Primary Care – a challenge and an opportunity

Draft version Primary Care – a challenge and an opportunity Executive Summary This short report was produced as part of the partnership between Caerphilly LHB and Rhondda Cynon Taff LHB coming together as Teaching LHBs The aim is to raise awareness about two projects that could inform the wider strategic planning necessary to develop and invigorate primary care in the South Wales Valleys The Primary Care Support Unit (PCSU) in Rhondda Cynon Taff and the Caerphilly arm of the Heads of the Valleys Project (CHVP) developed independently in response to similar issues facing primary care in the area Using different models, both projects were initiated in response to a need to improve the delivery and sustainability of primary care in the respective areas Until recently, there has been little in the way of joint working and planning between the two LHBs The formation of the RCT / Caerphilly teaching LHB is an opportunity to bring together the key messages and lessons from these two initiatives and develop the culture of open learning and strategic development Both schemes have individually achieved much There is a need to consolidate the benefits and lessons learned to enable other health communities to draw on the achievements to date We encourage others to engage with the projects, where appropriate, in a spirit of joint learning and development, towards fulfilling the wider agenda of delivering a World Class Health Service in Wales This report provides a description of each scheme including a brief account of the history of each project These findings were produced by the Clinical Directors and will be updated regularly All our documents will be available on our web site www.wales.nhs.uk/tlhb We very much hope you will join in with the discussion and debate In this way, we can share our views and experience to help and support each other in working towards our key objective – improving the health and quality of life of the people of Wales -1- Draft version 1 Why were these innovative schemes developed? The South Wales Valleys present difficult and complex challenges for sustainable primary care Both projects (in RCT and Caerphilly) were conceived in response to a need to improve the delivery and sustainability of primary care across the South Wales Valleys The communities are located in areas of post industrial Britain, with a history of coal mining and steel working There are high levels of physical ill health, unhealthy lifestyles, low social capital and high social deprivation These are areas of high decline with high levels of unemployment and increasing social problems In 1971 Julian Tudor Hart coined the "Inverse Care Law", demonstrating that areas with high levels of ill health and deprivation received a disproportionately low level of health care services Although these observations were of the western Welsh Valleys, they were equally applicable to the South Wales Valleys, and remain so today In Caerphilly and RCT, there was an impending primary care workforce crisis, with vacant practices, an impending retirement boom, iII health amongst medical practitioners, and a high level of single handed practices In some areas premises were sub-standard Primary healthcare teams were absent within some practices Recruitment into single handed and isolated practices was almost impossible, and the number of vacant practices was increasing Locum cover was difficult, expensive and only maintained (or more often, accelerated) decline in the standard of medical practice There was limited activity in terms of medical education and primary care research in these areas There were no links with academia and very limited post graduate training or medical student placements, thus hindering development of the next generation of clinicians There was a clear need to enhance services for the communities in the South Wales Valleys, with a focus on improving quality, access and equity Both Caerphilly and RCT LHBs independently recognised the need for early strategic intervention to address these issues In each area, a project was proposed and implemented with the aim of revitalising primary care services in the area As the projects evolved independently, different models were used However there were common features and shared core values Both projects have successfully achieved remarkable improvements in the quality and sustainability of primary care services provided A description of the two projects, similarities, differences and impact on primary care services provided are outlined in the following sections of this report -2- Draft version Caerphilly arm of the Heads of the Valleys project The Heads of the Valleys Project was designed and funded to revitalise primary care across the Gwent Valleys, by integrating clinical services with teaching and research It was envisaged that this would create an exciting environment to aid recruitment and retention The project was conceived in 2001, and became active in 2002 Two main centres were developed, (1) Gelligaer/Gilfach, in Caerphilly, and (2) Brynmawr/Beaufort in Blaenau Gwent The project was initially supported by Gwent Health Authority, two local health groups, and University of Wales College of Medicine Following the reorganisation into Local Health Boards, Caerphilly LHB and Blaenau Gwent LHB became the responsible organisations These two LHBs have taken slightly divergent paths in response to local priorities This report concentrates on the progress made in the Caerphilly Local Health Board area The centre in Caerphilly was developed to serve as a focus for change and revitalization of primary care services The vision for this centre included the following features: An environment that attracts and retains