, the third and independent sectors will begin using a shared IT system to collect and share information to support primary care. Health boards will encourage use of Add to Your Life and My Health online by their local populations. Each January, health boards will, through their annual refresh of their three year integrated medium term plans, informed by cluster level plans, demonstrate how they will provide increased capacity and a growing range of primary care close to home, including: Access for working people to see or speak to GP services in the evening and on a Saturday morning; Diagnostic tests; Local professionals trained to prescribe medicated treatment; Services to support healthy lifestyles, self care, rehabilitation, reablement, episodes of acute care and end of life care with dying in people s preferred place of care. Health boards will agree with Welsh Ambulance Service how paramedics can help to deliver care at home and in the community. Health boards will optimise the Eye Health Examination Wales (EHEW) service to provide the majority of care closer to home. R A R A A R R G A A A A A A G A A A A A A G A G A G A A G A A G G G G Health boards will also continue working with all services and practices in primary care including community pharmacists, dentists and optometrists on opening times. G G A G G A/G for GMS A 30

Health boards need to plan, educate and train a more flexible local healthcare workforce and develop the potential role of AHPs, which requires priority being given to their education and training. Health boards will work with their partners and service providers to develop more ways for people to access medication, treatment and information, advice and assistance in using and managing their medication in the best way. From April 2015, health boards will use the agreed national set of primary care quality and delivery requirements and measures, developed by health board directors of primary, community and mental health by December 2014, developed further by December 2015 to drive and report on continuous improvement in the quality of care. G A A A G A A G G A G G G G G A A A A A A 31

Introduction Appendix 6 PCID hub Primary Care Development and Innovation Hub: Update May 2016 This paper describes progress with establishing the Primary Care Development and Innovation Hub. The paper confirms the purpose for the Hub, and sets out the function, proposed structure and plans for governance. The paper clarifies the additional resource that PHW is contributing to the Hub. It includes a summary of work underway. Context A clear direction for primary care services in Wales is set out in the strategy Our plan for Primary Care services to 2018. Responsibility for delivering the strategy is shared between clusters, local health boards, Public Health Wales and others. Coordination of efforts of partners is key to making progress with the strategy. The Primary Care Development and Innovation Hub ( the Hub ) has been established to provide this. PHW has made improving the public s health through primary care services one of its seven strategic priorities. The new strategic focus has highlighted the need for PHW to be clearer about how work to support primary care is organised internally and presented externally to partners. The Hub development is central to how PHW support is to be organised for the future. PHW is restructuring its Primary Care Division in line with this. This paper includes the proposed new structure which combines resources from the Primary Care Grant with PHW resources. Changes to PHW structures are currently subject to formal consultation. Purpose of the Hub The Hub has been established to support local health boards in their responsibility to deliver transformational change in primary care. The initial focus for this is Supporting clusters to plan within their locality o Using information about health needs to guide plans o Using a prudent healthcare approach to focus on prevention and early intervention where possible Supporting the development of a skilled local workforce o In system leadership o In change management o In using population approaches to planning care 32

Functions of the Hub The Hub is adopting a programme management approach for the support for primary care transformation. The approach provides a framework to capture the work of a wide range of partners working to develop clusters. The functions of the Hub are to: Develop programmes to support cluster development Support the delivery of projects as part of overall agreed programmes Provide programme management infrastructure to o Ensure governance for work programmes o Ensure alignment of work projects/programmes with strategic goals o Provide assurance for delivery of agreed projects o Ensure interdependencies between projects are coordinated The Hub will be staffed by a combination of staff funded through a grant from Welsh Government, and by staff from within PHW being restructured within the Primary Care Division. The table in Appendix1 sets out the team in the Hub. The expectation is that the nature of the projects and overall programmes will evolve over time, and ultimately should complete the process of transformation in primary care as envisaged in the primary care strategy. The resources needed to support the programmes and projects will be kept under review, recognising that grant funding is until March 2018 and other funds are part of PHW main budgets. Support to the Hub from the Primary Care Professional Support Team It is proposed that the Hub is supported by a strong team of primary care professionals within PHW, reporting to the Deputy Director of Health and Wellbeing. These will be organised into a multidisciplinary Primary Care Professional Support team. The role of the team will be to support the agreed project and overall programmes within the Hub with professional advice and support for delivery. Contribute to identifying possible work projects overseen by the Hub Provide professional advice to projects To have key roles for delivery of agreed projects Contribute to relevant projects Facilitate the engagement of primary care professionals within projects from across Wales using professional networks 33

