The next item is a debate on the Health, Social Care and Sport Committee's report on primary care clusters, and I call on the committee Chair to move the motion—Dai Lloyd.

Motion NDM6624 Dai Lloyd

To propose that the National Assembly for Wales:

Notes the report of the Health, Social Care and Sport Committee on Primary Care Clusters, which was laid in the Table Office on 13 October 2017.

Motion moved.

Thank you very much, Presiding Officer. I'm very pleased to open this debate on our committee's report on primary care clusters.

Now, for patients, primary healthcare is their first point of contact with the healthcare system in the NHS. The main source of primary healthcare is in general practice. Primary care clusters are groups of general practitioners working with other health and social care professionals, and they do so in order to plan and provide services locally. The committee decided to undertake a review into primary care clusters as we wanted to take a close look at whether this model of working is delivering improved services to patients and whether it is on track to make the systemic changes we know are needed within primary care. 

From December 2016 to February 2017 we ran a public consultation. We received 47 written responses, representing a range of healthcare organisations, professional groups and individual clinical staff. We heard oral evidence from a number of witnesses and at events held in Carmarthen, Caernarfon and Wrexham we met with GPs, practice managers and other representatives from clusters and LHBs. The group discussions focused on the maturity of clusters, cluster development, workforce, funding, patient satisfaction, and accountability. The evidence we heard helped us come to some very clear conclusions and enabled us to make robust recommendations to the Cabinet Secretary.

The Deputy Presiding Officer took the Chair.

Earlier today, we met with people who gave evidence to the original inquiry over in the Pierhead at lunchtime, and that was in order to seek their views on the report’s findings and the Welsh Government’s response to it. I would like to take this opportunity to thank all those who took part in that.

Moving on to the conclusions and recommendations, our report covers a wide range of issues, including whether clusters are reducing demands on GPs, the benefits of multidisciplinary team working, and the level and allocation of funding. We have made a series of 16 recommendations to the Welsh Government and we hope they will contribute towards delivering the major step change we believe is needed in the development and direction of primary care clusters if they are to relieve pressure on GPs and Welsh hospitals.

Our first set of recommendations—1, 2, 3 and 4—relate to the pace and nature of cluster development. There is significant variation in the maturity of the 64 clusters and their stages of development. Whilst variation is not in itself a negative, the committee wants to be assured that this is as a result of responding to local needs, rather than because of a lack of consistency in the pace of development. We heard differing views about the purpose of clusters and believe this adds to the variation in how they are developing. Whilst some are very effective at bringing key delivery partners and stakeholders together, in other areas they appear to be primarily seen as a vehicle to apply for funds. According to some respondents there is a large degree of reliance on the energy and enthusiasm of individual GPs, GP practices or cluster leads, and that this is not a sustainable long-term model. We also heard that not all the right stakeholders are involved and that some clusters still have a focus on general medical practice.

We agree with the Welsh Government that primary care services should have a strong focus on local planning and delivery of services to meet the identified health needs of the population. Therefore we support the view that clusters need autonomy. However, this must be positioned within a much more defined and structured governance framework. There is a need for a clearer view on the future shape, accountability, powers and structure of clusters. Without this, there is a danger of a variety of ad hoc local approaches that will not deliver sustainable change. I therefore welcome the Cabinet Secretary’s acceptance, wholly or in principle, of recommendations 1 to 4.

Turning now to whether clusters are delivering the Welsh Government’s ambitions for primary care—these are recommendations 5, 6 and 7. We fully support the Welsh Government’s aim for clusters to play a significant role in planning the transfer of services and resources out of hospitals and into their local communities. This will not happen without an increased impetus and focus on how secondary care professionals can be meaningfully involved in cluster working, and how clusters can engage in the very big challenges around reducing unscheduled care. The Welsh Government must set out a clear plan as to how this aspect of cluster work will be taken forward.

We also heard about the need to change patient expectations in terms of the appropriateness of seeing a range of primary care professionals rather than seeing the GP. Examples were given of patients insisting on an appointment with a GP, despite there being other staff such as a practice nurse who it may have been more appropriate for them to see. We therefore support the need for a national campaign, building on the existing Choose Well strategy, to increase patient understanding and support for the increased multidisciplinary team approach. We welcome the Cabinet Secretary’s acceptance, wholly or in principle, of recommendations 5, 6 and 7.