a highly motivated workforce and trains the next generation High quality healthcare delivered from premises fit for purpose by well trained and motivated health professionals Excellent teamwork and communication delivering and monitoring quality of care against national standards Education and training of the next generation of healthcre professionals at both undergraduate and postgraduate level A resource that provides a focus for continued professional development for all established healthcare professionals in the valley area A support facility that can mentor new recruits into general medical practice and primary care A professional base from which clinical support can be offered to practices and professionals who are struggling to deliver care and meet national standards A base for clinical sabbaticals by established Principles with special skills who can help to regenerate the valleys areas Catalyse the attainment of NSF standards across Local Health Group areas 10 A test bed for establishment of a integrated primary healthcare information system 11 An opportunity for primary care to contribute to medical research -3- Draft version 2.1 Establishing the project A project board was established in October 2002 with representatives from Gwent Health Authority, Caerphilly and Blaenau Gwent Local Health Groups, the local medical committee, the community health council, and University of Wales College of Mediine A funding package of £1 million was agreed with the then NAfW, delivered over three years to support the project over five years The vacant practices at Gelligaer/Gilfach and Brynmawr/Beaufort were taken into the scheme Job advertisements were placed in summer 2002, and posts filled in October 2002 Practice management and nursing posts were also filled Job descriptions included personal and project development time It was envisioned that staff would undertake formal training from external bodies as part of their development, as well as opportunities to develop academic medicine 2.2 Initial challenges The practices involved had a clear remit to improve the standards of medical care, to develop the primary health care team, and to develop educational opportunities; prior to moving to more outward looking work The key initial challenge was to provide high quality, patient centered, and responsive primary care At the time the project started there was minimal computerisation of medical notes and prescribing, record keeping was below standard, there were ineffective appointment systems, unusual patient expectations, and very poor team working Prescribing and therapeutics monitoring was substantially below recommended guidelines For example prescriptions for antibiotics and benzodiazepines were readily available without medical assessment, and no record was kept of such prescription issues Sick notes were issued without assessment of the patient There was minimal monitoring of long term conditions, patients did not expect to have to see the doctor for a blood pressure check Medical notes contained limited clinical information or past medical history summaries Around this time the new GMS contract was also starting to be implemented, putting further pressure on change Changing patient expectations took time, getting patients to accept modern standards of safe clinical monitoring was challenging, especially around the need for regular reviews Changing perceptions of the interface between primary and secondary care work balance, was also an issue For example there was a need to explain to patients that some investigations were more effectively carried out in a primary care setting and did not require out patients services Issues around inappropriate expectations for sick certification and inappropriate use of antibiotics and benzodiazepines sometimes led to strain on the doctor patient relationship -4- Draft version A variety of staffing issues resulting from embedded substandard approaches to delivery of care delivery were uncovered These were primarily around administration and attitudes towards patients The nursing team was small and under-developed The development of a stable clinical team, allowing the growth of longer term relationships, and the practice of effective family medicine has assisted greatly in dealing with these challenges The development of an integrated and responsive administration team has been vital to the development and delivery of high quality clinical care 2.3 Project team The project team includes five GPs who contribute a total of twenty-seven clinical sessions per week, one practice manager, practice nurses and attached district nurses, health visitors and midwives The clinical team includes a clinical lead who is also a GP trainer (Dr John Holland), two clinical lecturers, and links to Cardiff University through Professor Helen Houston (Chair of General Practice and Dean of Undergraduate Studies at Cardiff University’s School of Medicine) Professor Houston retains an important role as a senior clinician involved in starting and guiding the project The clinical team is supported by a secretary, two administrative assistants, a reception team and two cleaners Many of the key players in the team have largely been attracted to post by the nature of the project, including all three non academic GP's, two clinical lecturers, one practice nurse, and the practice manager The primary care team meet on a weekly basis for practice based staff, and a monthly basis for attached staff The team also meet regularly with the community based services who accept referrals from the practice, for example the primary care counselling service, Gwent Alcohol Project, Fusion young people's drugs and alcohol service, and the Citizens Advice Bureau 2.4 Project achievements The