The Primary Care Professional Support team is being established from the Primary care division of PHW (see appendix 1). The organisational development process is currently underway, with an expectation of confirming arrangements by end of July 2016. In the interim, staff are continuing to contribute to delivery of agreed programmes of work. Governance of the Hub The Primary Care Development and Innovation Hub Board role is to agree the work programme of the Hub, and to receive reports on progress. Governance arrangements will be agreed at the first meeting of the Board in June 16. The proposed Board comprises: Directors of Primary and Community Care and Mental Health x 2 (Co-Chairs) Welsh government representatives x2 Director of NHS Quality Improvement ( PHW) Director of Health and Wellbeing (PHW) LHB Director of Public Health xthe broad remit of the board is to receive regular reports of progress and ensure projects deliver agreed project outputs in accordance with agreed plans. Detailed terms of reference will be agreed at the first meeting. Workplan for 2016/17 Ahead of the development of a formal work programme using programme management methods, there is an existing work plan which PHW has agreed. This is being delivered by a combination of 1000 lives team, the Primary care divisional team, and the Observatory. The projects within the current plan will be translated into the programme management process, with clear measures of progress and timelines for delivery. The staff being restructured within PHW represent additional capacity, and will enable a significantly enhanced programme to be delivered in 16/17. It will be a priority for the restructured team to work with partners to identify projects deliver strategic priorities. The Hub Board will provide direction and ultimate approval for this work programme. Appendix 2 lists the work currently being delivered. Progress with establishing the teams Programme Director- Rosemary Fletcher-takes up appointment on 1/6/16 Programme Coordinator- Kelly King- in post Programme Administrator- Caroline Maddox- in post Web developer- James Clarke- in post Restructuring of Primary Care Division- target of completion by July 16 subject to OD process 34

Resources The Hub developments set out in this paper are resourced by a combination of Primary Care Fund grant and PHW resources: Primary Care Fund- pay 350 000 - Non-pay 18 000 PHW - pay 670 000 - Non-pay 30 000 Total 1 069 000 Appendix 1 : Staffing structure The following structure is being proposed as part of the restructuring of the Primary Care Division. It may change in the course of formal consultation within the OD policy. Hub Programme Director x1 Programme Co-ordinator x1 Programme administrator x1 Web Developer x1 Programme Manager x2 Project Manager x2 Programme Support Officer x2 Senior Project Support Officer x2 Informatics lead analyst Informatics support analyst Advanced evidence and knowledge analyst Primary Care Professional Support Team GP Clinical input x 8 sessions Consultant Public Health 0.6wte (North) Consultant Public Health 0.5wte (South) Public Health Consultant Pharmacist x1 35

Public Health Principal Pharmacist x1 Primary Care Lead Nurse x1 Primary Care Improvement Lead Nurse x1 Appendix 2 Table of work in progress GP one online web-portal live Primary care one web-portal- in development, prototype ready in June; September launch Cluster leads database maintained Support to clusters on understanding needs and planning for prevention from Local Public Health teams Access to primary care quality improvement tools eg: Congestive Heart Failure; Atrial Fibrillation audits Skills based programmes for clusters being delivered from July 2016 Confident leaders programme: Development programme running from July 2016 for initial cohort of 20 cluster leads 1000 lives cluster workshops/ National primary care sponsored sessions Development of Cluster Profiles and Practice Profiles by Observatory- being developed in response to feedback from clusters. Primary Care Measures- developing a subset of measures for monitoring quality improvement in primary care. 36

