The 3rd Annual National Primary and Community Care Conference

15 November 2018. All Nations Centre, Cardiff

8.30am Registration, refreshments and marketplace exhibitions

9.30am Welcome and objectives for the day

Dr. John Boulton - Interim NHS Director of Quality Improvement and Patient Safety/Director of 1000 Lives Improvement

9.35am The citizens voice – reflections and observations on the Primary Care Model for Wales

Clare Jenkins & Alyson Thomas – Joint Chief Executives, Community Health Council

10am Operation GMS - the road back from ITU? Charlotte Jones – Chair GPC Wales

10.15am Cabinet Secretary Address Vaughan Gething AM - Cabinet Secretary for Health & Social Services

10.30am Refreshments and marketplace exhibitions

Session 1: Transforming access

11am

Reflections on progress across Wales

Community Pharmacy – Dylan Jones

Community Optometry – Andy Britton

General Dental Services – Richard Jones

General Medical Services – Dr. Gaynor Thomas This session will include a panel Q&A

Chaired by Paul Gimson – Programme Lead 1000 Lives Improvement

12.45pm Lunch and marketplace exhibitions

Session 2: Transforming access through multi professional care

1.30pm

The future multi-professional team

Advanced nurse practitioner - Amanda Monsell

Audiology - Natalie Phillips

Mental Health - Ian Wile

Occupational therapy - Kerrie Phipps

Paramedic - Grayham Mclean

Physiotherapy - Robert Caine

Social prescribing - Liesbeth Beeckman

Social work - Allison Hulmes

Co-production - Victoria Lloyd

Chaired by Philippa Ford - CSP Public Affairs and Policy Manager for Wales & Dr. Jane Harrison – Lead GP Advisor, Primary Care Division

Session 3: Technology to improve access and sustainability

2.45pm

How improvements in digital technology can help primary care to improve access and sustainability

My Healthcare - Damian Williams

Digital care: the patients’ point of view - Matthew Lloyd

Lessons learned from digital technology - Darryn Thomas

Text messaging services - Antonia Higgins

GP led telephone triage - Heather Potter

DEWIS & social prescribing - Richard Palmer

Skype & 111 services - Steve Bassett This session will include a panel Q&A of the presenters and Anne Marie Cunningham, Associate Medical Director of Primary Care, NWIS

Chaired by Paul Gimson

Session 4: Reflections and next steps

3.45pm Reflections, action and next steps

Judith Paget, CEO Aneurin Bevan UHB, Lead Chief Executive for Primary Care and Chair of the National Primary Care Board.

3.55pm Close Dr. John Boulton

4pm Departure refreshments and a final opportunity to view the marketplace exhibitions

Dr John Boulton

Dr John Boulton is currently Interim Director of Quality Improvement and Patient Safety and Director of 1000 Lives Improvement at Public Health Wales. Prior to this, he worked as Executive Director of Continuous Improvement at Aneurin Bevan University Health Board (ABUHB) in Wales. Dr Boulton has extensive experience in the field of Quality Improvement. Whilst working as a Rheumatologist John became interested in quality improvement methodologies. After becoming an active member of his Trust’s improvement team, he went onto lead the outpatient transformation program. His work within Rheumatology was shortlisted for a national award, and included improved scheduling of biological therapies, delivery of biologics within community settings, and improving patient experience within outpatient clinics.

In 2012 he was awarded a Quality Improvement fellowship at the Institute for Healthcare Improvement, sponsored by the Health Foundation. This enabled him to develop a deep understanding of Improvement science as well as observing how to achieve improvement at scale. Prior to moving to Wales, he worked in the State of Qatar as Clinical Lead for Quality Improvement at Hamad Medical Corporation. He led the corporate flow strategy resulting in the development of a flow collaborative, which built organisational capability, and ultimately produced marked improvements in flow. In addition, he supported IHI’s patient safety collaborative, which resulted in sustainable reductions in patient harm. Dr Boulton has presented extensively on Quality Improvement and mathematical modelling. He is currently European faculty for the IHI’s Improvement Coach Professional Development programme. Additionally in 2018 he became honorary Professor at the University of Swansea. Andy Britton

Andy has been the Optometrist Director of Specsavers in Haverfordwest since 2006. He has expanded the clinical scope of his practice via continued investment in equipment and technology. He also provides clinics as a sessional optometrist at Withybush hospital in their Macula and Glaucoma clinics. He graduated from Aston in 1996 and has practiced across all types of practice in South Wales and has been passionate advocate of continued personal development having completed a Postgraduate diploma in Clinical Optometry from Aston University and is currently undertaking the hospital based placement required for Independent Prescribing. Most recently, he has completed a Postgraduate Certificate in Glaucoma and is studying for the Higher Certificate, which will allow more autonomous management of patients in primary care.

Within Specsavers Andy is involved in training and development of both pre-registration Optometrists and peers as well as roles within both the Store Design and IT Development. He has a proven track record as a pre-registration supervisor having coached 5 graduate optometrists through to successful qualification as Optometrists. Andy is involved in the Local Optometric Committee as well as sitting on Optometry Wales as FODO representative. Robert Caine

Rob started working as an MSK advanced practitioner physiotherapist in January 2015. His current post is split between primary care and specialist rheumatology services. His role in GP surgeries is to take on MSK patients as a first point of contact and manage their MSK care. His team was one of the first of its kind in the UK and Rob’s remit was to set up the service in North Wales. He has gained a wealth of experience in rheumatology over the past 8 years, and presently runs specialist inflammatory back pain and Ankylosing Spondylitis clinics. Alongside his experience in MSK he is a qualified non-medical prescriber, and has several years experience in joint and soft tissue steroid injections. He has been a named author in several rheumatology papers, and has recently completed his MSc dissertation investigating GP opinion of the advanced practitioner physiotherapist in primary care.

Dr Anne Marie Cunningham

Dr Anne Marie Cunningham has worked part-time as a GP in Gelligaer for 16 years. She is also Associate Medical Director for Primary Care in NHS Wales Informatics Service. She says, "I want to work with users to make sure that we make the best use of technology to deliver safe, effective, efficient care".

Philippa Ford MBE

Pip qualified as a physiotherapist from St Mary’s Hospital, London in 1986 and started work in the Cardiff Royal Group of Hospitals, working in the NHS for 14 years. Areas of specialty included older people, respiratory care and physiotherapy service management. In 1999, Pip started working for the Chartered Society of Physiotherapy as Public Affairs and Policy Manager for Wales very soon after the launch of the National Assembly for Wales. The role involves engaging with politicians, Welsh Government, civil servants and other stakeholders in Wales, raising the profile of the profession, responding to key policy initiatives on behalf of the profession and supporting Welsh CSP members. Pip received an MBE for Services to Physiotherapy in the 2015 New Year’s Honours List.

Pip represents physiotherapy on the Primary and Community Care Reference Group and represents this group on the Transforming Primary Care Group. In 2018, working with three others, Pip was responsible for leading a piece of work looking at Multi-Professional Roles within the Transforming Primary Care Model in Wales. The document has recently been published on the Primary Care One website. Vaughan Gething AM

Vaughan was born in Zambia and brought up in Dorset. He was educated at Aberystwyth and Cardiff universities and is married to Michelle. Vaughan is a largely retired cricketer and a fan of both rugby and football. Vaughan was a solicitor and former partner at Thompsons. He is a member of the GMB, UNISON and Unite unions, and was the youngest ever President of the TUC in Wales. He has previously served as a county councillor and school governor. He has also been a community service volunteer – supporting and caring for a student with cerebral palsy and is former president of NUS Wales.

Between 1999 and 2001, Vaughan worked as a researcher to former AMs Val Feld and Lorraine Barrett. Between 2001 and 2003, Vaughan was the chair of Right to Vote – a cross-party project to encourage greater participation from black minority ethnic communities in Welsh public life. Vaughan is a member of the Co-operative Party. In June 2013 Vaughan Gething was appointed Deputy Minister for Tackling Poverty. In September 2014, Vaughan was appointed Deputy Minister for Health. In May 2016 he was appointed Cabinet Secretary for Health, Well-being and Sport. Vaughan was appointed Cabinet Secretary for Health and Social Services on 3 November 2017. Paul Gimson

Paul is a qualified pharmacist with over 20 years experience in pharmacy, management and quality improvement and has had a varied career with roles in community healthcare, the NHS, Welsh Government and academia. He has held leadership roles with Local Health Boards, the Royal Pharmaceutical Society and Community Pharmacy Wales. Paul is passionate about improvement and helping people to provide better care for their patients. He is a fellow of the Health Foundation and a graduate of their Generation Q programme which led him to 1000Lives, the NHS Wales improvement body based within Public Health Wales. Here he leads on primary care development and improved medicines safety.

Dr Andrew Goodall

Dr Andrew Goodall was appointed to the role of Director General of Health and Social Services/Chief Executive NHS Wales in June 2014. His role includes both supporting Ministerial priorities for health and social care within the Civil Service structures, and the leadership and oversight of NHS Wales. Including this current role, Andrew has been an NHS Chief Executive in Wales for 13 years, his previous post being that of Chief Executive of Aneurin Bevan University Health Board, a position held from the Health Board’s inception in October 2009 until 2014.

During his 27-year NHS career, Andrew has held planning and operational positions across a number of NHS organisations across South Wales as well as national roles. He has particular areas of interest in improving patient safety, quality and patient experience; partnership working across Public Services; and delivering frontline services through service improvement and modernisation. Dr Goodall has a law degree from Essex University and a PhD in Health Service Management from Cardiff Business School.

Dr Jane Harrison

Jane trained as a GP in London and has developed interests in medical education and health service redesign. On moving to Wales in 1994, she established an All Wales Network to provide education and support to salaried and freelance GPs. A subsequent secondment as Senior Medical Adviser to Welsh Government gave her the opportunity to focus on GP recruitment and retention issues and to develop guidelines for GPs with a Special Interest. From 2007 to 2015, as Assistant Medical Director for Primary Care within ABMU Health Board, Jane built on her interests in transformational change within the NHS in Wales and established the infrastructure for care pathway redesign. Learning from national and international experience, she led a Service Transformation Team to remodel critical clinical areas of the health board and drive whole system change. Jane currently works for Public Health Wales as Lead GP Adviser to the Primary & Community Care

Development and Innovation Hub offering leadership, advice and support on innovation, integration and redesign across Primary Care and the Community. Antonia Higgins

Tonia manages Brynderwen & Minster Surgeries, serving a population of circa 19,000 patients across Cardiff over two sites with an additional, part time GP surgery delivered to students at Cardiff Metropolitan University Cyncoed Campus. The practice serves a diverse population covering areas with some of the highest levels of both deprivation and affluence in Cardiff. The Practice has 10 Partners, is a training practice taking in Year 3, 4 and 5 medical students and GP Registrars. Originally a farmer, working in both agriculture and horticulture, Tonia moved into IT and worked as a trainer for Primary Care Clinical Systems across the country. For some years, she worked for PRIMIS undertaking data quality exercises in Exeter PCT and then on to Avon IM&T Consortium remaining in Primary Care. Tonia became a Practice Manager in 2004 as part of the Heads of the Valleys project in Caerphilly.

Allison Hulmes

Allison trained as nurse in 1984 at the West Glamorgan School of Nursing and after qualification, specialised in paediatrics at the University Hospital of Wales. During the late 1980’s Allison became interested in advocacy and started advocating for several residents of Ely Hospital, Cardiff. The residents were being resettled in the community following many years of institutionalisation. The over-riding concerns were of an adult safeguarding nature and this prompted Allison to return to University where she studied for a qualifying degree in law. This was followed by a combined Masters’ degree and Diploma in Social Work and many years spent as an adult safeguarding and deprivation of liberty coordinator in the City and County of Swansea. Allison’s deep interest in human rights has remained

throughout her career and she is currently studying for a Masters’ in human rights law. In 2012, Allison was one of the first Consultant Social Workers in Wales, in the newly formed Integrated Family Support Service. This role involved undertaking direct therapeutic interventions in families, where parental substance misuse was the primary risk factor to children, as well as supporting transformational change in the social work/care workforce. Allison is committed to promoting the highest standards of social work in Wales and has many years of experience in delivering training, coaching, mentoring and guest lecturing on social work programmes. Allison has worked as a Professional Officer for BASW Cymru (the professional association for social work in Wales) since 2016. This role involves supporting members and being Wales lead on national events and key policy drivers/campaigns, such as professional working conditions and the parliamentary review of health and social care. Allison regularly contributes to Professional Social Work magazine and social media. Clare Jenkins

Clare trained as a mental health nurse and went on to do a degree in Applied Social and Community Studies, working in Community Development and Further Education before spending almost 20 years working for and with trades unions. Clare joined the Community Health Council movement in June 2015 with a strong desire to empower and enable people and communities to have an active voice in the way their health services are designed and delivered. Clare lives in Cardiff with her husband, three children and Olive the dog.

Dr Charlotte Jones

Dr Charlotte Jones is chair of GPC Wales and is a member of the GPC UK executive team. Charlotte has been a principal in Uplands and Mumbles Surgery Swansea since 2002. She is a trainer; GP appraiser and still does OOH sessions having set up Swansea Out of Hours Service (which is now ABMU OOH service). Amongst her wide portfolio of roles and responsibilities, she has the responsibility for negotiating all aspects of the Welsh GMS contract as well as representing the profession at all levels. She is

committed to delivering solutions to the challenges facing GPs across Wales in her last year of office. Outside of work, Charlotte is a mother of two and has a Cavalier King Charles spaniel who considers herself as the third child in the family. Dylan Jones

Dylan has been a community pharmacist for Dudley Taylor Pharmacies Ltd in Llanidloes, Mid Wales for the last 16 years. During this time he has held numerous additional managerial positions within the company. For the last 10 years he has supported the local medical practice with prescribing advice and worked with them on many projects. 2years ago he became an Independent Prescriber and had a service commissioned by Powys Teaching Health Board to advise and where appropriate, treat and refer patients with acute illness locally. Recently Dylan became an elected member of the Welsh Pharmacy Board of the Royal Pharmaceutical Society.

Richard Jones

Richard qualified as a Dental surgeon in 1994 from Cardiff Dental School and then worked for a year as a Vocational Dental Practitioner at Glenhaven Dental Practice in Taffs Well. In January 1995 Richard joined Belgrave Dental centre as an Associate Dentist. He became a partner/practice owner at Belgrave Dental Centre in 1998, and was appointed a Vocational Trainer by the Wales Deanery that year, training until 2017. He continues to work part time at the practice 24 years on, which is currently one of 2 Prototype NHS practices in Wales. He is a partner in a second practice in Pontardawe which joined contract reform in 2017. Richard worked as a Clinical Assistant in the Restorative Dentistry Department at Morriston Hospital

from 1995 until 2003. In 2003 Richard was awarded a role as a Postgraduate Dental tutor employed by the Wales Deanery, providing accredited CPD courses from Llandough Medical and Dental Education Centre, and in 2017 relinquished his training role to become a Dental Foundation Training Programme Director with the Wales Deanery / HEIW. Richard completed his PG cert with distinction from Cardiff University in 2015 and now works part time as a Dental Practice Advisor advising both ABMU and CTUHB part time in dental matters including governance, performance, contractual issues, record keeping, standards and practice management and development. Matthew Lloyd

Matthew Lloyd has worked in the digital inclusion field since 2006. Originally trained as an engineer, he moved into community development in 2005. A year later, he was able to combine his community outreach skills with his technology skills when he joined the Communities @One project, the first national digital inclusion programme in Wales. His interest in overcoming challenges and supporting people to get online has continued. A successor project called Communities 2.0 followed, for which Matt created an ICT Strategy for the South West Wales region and led on 50 successful grant applications for community and voluntary organisations. Today, as Digital Communities Wales Project Manager, his work involves managing the team of DCW Advisers and supporting them to promote and develop digital inclusion initiatives across Wales. Matt is passionate about ensuring that, working in partnerships with organisations across Wales, support

reaches the 15% of people who are currently offline in Wales. Matt believes everyone can benefit from developing appropriate skills to make our increasingly digital world that little bit easier. More recently Matt and the DCW team has been working with health and social care organisations to introduce technology in ways of interest to the user thus breaking down that crucial barriers of a lack of interest or relevance.

Victoria Lloyd

Victoria has been with the Charity since it was established in 2009 following the merger of Age Concern Cymru and Help the Aged in Wales originally as Director of Influencing, Deputy Chief Executive and was appointed as Chief Executive in 2018. Victoria is the current Chair of the Wales Against Scams Partnership and the new Chair of Age Alliance Wales. Victoria joined Help the Aged in Wales in 2006, after spending 12 years at Cardiff Chamber of Commerce in a variety of roles, ultimately as Head of Operations and Policy.