project has successfully established a primary care facility that integrates clinical services with teaching and research It has also expanded the professional base to encompass other primary care professions, particularly nursing and other professions allied to medicine Rapid change has been achieved over many of the eleven areas that were set out in the vision statement: -5- Draft version 2.4.1 Environment The working environment in Gelligaer/Gilfach is currently satisfactory There are active plans to move Gilfach (which acts as a branch surgery) into, soon to be vacant, GP premises within close proximity to the existing site This will enhance the ability to deliver plans to develop GP training status The premises at Gelligaer are inadequate for modern Primary Care with no space for teaching, enhancing GMS or team development A new surgery is being planned on the site of The Old School, again in close proximity to the existing site 2.4.2 Health care delivery Heathcare delivery has improved dramatically The practice list size has increased without any increase in the local population size High quality patient centered responsive care is delivered and the health status of the patients has improved An audit of diabetic patients between 2004 and 2005 showed improvements in long term glycaemic control Before 2003 very few patients were screened for high blood pressure At present, around 80% of all adult patients have had a blood pressure recorded, and thus a large part of the clinical Iceberg has been identified This has resulted in a higher than expected prevalence of hypertension at around 18% of the adult population, (compared with the expected prevalence of 12.5%) Patients now have excellent access to primary care services Reception staff respond quickly to telephone calls, and are generally able to offer GP appointments for the next day Emergency nurse led clinics take place to deal with same day emergencies Afternoon emergencies are seen by a GP the same day Advance appointments for named GP's can be made two or three weeks in advance Telephone consultations are performed daily, and house calls are triaged by a GP for clinical need and made when appropriate The practice takes part and meets the high standards set in Advanced Access Program Information on ‘the next available appointment’ is provided on a monthly basis to Coaching Access Wales Long term condition clinics are run at both sites These are generally nurse led clinics covering diabetes, ischaemic heart disease, and respiratory disease Less prevalent long term conditions, such as epilepsy, are managed through a recall system within routine surgery appointments Appointments for these are available up to six weeks in advance A full range of GMS services, including child health clinics, antenatal care, and minor surgery are also provided High levels of data cleaning and accuracy in clinical summaries have achieved complete disease registers and high points achievement in the quality and outcomes framework for general medical services -6- Draft version 2.4.3 Monitoring Monitoring of care provided is now routinely performed with regular clinical audits Outcome and process data are routinely collected Regular clinical meetings allow clinicians to review their practice against national standards and the evidence base for best practice Other techniques such as problem case analysis and hot review are also used to monitor performance The team has responded rapidly to changes in policy For example when a possible link between COX-2 analgesics and heart disease became apparent, all patients on COX-2 analgesics were contacted within a two week period and offered counselling and appropriate alternative medication There are no longer patients on prescriptions for co-proxamol, as a result of the CSM announcement of planned withdrawal 2.4.4 Education and training Education and training has been developed for undergraduate medical students, nursing students, and reception staff Approval for placements has been granted by Cardiff University and the School of Nursing at Caerleon The practice supports three year five medical students a year, each on six week block attachments Nurses undertaking training as practice nurses are also supported Links were developed with the local college and the practice has NVQ students on placement learning reception and administrative duties The practice now meets the criteria to apply for status as a training practice; however this prime objective of training GPs in the locality is not yet met, primarily due to space considerations 2.4.5 Continuous Professional Development The aim to provide a focus for CPD for professionals in the wider medical community has not yet been tackled This need is currently being met in part by other LHB initiatives including "Clinical Forums", and is the role of the educational facilitator 2.4.6 Mentoring Mentoring of new recruits into general practice has occurred through the Clinical Director Gelligaer is currently supporting one salaried GP who is one year out of vocational training This role will expand as the team of salaried GP's increases in size, with two fairly newly qualified GP's commencing in post in Feb 2006 2.4.7 Clinical support Clinical support for practices and principles in difficulty has been offered to several practices Educational interventions to help support a GP in difficulty are undertaken on a weekly basis Support has been provided to a vacant practice run by the Caerphilly LHB salaried GP service Administrative and organisational support has also been offered to a local practice In 2003 -7- Draft version approximately 500 patients were absorbed from a run-down single - handed practice 2.4.8 Clinical sabbaticals Clinical sabbaticals have not developed This