Appendix 7: Pacesetter Report May 2016 1. Introduction The 20 Pacesetter projects are now progressing across all Health Boards and exciting early outcomes are emerging, both from individual projects and from a whole system view. This report provides an update of Pacesetter / Pathfinder progress to date and describes an emerging model for Primary Care in NHS Wales that is aligned to the principles and aims of the Welsh Government s Plan for a Primary Care Service for Wales up to March 2018 1. 2. Learning to date 2.1 Evolving project design - It has been necessary for some project designs to evolve and be reshaped in response to early challenges and/or opportunities, whilst ensuring that the key aims of original Pacesetter/Pathfinder submissions are adhered to. The need for teams to be responsive and flexible during the early stages of project development is clearly important if innovation is to be successful. Some projects have refocused their evaluations to ensure clear outcomes (e.g. Quality in Antibiotic Prescribing; Stoma Care Service); some have incorporated new ideas (e.g. Kidney Kit by Renal Pharmacy service); some have experienced a significant change in project conditions (e.g. Non-Medical Workforce in PC); whilst others have circumvented contractual constraints by redesigning the operational side of their service (e.g. Community Pharmacy Service). 2.2 Emerging Model for Primary Care - By taking a whole system view of the Pacesetter/Pathfinder projects, we are starting to see the Welsh Government Primary Care Plan model for Primary Care in Wales emerging (App 1), with the potential to reshape the NHS in Wales (App 2). Each project informs a component of the model, with evaluation criteria designed to assess the effectiveness of their service in delivering local improvements and big system change. It is exciting to find that this whole system model, which has evolved from front-line service redesign across Wales, mirrors the evidence in the literature of successful healthcare systems including the Kaiser Permanente Model for Integrated Care in California 2, the Nuka model of care in Alaska 3 and the IMPACT Clinic (Interprofessional Model of Practice for Aging and Complex Treatments) in Canada 4. The components of the new model for Wales are described in Section 3 below. 37

Innovation Networks The links and interdependencies between the Pacesetters are evolving naturally and provide opportunities for strong collaboration, support and shared learning. Project leads have formed networks to discuss progress in the development of new cluster models, Primary Care Support Teams and innovative roles in PC teams. Teams working on similar areas of change have found it invaluable to share their ideas, experiences and resources. Learning of common constraints and challenges across Health Boards is helpful to understand our systems at national level and to plan how best to progress innovation with pace. 1000Lives is supporting the development of these networks through theme focussed, facilitated workshops. Two of these have been held to date, with more to follow throughout the year. 2.3 IMT systems The Primary Care IM&T systems in operation across Wales are currently limited in their ability to support service evaluation and redesign. It is essential that robust, user-friendly systems be established to facilitate Primary Care workload analysis, underpin workforce planning and promote cluster working. A clear understanding of capacity, demand and flow at practice and cluster level is key if we are to meet the needs of our local populations and resource clinical teams effectively. The Joint Leadership Inverse Care Law Programme currently running in Aneurin Bevan and Cwm Taf University Health Boards offers a great opportunity to align population health needs with cluster workload data and inform local workforce planning. 3. Emerging Model for Primary Care The GP practice is at the heart of primary care and will continue to be so in the future. However, where the GP s role today is to treat the vast majority of people who come through their practice s doors, in the future their role will increasingly be to provide overarching leadership of multiprofessional teams made up of advanced practice nurses, community and district nurses, midwives, health visitors, healthcare support workers, pharmacists, physiotherapists, occupational therapists, podiatrists, dentists, optometrists, social services staff and staff working in care homes and third sector services. We need to plan for a sustainable GP workforce to meet population need and also focus on ensuring the wider primary care team providing care around the person is right, supporting an increase in the numbers and mix of skills of all professionals, including advanced and extended scope practitioners. Collaboration through primary care clusters creates better opportunities to take an innovative approach to designing primary care. Innovation in primary care is about generating new funding models, new service models and workforce roles, new ways of contracting and new partnerships with communities and the third and independent sectors. Innovation also includes new technology, products and services, and working with 38