Recommendations 8, 9 and 10 focus on issues related to staffing. There are obvious and substantial benefits to the multidisciplinary team approach on which the cluster model is based. However some of the associated practical difficulties are substantial and, in our view, potentially pose the most significant challenge to the future of cluster working. These include: the recruitment and retention of GPs and a wide range of other professionals involved in primary care; the question of who employs cluster staff and the associated issues of pensions and indemnity, perhaps the most significant barrier to effective cluster working; the potential for GPs to spend time dealing with HR and management issues rather than on delivering clinical care; that the clinical supervision of the MDT is becoming diluted as staff are placed outside traditional management models and physical locations; the negative impact of annual funding allocations impacting on the ability to recruit and retain staff; and associated governance issues.

We also heard about the need for properly planned and co-ordinated workforce training and skills development for staff. It is therefore disappointing that the Cabinet Secretary has rejected our call to put in place a national lead to co-ordinate training and development needs within clusters and I would welcome further explanation from the Cabinet Secretary of his reasons for this. Cluster funding was welcomed by all of those involved in cluster working, whether nationally or locally. We made three recommendations, 11, 12 and 13, in relation to funding, all of which were based on the evidence we received and were not calling for any additional funding. It is therefore disappointing that the Cabinet Secretary has chosen to disregard these important points.

The NHS needs timely and effective infrastructure to support the change to cluster working. This includes both the primary care estate and ICT infrastructure—recommendations 14 and 15. The evidence we heard suggests that progress in this area has been minimal and that the estate, in its broadest sense, remains a significant issue for the primary care sector. I welcome the Cabinet Secretary’s recent announcement of £68 million to deliver 19 new integrated health and care centres across Wales by 2021, as these will be key to relieving pressure on GPs and hospitals by keeping vital health services closer to home in people’s communities. I also look forward to hearing the Cabinet Secretary’s response to the findings of the parliamentary review of health and social care in relation to ICT infrastructure.

Our final recommendation, recommendation 16, relates to the need for a much clearer and robust mechanism for evaluating cluster work. Whilst in general we heard some positive feedback about the perceived impact of cluster initiatives, there was very limited quantifiable and measurable evidence to back up these perceptions. Concerns were expressed about whether it is possible to demonstrate the impact of clusters, and about whether there are mechanisms in place to ensure the robust evaluation of what they do, and the extent to which they are improving patient outcomes. Evaluation and monitoring were seen as vital not only in assessing progress, but also in ensuring that successful cluster work was shared with others and rolled out where appropriate. It is therefore disappointing that the Cabinet Secretary has rejected recommendation 16. I look forward to the debate this afternoon. Thank you.

I was very pleased to have been part of the Health and Social Care Committee when we decided to undertake this inquiry into primary care clusters. Our decision to look at this stemmed in great part from the concerns that other committee members and I had been made aware of through our discussions with doctors in general practice, and we wanted to evaluate this new method of working. I would like to thank the committee staff and all the witnesses who, through their frank evidence, enabled us to challenge the health boards and the Government, and develop a set of recommendations that we believe would enhance the development and authority of the GP cluster network in Wales. 

We heard of so much good practice by GP clusters where there is a strong representation and involvement by other healthcare professionals, such as occupational therapists, physiotherapists, palliative care nurses and mental health specialists. We heard of examples where an idea to enhance services to the patient had been nurtured, received funding, been piloted, shown to be good practice and then either expanded or stalled. In most examples, the barriers to best practice becoming common practice emerged with a similar theme. Health boards wanted to dictate and control the money, thereby stifling the very innovation we needed. There was a lack of sustainability in either people or the money, projects stopped and started, and projects were driven to year end rather than having longevity. 

Not all clusters engage with a broad spectrum of allied healthcare professionals, who had services and ideas to offer, but simply couldn't gain traction. Projects that worked have had to fight to be adopted as common practice by the health board. The checks and balances and reporting overwhelm the green shoots and, of course, there is a self-fulfilling prophecy. If the health boards don't adopt the successful projects and make them their own, then the cluster funding that's tied up in that project cannot be released to act as seed funding for the next innovation.

GPs sometimes found it extremely difficult to engage with the clusters themselves because of the sheer pressure of their case loads, and there was a sense by some allied healthcare professionals and community pharmacists that they could do more, that they were there ready, willing and able but that, in some instances, the cultural shift to stop thinking 'doctor' and utilise their skills and training was hard to achieve.