scheme was funded to get senior principles, from successful practices to move on a short term basis into the area to help practices in difficulty Whilst the scheme was advertised in Wales no principles were recruited, and thus HO VI has not been involved in this 2.4.9 Attainment of NSF standards Catalysing the achievements of NSF's and similar standards across the LHB has not been tackled Much of this work has been superseded by the development of the Quality and Outcomes Framework for GMS and locally enhanced services (for example around enhanced diabetic care) 2.4.10 Information systems Information systems within the project have recently been described as ‘exemplary’ by an independent medical advisor The practice is paper light, all consultations, medications, and incoming hospital letters are on computer All staff have undertaken training on both the clinical system, general computer use (via ECDL), and read code usage This training has increased staff confidence and their ability to provide a high standard of patient care Simple messaging and e-mail are used for staff communication as appropriate An intranet site is used for communication and also serves as a knowledge base This contains clinical protocols, with virtual links to useful sites (e.g links to Prodigy, and British Hypertensive Society), making information available in a timely manner during every consultation The practice has access to the local trust computer via Clinical workstation Browser, allowing access to test results, waiting list information, and in-patient lists The practice is currently working on implementing barcode labelling for patient information for laboratory test requests, in cooperation with the trust lab staff Handheld computers will shortly be loaded with clinical patient data for use in home visits 2.4.11 Research The practice has participated in a survey of chronic pain in the community led by the Dept of Anaesthetics, Cardiff University Patients have been recruited to research on sick certification, regarding patient expectations and their experience of the consultation (This work is being conducted by a HOVI GP in Blaenau Gwent) Currently the practice is also involved in a multi-centre trial on respiratory disease However, the vision of development of primary researchers within the project, who are not academically employed, has not yet materialised -8- Draft version Primary Care Support Unit, Rhondda Cynon Taff The Primary Care Support Unit (PCSU) as a concept took its roots from the London Academic Training Scheme Service development, together with retention and recruitment of primary care clinicians were recognised as priorities in order to revitalise primary care services in this area The PCSU concept was to enable developing clinicians to support the key service aims in a nurturing environment that encourages personal development At the heart of this model is flexibility that allows for innovative approaches to provide high quality primary care services in a sustainable manner The broad objectives of the PCSU were: (i) To address recruitment issues by allowing salaried GPs and nurses to experience working in RCT (ii) To support local GPs to develop themselves and their practices (iii) To improve and increase the level of primary care services available to patients (iv) To promote and raise the profile of RCT to attract high calibre GPs to the area It was envisaged that the PCSU would serve the following functions: To provide a resource centre for a population based clinical service To provide clinical cover at a GP practice that would release a clinician from the practice to provide population based clinical services from the resource centre To provide clinical and management support at practice level for the improvement of existing services and development of new services To support practices with recruitment problems by providing a salaried GP for a fixed number of sessions a week To directly manage practices where there are difficulties replacing retiring GPs To support local GPs or nurses who want to develop their skills and gain training To support local practices by providing training courses, training materials and educational events To aid the development of service redesign and operation plans, and enable the LHB to commission improved population based services 3.1 Establishing the project In RCT, the Local Health Group set up an innovative scheme in October 2000 in two rooms in a local GP surgery in Aberdare This initially comprised salaried GPs, nurse practitioners and nurse facilitator A Clinical Director was appointed in January 2001 In March 2001 the Rhondda Valley Primary Care Resource Centre was started In 2002 the PCSU and Rhondda Valley Primary Care Resource Centre merged and activities of PCSU were extended across RCT -9- Draft version 3.2 Project team The PCSU team consists of a clinical director, a manager, administrative staff, 18 salaried GPs (5 full-time, 13 part-time, equating to 13.9 WTE GPs), nurses, a nurse practitioner, specialist nurses, nurse facilitators and practice nurses Of the 18 GPs, there are 14 female GPs Staff retention has been very good, with many of the staff having been with the PCSU for or years Since the start of the scheme in 2000 the PCSU has only lost members of staff for the following reasons - GPs to take partnership in RCT practices - GPs to take partnership outside Wales - GP family moved outside Wales - nurse to work for another Welsh LHB 3.3 PCSU activities in 2005 3.3.1 GP Activities: • The PCSU has moved into a new phase, only limited sessional educational cover is now provided by the salaried GPs This is generally limited to work directly with LHB developments and projects • All the salaried GPs work on a sessional basis throughout