universities and industry to accelerate innovation and to support economic growth in Wales. It is about making the best use of buildings to promote professionals working together. Our Plan for a Primary Care Service for Wales up to March 2018, Welsh Government As shown in the diagram in Appendix 1, Primary Care stability lies at the heart of the emerging new model for Wales to ensure that GP practices and clusters are sustainable and can respond to future demands. Robust local workforce planning is reliant on accurate capacity, demand and flow analyses, alongside population health and social care needs at regional level. Primary Care Support Teams are to be evaluated in their effectiveness to stabilise vulnerable practices and work with professional teams on new ways of working to ensure sustainability in the longer term. The following narrative outlines how the new model for Primary Care is emerging from the work being done through the Pacesetter/Pathfinder projects. Safe and effective call-handling and triage systems at the front door of Primary Care are designed to direct patients to the most appropriate professional in the team, moving away from our current system in which the GP is the filter for the majority of patient contacts. Telephone advice is appropriate for a significant proportion of patient requests and, if delivered by a suitably experienced professional, can safely and effectively reduce the number of face-to-face consultations. Triaged calls are directed to the most appropriate member of the in-house multi-professional team, incorporating the skills of pharmacist, physiotherapist, occupational therapist, mental health counsellor, dietician, social services and other professionals working alongside the GP to manage the day-to-day workload of the practice. Some staff may provide services at cluster level, depending on their level of expertise and patient demand. As a result of effective triage and MDT working, the GPs and Advanced Practitioners in the practice are freed up to manage the more complex patients, now having the time to devote their attention and skills to those who require this level of expertise. Significantly longer appointment times can be given for the team to assess and manage patients, who are often elderly with multiple co-morbidities, with resources to hand that effectively address the health and social care needs of each individual. The MDT is also well placed to support care of the acutely ill within Virtual Wards and Community Hospitals, providing a service for people who would otherwise require admission. Good communication systems from clusters to the redesigned 111 Service will ensure that all professional teams have access to contemporaneous clinical records - essential for seamless care in- and out-of-hours, especially for patients with complex conditions and / or at the end of life. 39

This holistic MDT model within Primary Care offers a more proactive and preventative approach to care and is highly likely to reduce attendance at ED and avoid admissions, thereby allowing staff in hospitals to focus their resources on the very sick and on planned specialist care. The emergence of various models that promote collaborative cluster working, such as Federations and the Primary Care Hub, are aligned to this in-house MDT approach. Employment of staff across several practices can increase efficiency and ensure that a whole cluster can benefit from particular clinical and managerial expertise. GPs and other staff who have been freed up from the ever-increasing workload can devote their time and energies to developing new community services on a cluster basis, strengthening the shift of care from the acute setting. The Primary Care Plan reiterates the importance of Primary Care estates that are fit for purpose, designed to facilitate enhanced MDT working that is flexible and responsive to future changes. Although this is not the focus of a specific Pacesetter/Pathfinder project, its critical importance as a foundation for sustainability and to deliver quality services must not be forgotten. There are other notable benefits to the multidisciplinary approach to Primary Care, in addition to the shift of care closer to peoples homes. Early outcomes from the Primary Care Hub indicate there are significant improvements in Primary Care team morale, motivation and staff well-being. The ability to use their training and skills in the management of complex clinical cases will be appealing to GPs and Advanced Practitioners, in addition to the flexible career schemes on offer in some parts of Wales. These opportunities may well encourage practitioners at the end of their careers to defer retirement, retain younger staff in the area and attract new professionals into Wales. The exciting career opportunities for other HCPs offered through these new Primary Care roles, with increased responsibilities and a broader range of posts, are also likely to have beneficial effects to recruitment and retention in Wales. 4. Evaluation Each Pacesetter project has identified a discrete set of Process, Outcome and Balancing measures to evaluate the effectiveness of their service or system in delivering improvements both locally and within the whole system model. A table (available on request), shows that most projects have some early outcome data (as at April 2016) and indicates the anticipated timescales for final evaluation. Access to resources and expertise to establish robust Primary Care data collection systems across all Health Boards in Wales would have a significant impact on both the speed and depth of Pacesetter evaluations. The emergence of this integrated model for Primary Care is a significant outcome at this early stage, as is the establishment of the Innovation Networks that enable Primary Care teams to work collaboratively across NHS Wales. 40