But where it works, it works well. I would cite examples from the Argyle Street medical practice based in Pembroke Dock in my own constituency, a practice under immense pressure with the largest patient roll in Wales and three doctors down. For chronic conditions and palliative care, they have utilised cluster funding to bring on occupational therapists and palliative care nurses, some of whom are funded directly by the health board and who have become the new front line in helping these vulnerable patients, thereby enabling the doctors to act as a backstop for the more complex conditions.

However, our inquiry, as the Chair has said, did find that it was very much a mixed bag, which is why I find the rejection by Welsh Government of our recommendation 16 so utterly astonishing. We wanted Welsh Government to ensure that there's a clear methodology for the evaluation of cluster work. We believe this would enable best practice to be adopted as common practice more quickly and would help to identify why some projects didn't work and ensure that they were ceased rather than money continually being flung at them. The response by the Government is frankly jargonese, hiding behind the King's Fund, and I've never been able to get my head around any organisation, Government or not, that will spend money without costing that spend—and I reference commentary from your response to our budget report—or measuring outcomes. We must quantify and evaluate. How can we do that without the appropriate information?

Recommendation 11: the Welsh Government have rejected our recommendation that cluster development money should be allocated to individual clusters on a three-year rather than one-year basis, yet the need for sustainability in cluster funding to enable training to get the right staff on board to alleviate concerns over which organisation people work to, the need to pilot, trial, evaluate and adopt—you can't do all that in a year. But a three-year funding cycle at least enables some measure of sustainability. I urge the Cabinet Secretary to review these two recommendations again in the light of all the evidence the health and social care committee took.

I do recommend, Members, that this report is read by all of us, because, given the emphasis on primary care within the parliamentary review into health and social care, clusters are a model for the way forward, but they need to be funded, freed, accountable and, ultimately, evaluated.

As a member of the committee, I largely welcome the response of the Welsh Government to the report as we continue to develop and strengthen the primary care clusters in the years ahead.

My overriding impression from the evidence we took in this inquiry is that, for many, it was too soon to take an informed decision or an informed view on the overall success of the clusters. So, I do think that the evaluation of activity in existing and developing clusters will be vitally important if we are to roll out good practice across Wales.

So, today, however, rather than focusing on any of the particular recommendations, there are just three points that I want to make. Firstly, investing our money to help deliver much-needed change and ensuring that we share good practice. Secondly, investing our money to help people make the right choice about their care, building on the work of the Choose Well campaign that Dai Lloyd's already referred to and delivering change in the primary care settings. And thirdly, how the work on primary care clusters is just one part of the huge responsibility to be placed on this whole Assembly in light of the parliamentary review of health and social care.

So, first, I'd like to link the growing role of primary care clusters to the vital task of spending the health budget wisely. I think the case for cluster working is well evidenced, although evaluation at present is not, and the task facing the Welsh NHS is to ensure the examples of best practice are rolled out quickly and effectively as the cluster models mature. The challenge we all face, irrespective of party-political colour, is to ensure that the moneys we invest in the Welsh NHS help to make the real changes in service delivery that we know are required. We now need to ensure that clusters are able to influence integrated medium-term plans and that those plans allow for the intended innovation the cluster funding was intended to deliver. I'm firmly of the view that we can't afford to continue investing in models of care that don't respond to the ever-changing needs. The evidence tells us that we need to shift services to the primary setting and if done properly, clusters can be an effective way of doing this, and there are some excellent examples of good practice already out there.

In my own health board area of Cwm Taf, for example, we've seen the success in Merthyr of the Baby Teeth Do Matter project, which is ensuring that under two and five-year-olds are receiving early access to dental care through healthcare support workers and dental therapists. GP support officers are supporting GPs to focus on what they can do, helping people with social care needs and care co-ordination, and the cluster is leading with ICT projects like the GP web, which provides online triage.

Cwm Taf have also piloted a virtual ward cluster project in Aberdare, which, I understand, they're soon to roll out in Merthyr as well, which saw a multidisciplinary primary care team target 150 frequent hospital attendees, mainly elderly frail, by proactively visiting them in their own homes, to offer support through physios, occupational therapists, paramedics and pharmacists. Over an eight-month period, this has seen GP appointments reduce by 60 per cent, hospital admissions reduce by 80 per cent, and calls to out-of-hours services reduce by 90 per cent. This has allowed GPs time to deal with more complex issues in their surgeries. 