Amanda Monsell

I started my nursing career and qualified as a registered general nurse from South Glamorgan School of Nursing in 1985. I started by working in Llandough Hospital both on medical and surgical wards as well as coronary care and I soon realised I needed to gain more experience in nursing mental health patients and completed my mental health nursing in 1989. I started in general practice in 1990 and worked initially as a practice nurse gaining experience and completed my degree in Community Health Studies along with gaining my Specialist Practitioner Qualification in General Practice Nursing in 2003. I was fortunate to be able to access both the first supplementary prescribing course and the first independent prescribing conversion course in Wales and became a non-medical independent prescriber in 2007. I completed my Master’s in Advanced Clinical Practice in 2010 and have worked autonomously as an advanced nurse practitioner since this time. I am a generalist seeing patients across the lifespan both with undifferentiated and undiagnosed conditions as well as those for follow up and management. I

take an interest in mental health and women’s health and I am currently undertaking my FSRH diploma and hold a letter of competence for implant insertion and removal. I was seconded as a part time associate lecturer to Cardiff University for three years (2010 – 2013) where I taught primarily on the Non-Medical Prescribing course for nurses and pharmacists. I was successful in completing a post graduate certificate in education during this time passing with distinction. As a Queen’s Nurse, I am committed to ensuring the highest standards of patient care are met and continually strive to improve practice. As I have worked as both a specialist practice nurse and advanced nurse practitioner I fully understand the importance of good team relations and the intricacies by which general practice operates. I strongly believe that patient care is paramount and that having nurses and advanced nurse practitioners working alongside general practitioners provides a valuable service that patients appreciate. Judith Paget

Judith was appointed Chief Executive of Aneurin Bevan University Health Board in October 2014. Judith joined the Health Board as Director of Planning & Operations on 1st October 2009 and subsequently became Chief Operating Officer/Deputy CEO before her appointment as Chief Executive. Judith has worked in the NHS since 1980. During the 1980s she undertook various operational roles in hospitals within the Gwent area, leaving Gwent in 1990 to take up a post with East Dyfed Health Authority. She was subsequently appointed Director of Planning for Llanelli Dinefwr NHS Trust where she remained until 1996 when she joined lechyd Morgannwg Health Authority to establish the Locality Team in Bridgend. In 2000 Judith returned to Gwent as General Manager of Caerphilly Local Health Group and was subsequently appointed the Chief Executive of Caerphilly Local Health Board. In August 2007 she was seconded as Interim CEO of Powys Teaching Local Health Board where she remained until October 2009.

Judith was awarded a Companionship of the Institute of Health Service Managers in 2012. In June 2014, Judith won the Institute of Directors – Director in Public Service Award for Wales. Richard Palmer

With a degree in Information Systems Engineering, and a career that includes roles in the third sector, health and local government before joining Data Cymru in 2001. Richard has a wealth of experience around the use and impact of information. His work now includes leading on the ongoing development of Dewis Cymru and the soon to be launched Health & well-being Wales App.

Natalie Phillips

Natalie completed the MSc Audiology at University of Manchester in 2011 and completed the HTS at Wrexham Maelor Hospital. Since 2014, she has worked as a clinical scientist in Abertawe Bro Morgannwg University Health Board. Her current role is divided between the vestibular service and leading the Primary Care Service for Swansea area.

Kerrie Phipps

Kerrie Phipps is the Deputy Head of Occupational Therapy for Hywel Dda University Health Board with a portfolio of services across primary and secondary care; community and social care, and specialist services. A key focus of her remit is the development, implementation and delivery of integrated collaborative models of occupational therapy service provision that improve the individuals’ experience and are directly related to restoring independence, recovery and social inclusion. This includes the development of reciprocal clinical roles across agencies, settings and counties, and involves role redesign and integrated joint agency pathway development. Crucially occupational therapy provision as part of General Practice ‘toolkit’ is a fundamental component of this.

She’s an individual who aims to be brave and listen to concerns in order to ask a better question in order to do the right thing, as well as utilize her skills and influence in order to most importantly do things better. Dr Heather Potter

Heather has been a GP Partner for 29 yrs. in Skewen, Neath. She also acts as clinical lead to the Neath Primary Care Hub. She qualified from St Andrews and Manchester Universities in 1984. After meeting her Welsh husband and being won over by the country she moved to South Wales in 1988. Heather and her husband have three children mainly brought up on the beaches of Gower. Dr Potter is keen believer in Primary Care and has had a special interest in Access to Primary Care for 15 years.

Alyson Thomas

Alyson joined the Community Health Council movement in May 2015 where she focuses on encouraging and enabling members of the public to be actively involved in decisions affecting the design and delivery of NHS healthcare for their families and local communities. She has been a public servant for over 30 years. For most of the last ten years, Alyson’s work has focused on the NHS in Wales. She has been a Director at Healthcare Inspectorate Wales, governance advisor working on the 2009 NHS reforms in Wales, and independent reviewer of the leadership and governance of NHS Trusts and Local Health Boards. Alyson lives near Swansea with her husband, two grown up children and pet labrador Phoebe.

Darryn Thomas

I have worked in Primary Care for the past twelve years, working as a Senior Health Care Support Worker before stepping into the management side four years ago. Whilst working in a busy Practice in Prestatyn I got a sense that change would be needed in the future with regards to sustainability. As the Health Board stepping in, I valued the model that was being proposed and felt that in doing my best to help achieve this, we could change the shape and future of Primary Care. This has been a challenge, as any new structure can be when first starting, but by working in partnership with other professionals and patients, we are able to listen and create a model that reflects the patient’s needs.

Gaynor Thomas

Gaynor qualified from UWCM in 1998. On the completion of her General Practice training she worked for several years in the Primary Care Support Unit in Cwm Taf. She was one of the founding partners of Pont Newydd Medical Centre when it was returned to independent contractor status in 2010. Since then she has enjoyed being part of a growing multidisciplinary team, enabling the practice to become a training practice, now training GP registrars, medical students, undergraduate nurses and undergraduate pharmacy students. For the past year Gaynor has been the clinical lead for the Workforce and Training Hub Cymru. This is a pacesetter project looking at providing high quality general practice placements for

undergraduate nurses and the development of a two-year clear career structure and training path for undergraduate nurses. Dr Damian Williams

I am a GP in Birmingham, having been in Birmingham since I came to medical school in 1992. I am a clinical IT lead for Birmingham and Solihull CCG and particularly involved in our local shared medical record, online consultations and extended access. I also work for NHS as a Digital Clinical Champion, promoting uptake of patient online and other digital technologies that support clinicians and improve care for patients. I believe adoption of technology is necessary for the survival of the NHS and brings exciting opportunities for improving patient safety and care.

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Strategic Programme for Primary Care

November 2018

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Foreward The case for change as set out in The Parliamentary Review and the required ‘revolution from within’ is fully recognised by the National Primary Care Board. A Healthier Wales provides a clear plan for progressing this and we welcome the reinforcement of cluster working as part of the national model for local health and care. Whilst significant progress has been made through implementing the recommendations set out in the Primary Care Plan for Wales 2015 – 2018, there is still much to do to ensure our part in the National Transformation Programme and to fully implement the Primary Care Model for Wales. This document sets out the strategic programme of work for primary care which has been developed following the publication of A Healthier Wales. Some areas are a continuation of previous work, recognising that the pace and scale needs to be increased. Other areas have emerged as a priority in response to ‘A Healthier Wales’. Specifically of note, is the whole system approach to health and social care, stating that it will be a ‘wellness’ system, which aims to support and anticipate health needs, to prevent illness, and to reduce the impact of poor health and inequality. Primary care, as the first point of contact for the majority of citizens accessing health services, has a key role in maximising the opportunities for prevention and self-management. At the heart of the strategic programme for primary care is working closely with partners, shifting the focus to a social model of care, ensuring timely access to primary care services when required and working seamlessly across the whole system. This strategic programme sets out, at a high level the key workstreams required to progress this work. This is underpinned by detailed action plans. Whilst many actions fall to those that work within primary care, seamless models of care requires all partners to work together and I am would like to acknowledge the commitment of all those involved in the progress that has been made to date and the challenges ahead. The full implementation of the primary care model for Wales and the integral part that primary care plays within the national transformation programme gives primary care the permission to be bold, an opportunity that we must not miss. Judith Paget Chair, National Primary Care Board & Lead Chief Executive for Primary Care

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Executive Summary Our Plan for a Primary Care Service for Wales up to March 2018’ was published by Welsh Government in February 2015 and has provided the context and framework for the development of primary and community care over the last three years. Good progress has been made locally and the investment provided by Welsh Government to support innovation and development in primary care was provided at cluster level, health board level and at national level via a £40million primary care fund which included the Pacesetter Programme. Learning from the first cycle of Pacesetters influenced the development of a whole system, 24/7, transformational model for primary and community care. This has enabled a whole system approach to redesign, driven by national quality standards but with flexibility to respond to local community needs. Clusters are seen as pivotal to the delivery of this model. In January 2018, the Parliamentary Review of Health and Social Care in Wales was published and in June 2018 Welsh Government provided a response in ‘A Healthier Wales: our Plan for Health and Social Care’ which called for bold new models of seamless local health and social care at the local and regional level. The transformational model for primary and community care, which is a whole system approach to sustainable and accessible local health and wellbeing care, supports the vision set out in ‘A Healthier Wales’ and is now adopted as the Primary Care Model for Wales. Clusters remain at the heart of this model and, given the key principles that underpin ‘A Healthier Wales’ can be described as:

“A cluster brings together all local services involved in health and care across a geographical

area, typically serving a population between 25,000 and 100,000. Working as a cluster ensures care is better co-ordinated to promote the wellbeing of individuals and

communities.” Whilst work continues on the implementation of the Primary Care Model for Wales, ‘A Healthier Wales’ has brought a wider context to this work in terms of the links to the Regional Partnership Boards and the wider community infrastructure as the ‘wellness system’ approach is reinforced. It is therefore timely to review the strategic programme for primary care within this context and the following key strategic areas have emerged as priorities to run alongside the normal planning and delivery functions of Health Board teams:

Primary care key workstreams

Seamless working in Health Boards and with partners

Primary care contract reform A high level summary of actions are provided in this document against each of these priorities. There is also supporting documentation that provides more detailed action plans and a delivery mechanism for the strategic programme.

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1. Introduction This paper provides the key workstreams required for primary and community services to build on the work undertaken in response to ‘Our Plan for a Primary Care Service for Wales up to March 2018’ (Welsh Government, February 2015) and respond to ‘A Healthier Wales’ (Welsh Government, June 2018). The workstreams are not intended to replace work planned or underway at a local level by clusters, health boards, regional partnership boards, or to cut across wider transformational work, but rather to complement and enable pace and scale of transformation. 2. Strategic Context ‘Our Plan for a Primary Care Service for Wales up to March 2018’ was published by Welsh Government in February 2015 and has provided the context and framework for the development of primary and community care over the last three years. The plan was supported by A Planned Primary Care Workforce for Wales setting out the direction required to support a sustainable workforce shaped by local population needs and prudent health care principles. The definition of primary care used in the plan was very broad, see below, and now underpins this document.

What is primary care?

Primary care is about those services which provide the first point of care, day or night for more than 90% of people’s contact with the NHS in Wales. General practice is a core element of primary care: it is not the only element – primary care encompasses many more health services, including, pharmacy, dentistry, and optometry. It is also – importantly - about coordinating access for people to the wide range of services in the local community to help meet their health and wellbeing needs. These community services include a very wide range of staff, such as community and district nurses, midwives, health visitors, mental health teams, health promotion teams, physiotherapists, occupational therapists, podiatrists, phlebotomists, paramedics, social services, other local authority staff and all those people working and volunteering in the wealth of voluntary organisations which support people in our communities.

The scope of work has been influenced by a number of publications and areas of work during the period 2015 – 2018, which have added to the direction and breadth of the changes in primary care, as follows:

The Social Services and Well-being (Wales) Act 2014

The Well-being of Future Generations (Wales) Act 2015

Prudent Healthcare – Securing Health and Well-being for Future Generations 2016

Taking Wales Forward 2016 – 2021 Welsh Government

Prosperity for All – national strategy. The Welsh Government wellbeing objectives 2017 (September 2017)

Ministerial Taskforce on Primary Care Workforce - Train, Work, Live in Wales campaign 2017

GP Services in Wales: The Perspective of Older People (Older People’s Commissioner for Wales February 2017)

Health, Social Care and Sport Committee - Inquiry into Primary Care Clusters 2017

Services Fit for the Future – Quality and Governance in Health and Care in Wales (June 2017)

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In January 2018, the Parliamentary Review of Health and Social Care in Wales was published and in June 2018 Welsh Government provided a response in ‘A Healthier Wales: our Plan for Health and Social Care’ which called for bold new models of seamless local health and social care at the local and regional level. The primary care model for Wales, which is a whole system approach to sustainable and accessible local health and wellbeing care supports the vision set out in ‘A Healthier Wales’. ‘A Healthier Wales’ sets out the whole system approach to health and social care, stating that it will be a ‘wellness’ system, which aims to support and anticipate health needs, to prevent illness, and to reduce the impact of poor health and inequality. Primary care, as the first point of contact for the majority of citizens accessing health services, has a key role in maximising the opportunities for prevention and self-management. Working closely with partners, primary and community care must not miss opportunities to promote a social model of care and avoid over-medicalising. 3. ‘Our Plan for a Primary Care Service for Wales up to March 2018’ – Progress to Date ‘Our Plan for a Primary Care Service for Wales up to March 2018’ Welsh Government, February 2015, (hereafter referred to as the Primary Care Plan) detailed key actions to be taken forward at a national level, alongside 26 key actions to be taken forward at the local level. Welsh Government established the £43m national primary care fund to back the plan. The Integrated Care Fund also invested in local services improvements. A high level summary of progress against the actions included in the Primary Care Plan against the five themes follows.

I. Planning Care Locally

Pacesetter/Pathfinder Programme – 24 projects 2015-18, 15 projects commencing 2018

Emergence of a new ‘transformational’ model of primary care

Critical appraisal – external evaluation, workshop October 2018

Primary Care One website launched November 2017 as online resource for sharing good practice and learning

Cluster level needs assessments and plans with £10m for clusters to invest

Cluster development – Cluster Governance Framework of Good Practice

Pipeline of capital developments and integrated health and care centres

II. Improving Access and Quality

National project for directory of services

Signposting and triage – scoping exercise and recommendations complete

111 – roll out planned

Primary Care Measures Phase 1 and 2a introduced

Key Indicators for GMS developed

Capacity and demand modelling – Pathfinder project

Workshop to define what ‘good’ access looks like

Roll out of Choose Pharmacy and common ailments service

More eye care moved out of hospital and delivered in the community

Social prescribing (or community referral) models for systematic access to non clinical wellbeing services

Primary care contract reform programme

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III. Skilled Workforce

MDT working – review and recommendations complete

Physicians Associates

Community Paramedics

Compendium of new roles and models, including cluster level posts and indemnity solutions

Workforce planning in primary care training

Advanced practice training, such as non-medical prescribing

Expansion of Academic Fellows scheme beyond South Wales

Train, Work, Live campaign

IV. Equitable Access

Inverse care law schemes established in three health boards and learning shared

Transgender project

British Sign Language project

Welsh Language tool kit

V. Strong Leadership

National Primary Care Board

National Directors of Primary and Community Care peer group and sub groups

Primary and Community Care Development and Innovation Hub

National Professional Lead & National Director and Strategic Programme Lead

Confident leaders programme x 3

Cluster leads development programme ongoing

Further detail is available in the Directors of Primary & Community Care (formerly the Directors of Primary, Community & Mental Health) Annual Report 2017 – 18. Supporting documentation is available on the Primary Care One website. The investment provided by Welsh Government to support innovation and development in primary care was provided at cluster level, health board level (via Integrated Medium Term Plans) and at national level via a Pacesetter Programme. The Pacesetter Programme is a comprehensive range of initiatives, funded by Welsh Government, to stimulate innovation and promote the redesign of primary care services. The first cycle of 24 pacesetter projects began in April 2015 included a focus on at least one of the following:

improved access to services

moving care closer to home

increased sustainability of primary care services. These were led by Primary Care Teams across Wales and supported by the Primary Care Hub (Public Health Wales). Learning from the first cycle of Pacesetters influenced the development of a whole system, 24/7, transformational model for primary and community care. This has enabled a whole system approach to redesign, driven by national quality standards but with flexibility to respond to local community needs (see diagram overpage). Clusters are seen as the pivotal to the delivery of this model with 64 clusters in Wales.

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Further detail on the model and the key components can be found on the Primary Care One website. Critical Appraisal and Evaluation As part of the pacesetter evaluation process, the University of Birmingham was commissioned to undertake a critical appraisal of the Pacesetter Programme. The overall aim of the research was to strengthen the learning for future primary care transformation programmes in Wales through investigating the experiences of Pacesetter teams, exploring the views of stakeholders and comparing outcomes with current research evidence and international best practice. The final report, was published in June 2018 and can be found at: http://www.primarycareone.wales.nhs.uk/home The following sets out the implications of the findings for future Primary Care Transformation.

Development of evaluation capacity within health boards to assess the impact and mechanism of change have the connected skills, access to data and analytical support.

Workforce plans to include the development of competencies related to inter-professional working and teams, patient and community engagement, and leadership of change.

Availability of suitable infrastructure to embed engagement within transformation programmes.

Local infrastructure to support innovation in primary care that ensures those undertaking such changes are supported with project management and related tasks.

Opportunity for networking across health boards for those involved in leading innovation to provide peer support and challenge.