5. Opportunities 5.1 Technology Network - It is proposed that another Innovation Network is set up with a focus on Primary Care technology resources and IMT systems. This would provide an expert forum to understand current work in progress around Wales, share ideas for system development and pool expertise in the design of innovative products for Primary Care. 5.2 Demand and Capacity Linking to the proposed Technology Network, the outcomes of the Pacesetter projects could be used to support work on data, capacity planning and flow management. 5.3 Behavioural Change A common theme emerging from the Pacesetters/Pathfinders is the need to introduce Behavioural and Motivational methodologies into their service developments. Several of the projects aim to change the culture amongst the public and professionals to achieve significant shifts in the use of public services and to empower people to take ownership of their health. It would seem sensible to undertake a study of current research into these methodologies on a Once for Wales basis, with input from UK experts in the field, so that we have a sound knowledge base for this critical aspect of improving population health. 6. Risks and Constraints 6.1 The pace of innovation is hampered by some contractual and institutional arrangements. These include GMS and Community Pharmacy contractual constraints, issues with Standing Financial Instructions and protracted Human Resource processes. None of these challenges is insurmountable and findings from the Pacesetters offer learning that can be used to refine these processes and accelerate pace of future change. 6.2 The funding arrangements behind the Pacesetter innovations, although most welcome, are somewhat confusing. The success of these projects is dependent on additional funding being made available to Primary Care from Welsh Government. However the number of different funding pots, with similar aims, makes the application of these funds to discrete projects problematic and runs the risk of creating project siloes. The flexibility shown by Welsh Government in its approach to how these funds are used has been helpful, but some alignment or consolidation of funding streams in the future would provide clarity for teams in relation to future spending plans. 41

6.3 LHBs remain committed to the success of Pacesetters and Pathfinder projects. However the demands on Primary Care services in Wales continue to grow at pace and at present teams tasked with innovation are also responsible for maintaining a stable Primary Care workforce. Experience in change management demonstrates that innovation work requires dedicated resource and manpower to give it the maximum chance of success. 7. Recommendations The Directors of Primary Care are asked to note and approve the contents of this paper and to continue to support the work identified within the report, with particular reference to future planning as follows: 7.1 That 1000Lives continues to support the Pacesetter and Pathfinder programme of work 7.2 To provide clarity on future funding arrangements for the Pacesetter and Pathfinder projects 7.3 A Technology Innovation Network be established to share ideas for systems development to support cluster working and innovation 7.4 1000Lives to scope out service improvement work on patient flow in primary care, focussing on using data to understand demand and support workforce planning 7.5 1000Lives to explore the use of behavioural change methodologies to support the development of the emerging model for primary care 7.6 The Directors to confirm their support for the Primary Care model that is rapidly emerging across Wales through the work of the Pacesetter / Pathfinder teams. Jane Harrison and Paul Gimson, 1000Lives Improvement, April 20 References 1. Our Plan for a Primary Care Service for Wales up to March 2018: Welsh Government; Nov 2014 http://gov.wales/docs/dhss/publications/141106careen.pdf 2. Model Kaiser Permanente - California: A Model for Integrated Care for the Ill and Injured May 4, 2015; The Brookings Institution 3. Nuka System of Care, Alaska http://www.kingsfund.org.uk/publications/population-health-systems/nuka-system-care-alaska. The IMPACT Clinic: Innovative Model of Interprofessional Primary care for elderly patients with complexhealth care needs. Tracy CS et al; Can Fam Physician. 2013 Mar; e148-55 42