the RCT area with nominated local practices The PCSU GPs are helping to modernise and improve services for the local population by undertaking consultations and clinics • The Local Health Board continues to successfully manage two practices in Mountain Ash after the local GPs retired early due to illhealth There are 3.5 WTE PCSU GPs working in these two practices • The PCSU is continuing to work with other practices to provide suitable exit strategies, with the deployment of salaried GPs to enable continuity of services • Seven salaried GPs are working all their sessions in named host practices throughout RCT • Four female salaried GPs have recently returned from maternity leave and have chosen to undertake their sessions in their host practice This demonstrates their commitment and integration into the host practice team It also demonstrates that the LHB is an organisation that is successfully implementing flexible working • Three salaried GPs are involved in GP with Special Interest (GPwSI) schemes in dermatology and epilepsy - 10 - Draft version  • One salaried GP works sessions in Pathways to Work project (Condition Management Programme) Two salaried GPs work in the Diabetic Annual Review Service (DARES) Scheme 3.3.2 Nurse Activities:  One nurse is in a shared post in Cynon  Facilitation of the development of new chronic disease clinics – Coronary Heart Disease, Diabetes and asthma  Practice nurse educational sessions  Training Course for NVQ Care Qualification  Established a RCT Practice Nurse Group  GMS Contract  Supervisory support to the RCT Heart Attack Project  Development of nurse appraisals programme throughout RCT  Clinic support and facilitation at the LHB managed practices  Nurse practitioner led minor illness clinic at LHB managed practice 3.3 Project achievements 3.3.1 Resource centre for a population based service • Diabetic annual review service in the Rhondda D.A.R.E.S • Dermatology and Minor Surgery Service – Cynon Valley • Condition Management programme Pathways to Work 3.3.2 Clinical cover at a GP practice to release a clinician from the practice to provide population based clinical services from a Resource centre • Rhondda and Taff Ely Dermatology GPSI scheme 3.3.3 Provide clinical and management support at practice level to develop new services and improve existing services • • Asthma / Diabetes Clinics Cardiac disease registers - 11 - Draft version 3.3.4 Support practices that have recruitment problems by providing a salaried GP for a fixed number of sessions a week • Increasing numbers of practices in the Cynon and Rhondda 3.3.5 Directly manage practices where there are difficulties replacing retiring GPs • There are two managed practices in the Cynon at present The PCSU were involved before the GPs retired to allow for continuity of care and to provide support for the GP during the change over Once established and consolidated the PCSU GPs considered their options to continue as salaried GPs or to become Independent Contractors and take over the Practice 3.3.6 Support local GPs or nurses to develop skills and gain training • Numerous examples in the first years of the LHB E.g release to attend Minor surgery training, Child health training, and attendance at Consultant Clinics 3.3.7 Providing courses, Training materials and Educational events • The production of the New GMS contract Guide Book • Nurse Update Courses 3.3.8 Service redesign and operation plans to enable the LHB to commission improved population based services • • • Demand management project Heart Attack Project Pathways to work To date the PCSU has delivered across the model parameters There has however become an increasing focus on recruiting salaried GPs to best fit the requirements of individual practices that wish to have salaried GPs within the practice 3.4 Reasons for PCSU success Unlike other salaried GPs schemes the PCSU offers medical practitioners a supportive framework in which to work, it includes;     Good peer network to share information and advice Opportunity for GPs to sample work in challenging and stimulating areas whilst still being supported Flexibility to suit GPs who want flexible working arrangements Opportunities for GPs to work in a practice without getting involved in administration - 12 - Draft version      Opportunities for GPs to get involved in administration and practice development, especially with LHB managed practices Extensive support and opportunities for the development of new skills It enables newly qualified GPs to experience different practices whilst deciding their future career path Guaranteed income, annual leave and bank holidays The clinical director and PCSU manager are easily accessible to provide advice and support - 13 - Draft version Comparison of the two projects 4.1 A common vision Although these projects developed independently, there were common core values in developing these centres to act as foci for change and revitalisation These common features were: An environment that attracts and retains a highly motivated workforce and trains the next generation High quality health care delivered from premises fit for purpose by well trained and motivated health professionals Excellent teamwork and communication delivering and monitoring quality of care against national standards Education and training of the next generation at both undergraduate and postgraduate level A resource that provides a focus for continued professional development for all established healthcare professionals in the valley area A support facility that can help mentor new recruits into general medical practice and primary care Offer a professional base from which clinical support can be offered to practices and professional who are struggling to deliver care and meet