English: 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.
Welsh: Roeddwn yn falch iawn o fod yn rhan o'r Pwyllgor Iechyd a Gofal Cymdeithasol pan benderfynasom gynnal yr ymchwiliad hwn i glystyrau gofal sylfaenol. Roedd ein penderfyniad i edrych ar hyn yn deillio i raddau helaeth o bryderon roedd aelodau eraill y pwyllgor a minnau wedi eu clywed drwy ein trafodaethau gyda meddygon mewn ymarfer cyffredinol, ac roeddem eisiau gwerthuso'r dull newydd hwn o weithio. Hoffwn ddiolch i staff y pwyllgor a'r holl dystion a'n galluogodd, drwy eu tystiolaeth onest, i herio'r byrddau iechyd a'r Llywodraeth, a datblygu set o argymhellion y credwn y byddent yn gwella datblygiad ac awdurdod y rhwydwaith o glystyrau meddyg teulu yng Nghymru. Rydym wedi clywed cymaint am arferion da gan glystyrau meddygon teulu lle y ceir cynrychiolaeth gref a chyfranogiad gan weithwyr proffesiynol gofal iechyd eraill, megis therapyddion galwedigaethol, ffisiotherapyddion, nyrsys gofal lliniarol ac arbenigwyr iechyd meddwl. Clywsom am enghreifftiau lle roedd syniad i wella gwasanaethau i'r claf wedi cael ei feithrin, wedi derbyn cyllid, wedi'i dreialu, wedi'i amlygu fel enghraifft o arfer da ac yna, naill ai wedi ei ymestyn neu wedi arafu. Yn y rhan fwyaf o'r enghreifftiau, daeth yn amlwg fod thema debyg i'r rhwystrau a ataliai arferion da rhag dod yn ymarfer cyffredin. Roedd byrddau iechyd eisiau pennu a rheoli'r arian, gan lesteirio'r union arloesedd roeddem ei angen. Ceid diffyg cynaliadwyedd o ran pobl neu'r arian, roedd prosiectau'n dod i ben ac yn dechrau, a chaent eu gyrru o un flwyddyn i'r llall yn hytrach na bod unrhyw hirhoedledd yn perthyn iddynt. Nid yw pob clwstwr yn ymgysylltu â sbectrwm eang o weithwyr proffesiynol perthynol i ofal iechyd a oedd â gwasanaethau a syniadau i'w cynnig, ond nid oeddent yn gallu dal eu gafael. Mae prosiectau a weithiodd wedi gorfod ymladd i gael eu mabwysiadu fel arfer cyffredin gan y bwrdd iechyd. Mae cadw cydbwysedd ac adrodd yn drech nag unrhyw dwf newydd, ac wrth gwrs, ceir proffwydoliaeth sy'n gwireddu ei hun. Os nad yw byrddau iechyd yn mabwysiadu'r prosiectau llwyddiannus ac yn eu perchnogi, ni ellir rhyddhau'r arian clwstwr sydd ynghlwm wrth y prosiect hwnnw i weithredu fel cyllid sbarduno ar gyfer y cam arloesi nesaf. Roedd meddygon teulu weithiau'n ei chael hi'n eithriadol o anodd ymgysylltu â'r clystyrau eu hunain oherwydd pwysau eu llwyth achosion, ac roedd ymdeimlad gan rai gweithwyr proffesiynol perthynol i ofal iechyd a fferyllwyr cymunedol y gallent wneud mwy, eu bod yno yn barod, yn fodlon ac yn gallu ond bod y newid diwylliannol, mewn rhai achosion, i roi'r gorau i feddwl 'meddyg' a defnyddio eu sgiliau a hyfforddiant yn anodd ei gyflawni. Ond lle mae'n gweithio, mae'n gweithio'n dda. Hoffwn gyfeirio at enghreifftiau o bractis meddygol Stryd Argyle yn Noc Penfro yn fy etholaeth, practis sydd o dan bwysau aruthrol gyda'r rhestr hiraf o gleifion yng Nghymru a thri meddyg yn brin. Ar gyfer cyflyrau cronig a gofal lliniarol, maent wedi defnyddio arian clwstwr i gyflwyno therapyddion galwedigaethol a nyrsys gofal lliniarol, gyda rhai ohonynt yn cael eu hariannu gan y bwrdd iechyd yn uniongyrchol ac sydd wedi dod yn rheng flaen newydd i helpu'r cleifion hyn sy'n agored i niwed, gan alluogi'r meddygon i weithredu fel trefniant wrth gefn ar gyfer cyflyrau mwy cymhleth. Fodd bynnag, fel y dywedodd y Cadeirydd, canfu ein hymchwiliad gryn dipyn o gymysgedd, a dyna pam y teimlaf fod y ffaith bod Llywodraeth Cymru wedi gwrthod ein hargymhelliad 16 yn gwbl syfrdanol. Roeddem eisiau i Lywodraeth Cymru sicrhau y ceir methodoleg glir ar gyfer gwerthuso gwaith clwstwr. Credwn y byddai hyn yn galluogi i arfer gorau gael ei fabwysiadu fel arfer cyffredin yn gyflymach ac y byddai'n helpu i nodi pam na weithiodd rhai prosiectau a sicrhau eu bod yn cael eu dirwyn i ben yn hytrach na bod arian yn cael eu taflu atynt yn barhaus. A bod yn onest, jargon yw ymateb y Llywodraeth, ac mae'n cuddio y tu ôl i Gronfa'r Brenin, ac nid wyf erioed wedi gallu deall unrhyw sefydliad, Llywodraeth neu beidio, a fydd yn gwario arian heb gostio'r gwariant hwnnw - ac rwy'n cyfeirio at sylwadau o'ch ymateb i'n hadroddiad ar y gyllideb - na mesur canlyniadau. Rhaid inni fesur a gwerthuso. Sut y gallwn wneud hynny heb y wybodaeth briodol? Argymhelliad 11: mae Llywodraeth Cymru wedi gwrthod ein hargymhelliad y dylid dyrannu arian datblygu clwstwr i glystyrau unigol ar sail tair blynedd yn hytrach nag ar sail flynyddol, ac eto, yr angen am gynaliadwyedd arian clwstwr i alluogi hyfforddiant i gael y staff iawn ar gyfer lleddfu pryderon ynglŷn â threfniadau gwaith pobl, yr angen i gynnal peilot, treialu, gwerthuso a mabwysiadu - ni allwch wneud hynny mewn blwyddyn. Ond mae cylch ariannu tair blynedd o leiaf yn gwneud rhywfaint o gynaliadwyedd yn bosibl. Rwy'n annog Ysgrifennydd y Cabinet i adolygu'r ddau argymhelliad hyn eto yng ngoleuni'r holl dystiolaeth a gasglwyd gan y pwyllgor iechyd a gofal cymdeithasol. Aelodau, rwy'n argymell y dylai pawb ohonom ddarllen yr adroddiad hwn, oherwydd o ystyried y pwyslais ar ofal sylfaenol yn yr adolygiad seneddol o iechyd a gofal cymdeithasol, mae clystyrau'n fodel ar gyfer y ffordd ymlaen, ond mae angen eu rhyddhau, eu hariannu, eu dwyn i gyfrif, ac yn y pen draw, eu gwerthuso.