So, to resist change in service delivery, like the examples I've just given, is to encourage stagnation, and stagnation does not reflect what the people of Wales need from their health and social care system. Therefore, I welcome the Welsh Government's response that firms up the commitment to provide a clearer vision on the work of primary care clusters. 

This leads me to my second point. As the current pressures on the system show, the next phase of the work on primary care clusters must help to strengthen the important work that underpins the Choose Well campaign. It's beyond doubt that, as users of the NHS, we must continually be reminded about the way in which our personal choices can impact on the integrity of the whole system. Strengthening services in primary care clusters, therefore ensuring that people do not need to routinely visit a hospital for their treatment, is part of the overall strategy. Perhaps we need to move back to using the full terminology of 'accident and emergency' to reinforce what the hospital-based service is truly about.

Finally, and my third point, this report on primary care clusters is just one part of what I believe is a significant year for the NHS in Wales, as we will also need to work extra hard as we receive and consider with great care the recommendations of the parliamentary review of health and social care that we debated yesterday. We have much important work ahead.

Certainly, I learnt a great deal during this inquiry. I have experience in my constituency as an Assembly Member for Ynys Môn of seeing a cluster at work—a very effective cluster as I understand it. I've sat in on cluster meetings and have seen the multidisciplinary work coming together in a way that I believe was very effective on behalf of my constituents in Ynys Môn.

But I've also learnt in this inquiry that a cluster can mean something very, very different in different parts of Wales, depending on everything from geography to the size of individual GP surgeries, to the kind of correlation between different elements of the multidisciplinary teams—depending on personalities even, and depending on people's attitudes towards clusters and what their purpose was. We've heard from people who were seeing the cluster as something that was genuinely there to bring a team together. We've seen federalisation happening as a further step. We've heard of others seeing clusters as a mechanism just to draw in additional funding for a particular project.

So, if we look at the first recommendation, I think that that summarises, possibly, the major intention of what we discussed, which is the need for clarity with regard to what exactly a cluster is:

'The Welsh Government should publish a refreshed model for primary care clusters'  and that the model needs to be clear. I'm looking forward to seeing how that will be implemented by the Government.

Welsh Government has rejected five of the committee recommendations. That's nearly a third. I'm disappointed at that as a committee member. I don't think it's particularly acceptable, in that none of those five, I don't think, are particularly controversial. I don't consider them to have massive financial implications, but, of course, I look forward to hearing the Cabinet Secretary's comments.

Let me go through those rejected recommendations. Recommendation 10—that's about improving planning for national training. Given our frustrations in recent times about workforce planning in Wales, perhaps one obvious and rather cheeky comment would be to say that at least the Government is consistent in refusing to carry that out, but, again, I look forward to hearing more about the rationale. Recommendation 11 says three-year financial planning should be introduced. Why reject that when Government was supportive of LHBs moving in that direction? Recommendation 12 says to review funding streams to ensure maximum impact from funding. It beggars belief why there's anything wrong with that.

Recommendation 13—

'establish clear decision making processes for quickly evaluating and scaling up successful models and ceasing funding for less successful initiatives.'

I think, perhaps, this is one of the biggest problems in the NHS. Successful initiatives, and, goodness me, they exist. We've seen plenty of them. We know of plenty of examples of innovations devised by staff within the NHS and managers, but they're not scaled up effectively. We see failed ventures allowed to continue, and I think rejecting the recommendation there suggests to me that we have this persistent problem in that particular area.

Recommendation 16, then, says to

'ensure there is a much clearer and more robust mechanism for evaluating cluster work.'

Why on earth reject the idea of collecting evidence to see if a policy is working?

So, we learned much as a committee. I certainly learnt that the principle of clusters is a principle worth pursuing, and I think it's in the interests of the NHS in Wales to see how we pull different parts, in this case, of the primary care sector together in the interests of Welsh patients. I look forward to hearing more about what the Cabinet Secretary believes he has learnt too.

I'm a member of the committee, so I was very pleased to take part in this inquiry, and my view, I think in line with that of the committee and most of those who gave evidence to us, is that the principle of clusters is a very good one, that the principle of interdisciplinary work is excellent. But I think we all felt that there's a lot more work to do to make the clusters more effective, and there are a lot of issues that need to be ironed out.