Alterna ve PC Models Enhanced MDT to manage PC workload Triage systems Enhanced HCP roles MDT working Skills, Time and Resources for complex care Primary Care Sustainability PC WFP PC Support Teams Stable Primary Care Improved Access to Quality Care More Services delivered in Community Demand Capacity Flow New roles, pathways, services Acute Outreach Services Effec ve Pxing systems Effec ve Cluster working OOH 111 Redesign SPN comms MDT Support Hub Key: Pacesetter = Pacesetter / Pathfinder Project 43

EMERGING VISION FOR PRIMARY CARE AND THE NHS IN WALES... Analysis of pa ent flow, capacity, demand in PC Primary Care Workforce Planning New and Emerging Models of Primary Care Primary Care Triage Models GP Federa on Alt Cluster Models PC Estates fit for the Future Primary Care Support Teams New AHP roles in PC team Enhanced MDT working Greater AHP career opportuni es New PC services + pathways MORE GP AND HCP TIME FOR COMPLEX PATIENTS Mo vated GPs + AHPs Increased GP R&R? REDUCED HOSPITAL ADMISSIONS + ED ATTENDANCE Intermediate Care Outreach services inform PC skills to manage complex care Community Hospitals Extended Virtual Wards 44

Appendix 8: Primary Care contribution to USC PURPOSE In March 2016, the Programme Director for Unscheduled Care specifically asked the DPCMH to collate examples of local actions which could be or are already deployed to address unscheduled care demands within their local systems. DPCMH had previously jointly developed the Unscheduled Care 6 Urgent actions checklist for health and social care and a similar checklist of priorities to address and enhance Out of Hours service planning and delivery. In April 2016, the NHS Executive Board received a brief overview of key messages from Primary Care summarising the local and national response which was required to promote sustainability in primary and community care and ensure that primary and community care in its widest sense can support the transformation needed to the unscheduled care system to bring about sustainable change. INTRODUCTION The OECD Review of Health Care Quality UK, raising standards (Feb 2016), recommended that Wales should Put Primary Care front and centre as a force for dynamic system change. They propose that this requires the continued growth and support of primary care clusters and their activities as well as fostering new models of care delivery, incentivising innovation and news way of working. This reinforces the work that is already underway and requires a sharpening of focus and increase in pace of delivery. Implementation of Our plan for a Primary Care service for Wales up to March 2018 (Feb 2015), has made progress over the last 12 months, supported by additional funding for clusters and pacesetters. However, significant progress will only be made if equal priority is given at both individual Health Board and National level to improving primary, community and social care alongside secondary care. This will require the development of a balanced approach at Health Board level to core funding of areas where real evidence demonstrates benefits accruing to the whole system. The recent reports for the Delivery Unit are good examples of where such evidence exists and should be systematised. This paper and the attached Annex offers examples of evidence of models/approaches to care at a primary and community care level that are proven to be beneficial in reducing admissions and hospital attendances and so adding real value to the unscheduled care system and minimising pressure on secondary care services. 45

ANALYSIS OF THE SITUATION AND PROPOSED SOLUTIONS The challenges faced within unscheduled care are well documented, as are the evidence based solutions. Whilst attendance at ED remains predictably static, the complexity of patient need and other influencing factors have resulted in performance not improving despite numerous initiatives focussed on ED efficiency. The most significant issue is not the numbers of people presenting at ED but the ability to provide alternatives to admission alongside the ability to transfer patients safely and quickly from hospital and prevent readmission. This trend is likely to continue unless system change is addressed and a way of funding across pathways of care can ensure parity of resources aimed at primary and community based services proven to keep people out of hospital settings. Whilst social care is an important part of the solution, improvements and substitution of services will not manage all the pressures on the system. There is also a need to remove some of the complexity of different services that has been built into the system, and which have the real ability to confuse the public and the NHS. However, in the absence of accurate data outside hospital, fostering a better understanding of the way that local systems work will not be easy. Making our health systems fit for an ageing population (Kings Fund 2014), detailed evidence to support the improvement of each component of care which needs to be applied equally across the care pathway, as any one component affects the others. The components proposed relate closely to the 10 step CAREMORE model, as follows; Healthy active ageing and supporting independence Living well with simple or stable long term conditions Living well with complex co-morbidities, dementia and frailty Rapid support close to home in times of crisis Good acute hospital care when needed Good discharge planning and post discharge support Good rehabilitation and re-ablement after acute illness or injury High quality nursing and residential care for those who need it Choice, control and support towards end of life Integration to provide person-centred co-ordinated care (Kings Fund 2014:vi) 46