national standards Development of links with other organizations and opportunities for research and development The focus for both schemes was on directly improving patient care and access to services Primary health care professionals salaried to the LHBs were employed, with experienced GPs as the Clinical Director Both schemes benefited from links and placements with Cardiff University’s School of Medicine’s academic rotation 4.2 Differences between the two schemes The following table shows the main differences between the two schemes Characteristic Size Scope Undergraduate Training Staff training PCSU 20 GPs and nurses Multi focal Hub managed practices – GPs GPs in established practices GPs in locality services GPs just recruited for practices None Education for RCT wide - 14 - CHVP salaried GPs Beacon managed practice – GPs Medical and Nursing In house staff training Draft version Recruitment Chronic condition management Research practice nurses Recruits and supports salaried GPs for RCT practices and LHB salaried professionals Supports RCT practices to develop chronic condition management None undertaken to date Aspiration to support LHB salaried professionals Practice priority Involved in research projects 4.3 Headline achievements for the two schemes Both schemes have demonstrated successful recruitment of salaried GPs and nurses This has been an excellent boost to recruitment in formerly ‘hard to recruit ‘areas It has been observed that applications to join now exceed available posts Both schemes have attracted female GPs, demonstrated successful retention of salaried professionals, provided mentorship for young professionals and support infrastructure for professional development Managed practices have improved performance and services with demonstrable dramatic increase in measures such as Quality and Outcome Framework points Both schemes have provided a proactive approach to avoid potential service failure and a reactive approach to support recruitment and service crises The schemes have successfully provided support for the interface with other LHB initiatives eg Pathways to Work and the GPSI dermatology service Many clinicians, attracted to the area by the schemes and who have now “graduated” from both programs have continued to practice in the area, demonstrating the contribution of these schemes to sustainability of services The PCSU approach has helped sustain established practices and expand services available in those practices eg access to a female GP and establishing nurse led CDM clinics - 15 - Draft version Evaluation of these initiatives 5.1 Salaried Health Professionals Perspective All the clinicians that responded to the questionnaire survey responded that they would in the future consider working in the South Wales Valleys and that they would recommend the PCSU or the CHVP to colleagues About a third of these GPs indicated that they wished to become self employed GP Principals A third indicated they wished to be salaried GPs, while the remaining third were undecided at the time of the survey Over 80% of GPs from both schemes felt that they had good support from their scheme The majority (88%) of nurses from the PCSU also responded that they had very good support from the scheme Forty percent of these nurses indicated that they would in the future pursue an educational or support role, 30% indicated a preference for direct clinical provision, 20% indicated they would seek a leadership role and 10% indicated that they were interested in partnership in primary care The following quotes are examples of what the salaried health professionals said: What attracted you to the post and what has been positive for you? “The possibility of making a difference, versatility in my working life, continuing to keep myself updated” PCSU GP “The opportunity to pursue academic interests whilst working in a deprived community, in an innovative way” CHVP GP “The ability to develop existing clinical skills alongside providing chronic disease education for clinical colleagues and patients Working at setting the agenda for CDM care in the future Producing guidelines and protocols.” PCSU Nurse “Control of work life balance, protected study and admin time, the challenge, the LHB drive and honesty – eyes open when accepting the job Opportunity to Dermatology diploma, work in a variety of settings all with different challenges Finding a practice through the PCSU which I enjoy coming to work Lifting patient care and expectations in a managed practice has been rewarding” PCSU GP “I have been encouraged to pursue interest in palliative medicine and medicolegal medicine I have been attending the palliative care network group, the cancer network advisory group and clinical governance meetings I would recommend the scheme to a colleague looking for a salaried post” PCSU GP “In the future I want to develop services I can offer to patients and extend my role in training other professionals” CHVP GP - 16 - Draft version “The ability to improve services within primary care and the autonomy to be able to develop these services Seeing improvements in services and that positive links can be made between secondary and primary care In the future I would like to keep my clinical skills whilst continuing to develop as an effective educator” PCSU Nurse What has been less than positive for you and what would improve the scheme? “Some of the practices in RCT can be a difficult working environment and can still feel isolating at times” PCSU GP “As the PCSU gets bigger it gets more difficult for us all to meet together I would like more opportunity to meet and liaise with other PCSU professionals” PCSU GP “Lack of links with Blaenau Gwent practices In the future we should increase our community orientated focus