4. The Primary Care Model for Wales

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The transformation model for primary and community care aligns well with ‘A Healthier Wales’ and as the full implementation of the recommendations arising from ‘A Healthier Wales’ moves forward it is important that primary care is pivotal to the proposed bold and seamless models of care that are aspired to. As described in section 3, the pacesetter work has informed a transformation programme for primary care with the components of the model set out. This has been reinforced by ‘A Healthier Wales’ and is now adopted as the Primary Care Model for Wales. Key components of this model are:

Informed public

Empowered citizens

Support for self care

Community services

First point of contact

Urgent care

Direct access

People with complex care needs

MDT working Clusters remain at the heart of this model and, given the key principles that underpin ‘A Healthier Wales’ can be described as:

“A cluster brings together all local services involved in health and care across a geographical

area, typically serving a population between 25,000 and 100,000. Working as a cluster ensures care is better co-ordinated to promote the wellbeing of individuals and

communities.” The Primary Care Model for Wales is predicated on a social model of care and critical to this is the need to work across organisational boundaries in order to maximise all the assets in a community. Existing primary care clusters are predominantly health focused and delivered. Having said that, there are examples of clusters who have expanded beyond the boundaries of health in their development. Moving forward, clusters need to consider the assets available within their community for their local population. This means working across social care and the wider local authority services. The role of the third sector needs greater consideration both in terms of current delivery and potential opportunities in the future. Regional Partnership Boards and Area Plans are essential links to this wider network and whilst these have not featured highly for clusters in the past they will be pivotal going forward. 5. The Primary Care Model for Wales – Areas of Focus ‘A Healthier Wales’ shifts the focus to a ‘wellness system’. Whilst the primary care model for Wales includes elements that support such a system, there has been limited focus on these to date (with the exception of social prescribing). Going forward, a social model of care needs further development. This requires a focus on wellbeing and prevention and understanding the opportunities that exist across the health, social care and third sector workforce in order to really understand what matters to people and make every contact count. Whilst considering the development of the social model of care, the existing actions from a health perspective must continue. Of particular, note is the join up of in hours and out of hours primary care services to a 24/7 model to ensure access at the right time particularly for patients presenting with urgent primary care needs. ‘A Healthier Wales’ points towards exploring digital solutions, which is not an area previously explored in depth or systematically from a primary and community care perspective.

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Work to date on the primary care model for Wales has identified numerous workforce issues. There are currently a number of groups looking at the workforce issues and this needs a review and refocus within the context of ‘A Healthier Wales’. The Critical Appraisal highlights the need for health boards to develop local infrastructure to enable transformation within primary and community care. Health boards became integrated organisations in 2009 and it is timely for them all to reflect on how well developed their internal arrangements are in order to maximise the potential of integration. In turn, consideration of developing the relationships with key partners such as social services, wider Local Authority services and the Third Sector is required in order to ensure seamless working within the whole system at a local and regional level. It is noted that this may be undertaken through local transformation programmes. ‘A Healthier Wales’ makes reference to the contract reform programme of national primary care contracts. The contribution of this needs to be clear. The communication and engagement on the primary care model for Wales needs careful consideration and dedicated expertise to ensure understanding by all stakeholders and the public are clear on what this means going forward. The key strategic areas of work required to progress the implementation of the primary care model for Wales at pace are:

Primary care key workstreams

Seamless working across Health Boards and with partner organisations

Primary care contract reform

The following sections provide an overview of the tasks required under each strategic area. More detailed action plans will underpin each work stream, maximising the existing support from organisations such as the NHS Wales Shared Services Partnership and the Primary Care Hub (Public Health Wales) but also building new links with the Regional Partnership Boards, Directors of Social Services and Health Education and Improvement Wales (HEIW). 5.1 Primary Care Key Workstreams 5.1.1 Prevention and wellbeing Primary and community services have a key role in the ‘wellness’ system as described by ‘A Healthier Wales’ and every contact with a citizen or their carer/guardian should be used to promote prevention and self-management opportunities. Specifically, this includes:

Information for citizens to access – join up of Directory of Services, DEWIS & INFOENGINE and systematically embed in GP practice and cluster based websites to promote self-care.

Social prescribing (or community referrals) and local area co-ordination to increase in capacity of wellbeing services – action is required at regional level and national level. - At cluster and Regional Partnership Board level, a join up is required between

health, social care and the third sector to map the community assets available in

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that footprint and the ‘navigator’ roles already in place. A plan for sustainability of these assets should be developed.

- Local Area Co-ordination linked to Directory of Services.

- At a national level key enablers such as information sharing (information governance and information technology), evaluation frameworks for these types of interventions and the development of national definitions and standards for community navigators/connectors.

Making Every Contact Count (MECC) – systematic roll out of training across primary care underpinned by an understanding of the local community infrastructure (as described above at Regional Partnership Board level).

Prevention in clinical settings – maximising population benefit on key clinical risk factors (high BMI, high BP, fasting blood glucose, cholesterol), behavioural risk factors (smoking, alcohol consumption, rate of physical activity and diet) screening and immunisation.

Prevention in non clinical settings (e.g. whole school approach to prevention and wellbeing, falls risk)

Population risk reduction programmes – linked to prevention in clinical settings, learning from programmes such as the Inverse Care Law in Aneurin Bevan, ABMU and Cwm Taf Health Boards.

Compassionate Communities or equivalent e.g.

Health and well-being hubs/centres – ensure that the wellness approach and social model of care is a prominent feature of the planning.

Scaling up the delivery of national programmes, (e.g. NERS, Help Me Quit).

5.1.2 24/7 Model “Services which are seamless, delivered as close to home as possible” is set out by ‘A Healthier Wales’ and references that primary and community care is key to this. The transforming primary care model was developed as a 24/7 model but implementation has been predominantly focussed on in hours only. Many of the elements of the model can be applied to primary care delivery out of hours whilst recognising there are some issues specific to in hours delivery and out of hours delivery. Also, increased sustainability of primary care in hours and improved access will support out of hours delivery.

Urgent Care – scope includes urgent primary care both in hours and out of hours. Workstreams include: peer review of out of hours services workforce link to Unscheduled Care Programme including winter planning focus on key pathways such as end of life care, paediatrics and mental health opportunities to address capacity at peak times

Escalation Processes – whilst escalation processes are well developed and routinely used in secondary care, this has not been the case for primary care. More recently, work has been undertaken in OOHs but there is an inconsistency in reporting that

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requires attention. In addition, a ‘RAG’ rating for in hours services needs to be developed.

Self care and wider primary care contractor professions – “Choose Well” and the offer from contractor professions needs to be scoped and well articulated in order to promote population behaviour change. (Note: this links to the communication workstream and the prevention and wellbeing work steam, specifically the information to citizens).

Telephone first / sign-posting / triage – informed by the detailed review undertaken by the Primary and Community Care Development and Innovation Hub, there is a clear need to develop national definitions and standards, national training and competency framework.

Services in the community – there is a need to ensure join up across the separate services that are in place across the community (e.g. community nursing, community resource teams etc) to ensure best use of resources. This needs a further sense check against the local authority and third sector services available. Further, maximising the use of diagnostics and point of care testing in the community should be considered.

Management of rising risk – implementation of a structured approach (recognising there are a range of tools available for this) to risk identification and links to the appropriate responses to respond (from the whole system e.g. Third Sector, Local Authority).

5.1.3 Data & Digital Technology While the national primary care plan recognised the role of technology in improving access, previous strategic work on the development of primary care has not focussed on the potential of new technologies. ‘A Healthier Wales’ identifies this as a key enabler of transformation change to support new models of care. In the first instance, there will be a focus on ‘ensuring the relevant information is accurate, complete, up to date and shared between everyone responsible for the individuals care’ before moving on to new ways of accessing services and then more advanced digital solutions. Specifically, this will include:

Maximising the use of current systems available to maximise and share data and information. For example My Health Online, Welsh Community Care Information System (particularly the interface across services) and embedding the integrated DEWIS, Directory of Services and infoengine into practice/cluster websites

Maximising the use of new GP and pharmacy systems and the offer to MDT working

Specifically for pharmacy, progress the Welsh Hospital Electronic Prescribing, Pharmacy and Medicines Administration (WHEPPA) project will enable the computerisation of the process of prescribing, processing, stock control and recording the administration medicines in secondary care hospitals.

Progress IT solutions for eye care, specifically: implement optometry primary care e-referral to enable patients to be referred to secondary care safely; implement ophthalmic two-way IT systems between primary care and secondary care to enable ‘shared care’ of patients between different health professionals and care settings.

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Data to demonstrate activity and outcomes

Information sharing across cluster and organisations

Understanding the requirement around the use of mobile devices including the governance and workforce issues.

Digital systems to facilitate risk identification to drive patient safety.

Telephony – develop national telephony standards.

Video and skype – generally supported in principle yet under-utilised. There is a need to consider governance, security of data, training and integration to health record requirements.

Consideration needs to be given to the barriers to embracing technology including poverty and influencing behaviour change of the population.

5.1.4 Workforce & Organisational Development ‘A Healthier Wales’ references the multidisciplinary team approach as the common characteristic of the best new models being developed in Wales which is fundamental to the Primary Care for Wales. Work has been led by the Primary Care Workforce Group which has produced a final report highlighting the work undertaken to date and has identified key priorities for future work. In addition, the recent report on ‘Multi-Professional Roles within the Transforming Primary Care Model in Wales’ highlights areas requiring further work. Combining these recommendations the following are the key themes for focus:

Workforce planning and modelling – developing local population based modelling based upon demand analysis. This will inform the required competencies of the workforce required and inform workforce planning at community and national level.

A good place to work – addressing the issues of recruitment and retention, pay and employment terms as well as a focus on well-being.

Specific Role Development – priority areas include developing a national framework and training for the community navigator role and triage roles.

Education, training and skills – this includes developing mechanisms to increase opportunities for education and training within primary care settings, including mentoring and supervision requirements and career pathways.

Sharing best practice – building on the compendium of models and roles produced to date with the development of workforce elements of evaluation of new models.

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5.1.5 Communication & Engagement Whilst the primary care model for Wales is predicated on a social model of care, the focus has been on the health elements of the model to date. Further, it is recognised that the language has been from a health perspective and that this needs to widen to ensure the narrative is accessible to all and there are consistent communications from all stakeholders on the model. Initially, this will focus on:

User friendly articulation of the whole and different elements of the model for stakeholders (e.g. social care, third sector, secondary care). Consideration of how clusters/primary care interface with Regional Partnership Boards needs to be considered.

Forming the basis of how staff are trained to manage this message (e.g. receptionist/navigator role).

A public awareness and information/education campaign to promote and the embed the model with citizens across Wales.

‘A Healthier Wales’ talks about people having ‘a greater role and greater control in managing their own health and wellbeing, making decisions about treatment, and managing long term conditions’. This requires readily available information to citizens and an understanding of new models of care in order to influence behavioural change. As part of the Welsh Government’s ‘Transformation Programme’, there may be an over-arching workstream which primary care could align to. As a minimum this would need to include, both at national and local level: - New ways of accessing information

- Understanding of the new wider model at General Practice level e.g. enhanced MDT,

social prescribing (or community referral) and signposting to alternative practitioners (physiotherapists, counsellors, audiologists and existing contractor services e.g. community pharmacy and optometry).

- Links to existing national campaigns such as Choose Well and national plans such as Eye Health.

5.1.6 Transformation & the Vision for Clusters As the transformation programme develops (as per ‘A Healthier Wales’ recommendations), it is important that any learning is shared quickly across primary care and further informs the vision for clusters. Of specific note, will be any plans to accelerate the implementation of the full primary care model at cluster and regional level. Key links will be made with the national Transformation Programme and local transformation programmes.

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5.2 Seamless Working 5.2.1 Health Board arrangements to maximise seamless working The Critical Appraisal of the pacesetter programme referred to in section 3, set out the need for Health Boards to consider their local infrastructure and identify the capacity, skills and resources required to support the transformation of primary care. Based upon the recommendations of the Critical Appraisal, the following requires attention at health board level:

- Setting out arrangements for increasing the profile of primary care at health board level.

- Ensuring arrangements are in place to support data capture to inform demand/capacity planning for primary and community services.

- Having short, medium and long term planning in place informed by clusters that are evidenced in IMTPs.

- Demonstrating the use of the primary care measures and the key GMS indicators have informed these plans.

- Demonstrating the use of the financial framework to support rebalancing resources across the health system (WHC issued July 2018).

- Recognising the scale of change, ensuring workforce planning and organisational development plans are in place to support this.

- Ensuring evaluation frameworks supported by skilled support are in place to evidence impact on pacesetter/transformation model/transformation fund initiatives to inform business case development and investment decisions.

5.2.2 Seamless working across the whole system ‘A Healthier Wales’ sets out the need for services from different providers to be seamlessly co-ordinated and the need to develop shared values and partnership. Therefore, the following requires attention from a primary perspective:

- Consideration of the profile of primary care within the regional partnership board structures both in terms of the understanding of the primary care model by partners and representation within these structures.

- Ensure that regional partnership board plans are informed by cluster planning.

- Consideration of the priorities and actions plans of Public Service Boards and the

alignment locally with cluster plans.

- Build stronger relationships with key partners.

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5.3 How Primary Care Contractors will respond This section considers how primary care contractors will respond to ‘A Healthier Wales’ under the following headings,

- Resilience of individual/community

- Advice/access when required

- Supported and delivering workforce

5.3.1 GMS Resilience of individual/community – in conjunction with the commitments on access more generally within Prosperity for All, and the programme of reform, which has commenced (and is a tripartite approach of Welsh Government, GPC Wales and NHS Wales), the GMS contract reform will consider how best to contract and sustain GMS and deliver against a range of key priorities, recognising the value of the independent contractor model. The contract reform will explore ways to continue to improve access across primary care, particularly through clusters, to enable adoption and adaptation of the Primary Care Model. The policy for some time, and reinforced in ‘A Healthier Wales’, has been a shift to greater cluster working. During 2018-19 the Welsh Government Contract Reform Team is considering a new contracting mechanism to expedite clusters maturing and embedding a better population focussed service planning for General Practice across Wales. The proposed approach could see a potential shift of a number of additional services (such as Enhanced Services and quality measurement) to a cluster level and wider cluster workforce solutions to release capacity within GP practices and support delivery of local services to patients and enable cluster population based service planning and delivery. Advice/access when required - As part of the 2018-19 GMS contract negotiations it was agreed that GP practices should continue to optimise the availability of consultations during core hours, standardise messaging to patients out of hours and for each practice to review access and agree its position on the telephone first / sign-posting / triage component of the model. Demonstrating and developing quality improvement methodology in General Practice is another key priority with a view to deliver improved outcomes and experience for Welsh citizens, with a focus on the cluster as the vehicle for taking this forward. Supported and delivering workforce – Recruiting, retaining and diversifying the workforce is another key priority. As part of the GMS reform agenda, a number of areas will be taken forward across the General Practice workforce to ensure the longer term ambition of a sustainable workforce, reducing the barriers to becoming and remaining a GP. 5.3.2 Pharmacy Resilience of individual/community: Community pharmacies are a health asset, fulfilling a social and well-being function, often in the areas of Wales where the health and social challenges are greatest. Pharmacies contribute to social capital and build resilience in high streets in towns across Wales, but changing consumer habits means we must work with the community pharmacy sector helping it to adapt and ensure this contribution is maintained. Community pharmacies must continue to redefine their role, making them the most accessible source of an increasing range of clinical services and face to face advice from a healthcare professional - not simply a place to have a prescription dispensed.

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Key priorities include,

Community pharmacy contractual arrangements rebalanced to incentivise delivery of services which meet the needs of the communities they serve and not just the dispensing of prescriptions.

Pharmacies continue to target their services at those whose need is greatest and where there is potential for greatest health gain and narrowing of health inequality.

Community pharmacy fully integrated with primary care clusters to ensure delivery of efficient equitable services.

Advice/access when required: Community pharmacies are highly accessible, often open at weekends and evenings, they provide a convenient and less formal environment for people unable to, or who do not wish to, visit other health services. Key priorities include,

Community pharmacists continue to diagnose and treat a wider range of acute illnesses, relieving pressure on other parts of the NHS.

Community pharmacists accessing the Welsh GP record nationally and across all services to facilitate pharmacists safely and effectively meeting urgent and unscheduled care demand.

Communication with the public and action by other health services consistently promoting the role of community pharmacy as citizens’ first port of call for treatment of common ailments and advice on medicines.

Supported and delivering workforce: Community pharmacists are highly skilled primary care generalists; they manage minor illness and provide advice on medicines. Pharmacy technicians are critical to the safe and efficient operation of pharmacies, freeing up pharmacists to deliver more clinical services and increasingly delivering clinical services themselves. To increase the breadth of services available from community pharmacies, we will continue to raise the competence and confidence of the workforce in areas such as patient centred consultation, making every contact count, quality improvement, advanced clinical skills, and prescribing. Key priorities include,

All community pharmacists and pharmacy technicians to continue to be supported in developing their patient centred consultation skills and in “making every contact count”.

An improved awareness and understanding of quality improvement embedded in community pharmacy teams.

Continue to provide opportunities to access up to 200 modern apprenticeships for pharmacy technicians working in community pharmacy by 2021.

Continue to provide opportunities to train 100 community pharmacists as independent prescribers by 2020.

5.3.3 Optometry Resilience of individual/community: Community Optometry is a highly skilled workforce fulfilling a key health function, contributing to the social capital and building resilience in high streets in towns across Wales, community optometric practices continue to deliver the most accessible and appropriate professional eye health care for patients. There is a need to raise their profile and the awareness of the contribution they make. Commercial pressure to subsidise sight tests with spectacle sales leads to patients expecting a visit to the optometrist to be expensive and this can reduce the uptake of NHS eye care services. Moving the emphasis to eye health care will ensure optometric practices continue to be a health asset in the community and the first port of call for a patient with an eye problem. Regular and consistent access for optometric practice with primary care clusters is vital to develop integrated services and ensure understanding of the important role optometrists play in the eye health care of patients.

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Key priorities include,

Optometric practices targeting their services where there is potential for greatest health gain - the emphasis on eye health care

Community optometric contractual reform rebalancing the need for cross subsidy of clinical services.