Below are examples of evidence based primary care initiatives which relate to the key components above, which should be prioritised and made available consistently across the pathway and throughout Wales. Evidence based Priorities 1. Promote ways of assessing and managing multi morbidity in the community, including targeting of risk stratification, top end medications and intelligent risk lists for Palliative care and frail elderly. (Multimorbidity: clinical assessment and management. NICE guideline 2016). 2. Enhanced clinical input of pharmacists in GP practices, ED, care homes and community. (Good practice examples of pharmacists to support the urgent and emergency care agenda. Royal Pharmaceutical Society 2015) http://www.rpharms.com/promoting-pharmacy-pdfs/ue-care---good-practice.pdf 3. Direct access for GPs and other clinicians to diagnostics and services such as physiotherapy, audiology, OT, Podiatry etc. (Physiotherapy works: primary Care. Chartered Society of Physiotherapy 2015). 4. Alternatives to admission including hot clinics, psychiatric liaison services etc. and agreed pathways for falls and mental health etc. (Avoiding hospital admissions. What does the research evidence say? Purdy, S. Kings Fund 2010) 5. Consistent 24hr telephone access to specialist consultant expertise for GPs and clinicians. 6. Reduce the complexity of services available in the community ensuring that front line hospital staff have knowledge of the range of available services and acuity of care available locally. 7. Routine access to and use of community referral and social prescribing. (A review of community referral schemes. Thompson, L., Camic, P., and Chatterjee H. UCL 2015) SUMMARY Primary and Community Care services have been developing a raft of service models and alternatives to inpatient care over the past decade, however, the approach remains inconsistent and does not have the level of priority it requires in most cases at Health Board level The Primary Care plan for Wales has further assisted in demonstrating a focus on primary and community care services and over the past year has allowed a range of innovative approaches to be explored. 47

Sustainability of primary care services in their widest sense are crucial to improving the whole system approach to tackling the demands of unscheduled care. Demand and capacity work within primary care services is not well developed and largely not evidenced based. This is a key area for rapid development. There is already a large of body of evidence that demonstrates the most effective interventions that can be made within primary and community core in reducing demands for secondary care services. These are however, not consistently applied or resourced at Health Board level. Applying the CAREMORE model in primary care requires amendment of proposed steps as the routine management of urgent care within the community does not always result in transfer to secondary care services. Annex 1 provides an initial example of how this could be shaped for future use across Wales The approaches detailed above are specifically addressed towards in hours provision. Similar work is required to be undertaken on OOHs work and managed across Wales in a co-ordinated manner. The analysis of the situation as described previously mirrors the findings of the National Seasonal Planning event in March 2016 and its resultant recommendations. RECOMMENDATIONS 1. That the evidenced based approaches to improved pathways of care in primary and community care are prioritised for action at Health Board level consistently across Wales. 2. That activity in place across NHS Wales on pacesetters and pathfinders, which specifically aim to address unscheduled care within the community setting are reported upon actively to the USC Board and adopted where demonstrated to add value 3. That consideration be actively given to the resourcing of the whole pathways of care such that primary and community care services can fully implement evidence based interventions 4. That the CAREMORE approach for Primary Care as outlined in Annex 1 is enhanced such that ongoing redesign and focus at primary care level is embedded in the whole system response to unscheduled care. 48