More innovation CHVP GP “Some micro management Being a salaried GP and asked to cover other practices at short notice Slow progress on improving premises We should continue to develop a clear vision for the future” CHVP GP “The uncertainty of having temporary contracts in the early years, and the lack of clear nurse leadership within RCT practices We should develop a bigger nursing team to aid locality development The PCSU should consider employing practice nurses rather than the practices Permanent contracts to attract a wider range of staff” PCSU Nurse “Difficulties sometimes in maintaining patient continuity” PCSU Nurse - 17 - Draft version The future Both schemes have developed models for enhancing and improving the delivery of primary care in areas where the provision of primary care was facing a crisis The RCT PCSU demonstrated an approach that supports and enhances existing GP practices in service development, supported recruitment and continuing professional development The two schemes have shown that diversity is required; some are attracted by close academic links while others seek flexibility in working patterns with close clinical mentorship We have shown that the schemes can resolve a crisis in care provision (‘seeing the patients’) and in developing a quality service We have seen evidence of a wider spin off in terms of retention and recruitment for the area Having demonstrated what can be achieved, we need to continue our rapid development from ‘an effective solution to a crisis’ to instruments for crisis prevention and then on to becoming beacons for demonstrating the best way to high quality care Key to this is to integrate the learning and teaching functions This will need to focus on not just the clinicians but the support and administrative roles within practices Developing a suite of diagnostic tools with off the shelf solutions could be useful products of this process Audit and research should be developed and integrated with the future development of primary care schemes The opportunities through linkage to Universities and academic units will strengthen this evolution We must also consider the Schemes in the wider context of LHBs The established recruitment and support structures could be used as vehicles to support salaried clinicians across LHB boundaries This would further widen the scope for learning, support and research The possibilities for flexibility and service planning together with governance and training would be enhanced This is an opportunity to get to the root of the inverse care law and move to sustainable and attractive solutions In the future, more care will be delivered in primary care A sustainable health service depends on primary care increasing capacity and quality Increasing the role and skill of the medical generalist will be one key component of this process Enhancing the range and skill of other health care professionals will also be crucial The role of the nurse in the future will be key to unlocking capacity and new approaches to patient care There will inevitably be a need to ensure that health professionals fully embrace a team approach to patient care, and the patient themselves will need to understand the changes This will need concerted effort We will need to develop new local structures that integrate with plans for secondary and tertiary care re-configuration - 18 - Draft version Some topical questions the schemes could engage with include: • • • • • • • • How can the role of the general practitioner be developed and better utilised? What will be the new roles for the wider range of health care professions? Where will these people come form? Who will train them? What will their governance arrangements be? How can more be done for patients closer to home? How can the health service more effectively help patients to more for themselves, without consulting the health care service? How can primary care make better use of new diagnostics and tele medicine in doing more for people locally? How can we improve the provision of out of hours and unscheduled care? Should most GPs be re-integrated in some way into acute out of hours care, minor trauma and intermediate care? How can this be achieved? How should primary care resource centers be configured? What equipment and tele links should they have? What will be the appropriate staff mix? How we make the new services understandable and accessible to the patient? - 19 - Draft version Conclusion So far, the two schemes have blazed a trail out of some dangerous territory Now they need to survey the rapidly changing landscape before them and help pioneer the route to a sustainable primary care led NHS that rapidly increases its contribution to enhancing the heath and quality of life of the people of Wales A greater engagement at the level of policy and evaluation will be key ingredients of success The Teaching LHB is an opportunity to enable all LHBs to engage and benefit through shared learning and service opportunities With a primary care focus this can play a key role in enabling whole system change – the real challenge underpinning the future of our National Health Service - 20 - ... professionals Excellent teamwork and communication delivering and monitoring quality of care against national standards Education and training of the next generation at both undergraduate and postgraduate... care law and move to sustainable and attractive solutions In the future, more care will be delivered in primary care A sustainable health service depends on primary care increasing capacity and. .. deliver care and meet national standards A base for clinical sabbaticals by established Principles with special skills who can help to regenerate the valleys areas Catalyse the attainment of NSF standards