Community optometry fully integrated with primary care clusters to ensure delivery of efficient, equitable services.

Advice/access when required: Continue to increase access to a range of NHS eye health care services and provide a wider range of clinical services in optometric practices. Community optometric practices are highly accessible, often open at weekends and evenings. Providing additional qualifications for community optometrists to deliver more integrated eye care services, shifting between primary and secondary care, for both scheduled and unscheduled eye health care is essential. Key priorities include,

Community optometrists to continue to be involved in diagnosis and treatment of a wider range of eye care pathways, specifically, through the development of primary care ophthalmic diagnostic and treatment centres.

Access to electronic referrals and single shared electronic patient record.

Communication with the public to promote the role of community optometric practice, consistently promoting the role of community optometry - Doctors of the eyes.

Supported and delivering workforce: community optometrists are eye care generalists. It is important to continue to enhance the skill mix required to manage and treat a wider number of eye conditions in the community setting. This will enable a greater shift of services from secondary to primary care in line with current policy and prudent healthcare. To increase the breadth of services available from community optometry there is a need to enhance the workforce through advanced training and accreditation, whilst additionally providing a career structure for the optometric profession. Key priorities include,

Independent prescribing optometrists rolled out across primary care clusters.

Placements in hospital eye departments to achieve qualifications in medical retina, glaucoma, independent prescribing and leadership.

An improved awareness and understanding of quality improvement embedded in community optometry through contractual arrangements.

5.3.4 Dental

Resilience of individual/community; to raise the profile of the contribution improving oral health can make to wider health and well-being by empowering and guiding patients and the public to value, maintain and protect their own oral health, and that of their dependents. An increase in oral health literacy is important in achieving this and we want patients to understand how their behaviour affects their likelihood of developing dental disease. We want dental teams to personalise key messages by delivering consistent and correct advice to assist patients to lower their risk of oral disease so they can maintain and improve their oral health. Key priorities include,

Preventive advice and intervention ‘expectations’ being delivered in clinical practice.

All patients in contact with primary dental care will have their oral health need and risk assessed, explained and reported, so they understand their oral health status and the behaviours they can change to reduce their risk of oral disease.

Advice/access when required: to increase access to NHS primary care dentistry and provide dental services (primary, specialist, or urgent care) that meet the needs of local communities. Care should be accessible for those with the greatest health need first – a principle of Prudent Healthcare. The commitment is to increase access to NHS dental care, particularly for patients who have not seen a dentist in the previous two years (one year for children). Key priorities include,

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Year-on-year increase in the proportion of people who have seen an NHS dental practitioner in the last 2 years (1 year for children) in all Health Boards.

Contracts which build in daily access flexibility and expanded opening hours.

Anyone experiencing dental pain affecting daily life will receive effective dental treatment and receive a timely offer to return and have a comprehensive oral health risk and need assessment completed.

All patients attending NHS primary dental care services will receive an oral health risk and need assessment at least once a year with follow up reviews dictated by the findings.

Supported and delivering workforce: a step-up in the effective use of skill mix within dental practice teams and specialist services through an increase in the number of hygienists, therapists and dental nurses with additional skills, trained and retained in Wales, and working to the extent of their scope of practice. This will create an efficient preventive-led dental team. Widened access to employment opportunities will offer prospects for individuals from local communities, motivate dental teams and support them to achieve their professional and personal goals by offering a career structure. Key priorities include,

Dental Care Professional Faculty established and Making Prevention Work in Practice programme rolled-out in 2018.

Innovation fund supporting expansion of Dental Care Professionals in practice

6. Conclusion This paper provides the primary care response to ‘A Healthier Wales’, describing a status position on the development of primary care and identifies key strategic areas for further focus. This forms the basis of a strategic programme for primary care. There will be a delivery and evaluation mechanism to support this strategic programme which will provide the detail of actions, milestones and outcomes at cluster, regional and national levels. It should be noted that some areas of work will continue under ‘business as usual’ led by the Health Board Directors of Primary & Community Care.

Components of Transformational Model for Primary and Community Care

A transformational programme of change to primary care and community services is underway to safeguard the health and wellbeing of the people of Wales, building on the excellent services currently provided by professionals across the country. The new model takes a whole system approach to redesign, driven by national quality standards but with flexibility to respond to local community needs (see diagram Appendix 1).

1. Principles of Primary and Community Care Transformational Model The citizen is central to the new model, with inclusion of all ages and demographics. Access will ensure the right care is available at the right time from the right source, at or close to home. The model is founded on:

Service developments based on population need, with planning and transformation led through local primary care clusters

Promotion of healthy living and the demedicalisation of wellbeing

A population focus as the basis for service planning and delivery across local communities

A more preventative, pro-active and co-ordinated primary care system which includes general practice and community service provision through community resource teams (CRTs) or frailty services

A whole system approach through the integration of health, local authority and voluntary sector services, facilitated by collaboration and consultation

Holistic care for citizens that incorporates physical, mental, and emotional wellbeing, linked to healthy life style choices

Integrated, streamlined care on 24/7 basis, focusing on the sickest patients during out of hours

Greater community resilience through empowered citizens and access to a range of community assets

Advice and support available to help people remain healthy, with easy access to local services for care when people need it

Strong multi-professional leadership across sectors and agencies to drive quality improvement

Technological solutions to improve access to information, advice & care and support self-care

2. Informed Public A shared understanding of the case for change, setting out what good looks like and explaining the benefits, is critical to success. Cultural change requires information, education, motivation and inspiration of the public to empower people to take ownership of their health. Communication strategies require a strong primary and community care focus to inform both public and professionals of the new models and service developments. Cultural differences between geographical areas may require different approaches to change behaviour. Involving children and young people in understanding the importance of self-responsibility is a key enabler for future change. Healthcare professionals use brief interventions and approaches including making every contact count (MECC) to make an impact on lifestyle behaviours and choices

3. Empowered Citizens Including people in the design of their local services, using feedback on user experiences and giving people active roles in the change process, all promote public empowerment. Local champions can share the value of primary and community care innovations through their own positive experiences. Motivational interviewing and coaching techniques have been found to be effective in supporting behaviour change. Patients and service users are encouraged to make informed choices together with their health and social care professionals.

4. Support for Self Care People are assisted to take responsibility for their health by building their knowledge, skills and confidence. Self care and taking responsibility is key to transformational change, with active involvement of people and carers in decisions about their care, and a range of local resources available to promote self-care and self-referral. Smart technology assists with monitoring, self-care and communications.

5. Community Services The model incorporates the ability for healthcare professionals in general practice to refer to a greater range of community services and pathways, with up-to-date information and advice on health and wellbeing. The model also includes non-clinical care and support in addition to clinical services. An increasing range of options for help and advice includes conversations with local health teams by phone, email or video call. Systems are designed to support decision-making and ensure there is access to the best professional or service when necessary. Community resources may be accessed through self-referral or by telephone triage acting as a social prescribing mechanism, with the use of Link Workers, Social Prescribers and technology to support signposting. It is essential that these local services are easily accessible, sustainable and meet the needs of the community. 6. Cluster Working Employment of staff to work across clusters increases efficiency and ensures the local population has good access to clinical, social and managerial expertise. Cluster teams recruit professionals including pharmacists, physiotherapists, social workers, paramedics, physicians’ associates, occupational therapists, mental health counsellors, dietitians, third sector workers and other local authority staff to increase capacity for managing the everyday needs of the local population.

General practice stability lies at the heart of the new model and is essential to ensure that local health services are sustainable and can respond to future demands. Local support from health boards helps to stabilise vulnerable GP practices and effective local workforce planning will ensure sustainability in the longer term.

Cluster teams are breaking down artificial barriers within local health and social care systems to promote integrated care around the needs of the local population. Integrated working and cultural change are facilitated by joint contracts, shared learning sessions, co-location of staff and opportunities for professionals to rotate between different sectors. The emergence of various models that promote collaborative cluster working, such as Federations, Social Enterprises and the Primary Care Hub, are aligned to this integrated multi-professional approach.

6. Clinical Triage / Telephone First Systems in General Practice Safe and effective call-handling and clinical triage systems at the front door of primary care are designed to direct people to the most appropriate professional / service, moving away from the current system in which the GP filters the majority of patient contacts. Telephone advice is appropriate for a significant proportion of people’s requests and, if given by a suitably experienced professional, can safely and effectively reduce the number of face-to-face consultations. This telephone first model, incorporating call handling (or care navigation) and clinical triage, has the potential to direct or signpost people beyond the multi- professionals around the GP.

The telephone first / triage model is also about ensuring access to the right care from the right service in a timely way, directing people to:

Clinical professionals integrated within the local multi-professional cluster team, including optometric and dental professionals to manage eye, tooth and oral health problems; community pharmacists to manage common ailments and medication-related problems and physiotherapists to manage musculoskeletal problems

Non-clinical community services when appropriate, with referrals assisted by link workers or social prescribers who are integrated within the local multi professional team

7. 111 and Out-of-Hours Care The redesigned 111 Service ensures appropriate management of people with urgent needs in the out-of-hours period, with good communication systems to ensure that professional teams have access to contemporaneous clinical records. This is essential for seamless care across in- and out-of-hours, especially for patients with complex conditions and / or at the end of life.

111, supported by a national virtual directory of services, also acts as a social prescribing mechanism to signpost people 24/7 to local services and sources of help.

8. Direct access People can directly access a range of local health services that include: community pharmacists for advice and treatment for a range of common ailments; optometrists for advice and treatment of routine and urgent eye problems; dentists for toothache and oral health; physiotherapists for musculo-skeletal problems; audiologists for hearing problems. Some of these services may not be available yet everywhere but they are developing and transforming over time.

9. People with Complex Care Needs As a result of effective triage and enhanced multidisciplinary cluster working, GPs and Advanced Practitioners have more time to proactively care for people with more complex needs at home or in the community - often the elderly with multiple co-morbidities. Significantly longer consultation times are required to assess, plan and coordinate anticipatory care.

People who present with both health and social care needs can be supported by seamless care from community resource teams, frailty or other integrated local health and care teams. Complex issues arising from welfare, housing and employment problems can be better managed through a whole system, multi-professional approach. The cluster team is also well placed to support care of the acutely ill within Virtual Wards and Community Hubs, working alongside specialist colleagues to care for those who would otherwise be admitted to hospital and risk losing their independence. Such community teams can also facilitate prompt discharge from hospital.

This holistic multidisciplinary model therefore offers a more proactive and preventative approach to care, with people managed earlier in their care pathways when they respond better to education and support for self-care. The result is better outcomes and experiences for people and carers. The model has the potential for a wider range of planned care to be undertaken in the community, including outpatient appointments and treatments, and diagnostic tests. It could also reduce referrals to secondary care and unscheduled care admissions, allowing hospital staff to focus resources on the very sick and on planned specialist care.

10. Infrastructure to support Transformation The Primary Care Transformational Model must be underpinned by an infrastructure that is fit for purpose and designed to facilitate enhanced MDT working. Local health facilities, informatics and telephony systems need to be flexible and responsive to future changes, supporting multi-professional working and telephone first/triage components. Digital options to seek and receive care need to become commonplace. Direct access to diagnostic services in the community by cluster clinicians is essential to the delivery of quality care closer to home. 11. Anticipated Outcomes National and international research, taken alongside the evidence emerging from the Pacesetter Programme, indicates the potential benefits of the transformational model for primary and community care:

Improved citizens’ health and wellbeing Greater community resilience Better practitioner morale, motivation and wellbeing Increased recruitment and retention of primary care and community staff Sustainable models of care

Jane Harrison, Lead GP Adviser,

Primary Care Hub (PHW) February 2018

3edd Cynhadledd Genedlaethol Flynyddol Gofal Sylfaenol a Chymunedol

15 Tachwedd 2018. Canolfan yr Holl Genhedloedd, Caerdydd

8.30am Cofrestru, lluniaeth ac arddangosfeydd

9.30am Croeso ac amcanion y dydd

Dr John Boulton - Cyfarwyddwr Dros Dro Gwella Ansawdd a Diogelwch Cleifion y GIG, a Chyfarwyddwr 1000 o Fywydau - Gwasanaeth Gwella

9.35am Llais y dinesydd - myfyrdodau ac arsylwadau ar y Model Gofal Sylfaenol i Gymru

Clare Jenkins ac Alyson Thomas - Cyd Brif Weithredwyr, Cyngor Iechyd Cymuned

10am Ymgyrch GMS - y ffordd yn ôl o ITU? Charlotte Jones - Cadeirydd GPC Cymru

10.15am Anerchiad gan Ysgrifennydd y Cabinet Vaughan Gething AC - Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol

10.30am Cofrestru ac arddangosfeydd

Sesiwn 1: Trawsnewid mynediad

11am

Myfyrdodau ar gynnydd ledled Cymru

Fferylliaeth Gymunedol - Dylan Jones

Optometreg Gymunedol - Andy Britton

Gwasanaethau Deintyddol Cyffredinol - Richard Jones

Gwasanaethau Meddygol Cyffredinol - Dr. Gaynor Thomas Bydd y sesiwn hon yn cynnwys sesiwn Holi ac Ateb gyda phanel

Dan Gadeiryddiaeth Paul Gimson - Arweinydd y Rhaglen 1000 o Fywydau, Gwasanaeth Gwella

12.45pm Cinio ac arddangosfeydd

Sesiwn 2: Trawsnewid mynediad drwy ofal aml-broffesiynol

1.30pm

Tîm aml-broffesynol y dyfodol

Uwch ymarferydd nyrsio - Amanda Monsell

Awdioleg - Natalie Phillips

Iechyd Meddwl - Ian Wile

Therapi galwedigaethol - Kerrie Phipps

Parafeddyg - Grayham Mclean

Ffisiotherapi - Robert Caine

Presgripsiynu cymdeithasol - Liesbeth Beeckman

Gwaith cymdeithasol - Allison Hulmes

Cyd-gynhyrchu - Victoria Lloyd

Dan gadeiryddiaeth Philippa Ford - Rheolwr Materion Cyhoeddus a Pholisi CSP Cymru a Dr. Jane Harrison - Cynghorydd Arweiniol Ymarfer Cyffredinol, Is-adran Gofal Sylfaenol

Sesiwn 3: Technoleg i wella mynediad a chynaliadwyedd

2.45pm

Sut y gall gwelliannau mewn technoleg ddigidol helpu gofal sylfaenol i wella mynediad a chynaliadwyedd

Fy Ngofal Iechyd - Damian Williams

Gofal digidol: safbwynt y cleifion - Matthew Lloyd

Gwersi a ddysgwyd o dechnoleg ddigidol - Darryn Thomas

Gwasanaethau negeseuon testun - Antonia Higgins

Trwyddedau ffôn dan arweiniad meddyg teulu - Heather Potter

DEWIS a phresgripsiynu cymdeithasol - Richard Palmer

Gwasanaethau Skype ac 111 - Steve Bassett Bydd y sesiwn hon yn cynnwys panel Holi ac Ateb o blith y cyflwynwyr ac Anne Marie Cunningham, Cyfarwyddwr Meddygol Cyswllt Gofal Sylfaenol, NWIS

Dan Gadeiryddiaeth Paul Gimson

Sesiwn 4: Myfyrdodau a'r camau nesaf

3.45pm Myfyrdodau, camau gweithredu a'r camau nesaf

Judith Paget, Prif Swyddog Gweithredol Bwrdd Iechyd Aneurin Bevan, Prif Weithredwr Arweiniol Gofal Sylfaenol a Chadeirydd y Bwrdd Gofal Sylfaenol Cenedlaethol.

3.55pm Diweddglo Dr. John Boulton

4pm Lluniaeth cyn ymadael a chyfle olaf i weld yr arddangosfeydd

Dr John Boulton

Dr John Boulton yw Cyfarwyddwr Dros Dro Gwella Ansawdd a Diogelwch Cleifion a Chyfarwyddwr Mil o Fywydau – Gwasanaeth Gwella yn Iechyd Cyhoeddus Cymru. Cyn hyn, bu’n gweithio fel Cyfarwyddwr Gweithredol Gwelliant Parhaus ym Mwrdd Iechyd Prifysgol Aneurin Bevan (BIPAB). Mae gan Dr Boulton brofiad helaeth ym maes Gwella Ansawdd. Tra roedd yn gweithio fel Rhewmatolegydd, datblygodd John ddiddordeb mewn methodolegau gwella ansawdd. Ar ôl dod yn aelod gweithgar o dîm gwella ei Ymddiriedolaeth, aeth ymlaen i arwain y rhaglen drawsnewid ar gyfer cleifion allanol. Cyrhaeddodd ei waith o fewn Rhewmatoleg y rhestr fer i ennill gwobr genedlaethol, ac roedd yn cynnwys gwell amserlennu o ran therapïau biolegol, darparu biolegaeth o fewn lleoliadau cymunedol, a gwella profiad cleifion o fewn clinigau cleifion allanol.

