Practices in Wales have the option to work within a cluster in order to provide help for one another. The neighbourly advice has so far served well for Central and South Denbighshire cluster group
From April 2014, cluster working became a priority within Wales, replacing 160 points from quality outcomes framework (QOF)/ quality and productivity (QP). Cluster groups are set within the locality and run over a three-year period. The idea is that practices will become strengthened by participating within their cluster, focusing on areas to support, reinforce networking and also for the first time having an opportunity to commission a service identified within their area.
The aim of a cluster is to improve mutual working, expand and enhance synchronisation of care within the community and reduce disparity of health within the cluster population.
The cluster at work
As a practice manager of a semi-rural practice in North Wales, the surgery I work at falls under the Central and South Denbighshire cluster group. The health board sets up the cluster and the practices are incentivised to take part due to the value attached to the points available. The money to set up the cluster comes from the Welsh Assembly Government. Practices do not have to be part of the cluster group, but if they choose not to then this would clearly be a significant reduction in income for the practice. Few, if any practices can afford to make that decision.
There are eight practices within the Denbighshire group. Part of the cluster intention is for practices to develop their own practice development plan and also contribute to the annual GP cluster plan. The plan allows practices to identify areas of concern and work with the health board who provides relevant information and who will respond to requests for data in order that the practice can complete the plan with up-to-date information and the ability to compare data.
In practical terms the development plan is a fairly lengthy document and a considerable piece of work. The plan covers exploring the demographics of the practice area and whether there are any particular issues in that area, perhaps social factors or higher than usual prevalence factors. A needs assessment is carried out on the practice population and any important issues practices may have that have arisen from complaints or upon analysis of significant events should be included. Access is, of course, considered along with consultation rates and waiting times. Any additional services the practice provides is noted. A detailed breakdown of practice staff and also any premises issues are also sought. The practice plan is made available online to the public through My Local Health Service (see Resources).
Once the practice plans have been finalised these will form the basis of the cluster network plan. Comparisons will be made between many aspects including access, what is available at some practices and not others eg, My Health Online (see Resources). Consideration is also made of services that are available in one surgery but not in another, and how practices can collaboratively enhance any existing surgery and perhaps make their own service available to patients from other practices. For example, in South Denbighshire some practices did not have full sexual health clinics where IUDs could be fitted. An agreement was made that practices could refer patients to the practice that did. Another surgery held specific minor illness clinics with a GP who had a specialist interest in this field, this expertise benefitted patients from this additional service while also removing the wait for the service within secondary care.
The cluster has worked over the last 12 months to prioritise what services can be commissioned that will make a real difference to its patients. New methods are deliberated that will assist and strengthen benefits to the service provided within the local communities. These services could be related to new equipment, new clinical roles or perhaps a new service identified to assist with a particular vulnerable group omitted from or under resourced within the current structure.
The local health board has a presence at every meeting; practices have to attend four cluster group meetings and one final meeting to agree the final cluster network report. The cluster focuses on three pathways; practices partake in these nominated national care pathways incorporating end of wlife care (particularly looking at emergency unscheduled admissions and palliative patients), early detection of cancer and reviewing elderly patients, minimising the harms of polypharmacy. Individual cases are examined. Good and bad practice is then identified and themes are established and shared to ensure good practice is entrenched in everyday care.
In addition there is a requirement for practices to meet and hold a multidisciplinary team meeting twice a year, the aim of this is to improve networking across not only statutory bodies but also the third sector. At Pen-y-Bont we used these multidisciplinary team meetings to strengthen relationships between various organisations including Single Point of Access (where one phone number is based at the local authority; they take self-referrals or referrals from professionals and the staff then source the most appropriate support for that person) social workers, carer organisations, mental health services and district nurses. There was also an opportunity for the whole practice team to be present, which enabled everyone to gain knowledge of existing services within the community. Any multidisciplinary issues identified are then raised at cluster level.
Along with these priorities, patients’ views have been firmly put on the table as a main concern. It is required that cluster practices offer patients a platform to give their views and the practice is expected to show that they have not just compiled these views but have looked at themes and again reported back to their cluster should any improvements be detected. Service users are expected to have an impact on the final cluster network plan. Practices have therefore had to look firmly at their patient participation groups and how useful and dynamic they are.
Within our surgery at Pen-y-Bont we decided to look at an online patient participation group. This has been added to the existing website and has been a phenomenal success. Previous patient participation groups may have consisted of at best five patients meeting on a face-to-face basis. Within three months the online group had almost 40 participants, also other patients have been given the option to become ‘website subscribers’ only, this also reached more than 30 patients within the first two months. This enables practices to not only gain feedback quickly but also provides a much less time-consuming approach with much better outcomes. Patients regularly complete surveys or direct questions about what matters to them. The site neatly puts the information into graphs. The largest group using the online patient participation groups is surprisingly those over 65, proving that online groups are more likely to include patients in this age range, rather than exclude.
Services on offer
The clinical governance tool is another addition to the cluster network that practices are required to complete this year. Again, this is a very consuming and a considerable piece of work. The tool includes more than 50 questions relating to different themes covering issues from dignity to infection control. Practices are required to self-audit and also demonstrate how they have reached these achievements. In addition, there is much more emphasis this year on child protection, learning disability and protection of vulnerable adults. Practices are expected to have minimum standards within these priorities and feedback to the cluster any improvements that may need to be considered.
Alongside the work that is done in practices, the aim is to bring common themes the cluster finds when reviewing the pathways, gaps in service and innovative ideas. These ideas could include perhaps the development of new clinical roles, an increase in shared services, new technologies and an increase in the use of third sector organisations to enhance services within general practice. After much deliberation the Central and South Denbighshire cluster decided to commission an advanced nurse practitioner to work within the care homes of the cluster with the idea that patients would receive continuity of care from an appropriately skilled clinician and that practices would be partly relieved of some of the daily additional pressure. Other clusters have bought in new services, such as additional counseling within the practice setting, providing easier access and a better service to patients while again hopefully relieving some strain on resources.
Dr Mat Davies is the locality lead for Central and South Denbighshire cluster network. He says: “It can be both good and bad for local GPs to have some say and freedom to make decisions on what needs doing at a local level. Working with colleagues in social care, leisure services, third sector, public health feels very progressive and more cohesive. Some of the schemes we have set up are working well for patients and professionals.”
In addition though Dr Davies did note some dissatisfaction too stating that “frustrations over having to work within the red tape of the health board rather than the freedom we are used to in general practice (for example, advertising a job takes months rather than a few days)”. However he concluded that he does “enjoy the challenge of trying to enthuse and engage the local GPs in what is a progressive way of doing things”.
As with many schemes the cluster network has hurdles to jump and unfortunately does bring about more paper to push. However, it also provides opportunity and a degree of autonomy when commissioning new services. There may be stumbling over red tape but with it small steps are being taken through commissioning, which should bring improvement in care.
Dwysan Edwards, practice manager, Meddygfa Pen-y-Bont Surgery.
My Local Health Service – mylocalhealthservice.wales.gov.uk/#/en
My Health Online – myhealthonline-emisweb.wales.nhs.uk/Home/ViewLanguages