The highlight of the inquiry for me was the focus group in Carmarthen, ably facilitated by Angela Burns, where we were able to hear first-hand about the issues that concerned the participants there and the frustrations that they experienced in the cluster groups. Of course, the Chair mentioned in his contribution the lunchtime meeting we had with the professionals here today before this report, and in that meeting at lunchtime, I was so struck by the enthusiasm of the participants there for doing a good job in the health service and really making a great commitment. I think that came over really strongly today, and I think they all were, in principle, in support of the clusters, but they were very keen to raise the very practical ways that the clusters could be improved and the ways that we could move forward.

Obviously, one of those key issues is funding, and Members who've spoken before me have raised the issues about funding, but I think there is definitely some tension between the local health boards and the funding to the cluster groups. I think it was also mentioned in the report, and I think the BMA stated that they were aware of significant delays in the release of these funds. And there is a case, as well, for the cluster development money to be allocated directly to the clusters rather than to the health boards. So, along with the issue of the annual funding, I hope that the Cabinet Secretary will look at these issues, because there is this great enthusiasm, and I think that we need to make it as easy as possible for the clusters to develop.

The multidisciplinary working is so much to be welcomed, and one of the very interesting discussions in the Carmarthen focus group was how the patients are not able to see the GP in the way that they used to, and for some of the elderly patients who were used to seeing a GP and used to seeing always the same GP, it's quite a break in culture to see the nurse instead, or to see another allied professional more appropriate for their needs. I think, obviously, being able to see someone who is most appropriate for their needs is the key thing of multidisciplinary work. I think that as patients gradually get used to this way of operating, it will be a very effective way to operate, and the patient will see the most relevant person. I think there is, also, the opportunity, because I think patients do like continuity, they do like to see the same person, that there's no reason that can't be an allied health professional who sees them on a regular basis. That could be the same person.

I wanted to just mention quickly my experience in the constituency. Certainly, in this inquiry, fears about shortages of GPs and the difficulties of replacing GPs have cropped up all over the place, and we have had a difficult experience in Cardiff North where one of the local GP surgeries actually closed down. What happened was the existing partners of Llwynbedw practice in Birchgrove and Cathedral View in Llandaff North gave notice of their intention of terminating the general medical services contract, giving six months' notice. The health board were unable to secure another group of GPs to take over the practice, and no single practice came forward to take it over. So, both the buildings belonged to the GPs—the existing GPs. One of those is being sold. But this has had a very upsetting effect on many of my constituents who've contacted me, because it has resulted in the disruption of the pattern of healthcare that they were used to receiving. I attended a meeting of the cluster group in Cardiff North, and I know that the GPs in that cluster group felt that it should have been possible to stop this disruption for patients, and there should have been some way of ensuring that these—many elderly—patients weren't left bereft, because they were no longer able to go to the surgery they'd been to for many years. And it has resulted in a much heavier case load for other GP surgeries.

So, I think that the cluster groups are an excellent way forward that does give the opportunity for expertise to be shared, to bring in the allied professionals, and in this meeting at lunch time today, I was sitting next to the only nurse who is the lead in a cluster group. There's only one in Wales who leads a cluster group, but we hope that is a pattern that may happen in many other place.

I'd like to thank the committee clerks and all those who gave evidence to our committee during our inquiry into primary care clusters. Primary care clusters have the potential to transform the care delivered in our communities, but whilst we saw some excellent examples of successful clusters, there is a large variation in performance. Many GPs expressed their disappointment at the clusters. Some were highly critical. One GP described their cluster as 'amateur'. Whilst there is widespread support for the principles behind the clusters, it is broadly felt that they're not living up to the expectations. 

Many witnesses pointed to the fact that development was being held up by local health boards. Cluster development funding is controlled by local health boards, and many of the clusters found they were unable to use the moneys in the most effective way, due to overly bureaucratic rules and regulations. We heard that around 90 per cent of the funding was being used to pay for staffing costs. We also heard, time and time again, that the local health board's role in allocating development moneys added unnecessary delays in getting the funding to the clusters. The Welsh NHS Confederation told us that the need to spend moneys by year end made it difficult to redesign a service, recruit, train and make real change, due to the inflexibility and insufficient lead time. As a committee, we felt that funding should go directly to the clusters, and that it should be allocated on a three-year basis to avoid short-term planning decisions, which often do not offer the best value for money. I'm disappointed that the Cabinet Secretary has rejected recommendation 11, and I urge him to reconsider.