Yn 2012 enillodd gymrodoriaeth Gwella Ansawdd yn y Sefydliad Gwella Gofal Iechyd, o dan nawdd y Sefydliad Iechyd. Roedd hyn yn ei alluogi i ddatblygu dealltwriaeth ddofn o wyddor gwella yn ogystal ag arsylwi sut i gyflawni gwella ar raddfa fawr. Cyn symud i Gymru, bu’n gweithio yng ngwladwriaeth Qatar fel Arweinydd Clinigol ar gyfer Gwella ansawdd yng Nghorfforaeth Feddygol Hamad. Arweiniodd strategaeth llif y gorfforaeth gan arwain at ddatblygu cydweithrediaeth llif, a arweiniodd at gynyddu capasiti sefydliadol ac, yn y pen draw, at welliant pendant mewn llif. Ar ben hynny, cefnogodd gydweithrediaeth diogelwch cleifion y Sefydliad Gwella Gofal Iechyd, gan arwain at ostyngiadau cynaliadwy mewn niwed i gleifion. Mae Dr Boulton wedi cyflwyno’n helaeth ar Wella Ansawdd a modelu mathemategol. Ar hyn o bryd, mae’n aelod o’r Gyfadran Ewropeaidd ar gyfer rhaglen Datblygu Proffesiynol i Hyfforddwyr Gwella y Sefydliad Gwella Gofal Iechyd. Yn 2018, daeth, hefyd, yn Athro anrhydeddus ym Mhrifysgol Abertawe. Andy Britton

Mae Andy wedi bod yn Gyfarwyddwr Optometryddion Specsavers Hwlffordd ers 2006. Mae wedi ehangu cwmpas clinigol ei bractis drwy barhau i fuddsoddi mewn offer a thechnoleg. Mae hefyd yn darparu clinigau fel optometrydd sesiynol yn Ysbyty Llwynhelyg yn y clinigau Macwla a Glawcoma. Graddiodd o Aston ym 1996 ac mae wedi gweithio ym mhob math o bractisau yn ne Cymru ac wedi bod yn eiriolwr brwd dros ddatblygiad personol parhaus ar ôl cwblhau diploma ôl-radd mewn Optometreg Glinigol ym Mhrifysgol Aston ac ar hyn o bryd, mae ar leoliad mewn ysbyty sydd ar gyfer Rhagnodi annibynnol. Yn ddiweddar, cwblhaodd Dystysgrif Ôl-radd mewn Glawcoma ac mae’n astudio ar gyfer y Dystysgrif Uwch, a fydd yn caniatáu ar gyfer rheoli cleifion yn fwy annibynnol mewn gofal sylfaenol. O fewn Specsavers mae Andy yn ymwneud â hyfforddi a datblygu Optometryddion cyn cofrestru a

chydweithwyr, yn ogystal â rolau Dylunio’r Siop a Datblygu TG. Mae ganddo gefndir o weithio arolygydd cyn-cofrestru ar ôl hyfforddi 5 optometrydd graddedig yn eu blaenau i gymhwyso’n llwyddiannus fel Optometryddion. Mae Andy ar y Pwyllgor Optometryddion Lleol hefyd ac yn aelod o Optometreg Cymru fel cynrychiolydd FODO. Robert Caine

Dechreuodd Rob weithio fel uwch ymarferydd ffisiotherapydd cyhyrysgerbydol ym mis Ionawr 2015. Caiff ei swydd bresennol ei rhannu rhwng gofal sylfaenol a gwasanaethau rhewmatoleg arbenigol. Ei rôl mewn practisau meddygon teulu yw derbyn cleifion cyhyrysgerbydol fel pwynt cyswllt cyntaf a rheoli eu gofal cyhyrysgerbydol. Ei dîm ef oedd ymysg y cyntaf o’i fath yn y DU a chylch gwaith Rob oedd sefydlu’r gwasanaeth yng ngogledd Cymru. Mae wedi magu profiad helaeth mewn rhewmatoleg dros yr 8 mlynedd diwethaf ac, ar hyn o bryd, mae’n cynnal clinigau poen llidiol y cefn a chlinigau Sbondylitis sy’n Achosi Ymasiad. Ynghyd â’i brofiad ym maes cyhyrysgerbydol, mae’n rhagnodydd anfeddygol cymwysedig, sydd â blynyddoedd lawer o brofiad mewn pigiadau steroid y cymalau a meinwe meddal. Mae wedi cael ei enwi’n awdur mewn llu o bapurau rhewmatoleg, a chwblhaodd ei draethawd hir yn ddiweddar

ar gyfer ei MSc yn archwilio barn meddygon am ffisiotherapyddion rhewmatoleg uwch mewn gofal sylfaenol. Dr Anne Marie Cunningham

Mae Dr Anne Marie Cunningham wedi gweithio’n rhan-amser fel meddyg teulu yng Ngelligaer ers 16 mlynedd. Mae hi hefyd yn Gyfarwyddwr Meddygol Cyswllt ar gyfer Gofal Sylfaenol yng Ngwasanaethau Gwybodeg GIG Cymru. Meddai, "Rwy’n awyddus i weithio gyda defnyddwyr i sicrhau ein bod yn gwneud y defnydd gorau o dechnoleg er mwyn darparu gofal diogel, effeithiol ac effeithlon".

Philippa Ford MBE

Cymhwysodd Pip fel ffisiotherapydd o Ysbyty St Mary’s, Llundain ym 1986 a dechreuodd weithio yn y Grŵp Brenhinol o Ysbytai Caerdydd, gan weithio yn y GIG am 14 blynedd. Roedd ei meysydd arbenigol yn cynnwys pobl hŷn, gofal anadlol, a rheoli gwasanaethau ffisiotherapi. Ym 1999, dechreuodd Pip weithio i’r Gymdeithas Siartredig Ffisiotherapi fel Rheolwr Materion Cyhoeddus a Pholisi ar gyfer Cymru yn fuan iawn ar ôl sefydlu Cynulliad Cenedlaethol Cymru. Mae’r swydd yn cynnwys ymgysylltu â gwleidyddion, Llywodraeth Cymru, gweision sifil a rhanddeiliaid eraill yng Nghymru, yn codi proffil y proffesiwn, ymateb i fentrau polisi allweddol ar ran y proffesiwn a chefnogi aelodau Cymdeithas Siartredig Ffisiotherapi Cymru. Cafodd Pip MBE am Wasanaethau i Ffisiotherapi yn Rhestr Anrhydeddau’r Flwyddyn Newydd yn 2015.

Mae Pip yn cynrychioli ffisiotherapi ar y Grŵp Cyfeirio Gofal Sylfaenol a Chymunedol ac yn cynrychioli’r grŵp hwn ar y Grŵp Trawsnewid Gofal Sylfaenol. Yn 2018, gan weithio gyda thri arall, Pip oedd yn gyfrifol am arwain darn o waith oedd yn ystyried Rolau Aml-Broffesiynol o fewn y Model Trawsnewidiol ar gyfer Gofal Sylfaenol yng Nghymru. Cyhoeddwyd y ddogfen hon yn ddiweddar ar wefan Gofal Sylfaenol Un. Vaughan Gething AC

Cafodd Vaughan ei eni yn Zambia a’i fagu yn Dorset. Cafodd ei addysg ym mhrifysgolion Aberystwyth a Chaerdydd, ac mae’n briod â Michelle. Mae Vaughan yn gricedwr sydd wedi ymddeol fwy neu lai, ac mae’n hoff o rygbi a phêl-droed. Roedd Vaughan yn gyfreithiwr ac yn gyn bartner yn Thompsons. Mae’n aelod o undebau’r GMB, UNSAIN ac Unite, ac ef oedd Llywydd ieuengaf erioed y TUC yng Nghymru. Bu’n gynghorydd sir yn y gorffennol, ac yn llywodraethwr ysgol. Mae hefyd wedi bod yn wirfoddolwr gwasanaethu’r gymuned - yn rhoi cymorth a gofal i fyfyriwr â pharlys yr ymennydd ac mae’n gyn-lywydd UCMC (Undeb Cenedlaethol Myfyrwyr Cymru).

Rhwng 1999 a 2001, bu Vaughan yn gweithio fel ymchwilydd i’r cyn-Aelod Cynulliad Val Feld ac i Lorraine Barrett. Rhwng 2001 a 2003, Vaughan oedd Cadeirydd Right to Vote – prosiect trawsbleidiol i annog mwy o gyfranogiad gan gymunedau pobl dduon a lleiafrifoedd ethnig yng Nghymru. Mae Vaughan yn aelod o’r Blaid Gydweithredol. Ym mis Mehefin 2013, penodwyd Vaughan Gething yn Ddirprwy Weinidog Trechu Tlodi. Ym mis Medi 2014, penodwyd Vaughan yn Ddirprwy Weinidog Iechyd. Ym mis Mai 2016, cafodd ei benodi’n Ysgrifennydd y Cabinet dros Iechyd, Llesiant a Chwaraeon. Penodwyd Vaughan yn Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol ar 3 Tachwedd 2017. Paul Gimson

Mae Paul yn fferyllydd cymwys gyda thros 20 mlynedd o brofiad ym maes fferylliaeth, rheoli a gwella ansawdd ac mae wedi cael gyrfa amrywiol gyda rolau mewn gofal iechyd cymunedol, y GIG, Llywodraeth Cymru ac academia. Mae wedi dal swyddi arweiniol gyda Byrddau Iechyd Lleol, y Gymdeithas Fferyllol Frenhinol a Fferylliaeth Gymunedol Cymru. Mae’n Paul yn teimlo’n gryf ynghylch gwella a helpu pobl i ddarparu gwell gofal i’w cleifion. Mae’n gymrawd y Sefydliad Iechyd ac yn un o raddedigion ei raglen Generation Q, a’i harweiniodd at 1000 o Fywydau, corff gwella GIG Cymru o fewn Iechyd Cyhoeddus Cymru. Yma, mae’n arwain ar ddatblygu gofal sylfaenol a gwella diogelwch meddyginiaethau.

Dr Andrew Goodall

Penodwyd Dr Andrew Goodall i swydd Cyfarwyddwr Cyffredinol Iechyd a Gwasanaethau Cymdeithasol/Prif Weithredwr GIG Cymru ym mis Mehefin 2014. Mae ei rôl yn cynnwys cefnogi blaenoriaethau Gweinidogol ar gyfer iechyd a gofal cymdeithasol o fewn strwythurau’r Gwasanaeth Sifil, ac arwain a goruchwylio GIG Cymru. Gan gynnwys ei rôl bresennol, mae Andrew wedi bod yn Brif Weithredwr yn y GIG yng Nghymru ers 13 blynedd. Ei swydd flaenorol oedd Prif Weithredwr Bwrdd Iechyd Prifysgol Aneurin Bevan, a bu yn y swydd honno ers sefydlu’r Bwrdd Iechyd ym mis Hydref 2009 tan 2014.

Yn ystod ei yrfa 27 mlynedd, mae Andrew wedi dal swyddi cynllunio a gweithredol mewn nifer o sefydliadau’r GIG ledled de Cymru, yn ogystal â swyddi cenedlaethol. Mae ganddo ddiddordeb arbennig ym meysydd gwella diogelwch cleifion, ansawdd a phrofiad cleifion; gweithio mewn partneriaeth ar draws Gwasanaethau Cyhoeddus; a darparu gwasanaethau rheng flaen drwy wella a moderneiddio gwasanaethau. Mae gan Dr Goodall radd yn y gyfraith o Brifysgol Essex a Doethuriaeth mewn Rheoli Gwasanaethau Iechyd o Ysgol Fusnes Caerdydd.

Dr Jane Harrison

Hyfforddodd Jane fel meddyg teulu yn Llundain, ac mae’n ymddiddori mewn addysg feddygol ac ailddylunio gwasanaethau iechyd. Pan symudodd i Gymru ym 1994, sefydlodd Rwydwaith Cymru Gyfan i ddarparu addysg a chymorth i feddygon teulu cyflogedig a llawrydd. Yn sgil secondiad dilynol fel Uwch Gynghorydd Meddygol i Lywodraeth Cymru, cafodd gyfle i ganolbwyntio ar faterion yn ymwneud â recriwtio a chadw meddygon teulu a llunio canllawiau ar gyfer meddygon teulu gyda Diddordeb Arbennig. Rhwng 2007 a 2015, fel Cyfarwyddwr Meddygol Cynorthwyol ar gyfer Gofal Sylfaenol o fewn Bwrdd Iechyd Prifysgol Abertawe Bro Morgannwg, adeiladodd Jane ar ei diddordeb mewn trawsnewid y GIG yng Nghymru a sefydlodd y seilwaith ar gyfer ail-ddylunio llwybr gofal. Gan ddysgu o brofiad cenedlaethol a rhyngwladol, arweiniodd Dîm Trawsnewid Gwasanaeth i ailfodelu meysydd clinigol critigol o’r bwrdd iechyd a llywio newid ar gyfer y system gyfan. Mae Jane yn gweithio i Iechyd Cyhoeddus Cymru fel Cynghorydd Arweiniol meddygon teulu i’r Hyb

Datblygu ac Arloesi Gofal Sylfaenol a Chymunedol, gan gynnig arweiniad, cyngor a chymorth o ran arloesi, integreiddio ac ail-ddylunio yn y maes Gofal Sylfaenol a’r Gymuned. Antonia Higgins

Tonia sy’n rheoli Meddygfeydd Brynderwen a Minster, sy’n gwasanaethu poblogaeth o tua 19,000 o gleifion ledled Caerdydd, dros ddau safle, gydag un feddygfa ychwanegol, rhan amser yn cael ei darparu ar gyfer myfyrwyr Campws Cyncoed Prifysgol Fetropolitan Caerdydd. Mae’r practis yn gwasanaethu poblogaeth amrywiol sy’n cynnwys ardaloedd gyda’r lefelau uchaf o amddifadedd a chyfoeth yng Nghaerdydd. Mae gan y Practis 10 o bartneriaid, ac mae’n bractis sy’n hyfforddi, gan dderbyn myfyrwyr meddygol blynyddoedd 3, 4 a 5 a chofrestryddion mewn ymarfer cyffredinol. Ffermwr oedd Tonia’n wreiddiol, gan weithio ym meysydd amaethyddiaeth a garddwriaeth, a symudodd i faes TG fel hyfforddwr ar gyfer Systemau Clinigol Gofal Sylfaenol ledled y wlad. Am rai blynyddoedd, bu’n gweithio i PRIMIS yn ymgymryd ag ymarferion ansawdd data yn ymddiriedolaeth gofal sylfaenol Exeter, ac yna ymlaen i Gonsortiwm Technoleg a Rheoli Gwybodaeth Avon, gan aros ym maes Gofal Sylfaenol. Daeth Tonia yn Rheolwr Practis yn 2004 fel rhan o brosiect Blaenau’r Cymoedd yng Nghaerffili.

Allison Hulmes

Hyfforddodd Allison fel nyrs yn Ysgol Nyrsio Gorllewin Morgannwg ym 1984 ac ar ôl cymhwyso, arbenigodd ym maes pediatreg yn Ysbyty Athrofaol Cymru. Yn ystod diwedd y 1980au, dechreuodd diddordeb Allison ym maes eiriolaeth a dechreuodd eirioli ar ran llawer o drigolion Ysbyty Trelai, Caerdydd. Roedd y trigolion yn cael eu hadleoli yn y gymuned ar ôl treulio blynyddoedd lawer mewn cartref. Roedd y prif bryderon yn ymwneud â diogelu oedolion a dyma oedd yr ysgogiad i Allison ddychwelyd i’r brifysgol lle yr astudiodd ar gyfer gradd yn y gyfraith. Dilynwyd hyn gan gyfuniad o radd Meistr a Diploma mewn Gwaith Cymdeithasol a threuliodd flynyddoedd lawer yn gydgysylltydd diogelu oedolion ac amddifadu rhyddid yn Ninas a Sir Abertawe. Mae diddordeb dwfn Allison ym maes hawliau dynol wedi parhau drwy gydol ei gyrfa ac mae’n

astudio ar hyn o bryd am radd Meistr mewn cyfraith Hawliau Dynol. Yn 2012, Allison oedd un o’r Gweithwyr Cymdeithasol Ymgynghorol cyntaf yng Nghymru, yn y Gwasanaeth Cefnogi Teulu Integredig newydd. Roedd y swydd yn golygu cynnal ymyriadau therapiwtig uniongyrchol mewn teuluoedd, lle roedd camddefnyddio sylweddau ymysg rhieni yn brif ffactor risg i blant, yn ogystal â chefnogi trawsnewid y gweithlu gwaith/gofal cymdeithasol. Mae Allison wedi ymrwymo i hyrwyddo’r safonau uchaf ym maes gwaith cymdeithasol yng Nghymru ac mae ganddi flynyddoedd lawer o brofiad mewn darparu hyfforddiant, hyfforddi a mentora ac fel darlithydd gwadd ar raglenni gwaith cymdeithasol. Mae Allison wedi gweithio fel Swyddog Proffesiynol i BASW Cymru (y gymdeithas broffesiynol ar gyfer gwaith cymdeithasol yng Nghymru) ers 2016. Mae’r rôl hon yn golygu cefnogi aelodau a bod yn arweinydd i Gymru ar ddigwyddiadau cenedlaethol ac ymgyrchoedd polisi allweddol, megis amodau gwaith proffesiynol a’r adolygiad seneddol o iechyd a gofal cymdeithasol. Mae Allison yn cyfrannu’n rheolaidd i’r cylchgrawn a chyfryngau cymdeithasol Professional Social Work. Clare Jenkins

Cymhwysodd Clare fel nyrs iechyd meddwl ac aeth ymlaen i astudio ar gyfer gradd mewn Astudiaethau Cymdeithasol a Chymunedol Cymhwysol gan weithio yn y meysydd Datbltygu Cymunedol ac Addysg Uwch cyn treulio bron 20 mlynedd yn gweithio i a chydag undebau llafur. Ymunodd Clare â’r mudiad Cyngor Iechyd Cymuned ym mis Mehefin 2015 gydag awydd gref i rymuso pobl a chymunedau i gael llais yn y ffordd y caiff eu gwasanaethau iechyd eu cynllunio a’u darparu. Mae Clare yn byw yng Ngaerdydd gyda’i gŵr, tri o blant ac Olive y ci.

