Maximising the potential of GP clusters in Wales

Primary health care provides the first point of contact in NHS Wales and is largely focussed on general practice. In fact, more than 19 million contacts are made with primary care each year in the Welsh NHS, provided by GP’s working in local communities.

The structure of how primary care is delivered continues to evolve by necessity. The expanding, multi-disciplinary, primary care now often includes allied healthcare professionals such as physiotherapists, occupational therapists, pharmacists and nurse practitioners who bring their specific skills to strengthen the team and reduce pressure on GPs. In keeping with prudent healthcare values, this diversification of the team ensures that patients see the right professional, at the right place at the right time.

As an example of the value of multidisciplinary working, the Chartered Society of Physiotherapists has estimated that musculoskeletal (MSK) health issues are the most common cause of repeat GP appointments and account for up to 30% of a GP caseload. It contends that most of them can be dealt with effectively by a physiotherapist without any need to see the GP. It is therefore an increasing a priority for practices to identify how they can expand their primary care team against the backdrop of increasing financial pressures.

Outside of changes to who you might see at a doctor’s surgery, how primary care is organised at a local level continues to change too. Local Health Boards throughout Wales have created Primary Care ‘clusters’, which simply means the bringing together of several neighbouring GP practices covering a population of between 30,000-50,000 patients.  These clusters have the potential to provide the structure and finance to help practices collectively innovate and, if appropriate, diversify their primary care teams.

Clusters are not the merging of practices. Rather, they allow for joint working between practices and key partners to enable patients within that area to have access to services they may otherwise struggle to access. The aim is to better integrate services in order to meet the local population’s needs. Clusters promote and retain high quality general practice, and develop working with primary and community care partners within health and social care sectors. Many also support and facilitate collaboration between member practices, including those which may be struggling to remain financially viable. This type of working takes many forms including the sharing of staff and expertise, peer support and workload management.

It is hoped that the development of clusters will assist with combating the unprecedented challenges currently facing general practice. In 2016 BMA Cymru Wales’ Urgent Prescription survey found that 82.1% of respondents were worried about the sustainability of their practice. There is no indication that this level of concern has decreased as we move into 2017. The need to place general practice on a more sustainable footing has never been starker. Clusters are an important part of changing the landscape for general practice.

There is widespread support for the cluster model; to both determine and address the health needs of the surrounding population. However, despite investment, cluster networks are not yet working effectively and the pace of development is not uniform across the country. Nor has the new money truly transformed services. There is widespread concern that LHBs are reluctant to devolve decision making as a consequence. This has led to challenging experiences for those in the early stages of establishing cluster networks.

In our survey of GPs, undertaken in April 2017, we found that:

• 60% of respondents did not think clusters had sufficient strategic autonomy from health boards.

• 56% of respondents did not think clusters had enough financial autonomy from health board in spending directly allocated funding.

In April 2016, the Welsh Government announced an extra £43m a year for four years for general practice — with £10m handed to Wales’s 64 clusters.

To date, cluster money has been used variably, and going forward, this needs to change. Cluster monies must be used in a targeted way, maximising impact and sharing best practice where it is identified. The BMA’s Welsh General Practitioners Committee has urged cluster leads to consider how available funding can be best spent on making their working day less pressured, with the ultimate goal of improving services and access available to patients.

Last year we wrote to cluster leads advising them of the importance of using cluster monies strategically to transform primary care. To support this transformative agenda it is essential that Local Health Boards make the new monies available to clusters to support them to tackle these pressures in innovative ways. Currently, some health boards are not making it easy enough for clusters to draw down funds in a timely and appropriate way.

In addition to the challenges posed by the autonomy and funding of clusters, the time implications for GPs to engage meaningfully with clusters continues to be a barrier. Given that an aim of clusters is to reduce the burden on GPs it is concerning that for many the time they’ve invested has not been worthwhile. Our survey found that:

• 64% of respondents do not feel that the time they spend on cluster work is adequately resourced.

• 47% of respondents believe that cluster work adversely affects their clinical time.

• 46% said that cluster working had affected their working lives, but not necessarily in a positive way.

Several respondents noted that cluster work took their (or their GP partners’ time) away from patients, creating additional paperwork rather than any discernible benefit. On the other hand, some highlighted workload reduction brought about through the establishment of practice based pharmacy and the employment of advanced nurse practitioners to visit care homes.

Despite pockets of good practice, and the obvious potential of the cluster model, it is evident that clusters are not yielding positive results across Wales. It is clear that the use of cluster monies must be improved if outcomes are to be maximised. Cluster leads must consider how available funding can be best spent on making the working day less pressured, with the ultimate goal of transforming services and access available to patients. To support this, training and support must be put in place to enable clusters to deliver effectively.

Ultimately, clusters will only deliver if there is a fundamental change in approach by Health Boards, which must devolve decision making and provide clusters with sufficient support and resources (personnel and financial). We believe that clusters should become true legal entities with clearer governance and financial frameworks, which will then enable those clusters that are flourishing to have the tools they need to develop further and sustain delivery, while allowing others to get fully off the ground.