It became apparent to me, over the course of this inquiry, that it wasn't just the funding issues: health boards were hindering the ability of the clusters to deliver real change. The British Medical Association called for greater autonomy for clusters, and that they should be at arm's length from local health boards. I'm therefore pleased that the Cabinet Secretary has accepted recommendations 2 and 3, which recommend new governance structures and delegation of decision making to clusters. 

Of course, the clusters are only effective when they have consistent and clear leadership. The BMA told us that where clusters are successful, it's largely due to specific individuals who have shown proactive leadership despite the constraints of their clinical responsibilities. The committee feels that all relevant professionals need the time and space to be meaningfully involved. We recommend that there be a refreshed model and that guidance be published, setting out core membership to ensure that clusters involve the right people and have the best possible leadership team. I'm pleased that the Welsh Government have accepted this. The Cabinet Secretary has indicated that a workshop will take place next month to draw together proposed governance arrangements. The BMA has requested that the date of this workshop be moved to allow GPs to attend. I would be grateful if the Cabinet Secretary could inform us if that is possible.

All of us here want primary care clusters to succeed. As highlighted by the parliamentary review, the future of care will focus more on primary rather than secondary care, so it is important that we improve health and care provision in our local communities. Clusters have an important role to play in delivering those improvements and change. Our committee have made 16 suggestions for improving the role and operation of primary care clusters, and I urge the Welsh Government to reconsider and accept all of our recommendations. Thank you. Diolch yn fawr.

This report was published in October, and I'm obviously keen to understand why we're only debating it now. I appreciate you have to wait for the Government's response, but as I'm not a member of the committee, it is important that we are all absorbing the evidence that you're gathering, because we are talking about half our whole budget, and therefore we all have a duty to ensure that the money we are allocating to health is being spent in the best possible way.

I think primary care clusters are hugely important as a way of breaking down artificial barriers—artificial demarcation lines—between different professionals. It's also a way of tackling underperforming practices, or struggling practices, like the case that Julie Morgan's just described where the practice went out of business and nobody was prepared to take it on. Had they known about it earlier, had the cluster arrangements been closer, perhaps another practice would have been ready to take it on, particularly if they weren't presented with a surprise.

Today, I've had an excellent experience with a practice manager. I needed to very quickly establish whether a particular form that's called DS1500 had been provided to the DWP to enable somebody to get the attendance allowance that people are entitled to at the end of their life. So, this is an urgent matter. I have nothing but praise for the practice manager. This is a practice manager task. It's nothing to do with a GP in the sense that I'm not seeking clinical advice; I'm seeking administrative advice. I need to know whether this form has been sent. When we managed to establish that the DWP had lost the form, she immediately agreed to send it again and to ensure that it got there in time. So, I would just like to say that any GP who is not delegating the day-to-day administrative management of their practice to a practice manager is not using their clinical skills effectively. They should not be needing to worry about whether or not the equipment that people need to examine patients is available. That is something that somebody else should be doing.

Equally, I do find it very frustrating when I visit pharmacists to learn that GP practices are resistant to sharing the information about what medication patients are receiving. This should be available through the IT system, to enable the pharmacist, who is the specialist in medicines, to be seeing exactly what cocktail of drugs this patient is getting and whether or not what's been written on the prescription is appropriate to that individual. I'm afraid it's not uncommon, with prescriptions, for the point to be in the wrong place, and that can be extremely worrying. Of course, pharmacists are the front line. Everybody knows stories of the difficulties of getting an appointment with the GP, whereas with the pharmacist, you can walk in and you will get the advice immediately. So, I think that clusters need to be working much more closely with pharmacists, as well as other professionals, who will enable us to share the workload more effectively in line with prudent healthcare. I read, with some puzzlement, that pharmacists weren't always invited. It's not that everybody needs to be at the cluster meeting on every single occasion. It all depends on what is the subject that's going to be discussed at a particular meeting.

Should the health boards be more or less involved? Well, we always have to follow the money because if health boards aren't prepared to ensure that the money is being passed down from secondary to primary care, we are never going to get the change that we need to ensure that we have a sustainable health service.

I'd just like to finish by reminding people that I mentioned in the Assembly previously the case study of Canterbury, New Zealand, which has spent several years getting more integrated care between primary, secondary and community care, and that that has prevented the ballooning of demands on hospital care, which we all need to see. We don't need reminding as to what's going on out in the world today. So, we need to learn quickly and we need to get on with this rather than delaying further. This has to be one way forward.

Thank you. I now call the Cabinet Secretary for Health and Social Services, Vaughan Gething.