5. That work is prioritised for the DPCMH on the development of demand and capacity modelling within the Primary Care setting such that a whole system demand and capacity map is readily available and can be used to address gaps that emerge on a dynamic basis 6. That the current range of work on Out of Hours services is reviewed and managed through a specific co ordinated programme board reporting to the DPCMH and thence the USC Board, ensuring a key link to 111. PRIMARY CARE CONTRIBUTION TO CAREMORE Step 0: Maintain health and well being (Help me to remain independent) 1. Coordinate more effectively with Public Health around communications and consistency of messages to engage effectively with the public. 2. Promote ways of assessing and managing multi morbidity in the community 3. Provide sufficient support to help service users live with their condition including community referrals and social prescribing. Step 1: Sign post or redirect me (Help me Choose) 1. Promote use of clinical triage in hours and out of hours. 2. Agree an all Wales Communications Plan This can include co-ordinated Choose Well Campaigns - Dr Olivia DVD s, effective use of the press, social media. Messages in GP practices e.g. Be Winter Wise. 3. 111 pathways review and use of DOS Step 2: Assess my need 1. Enhanced triage and telephone consultations as well as rapid access to home visiting through the PCST and APPs. 2. Support to develop Cluster approaches to first contact in hours 3. Redesigned GP OOHs model (DGH co location, shift bundling and MDT). Step 3: Make sure I see the right person (See me) 1. Establish, well publicised telephone and online advice for GPs/clinicians must be consistent and managed by experienced ANNEX 1 49

professionals 2. Rapid access to community teams and social care to support Primary care and avoid admission 3. 7-day Psychiatric Liaison Service (up from 5 days) 4. Dedicated Primary and Community on-call rota 5. Community Resource Team involvement alongside GPs and locality Pharmacists in local Care Homes enhanced levels of input and use as first point of contact. Step 4: Treat me at or close to home 1. Roll out GP based Pharmacists across GP clusters 2. Establish and maximise the use of the Virtual Ward concept with intelligence from frequent OOH callers and frequent ED from care homes and WAST, alongside a CH resource. 3. Physician Response Units, Falls Response Units, and 24/7 Community Nursing 4. Acute GP Unit - providing a more focused assessment and access to some diagnostics and hot clinics. 5. Strengthened @Home services IV antibiotics, care home in reach. 6. Recruitment of qualified nurse practitioners or training of own staff and specialist nurses in the community. 7. Enhance core community services with different roles e.g. phlebotomy support to DNs. Step 5: Take me to a healthcare facility 1. Rapid access to community and social care to provide alternative out of hospital solutions 2. Share learning with WAST 3. Maximise the use of the Community Hospitals and any associated MIUs (Current profile admission is often traditional and vague) a ramp up of admission criteria, more proactive GP input and more rigorous MDTs will help (recent points prevalence indicates poor MDT practice). This should always include Social Work and may benefit from a more proactive DN presence at ward level. Step 6: Assess my condition 1. More publicised and consistent use of WebGP Step 7: Give me a diagnosis 50

Step 8: Give me treatment Step 9: Discharge me 1. Timely and accurate discharge information and handovers of care to prevent readmission and enable effective primary and community care. 2. EDALs electronic prescribing and discharge. 3. Use of a dedicated District Nursing / Community Liaison post at each DGH with key links into the community they know what can be supported. It does deskill the ward discharge functions but on a short term basis it does work. 4. A work stream to look at lack of capacity in care homes and domiciliary care. Step 10: Continuing to care for me 1. Collaborative working with Local Authority, Social Services and Care Homes to resolve issues around DToCs where funding has been an issue to use CHC for 4 weeks as a stop gap and free up capacity. 2. Increase the Reablement and OT resource of CRTs to reflect a greater emphasis on maintaining functional capability. 3. Re-jig the DN model and consider employing Health Care Assistants to work to DN s. This will increase the number of people being given the full range of care at home and avoid episodes of emergency admissions. 4. Improve coordination with the Voluntary and 3 rd Sector for greater community care co-ordination. 51

Appendix 9: Primary Care overview of priorities 52

53