16 January 2018
The Assembly is due to debate the Health, Social Care and Sport Committee’s report on primary care clusters on 17 January.
The Committee‘s inquiry focused on the role of clusters (groups of GPs working with other health and care professionals to plan and provide services locally) and examined whether the model is transforming primary care to better meet local need, and delivering improved services to patients as intended. There are 64 cluster networks across Wales (determined by local health boards in each area), serving populations of between 30 and 50 thousand patients.
After reviewing the evidence, the Committee concluded that that clusters have a long way to go before they deliver on the Welsh Government’s ambitions for them to play a significant role in planning the transfer of services and resources out of hospitals and into local communities.
Members of the Committee heard positive examples of work in individual GP practices and in specific clusters across Wales, but concluded that much of this appears to be driven by the enthusiasm and commitment of certain members of staff, leading to a concern that the cluster model may be over-reliant on key individuals. There were also clear concerns from some professional groups that they are not being included in cluster work as much as they should be.
Some of the main challenges to emerge were practical difficulties. This included concerns that the short term nature of cluster development money makes it difficult to recruit and retain staff, and challenges in relation to employment issues and indemnity. The Committee also heard from stakeholders that the current primary care estate and digital infrastructure are not fit for purpose to accommodate the cluster model of working.
The report concluded that a major step-change is needed if primary care clusters are to relieve pressures on GPs and Welsh hospitals, as there is currently limited evidence to demonstrate their impact.
The Committee made 16 recommendations in its report, including:
- The Welsh Government should publish a refreshed model for primary care clusters which restates a clearly defined vision for them from the beginning of the new financial year;
- The Welsh Government must ensure there is a much clearer and more robust mechanism for evaluating cluster work. Despite the clear challenges, there must be attention given to how evaluation mechanisms can begin to measure the impact of cluster work on patient outcomes.
Welsh Government’s response
The Welsh Government’s response to the Committee report stresses the fact that it doesn’t want to be ‘overly prescriptive’ about how clusters should develop.
The Cabinet Secretary for Health and Social Services noted that the Committee’s recommendations do not recognise the progress made by clusters, and says for his part, he will continue to encourage clusters to evolve and mature as the right approach to planning accessible and sustainable local care.
The Cabinet Secretary says the Welsh Government will further articulate its vision in an NHS and social care action plan which will be published in April 2018; the action plan will be informed by practice to date, the Committee’s report and the outcome of the Parliamentary Review of health and social care. He also states the primary care board will be asked to agree the governance arrangements by June 2018.
The Welsh Government accepted 11 (3 of these in principle) and rejected 5 of the 16 recommendations.
Recommendation 10 – The Welsh Government should put in place a national lead to co-ordinate training and development needs within clusters. It should also set out its expectations as to how training needs will be identified systematically at a local level.
The Welsh Government rejects this, stating that the national plan for a primary care service for Wales requires health boards to support their clusters with development needs. It says that nationally, health board directors will continue to work with Public Health Wales’ primary care hub and the 1000Lives Team to provide a coordinated programme of training and organisational development support for clusters.
Recommendation 11 – The Welsh Government should ensure that cluster development money is allocated to individual clusters on a three year rather than a one year basis.
The Welsh Government rejects this, stating that it has allocated the £10 million from the national primary care fund for clusters to determine how to invest on a recurrent basis. It says as the planning function of clusters matures, clusters will increasingly be better able to realise the opportunities of taking decisions on the use of this funding through their rolling 3 year plans.
Recommendation 12 – The Welsh Government should undertake a review to identify current primary care funding streams in order to work towards rationalising and maximising the impact of the total available funding.
The Welsh Government rejects this saying recurrent funding streams for primary care contracted services are already clearly identified through the annual health board allocation letter.
Recommendation 13 – The Welsh Government should work with health boards and cluster leads to establish clear decision making processes for quickly evaluating and scaling up successful models and ceasing funding for less successful initiatives.
The Welsh Government rejects this, saying that a decision-making process already exists with ‘the national pacesetter programme’, which was established in 2015-16. The national pacesetter programme is undergoing external critical appraisal which is due to report in February 2018.
The Cabinet Secretary states that decisions on scaling up good practice already exists in the form of the 3 year rolling plans which clusters and health boards produce each year. However he does accept that the pace and scale of adopting and adapting good practice needs to increase, and says he will ask health boards to review their planning processes, and will be monitoring tangible results.
Recommendation 16 – Evidencing whether primary care clusters are an effective model and deliver value for money is crucial. As a matter of urgency, the Welsh Government must ensure there is a much clearer and more robust mechanism for evaluating cluster work. Despite the clear challenges, there must be attention given to how evaluation mechanisms can begin to measure the impact of cluster work on patient outcomes.
The Welsh Government rejects this, saying there is established evidence on the value of the cluster model, and that clusters will evaluate the effectiveness of their initiatives locally:
Our national plan for a primary care service for Wales is underpinned by existing evidence from the King’s Fund that assessing population need and planning and delivering care to meet that need is most effective when done at a very local level of between 25,000 and 100,000 population. The OECD 2016 review of UK health systems and the interim report from the Parliamentary Review of health and social care provide further evidence of the value of cluster working.
To measure the impact of local collaboration on the health and wellbeing outcomes of their populations, clusters can use the results of evaluation of their local initiatives and the new nationally agreed set of quality and delivery measures for primary care. I expect this information to provide a reliable indication of the value of clusters. Sharing this information will help inform and justify future plans at cluster and health board level across Wales.
Article by Amy Clifton, National Assembly for Wales Research Service