Thank you, Deputy Presiding Officer, and I'm grateful to the committee for undertaking this inquiry into primary care clusters. The Welsh Government set out, yet again, in 'Prosperity for All' that we continue to see primary care clusters as key catalysts for reform and change in local healthcare. I want clusters to continue to develop their role as local collaborative mechanisms for assessing the needs of communities, and then making the best use of available resources. That means using funding, people, skills and other assets within the national health service, but also in local authorities, the third sector and communities themselves, to meet that need. 

We are already seeing the benefits of collaboration at cluster level, with evidence of increased collaboration resulting in a better use of resources. We also see GP practice mergers, federations and social enterprises as some of the solutions to sustainability. To improve access, as well as sustainability, clusters continue to develop and make use of a wide range of health professionals. We increasingly see pharmacists, physiotherapists and paramedics working alongside GPs within the local healthcare team—more people having more timely access to the right professionals for their needs closer to home. 

It also means that services are better able to manage demand and, increasingly, capacity and better manage workloads. For example, the bay cluster in Swansea makes prudent use of a paramedic to carry out house calls. That has resulted in people, often the elderly, being seen sooner and not having to wait for the GP to finish surgery. And, in the Llanelli cluster, they've appointed two social prescribers who are helping people access the care they need from a wide range of non-clinical services that are available from the third sector, and that's reduced the call on GP time. Some of the people who've been supported by these services have actually gone on themselves to become involved in volunteering and helping others as a result. Now, to keep people at home and avoid inappropriate emergency admissions to hospital, the cluster in north Powys is making prudent use of the new professional roles of urgent care practitioners and physician associates. I expect the pace and scale of innovation and improvement to continue to increase.

I do welcome the fact that the body of the committee report recognised the wide range of good work being undertaken by clusters. This has developed since the national plan for a primary care service in Wales was published in 2014. However, while I gently disagree with some of the tenor of the recommendations, I note that they fully recognise the progress made by clusters in what is a relatively short period of time. At the outset—and I'm not saying this because there was a different Minister at the time—there was a significant current of antipathy and ambivalence within primary care towards the creation of clusters. People doubted that they'd make any difference, and, worse, many people said they would simply take up time, and there'd be more meetings to attend and more forms to fill. There is now a significantly different attitude and approach to clusters within not just general practitioners, but the broader teams of local healthcare. And, as we heard from Jenny Rathbone, more people want to be engaged and involved in the discussion and the decision making, and the value that brings. For my part, I will continue to encourage clusters to evolve and mature as the right approach to planning accessible and sustainable local healthcare.

I outlined in both my written and my oral evidence to committee, and again in my response to the recommendations, that there are already a number of key pieces of work already under way or planned that address the lines of enquiry and the recommendations. I make it clear in my evidence that we have to be careful to avoid being overly prescriptive about how clusters should develop. We set out to ensure they had the flexibility to respond to local challenges and needs assessments whilst providing a framework within which clusters and health boards operate.

The time is now right for some collective national action to support clusters to evolve. That will be informed by learning and the innovative solutions so far undertaken. So, I've asked the national primary care board to agree a set of national governance arrangements for cluster working by June of this year. And, importantly, I've asked for those governance arrangements to be enabling and not overly prescriptive. I expect them to be designed to support each cluster's individual development journey. And I set out in my response that this work will address a number of the recommendations in the report.

I recognise that committee members will always be disappointed where a Government rejects recommendations, but I would gently say that I don't think it's unacceptable for a Government to reject recommendations any more than it is acceptable for a committee to make recommendations that are difficult or challenging. We, as a Government, have to accept the need to come here for scrutiny and explain what we're doing and why, just as, I think, committees need to know that there is good faith in either rejecting or accepting only in principle.

I just want to turn to recommendation 10. I think there's something here about recommending a national lead to deal with all these local services. I don't think that would actually deliver the sort of improvement that I know Members are generally looking for in training.

And, in response to recommendation 11, I just want to point out that we've made £10 million available on a recurrent basis for clusters to decide how to invest, and I recognise some of the evidence given, both to the committee and that I've heard individually, about some of the variance in the agility with which clusters can use that money together with their local health board. But clusters do take different decisions on how best to use moneys. They have different cluster development plans that they themselves have been involved in designing, and, while it's used to test innovative solutions, I have asked health boards to review their planning processes to ensure systematic evaluation.