Dr Charlotte Jones

Dr Charlotte Jones yw cadeirydd Pwyllgor Meddygon Teulu Cymru ac mae’n aelod o dîm gweithredol Pwyllgor Meddygon Teulu’r DU. Mae Charlotte wedi bod yn brif ymarferydd ym Meddygfa Uplands and Mumbles Abertawe ers 2002. Mae’n hyfforddwr; yn arfarnydd Meddyg Teulu ac yn dal i gynnal sesiynau y tu allan i oriau ar ôl sefydlu Gwasanaeth y Tu Allan i Oriau Abertawe (sydd bellach yn wasanaeth y Tu Allan i Oriau Prifysgol Abertawe Bro Morgannwg).

Ymhlith ei phortffolio eang o swyddi a chyfrifoldebau, mae’n gyfrifol am negodi pob agwedd ar gontract ar gyfer gwasanaethau meddygol cyffredinol Cymru yn ogystal â chynrychioli’r proffesiwn ar bob lefel. Mae’n ymroddedig i sicrhau atebion i’r heriau sy’n wynebu meddygon teulu ledled Cymru yn ystod ei blwyddyn olaf yn y swydd. Y tu allan i’r gwaith, mae Charlotte yn fam i ddau o blant ac mae ganddi sbaniel Cavalier King Charles sy’n ystyried ei hun yn drydydd plentyn y teulu. Dylan Jones

Mae Dylan wedi bod yn fferyllydd cymunedol i Dudley Taylor Pharmacies Ltd yn Llanidloes, yn y canolbarth, ers 16 mlynedd. Yn ystod y cyfnod hwn, mae wedi dal nifer o swyddi rheoli ychwanegol o fewn y cwmni. Dros y 10 mlynedd diwethaf mae wedi cefnogi’r practis meddygol lleol gyda chyngor rhagnodi ac mae wedi gweithio gyda’r practis ar nifer o brosiectau. Ddwy flynedd yn ôl, daeth yn Rhagnodydd Annibynnol a chafodd ei gomisiynu gan Fwrdd Iechyd Addysgu Powys i gynghori cleifion â salwch aciwt yn lleol, a phan oedd hynny’n briodol, eu trin a’u hatgyfeirio hefyd. Yn ddiweddar, etholwyd Dylan yn aelod o Fwrdd Fferylliaeth Cymru o’r Gymdeithas Fferylliaeth Frenhinol.

Richard Jones

Cymhwysodd Richard fel Deintydd ym 1994 o Ysgol Ddeintyddol Caerdydd ac yna bu’n gweithio am flwyddyn fel Ymarferydd Deintyddol Galwedigaethol yn Neintyddfa Glenhaven yn Ffynnon Taf. Ym mis Ionawr 1995, ymunodd Richard â chanolfan Ddeintyddol Belgrave fel Deintydd Cyswllt. Daeth yn bartner/perchennog y practis yng Nghanolfan Ddeintyddol Belgrave ym 1998, a chafodd ei benodi’n Hyfforddwr Galwedigaethol gan Ddeoniaeth Cymru y flwyddyn honno, gan hyfforddi tan 2017. Mae’n parhau i weithio’n rhan amser yn y practis, 24 mlynedd yn ddiweddarach, a dyma un o 2 bractis Prototeip y GIG yng Nghymru. Mae’n bartner mewn ail bractis ym Mhontardawe, pan ymunodd y practis hwn â’r broses diwygio’r contract yn 2017.

Bu Richard yn gweithio fel Cynorthwy-ydd Clinigol yn yr Adran Ddeintyddol Adferol yn Ysbyty Treforys rhwng 1995 a 2003. Yn 2003, dyfarnwyd swydd tiwtor Deintyddol Ôl-radd i Richard gan Ddeoniaeth Cymru, i ddarparu cyrsiau DPP achrededig o Ganolfan Addysg Feddygol a Deintyddol Llanddochau ac, yn 2017, rhoddodd y gorau i’w swydd hyfforddi er mwyn dod yn Gyfarwyddwr Rhaglen Hyfforddi Sylfaen Deintyddol gyda Deoniaeth Cymru / AaGIC. Cwblhaodd Richard ei dystysgrif Ôl-radd gydag anrhydedd o Brifysgol Caerdydd yn 2015 ac mae bellach yn gweithio fel Cynghorydd Practis Deintyddol yn cynghori Prifysgol Abertawe Bro Morgannwg a Bwrdd Iechyd Prifysgol Cwm Taf yn rhan amser mewn meysydd deintyddol sy’n cynnwys llywodraethu, perfformiad, materion yn ymwneud â chontractau, cadw cofnodion, safonau a rheoli a datb lygu practis. . Matthew Lloyd

Mae Matthew Lloyd wedi gweithio yn y maes cynhwysiant digidol ers 2006. Wedi hyfforddi’n wreiddiol fel peiriannydd, symudodd i faes datblygu cymunedol yn 2005. Flwyddyn yn ddiweddarach, llwyddodd i gyfuno ei sgiliau allgymorth cymunedol â’i sgiliau technoleg pan ymunodd â phrosiect Cymunedau @Ei Gilydd, sef y rhaglen cynhwysiant digidol genedlaethol gyntaf yng Nghymru. Mae ei ddiddordeb mewn gorchfygu heriau a chefnogi pobl i fynd ar-lein wedi parhau. Dilynwyd Cymunedau @Ei Gilydd gan brosiect Cymunedau 2.0, a chrëodd Matt Strategaeth TGCh ar gyfer rhanbarth de-ddwyrain Cymru ac arwain ar 50 o geisiadau llwyddiannus am grantiau i sefydliadau cymunedol gwirfoddol. Heddiw, fel Rheolwr Prosiect Cymunedau Digidol Cymru, mae ei waith yn golygu rheoli tîm o Gynghorwyr Cymunedau Digidol Cymru a’u cefnogi i hyrwyddo a datblygu mentrau cynhwysiant digidol ledled Cymru. Mae Matt yn benderfynol o sicrhau bod cymorth, drwy weithio mewn partneriaethau â sefydliadau ledled

Cymru, yn cyrraedd y 15% o bobl yng Nghymru nad ydynt ar-lein. Barn Matt yw y gall unrhyw un elwa o feithrin y sgiliau priodol i wneud ein byd cynyddol ddigidol ychydig yn rhwyddach. Yn fwy diweddar, mae Matt a thîm Prosiect Cymunedol Cymru wedi bod yn gweithio gyda sefydliadau iechyd a gofal cymdeithasol i gyflwyno technoleg mewn ffyrdd sydd o ddiddordeb i’r defnyddiwr a thrwy hynny ddileu’r rhwystrau pwysig sy’n ymwneud â diffyg diddordeb neu berthnasedd.

Victoria Lloyd

Mae Victoria wedi bod gyda’r elusen ers ei sefydlu yn 2009 ar ôl uno Age Concern Cymru a Help the Aged yng Nghymru, yn wreiddiol fel Cyfarwyddwr Dylanwadu, yna’n Ddirprwy Brif Weithredwr cyn cael ei phenodi’n Brif Weithredwr yn 2018. Victoria yw Cadeirydd Partneriaeth Cymru yn erbyn Sgamiau a Chadeirydd newydd Cynghrair Henoed Cymru. Ymunodd Victoria â Help the Aged Cymru yn 2006, ar ôl treulio 12 mlynedd yn Siambr Fasnach Caerdydd mewn amrywiaeth o rolau, ac yn y pen draw fel Pennaeth Gweithrediadau a Pholisi.

Amanda Monsell

Dechreuais fy ngyrfa nyrsio a chymhwyso fel nyrs gyffredinol gofrestredig o Ysgol Nyrsio De Morgannwg ym 1985. Dechreuais drwy weithio yn Ysbyty Llandochau ar wardiau meddygol a wardiau llawfeddygol yn ogystal â gofal coronaidd a sylweddolais yn fuan iawn bod angen i mi fagu mwy o brofiad yn y maes nyrsio cleifion iechyd meddwl gan gwblhau fy hyfforddiant nyrsio iechyd meddwl ym 1989. Dechreuais weithio ym maes ymarfer cyffredinol ym 1990 a gweithio i ddechrau fel nyrs practis yn ennill profiad a chwblhau fy ngradd mewn Astudiaethau Iechyd Cymunedol ynghyd ag ennill fy Nghymhwyster Arferydd Arbenigol mewn Nyrsio Cyffredinol yn 2003. Roeddwn yn ffodus i allu dilyn y cwrs rhagnodi atodol cyntaf a’r cwrs trosi rhagnodi annibynnol cyntaf yng Nghymru a dod yn ragnodydd annibynnol anfeddygol yn 2007. Llwyddais i gwblhau fy ngradd Meistr mewn Practis Clinigol Pellach yn 2010 ac rwyf wedi gweithio’n annibynnol fel ymarferydd nyrsio pellach ers hynny. Rwy’n gweithio’n gyffredinol, yn gweld cleifion ar draws gwahanol oedrannau, gyda chyflyrau heb

wahaniaethu a heb ddiagnosis yn ogystal â’r rhai ar gyfer apwyntiadau dilynol a rheoli. Mae gennyf ddiddordeb ym maes iechyd meddwl ac iechyd menywod, ac rwy’n meddu ar lythyr cymhwysedd ar gyfer gosod a thynnu mewnblaniadau. Cefais secondiad fel darlithydd cyswllt rhan amser i Brifysgol Caerdydd am dair blynedd ( (2010 - 2013) lle bûm yn addysgu’n bennaf ar y cwrs Rhagnodi Anfeddygol ar gyfer nyrsys a fferyllwyr. Llwyddais i gwblhau tystysgrif ôl-radd mewn addysg yn ystod y cyfnod hwn, gan basio gydag anrhydedd. Fel Nyrs y Frenhines, rwyf wedi ymrwymo i sicrhau y caiff y safonau uchaf o ran gofal cleifion eu cyrraedd a bob amser yn ymdrechu i wella fy ymarfer. Gan fy mod wedi gweithio fel nyrs practis arbenigol ac ymarferydd nyrsio pellach, rwy’n deall yn iawn pa mor bwysig yw perthynas dda o fewn y timau a’r cymhlethdodau sy’n gweithredu practisau cyffredinol. Rwy’n credu’n gryf mai gofal cleifion sy’n dod gyntaf a bod cael nyrsys ac ymarferwyr nyrsio pellach yn gweithio ochr yn ochr ag ymarferwyr cyffredinol yn sicrhau gwasanaeth gwerthfawr a gaiff ei werthfawrogi gan gleifion. Judith Paget

Penodwyd Judith yn Brif Weithredwr Bwrdd Iechyd Prifysgol Aneurin Bevan ym mis Hydref 2014. Ymunodd Judith â’r Bwrdd Iechyd fel Cyfarwyddwr Cynllunio a Gweithrediadau ar 1 Hydref 2009 ac yn y pen draw daeth yn Brif Swyddog Gweithrediadau ac yn Ddirprwy Brif Weithredwr cyn ei phenodi’n Brif Weithredwr. Mae Judith wedi gweithio i’r GIG ers 1980. Yn ystod y 1980au, ymgymerodd ag amrywiaeth o swyddi gweithredol mewn ysbytai yn ardal Gwent, gan adael Gwent ym 1990 i dderbyn swydd gydag Awdurdod Iechyd Dwyrain Dyfed. Wedyn, fe’i penodwyd yn Gyfarwyddwr Cynllunio yn Ymddiriedolaeth GIG Llanelli Dinefwr, ac arhosodd yno tan 1996 pan ymunodd ag Awdurdod Iechyd Morgannwg i sefydlu’r Tîm Ardal ym Mhen-y-bont ar Ogwr. Yn 2000, dychwelodd Judith i Went fel Rheolwr Cyffredinol Grŵp Iechyd Lleol Caerffili ac yna cafodd ei phenodi’n Brif Weithredwr Bwrdd Iechyd Lleol Caerffili. Ym mis Awst 2007, cafodd secondiad fel Prif Weithredwr Interim Bwrdd Iechyd Lleol Addysgu Powys, ac arhosodd yno tan fis Hydref 2009.

Dyfarnwyd Cwmnïaeth Sefydliad Rheolwyr Gwasanaethau Iechyd i Judith yn 2012. Ym mis Mehefin 2014, enillodd Judith Wobr Sefydliad y Cyfarwyddwyr - Cyfarwyddwr mewn Gwasanaeth Cyhoeddus ar gyfer Cymru. Richard Palmer

Gyda gradd mewn Peirianneg Systemau Gwybodaeth, a gyrfa sy’n cynnwys rolau yn y trydydd sector, iechyd a llywodraeth leol cyn ymuno â Data Cymru yn 2001. Mae gan Richard brofiad gwerthfawr yn ymwneud â defnyddio gwybodaeth a’i effaith. Mae ei waith bellach yn cynnwys arwain ar ddatblygiad parhaus Dewis Cymru a’r Ap Iechyd a Llesiant Cymru a gaiff ei lansio cyn bo hir.

Natalie Phillips

Cwblhaodd Natalie radd MSc Awdioleg ym Mhrifysgol Manceinion yn 2011 a chwblhau HTS yn Ysbyty Maelor Wrecsam. Ers 2014, mae wedi gweithio fel gwyddonydd cynorthwyol ym Mwrdd Iechyd Prifysgol Abertawe Bro Morgannwg. Caiff ei swydd bresennol ei rhannu rhwng y gwasanaeth festibwlar ac arwain y Gwasanaeth Gofal Sylfaenol ar gyfer ardal Abertawe.

Kerrie Phipps

Kerrie Phipps yw Dirprwy Bennaeth Therapi Galwedigaethol i Fwrdd Iechyd Prifysgol Hywel Dda, gyda phortffolio o wasanaethau ar draws gofal sylfaenol a gofal eilaidd; gofal cymunedol a chymdeithasol a gwasanaethau arbenigol. Un o elfennau allweddol ei chylch gwaith yw datblygu, gweithredu a darparu modelau cydweithredol integredig o ddarparu gwasanaeth therapi galwedigaethol sy’n gwella profiad yr unigolyn ac sy’n uniongyrchol berthnasol i adfer annibyniaeth, gwellhad a chynhwysiant cymdeithasol. Mae hyn yn cynnwys datblygu rolau clinigol cyfatebol ar draws asiantaethau, lleoliadau a siroedd, ac mae’n cynnwys ail-ddylunio rolau a datblygu llwybr integredig rhwng asiantaethau. Yr hyn sy’n bwysig yw bod darparu therapi galwedigaethol fel rhan o ‘becyn cymorth’ Ymarfer cyffredinol yn gydran hanfodol o hyn.

Mae’n unigolyn sy’n anelu at fod yn ddewr a gwrando ar bryderon er mwyn gofyn cwestiwn gwell er mwyn gwneud y peth iawn, yn ogystal â defnyddio’i sgiliau a’i dylanwad er mwyn gwneud pethau’n well. Dr Heather Potter

Mae Heather wedi bod yn bartner mewn practis meddyg teulu yn Sgiwen, Castell-nedd, ers 29 mlynedd. Mae hefyd yn gweithredu fel arweinydd clinigol yn Hyb Gofal Sylfaenol Castell-nedd. Cymhwysodd o Brifysgolion St Andrews a Manceinion ym 1984. Ar ôl cwrdd â’i gŵr a syrthio mewn cariad â’i wlad enedigol, symudodd i dde Cymru ym 1988. Mae gan Heather a’i gŵr dri o blant, sydd wedi’u magu yn bennaf ar draethau Gŵyr. Mae Dr Potter yn credu’n gryf mewn Gofal Sylfaenol ac mae wedi ymddiddori’n benodol mewn Mynediad at Ofal Sylfaenol ers 15 mlynedd.

Alyson Thomas

Ymunodd Alyson â’r mudiad Cyngor Iechyd Cymuned ym mis Mai 2015 ble maen canolbwyntio ar annog a galluogi aelodau o’r cyhoeddi i gymryd rhan weithredol mewn penderfyniadau sy’n effeithio ar y ffordd y mae gofal iechyd y GIG yn cael ei ddylunio a’i ddarparu er budd eu teuluoedd a chymunedau lleol. Mae wedi gweithio i wasanaethau cyhoeddus ers dros 30 mlynedd. Am y rhan fwyaf o’r deng mlynedd diwethaf, mae gwaith Alyson wedi canolbwyntio ar y GIG yng Nghymru. Bu’n Gyfarwyddwr yn Arolygiaeth Gofal Iechyd Cymru, yn gynghorydd ar lywodraethu gan weithio ar ddiwygio’r GIG yng Nghymru yn 2009, ac yn adolygydd annibynnol o drefniadau arwain a llywodraethu Ymddiriedolaethau’r GIG a Byrddau Iechyd Lleol. Mae Alyson yn byw ger Abertawe gyda’i gŵr, dau o blant sydd bellach yn oedolion a Phoebe y labrador.

