Cardiff South West cluster comprises of 10 GP practices which cares for 60,000 people in areas of high deprivation. Following a successful bid to Welsh Government, the cluster won grant funding to support the accelerated development of multi-disciplinary, multi-agency working in order to progress work in community development and empowering individuals to take more control over their health and wellbeing, and also reduce the demands on both GP practice and hospital-based services.
Support is offered to people with complex needs linking them to care in their local community. An integrated care hub hosts a multidisciplinary team including cluster pharmacists, occupational therapists and social prescribers who come together to support patients based on what matters to them. MDT meetings were introduced in Feb 2019 to help GPs manage their complex patients who often have social as well as medical needs, and the GP hub was introduced in Sept in 2019 to support GPs with more complex patients to enable their recovery at home.
We have been supporting the evaluation of this project by gathering qualitative data, interviewing staff and patients. As well as providing evidence of improvements in patient care, this is also providing feedback on further potential improvements, and learning points.