I'm trying to deal here, again, with recommendation 13, in part, because that three-year rolling planning process, at cluster and at health board level, has to ensure that unsuccessful initiatives are stopped and successful ones are scaled up and funded from health boards core discretionary resources. I expect that to release funding at cluster level to invest in new innovative projects to drive continuous improvement.

Just on a specific point mentioned by the UKIP spokesperson, I'm happy to confirm that David Bailey, Dr David Bailey from the BMA, will be taking part in the February workshop, so there will be doctor representation there from the ground.

I think we also need to reflect, having had the report and having had the series of responses to the recommendations, that we also yesterday had the parliamentary review, and the significant status and thought given to the role of primary care within that review, and recommendations about planning and about the role of primary care being more specific in the integrated medium term plan process, and indeed changes they've recommended for the IMTP process itself and about the relationship with local government. They're things that we need to be open minded to and to take on board in actually coming to our final response to it.

So, this isn't a point in time where there is a closed door on everything and anything. I expect to see more evidence for the efficacy of clusters in different parts of Wales in the quality and outcomes framework we already have for primary care. That should really help us to understand and evaluate the real impact of clusters. There will of course be learning about what works and what is not working. I think the committee report and its recommendations have been a useful exercise to help take us forward and to actually spread more understanding about the work that clusters are undertaking. 

Having noted the recommendations, I'm pleased again to recognise that a range of them centre on areas of work that we too have already recognised and expect to report back to the Assembly upon. As I said in my response, action is under way or planned, and the committee's report and the wealth of evidence it contains will help to inform our work and our future consideration.

Thank you. Can I call Dai Lloyd to reply to the debate?

Thank you very much, Presiding Officer. I'd like to thank everyone who has participated in the debate and again echo our thanks to the clerks and researchers for all of their work, and of course to those who have provided us with evidence over the past months. It was wonderful to meet with many of them, as Julie Morgan said, at lunchtime at the Pierhead in order to complete the circle, as it were. They'd presented evidence, they'd read our report, they'd seen the Government's response to it, and then they could discuss that. That's the first time that we as a committee have done that, and I would see it as a template for other committees, as a modus operandi for them too.

There were a number of speakers: Angela, Rhun, Dawn, Julie, Caroline, Jenny. I was pleased to have a contributor who is not a committee member—not that I want to disrespect any committee member who spoke, but it was nice to have a non-committee member contributing to the debate, and, of course, we also heard from the Cabinet Secretary himself.

The fundamental point—and we will continue to disagree on this point, I'm sure—is this need for financial security to employ, in particular to employ new staff at cluster level. The Cabinet Secretary himself mentioned those examples of clusters employing paramedics, and also pharmacists. It's far easier to employ someone on a three-year contract than a one-year contract. That's the fundamental point that many of our witnesses made, that they need that financial security, and also contractual and pension security, in terms of who manages those. Because the clusters themselves are an entity that, unlike the health boards, are not a legal entity in terms of employment issues. So, those are the issues that need to be resolved in order to get those paramedics and pharmacists, who do laudable work, I have to say, because the paramedics we have in the cluster that I am part of have transformed the way we work. If there's an emergency call now in the middle of a surgery, a GP doesn't have to leave the surgery, and all the patients there, to go and see someone who may have fallen or whatever. The paramedic is there and they phone us. It has transformed the way in which we run our services from day to day. Therefore, they do make a valuable contribution, and we need to retain them and respect them.

So, we've heard all of the arguments made, and I won't rehearse the arguments as to which recommendations have been accepted and which have been rejected, but it is true to note that these clusters are an exciting development. I'm old enough to have had the very debate that the Cabinet Secretary mentioned—at the start, years ago, no-one was sure whether these were going to work or whether they would be an additional layer of bureaucracy for GPs, with not enough of us in place in the first place, and more work would need to be done and so on. Well, we've partially overcome that problem, but partially the jury is still out. That's why people are asking, and that's why the main recommendation of this report is that we need a fundamental change, a step change indeed, in terms of the development of the clusters and their implementation, so that we can secure and achieve this aspiration of having these MDTs working together for the benefit of our patients. Thank you very much.  

Thank you. The proposal is to note the committee report. Does any Member object? No. Therefore, the committee report is noted and agreed in accordance with Standing Order 12.36.  

Motion agreed in accordance with Standing Order 12.36.

Unless three Members wish for the bell to be rung, I now intend to proceed to voting time.