Primary Care – a challenge and an opportunity

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 prim

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 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 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:

1 An environment that attracts and retains a highly motivated workforce and trains the next generation

2 High quality healthcare delivered from premises fit for purpose by well trained and motivated health professionals

3 Excellent teamwork and communication delivering and monitoring quality of care against national standards

4 Education and training of the next generation of healthcre professionals

at both undergraduate and postgraduate level

5 A resource that provides a focus for continued professional

development for all established healthcare professionals in the valley area

6 A support facility that can mentor new recruits into general medical practice and primary care

7 A professional base from which clinical support can be offered to

practices and professionals who are struggling to deliver care and meet national standards

8 A base for clinical sabbaticals by established Principles with special skills who can help to regenerate the valleys areas

9 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

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

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, 2 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:

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

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

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

3 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:

1 To provide a resource centre for a population based clinical service

2 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

3 To provide clinical and management support at practice level for the improvement of existing services and development of new services

4 To support practices with recruitment problems by providing a salaried

GP for a fixed number of sessions a week

5 To directly manage practices where there are difficulties replacing retiring GPs

6 To support local GPs or nurses who want to develop their skills and gain training

7 To support local practices by providing training courses, training

materials and educational events

8 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 2 salaried GPs, 2 nurse practitioners and 1 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

3.2 Project team

The PCSU team consists of a clinical director, a manager, 2 administrative staff, 18 salaried GPs (5 full-time, 13 part-time, equating to 13.9 WTE GPs), 8 nurses, a nurse practitioner, 2 specialist nurses, 3 nurse facilitators and 2 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 3 or 4 years Since the start of the scheme in 2000 the PCSU has only lost 5 members of staff for the following reasons

- 2 GPs to take partnership in RCT practices

- 2 GPs to take partnership outside Wales

- 1 GP family moved outside Wales

- 1 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 ill-health 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