Darryn Thomas

Rwyf wedi gweithio ym maes Gofal Sylfaenol am y 12 mlynedd diwethaf, gan weithio fel Uwch Weithiwr Cymorth Gofal Iechyd cyn camu i’r maes rheoli bedair blynedd yn ôl. Tra roeddwn yn gweithio mewn practis prysur ym Mhrestatyn, sylweddolais y byddai angen newid yn y dyfodol o ran cynaliadwyedd. Wrth i’r Bwrdd Iechyd gamu i mewn, roeddwn yn gwerthfawrogi’r model a oedd yn cael ei gynnig gan deimlo, wrth wneud fy ngorau i gyflawni hyn, y byddem yn newid ffurf a dyfodol Gofal Sylfaenol. Mae hyn wedi bod yn her, fel unrhyw strwythur newydd ar y dechrau, ond, drwy weithio mewn partneriaeth â gweithwyr proffesiynol eraill a chleifion, rydym wedi gallu gwrando a chreu model sy’n adlewyrchu anghenion cleifion.

Gaynor Thomas

Graddiodd Gaynor o Goleg Meddygaeth Prifysgol Cymru ym 1998. Ar ôl cwblhau ei hyfforddiant ymarfer cyffredinol, gweithiodd am nifer o flynyddoedd yn yr Uned Gymorth Gofal Sylfaenol yng Nghwm Taf. Hi oedd un o sylfaenwyr Canolfan Feddygol Pont Newydd pan gafodd ei ddychwelyd i’r statws contractiwr annibynnol yn 2010. Ers hynny, mae wedi mwynhau bod yn rhan o dîm amlddisgyblaethol sy’n tyfu, gan alluogi’r practis i ddod yn bractis hyfforddi, sydd bellach yn hyfforddi cofrestryddion meddygon teulu, myfyrwyr meddygol, nyrsys o dan hyfforddiant a myfyrwyr fferylliaeth o dan hyfforddiant.

Dros y flwyddyn ddiwethaf, mae Gaynor wedi bod yn arweinydd clinigol ar gyfer Hyb Gweithlu a Hyfforddiant Cymru. Mae hwn yn brosiect sy’n gosod y seiliau gyda’r gobaith o ddarparu lleoliadau ymarfer cyffredinol o ansawsdd uchel i nyrsys dan hyfforddiant a datblygu strwythur gyrfa clir dwy flynedd a llwybr hyfforddiant ar gyfer nyrsys sy’n hyfforddi. Dr Damian Williams

Rwy’n feddyg teulu yn Birmingham, ers symud i’r ysgol feddygol yn Birmingham ym 1992. Rwy’n arweinydd TG clinigol ar gyfer Grŵp Comisiynu Clinigol Birmingham a Solihull ac yn ymwneud yn arbennig â’r cofnod meddygol a rennir, ymgyngoriadau ar-lein a mynediad estynedig. Rwyf hefyd yn gweithio i’r GIG fel Hyrwyddwr Clinigol Digidol, yn hyrwyddo’r defnydd o dechnolegau ar-lein ymysg cleifion a thechnolegau digidol eraill sy’n cefnogi clinigwyr ac yn gwella gofal cleifion. Credaf fod mabwysiadu technoleg yn angenrheidiol er mwyn i’r GIG oroesi ac mae’n cynnig cyfleoedd cyffrous ar gyfer gwella diogelwch a gofal cleifion.

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Rhaglen Strategol ar gyfer Gofal Sylfaenol

Tachwedd 2018

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Rhagair Mae’r Bwrdd Gofal Sylfaenol Cenedlaethol yn cydnabod yn llwyr yr achos dros newid a’r ‘chwyldro o’r tu mewn’ sydd ei angen, fel y nodir yn Yr Adolygiad Seneddol. Mae Cymru Iachach yn cynnwys cynllun clir ar gyfer datblygu hyn ac rydym yn croesawu cryfhau’r gwaith clwstwr fel rhan o’r model cenedlaethol ar gyfer iechyd a gofal. Er y gwnaed cynnydd sylweddol drwy roi’r argymhellion a nodwyd yn y Cynllun ar gyfer Gwasanaeth Gofal Sylfaenol i Gymru 2015-2018 ar waith, mae llawer i’w wneud o hyd i sicrhau ein cyfraniad at y Rhaglen Drawsnewid Genedlaethol, ac i weithredu’r Model Gofal Sylfaenol i Gymru yn llawn. Mae’r ddogfen hon yn amlinellu’r rhaglen waith strategol ar gyfer gofal sylfaenol a ddatblygwyd yn dilyn cyhoeddi Cymru Iachach. Mae rhai agweddau yn barhad ar waith blaenorol, gan gydnabod bod angen cyflymu ac ehangu’r gwaith. Mae meysydd blaenoriaeth eraill wedi dod i’r amlwg mewn ymateb i ‘Cymru Iachach’. Yn benodol, trefn system gyfan ar gyfer iechyd a gofal cymdeithasol gan ddatgan mai system ‘iachusrwydd’ fydd hon, sy’n anelu at gefnogi a rhagweld anghenion iechyd, atal salwch a lleihau effaith iechyd gwael ac anghydraddoldeb. Mae gan y maes Gofal Sylfaenol, fel y pwynt cyswllt cyntaf i’r mwyafrif o ddinasyddion sy’n defnyddio gwasanaethau iechyd, ran allweddol i’w chwarae o ran gwneud y gorau o gyfleoedd atal a hunanreoli. Mae cydweithio’n agos gyda phartneriaid, gan newid y ffocws i fodel gofal cymdeithasol, sicrhau mynediad amserol i wasanaethau gofal sylfaenol pan fydd eu hangen a gweithio mewn modd cydlynol ar draws yr holl system, wrth wraidd y rhaglen strategol ar gyfer gofal sylfaenol. Mae’r rhaglen strategol hon yn amlinellu’r prif ffrydiau gwaith sydd eu hangen er mwyn datblygu’r gwaith hwn, a hynny ar y lefel uchel. Caiff hyn ei ategu gan gynlluniau gweithredu manwl. Er mai’r rhai sy’n gweithio mewn gofal sylfaenol fydd yn cyflawni llawer o’r camau gweithredu, mae model gofal cydlynol yn ei gwneud yn ofynnol i’r holl bartneriaid gydweithio a hoffwn gydnabod ymrwymiad y rhai sydd wedi cyfrannu at y cynnydd hyd yn hyn yn ogystal â’r heriau sydd o’n blaenau. Mae rhoi’r model gofal sylfaenol ar gyfer Cymru ar waith yn llawn, a’r rhan annatod y mae gofal sylfaenol yn ei chwarae o fewn y rhaglen drawsnewid genedlaethol, yn rhoi caniatâd i ofal sylfaenol fod yn feiddgar - cyfle na ddylem ei golli. Judith Paget Cadeirydd, Bwrdd Gofal Sylfaenol Cenedlaethol a Phrif Weithredwr Arweiniol Gofal Sylfaenol

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Crynodeb Gweithredol Cyhoeddwyd Ein Cynllun ar gyfer Gwasanaeth Gofal Sylfaenol i Gymru hyd at fis Mawrth 2018 gan Lywodraeth Cymru ym mis Chwefror 2015 ac mae wedi rhoi cyd-destun a fframwaith ar gyfer datblygu gofal sylfaenol a chymunedol dros y tair blynedd diwethaf. Gwnaed cynnydd da yn lleol ac mae buddsoddiad o £40 miliwn, a roddwyd gan Lywodraeth Cymru, yn cefnogi arloesi a datblygu mewn gofal sylfaenol ar lefel clwstwr, lefel bwrdd iechyd ac yn genedlaethol drwy gronfa gofal sylfaenol sy’n cynnwys y Rhaglen Pennu Cyfeiriad. Gan ddysgu o’r cylch cyntaf o Brosiectau Pennu Cyfeiriad, datblygwyd model system gyfan, 24/7, trawsnewidiol ar gyfer gofal sylfaenol a chymunedol. Mae hyn wedi arwain at fabwysiadu trefn system gyfan ar gyfer ailddylunio, yn seiliedig ar safonau ansawdd cenedlaethol ond gyda’r hyblygrwydd i ymateb i anghenion cymunedau lleol. Ystyrir bod clystyrau yn ganolog i gyflwyno’r model hwn. Ym mis Ionawr 2018 cyhoeddwyd yr Adolygiad Seneddol o Iechyd a Gofal Cymdeithasol yng Nghymru ac ym mis Mehefin 2018, ymatebodd Llywodraeth Cymru yn ‘Cymru Iachach: ein Cynllun ar gyfer Iechyd a Gofal Cymdeithasol’ gan alw am fodelau newydd beiddgar ar gyfer gwasanaethau iechyd a gofal cymdeithasol di-dor yn lleol ac yn rhanbarthol. Mae’r model trawsnewidiol ar gyfer gofal sylfaenol a chymunedol, sy’n drefn system gyfan ar gyfer sicrhau gofal iechyd a llesiant cynaliadwy a hygyrch, yn cefnogi’r weledigaeth sydd yn ‘Cymru Iachach’ ac mae bellach wedi ei fabwysiadu fel Model Gofal Sylfaenol i Gymru. Mae clystyrau yn parhau i fod wrth wraidd y model hwn a chan ystyried yr egwyddorion sylfaenol sy’n sail i ‘Cymru Iachach’ gellid eu disgrifio fel a ganlyn:

“Mae clwstwr yn dod â’r holl wasanaethau lleol sy’n ymwneud ag iechyd a gofal ynghyd ar draws

ardal ddaearyddol sydd, fel arfer yn gwasanaethu poblogaeth o rhwng 25,000 a 100,000. Mae gweithio o fewn clwstwr yn sicrhau bod gofal wedi’i gydlynu’n well er mwyn hyrwyddo llesiant

unigolion a chymunedau.” Er bod gwaith yn parhau ar weithredu’r Model Gofal Sylfaenol i Gymru mae ‘Cymru Iachach’ wedi dod â chyd-destun ehangach i’r gwaith hwn, o ran y cysylltiadau gyda’r Byrddau Partneriaeth Rhanbarthol a’r seilwaith cymunedol ehangach wrth i’r drefn ‘system iachsurwydd’ hon gael ei hatgyfnerthu. Mae’n amserol felly adolygu’r rhaglen strategol ar gyfer gofal sylfaenol yn y cyd-destun hwn ac mae’r meysydd strategol allweddol a ganlyn wedi’u hamlygu fel blaenoriaethau i gyd-redeg â swyddogaethau cynllunio a chyflawni timau Byrddau Iechyd:

Prif ffrydiau gwaith gofal sylfaenol

Cydweithio di-dor mewn Byrddau Iechyd a chyda phartneriaid

Diwygio contractau gofal sylfaenol Yn y ddogfen hon, darperir crynodeb lefel uchel o gamau gweithredu sy’n cyfateb â phob un o’r blaenoriaethau hyn. Mae dogfennaeth ategol hefyd sy’n rhoi cynlluniau gweithredu manylach a dulliau cyflawni ar gyfer y rhaglen strategol.

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1. Cyflwyniad Mae’r papur hwn yn nodi’r prif ffrydiau gwaith sydd eu hangen er mwyn i ofal sylfaenol a chymunedol allu adeiladu ar y gwaith a wnaed mewn ymateb i ‘Ein Cynllun ar Gyfer Gwasanaeth Gofal Sylfaenol i Gymru hyd at fis Mawrth 2018’ (Llywodraeth Cymru, Chwefror 2015) ac mewn ymateb i ‘Cymru Iachach’ (Llywodraeth Cymru, Mehefin 2018). Nid yw’r ffrydiau gwaith wedi eu bwriadu i ddisodli’r gwaith sydd wedi’i gynllunio neu sydd ar y gweill ar lefel leol gan glystyrau, byrddau iechyd a byrddau partneriaeth rhanbarthol, nac ychwaith i amharu torri ar waith trawsnewidiol ehangach. Yn hytrach maent yno i ategu’r gwaith trawsnewid a’i gyflymu a’i ehangu. 2. Cyd-destun Strategol Cyhoeddwyd ‘Ein Cynllun ar gyfer Gwasanaeth Gofal Sylfaenol i Gymru hyd at fis Mawrth 2018’ gan Lywodraeth Cymru ym mis Chwefror 2015 ac mae wedi rhoi cyd-destun a fframwaith ar gyfer datblygu gofal sylfaenol a chymunedol dros y tair blynedd diwethaf. Ategwyd y cynllun gan Gweithlu Gofal Sylfaenol wedi’i Gynllunio i Gymru, sy’n gosod y cyfeiriad angenrheidiol er mwyn cefnogi gweithlu cynaliadwy sy’n seiliedig ar anghenion y boblogaeth leol ac egwyddorion gofal iechyd darbodus. Roedd diffiniad gofal sylfaenol, a ddefnyddiwyd yn y cynllun, yn eang iawn ac mae bellach yn sail i’r ddogfen hon.

Beth yw gofal sylfaenol?

Gofal sylfaenol yw’r gwasanaethau hynny sy’n darparu’r pwynt gofal cyntaf, ddydd neu nos, ar gyfer mwy na 90% o gysylltiadau pobl gyda’r GIG yng Nghymru. Mae ymarfer cyffredinol yn un o elfennau craidd gofal sylfaenol ond nid dyma’r unig elfen. Mae gofal sylfaenol yn cwmpasu llawer mwy o wasanaethau iechyd gan gynnwys fferylliaeth, deintyddiaeth ac optometreg. Yn bwysig iawn, mae’n cynnwys cydlynu mynediad pobl at ystod eang o wasanaethau yn y gymuned i’w helpu i ddiwallu eu hanghenion iechyd a llesiant. Mae’r gwasanaethau cymunedol hyn yn cynnwys ystod eang iawn o staff megis nyrsys cymunedol ac ardal, bydwragedd, ymwelwyr iechyd, timau iechyd meddwl, timau hybu iechyd, ffisiotherapyddion, therapyddion galwedigaethol, podiatryddion, gwaedyddion, parafeddygon, gwasanaethau cymdeithasol, staff eraill awdurdodau lleol a’r holl bobl sy’n gweithio a gwirfoddoli yn y cyfoeth o fudiadau sy’n cefnogi pobl yn ein cymunedau.

Mae cwmpas y gwaith wedi cael ei ddylanwadu gan nifer o gyhoeddiadau a meysydd gwaith yn y cyfnod rhwng 2015-2018, ac mae wedi ychwanegu at gyfeiriad ac ehangder y newidiadau mewn gofal sylfaenol fel a ganlyn:

Deddf Gwasanaethau Cymdeithasol a Llesiant (Cymru) 2014

Deddf Llesiant Cenedlaethau’r Dyfodol (Cymru) 2015

Gofal Iechyd Darbodus – Sicrhau Iechyd a Llesiant Cenedlaethau’r Dyfodol 2016

Symud Cymru Ymlaen 2016 – 2021 Llywodraeth Cymru

Ffyniant i Bawb: y Strategaeth i Gymru. Amcanion llesiant Llywodraeth Cymru 2017 (Medi 2017)

Tasglu Gweinidogol ar Weithlu Gofal Sylfaenol – ymgyrch 2017 Hyfforddi, Gweithio, Byw yng Nghymru

Gwasanaethau Meddygon Teulu yng Nghymru: Safbwynt Pobl Hŷn (Comisiynydd Pobl Hŷn Chwefror 2017)

Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon – Ymchwiliad i ofal sylfaenol: Clystyrau 2017

Gwasanaethau sy’n Addas i’r Dyfodol – Ansawdd a Llywodraethiant ym maes Iechyd a Gofal yng Nghymru (Mehefin 2017)

Ym mis Ionawr 2018 cyhoeddwyd yr Adolygiad Seneddol o Iechyd a Gofal Cymdeithasol yng Nghymru ac ym mis Mehefin 2018 ymatebodd Llywodraeth Cymru yn ‘Cymru Iachach: ein Cynllun

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ar gyfer Iechyd a Gofal Cymdeithasol’, gan alw am fodelau newydd beiddgar o wasanaethau iechyd a gofal cymdeithasol di-dor yn lleol a rhanbarthol. Mae’r model gofal sylfaenol ar gyfer Cymru, sy’n drefn system gyfan ar gyfer gofal iechyd a llesiant cynaliadwy a hygyrch, yn cefnogi’r weledigaeth a amlinellir yn ‘Cymru Iachach’. Mae ‘Cymru Iachach’ yn amlinellu’r drefn system gyfan ar gyfer iechyd a gofal cymdeithasol gan ddatgan mai ‘system iachusrwydd’ ydyw, sy’n anelu at gefnogi a rhagweld anghenion iechyd, atal salwch a lleihau effaith iechyd gwael ac anghydraddoldeb. Mae gan ofal sylfaenol, fel pwynt cyswllt gyntaf y mwyafrif o ddinasyddion sy’n defnyddio gwasanaethau iechyd, ran allweddol i’w chwarae o ran gwneud y gorau o gyfleoedd atal a hunanreoli. Gan gydweithio’n agos â phartneriaid, ni ddylai gofal sylfaenol a chymunedol fethu cyfleoedd i hyrwyddo model gofal cymdeithasol, gan osgoi gorddibyniaeth ar feddyginiaeth. 3. ‘Ein Cynllun ar gyfer Gwasanaeth Gofal Sylfaenol i Gymru hyd at fis Mawrth 2018’ – Y Cynnydd Hyd Yma Yn ‘Ein Cynllun ar gyfer Gwasanaeth Gofal Sylfaenol i Gymru hyd at fis Mawrth 2018’ Llywodraeth Cymru, Chwefror 2015 (y cyfeirir ato fel y Cynllun Gofal Sylfaenol o hyn ymlaen) nodwyd y prif gamau gweithredu i’w datblygu ar lefel genedlaethol, ynghyd â 26 o gamau allweddol i’w datblygu yn lleol. Sefydlodd Llywodraeth Cymru gronfa gofal sylfaenol genedlaethol gwerth £43 miliwn er mwyn cefnogi’r cynllun. Buddsoddodd y Gronfa Gofal Integredig hefyd mewn gwelliannau i wasanaethau lleol. Mae crynodeb lefel uchel o’r cynnydd yn erbyn y camau gweithredu ar gyfer y pum thema yn y Cynllun Gofal Sylfaenol fel a ganlyn.

VI. Cynllunio Gofal yn Lleol

Rhaglen Pennu Cyfeiriad/Braenaru – 24 o brosiectau 2015-18, 15 prosiect yn dechrau yn 2018

Darganfod model gofal sylfaenol newydd ‘trawsnewidiol’

Arfarniad beirniadol – gwerthusiad allanol, gweithdy Hydref 2018

Lansio gwefan Gofal Sylfaenol Un ym mis Tachwedd 2017, adnodd ar-lein i rannu arferion da a’r hyn a ddysgwyd

Asesiadau o anghenion a chynlluniau ar lefel clwstwr, gyda £10 miliwn i’r clystyrau ei fuddsoddi

Datblygiad clystyrau – Fframwaith Llywodraethu Arfer Dda i Glwstwr

Ffynhonnell o ddatblygiadau cyfalaf a chanolfannau iechyd a gofal integredig

VII. Gwella Mynediad ac Ansawdd

Prosiect cenedlaethol ar gyfer cyfeiriadur gwasanaethau

Cyfeirio a brysbennu – cwblhau ymarfer pennu gwmpas ac argymhellion

111 – cynllunio’r broses gyflwyno

Cyflwyno Mesurau Gofal Sylfaenol Camau 1 a 2a

Datblygu dangosyddion allweddol ar gyfer Gwasanaethau Meddygol Cyffredinol

Modelu capasiti a galw – Prosiect braenaru

Gweithdy i ddiffinio beth yw mynediad ‘da’

Cyflwyno’r cynllun Dewis Fferyllfa a’r gwasanaeth anhwylderau cyffredin

Symud mwy o wasanaethau gofal llygaid o’r ysbyty i’r gymuned

Modelau presgripsiynu cymdeithasol (neu atgyfeirio cymunedol) ar gyfer mynediad systematig i wasanaethau llesiant nad ydynt yn glinigol

Rhaglen diwygio contract gofal sylfaenol

VIII. Gweithlu Medrus

Gweithio fel tîm amlddisgyblaeth - adolygiad ac argymhellion wedi’u cwblhau

Cymdeithion Meddygol

Parafeddygon Cymunedol

Compendiwm o swyddogaethau a modelau newydd gan gynnwys swyddi ar lefel clystyrau ac atebion indemniad

Hyfforddiant ar gynllunio’r gweithlu gofal sylfaenol

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Hyfforddiant ymarfer uwch, fel presgripsiynu anfeddygol

Ehangu’r cynllun Cymrodyr Academaidd y tu hwnt i Dde Cymru

Ymgyrch Hyfforddi, Gweithio, Byw

IX. Mynediad Teg

Sefydlu cynlluniau cyfraith gofal gwrthgyfartal mewn tri bwrdd iechyd gan rannu’r hyn a ddysgwyd

Prosiect Trawsryweddol

Prosiect Iaith Arwyddion Prydain

Pecyn offer y Gymraeg

X. Arweinyddiaeth Gadarn

Bwrdd Gofal Sylfaenol Cenedlaethol

Grwpiau ac is grwpiau cymheiriaid Cyfarwyddwyr Cenedlaethol Gofal Sylfaenol a Chymunedol

Canolfan Datblygu ac Arloesedd Gofal Sylfaenol a Chymunedol

Arweinydd Cenedlaethol Proffesiynol a Chyfarwyddwr Cenedlaethol ac Arweinydd Rhaglen Strategol

Rhaglen arweinwyr hyderus x 3

Parhau gyda rhaglen datblygu arweinwyr clwstwr Mae rhagor o fanylion ar gael yn Adroddiad Blynyddol Cyfarwyddwyr Gofal Sylfaenol a Chymunedol 2017-18 (sef y Cyfarwyddwyr Gofal Sylfaenol, Cymunedol ac Iechyd Meddwl gynt). Mae dogfennau ategol ar gael ar wefan Gofal Sylfaenol Un. Rhoddwyd buddsoddiad gan Lywodraeth Cymru er mwyn cefnogi arloesedd a datblygiad mewn gofal sylfaenol a hynny ar lefel clwstwr, bwrdd iechyd (drwy Gynlluniau Tymor Canolig Integredig) ac ar lefel genedlaethol drwy Raglen Pennu Cyfeiriad. Ystod o fentrau cynhwysfawr yw’r Rhaglen Pennu Cyfeiriad, sydd wedi’u hariannu gan Lywodraeth Cymru er mwyn ysgogi arloesedd a hybu ailddylunio gwasanaethau gofal sylfaenol. Dechreuodd y cylch cyntaf o 24 o brosiectau ym mis Ebrill 2015 gan ganolbwyntio ar o leiaf un o’r canlynol:

gwella mynediad at wasanaethau

symud gofal yn nes at y cartref

gwella cynaliadwyedd gwasanaethau gofal sylfaenol. Arweiniwyd y rhain gan Dimau Gofal Sylfaenol ledled Cymru a chawsant eu cefnogi gan y Ganolfan Gofal Sylfaenol (Iechyd Cyhoeddus Cymru). Gan ddysgu o’r cylch cyntaf o brosiectau Pennu Cyfeiriad, datblygwyd model trawsnewidiol system gyfan, 24/7 ar gyfer gofal sylfaenol a chymunedol. Mae hyn wedi arwain at fabwysiadu trefn system gyfan o ail-ddylunio yn seiliedig ar safonau ansawdd cenedlaethol ond gyda’r hyblygrwydd i ymateb i anghenion cymunedau lleol (gweler y diagram dros y dudalen). Ystyrir bod clystyrau yn ganolog i gyflwyno’r model hwn gan fod 64 clwstwr yng Nghymru.

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Modelau GofalCynaliadwy

Gofal

Sylfaenol

Sefydlog

Modelau

Clwstwr

Newydd

Gweithwyr

proffesiynol

ysgogedig

Llai o achosion o

dderbyn i’r

ysbyty/ Achosion

Brys y gellir eu

hatal a’u hosgoi

Dull Systemau Cyfan

Integredig

Gofal Cymhleth

ac Arbenigol yn y

Gymuned

Adnoddau Cymunedol

Cynaliadwy

Gwella

lles

dinasyddion

Hyrwyddo

Byw’n Iach

Adnoddau

Hygyrch

Amrywiaeth Eang o Adnoddau

Cymunedol

Cefnogaeth i

Hunan Ofal

Gwell

Gwydnwch

Cymunedol

Cyhoedd

Gwybodus

Dinasyddion

Grymus

Gwell

mynediad at

ofal

o ansawdd

DULL SYSTEM GYFAN CYMRU GYFAN

Mae rhagor o fanylion am y model a’r elfennau allweddol ar wefan Gofal Sylfaenol Un. Arfarniad Beirniadol a Gwerthusiad Fel rhan o broses werthuso’r rhaglen pennu cyfeiriad, comisiynwyd Prifysgol Birmingham i gynnal arfarniad beirniadol o Raglen Pennu Cyfeiriad. Nod cyffredinol yr ymchwil oedd cryfhau’r dysgu ar gyfer rhaglenni trawsnewid gofal sylfaenol yng Nghymru yn y dyfodol, drwy ymchwilio i brofiadau timau Pennu Cyfeiriad, archwilio barn rhanddeiliaid a chymharu’r canlyniadau gyda thystiolaeth ymchwil bresennol ac arfer orau rhyngwladol. Cyhoeddwyd yr adroddiad terfynol ym mis Mehefin 2018 ac mae ar gael ar: http://www.gofalsylfaenolun.cymru.nhs.uk/hafan Mae’r canlynol yn nodi goblygiadau’r canfyddiadau ar gyfer Trawsnewid Gofal Sylfaenol yn y dyfodol.

Datblygu’r capasiti gwerthuso o fewn byrddau iechyd er mwyn asesu effaith a dulliau newid sydd â’r sgiliau cysylltiedig, mynediad i ddata a chymorth dadansoddol.

Cynlluniau’r gweithlu i gynnwys datblygu cymwyseddau sy’n gysylltiedig â chydweithio rhwng

proffesiynau a thimau, ymgysylltu â chleifion a’r gymuned ac arwain newid.

Gosod seilwaith addas i ymgorffori ymgysylltu o fewn y rhaglenni trawsnewid.

Seilwaith lleol sy’n cefnogi arloesedd mewn gofal sylfaenol gan sicrhau bod y rhai sy’n ymgymryd â’r newidiadau yn cael cymorth i reoli prosiectau a chyda thasgau cysylltiedig.

Cyfle i’r rhai sy’n arwain ar arloesi rwydweithio ar draws byrddau iechyd er mwyn cynnig her

a chymorth i gyfoedion.

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4. Model Gofal Sylfaenol i Gymru Mae’r model trawsnewid ar gyfer gofal sylfaenol a chymunedol yn cyd-fynd yn dda â ‘Cymru Iachach’ ac wrth i argymhellion Cymru Iachach’ gael eu rhoi ar waith yn llawn, mae’n bwysig bod gofal sylfaenol yn ganolog i’r modelau gofal beiddgar a di-dor arfaethedig. Fel y disgrifir yn adran 3, mae’r gwaith pennu cyfeiriad wedi bod yn sail i raglen drawsnewid gofal sylfaenol gan nodi elfennau unigol y model. Mae hyn wedi cael ei ategu gan ‘Cymru Iachach’ ac mae bellach wedi’i fabwysiadu fel y Model Gofal Sylfaenol i Gymru. Prif elfennau’r model yw:

Cyhoedd gwybodus

Dinasyddion grymus

Cefnogi hunan ofal

Gwasanaethau cymunedol

Pwynt cyswllt cyntaf

Gofal brys

Mynediad uniongyrchol

Pobl ag anghenion gofal cymhleth

Gweithio fel tîm amlddisgyblaeth. Mae clystyrau yn parhau i fod wrth wraidd y model hwn a chan ystyried yr egwyddorion sylfaenol sy’n sail i ‘Cymru Iachach’ gellid eu disgrifio fel hyn:

“Mae clwstwr yn dod â’r holl wasanaethau lleol sy’n ymwneud ag iechyd a gofal ynghyd ar draws

ardal ddaearyddol sydd, fel arfer yn gwasanaethu poblogaeth o rhwng 25,000 a 100,000. Mae gweithio o fewn clwstwr yn sicrhau bod gofal wedi’i gydlynu’n well er mwyn hyrwyddo llesiant

unigolion a chymunedau.” Mae’r Model Gofal Sylfaenol i Gymru wedi’i seilio ar fodel gofal cymdeithasol ac mae gweithio ar draws ffiniau sefydliadau er mwyn gwneud y gorau o’r holl asedau mewn cymuned yn greiddiol i hyn. Mae clystyrau gofal sylfaenol presennol yn canolbwyntio ar iechyd a darparu gwasanaethau. Wedi dweud hynny mae enghreifftiau o glystyrau sydd wedi ehangu y tu hwnt i ffiniau iechyd wrth iddynt ddatblygu. Wrth symud ymlaen mae angen i glystyrau ystyried yr asedau sydd ar gael o fewn eu cymuned ar gyfer eu poblogaeth leol. Mae hyn yn golygu gweithio ar draws gofal cymdeithasol a gwasanaethau ehangach awdurdodau lleol. Mae angen rhoi ystyriaeth bellach i gyfraniad y trydydd sector yn nhermau'r ddarpariaeth bresennol a’r cyfleoedd posibl yn y dyfodol. Mae Byrddau Partneriaeth Rhanbarthol a Chynlluniau Ardal yn gysylltiadau hanfodol i’r rhwydwaith ehangach ac er nad ydynt wedi bod yn flaenoriaeth i glystyrau yn y gorffennol, byddant yn ganolog wrth symud ymlaen. 5. Y Model Gofal Sylfaenol i Gymru – Meysydd i Ganolbwyntio Arnynt Mae ‘Cymru Iachach’ yn symud y ffocws tuag at ‘system iachusrwydd’. Er bod y Model Gofal Sylfaenol i Gymru yn cynnwys elfennau sy’n cefnogi system o’r fath, prin fu’r sylw a roddwyd i’r rhain hyd yma (ac eithrio presgripsiynu cymdeithasol). Wrth symud ymlaen mae angen datblygu’r model cymdeithasol o ofal ymhellach. Mae’n galw am ganolbwyntio ar lesiant ac atal, gan ddeall beth yw’r cyfleoedd sy’n bodoli ar draws y gweithlu iechyd, gofal cymdeithasol a’r trydydd sector i ddeall yn iawn beth sy’n bwysig i bobl a gwneud yn siŵr bod pob cyswllt yn cyfrif. Wrth ystyried datblygu’r model cymdeithasol o ofal, mae’n rhaid parhau â’r camau gweithredu presennol o safbwynt iechyd. Yn benodol, uno gwasanaethau gofal sylfaenol a ddarperir o fewn oriau gwaith a’r tu allan i oriau i greu model 24/7 er mwyn sicrhau mynediad ar yr adeg briodol yn enwedig i gleifion gydag anghenion gofal sylfaenol brys. Mae ‘Cymru Iachach’ yn cyfeirio at atebion digidol, maes nad yw wedi cael ei archwilio’n fanwl nac yn systematig o’r blaen o ran gofal sylfaenol a chymunedol.

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Mae’r gwaith ar y Model Gofal Sylfaenol i Gymru hyd yma wedi nodi nifer o faterion yn ymwneud â’r gweithlu. Ar hyn o bryd mae nifer o grwpiau yn edrych ar faterion y gweithlu ac yng nghyd-destun ‘Cymru Iachach’ mae angen adolygu hyn ac ailedrych arno. Mae’r Arfarniad Beirniadol yn amlygu’r angen i fyrddau iechyd ddatblygu seilwaith lleol sy’n galluogi trawsnewid o fewn gofal sylfaenol a chymunedol. Daeth byrddau iechyd yn sefydliadau integredig yn 2009 ac mae’n amserol iddynt i gyd ystyried pa mor dda y mae eu trefniadau mewnol wedi datblygu er mwyn gwneud y gorau o botensial integreiddio. Yn yr un modd mae angen ystyried datblygu perthynas gyda phartneriaid allweddol ar lefel leol a rhanbarthol, megis gwasanaethau cymdeithasol, gwasanaethau ehangach Awdurdodau Lleol a’r Trydydd Sector, er mwyn sicrhau trefniadau gweith di-dor o fewn y system gyfan. Nodir bod modd gwneud hyn drwy raglenni trawsnewid lleol. Mae ‘Cymru Iachach’ yn cyfeirio at y rhaglen genedlaethol o ddiwygio contractau gofal sylfaenol. Mae angen i gyfraniad hyn fod yn glir. Mae angen ystyried yn ofalus y cyfathrebu a’r ymgysylltu o ran y model gofal sylfaenol I Gymru ac mae angen arbenigedd pwrpasol er mwyn sicrhau bod yr holl randdeiliaid a’r cyhoedd yn glir ynghylch beth mae hyn yn ei olygu wrth symud ymlaen. Dyma’r prif feysydd gwaith strategol sydd eu hangen ar mwyn rhoir model gofal sylfaenol i Gymru ar waith yn gyflym:

Prif ffrydiau gwaith gofal sylfaenol

Gweithio’n ddi-dor ar draws Byrddau Iechyd a chyda sefydliadau partner.

Diwygio contractau gofal sylfaenol Mae’r adrannau canlynol yn rhoi trosolwg o’r tasgau angenrheidiol ar gyfer pob maes strategol. Bydd cynlluniau gweithredu manylach yn sail i bob ffrwd waith gan wneud y gorau o’r cymorth presennol gan Bartneriaeth Cydwasanaethau GIG a Hwb Gofal Sylfaenol (Iechyd Cyhoeddus Cymru) ond hefyd creu cysylltiadau newydd gyda Byrddau Partneriaeth Rhanbarthol, Cyfarwyddwyr Gwasanaethau Cymdeithasol ac Addysg a Gwella Iechyd Cymru. 5.1 Prif Ffrydiau Gwaith Gofal Sylfaenol 5.1.1 Atal a llesiant Mae gan wasanaethau sylfaenol a chymunedol ran allweddol i’w chwarae yn y system ‘iachusrwydd’ fel y disgrifiwyd yn ‘Cymru Iachach’ a dylid defnyddio pob cyswllt gyda dinesydd neu ei ofalwr/gwarcheidwad i hyrwyddo cyfleoedd i atal neu hunanreoli. Yn benodol mae’n cynnwys:

Gwybodaeth i ddinasyddion gael mynediad - uno Cyfarwyddiadur Gwasanaethau DEWIS ac INFOENGINE a’u hymgorffori’n systematig yng ngwefannau meddygon teulu a chlystyrau er mwyn hyrwyddo hunanofal.

Presgripsiynu cymdeithasol (neu atgyfeiriadau cymunedol) a chydlynu ardal leol er mwyn cynyddu galluoedd gwasanaethau llesiant - mae angen camau gweithredu ar sail ranbarthol a chenedlaethol. - Ar sail clwstwr a Bwrdd Partneriaeth Rhanbarthol mae angen cysylltu iechyd, gofal

cymdeithasol a’r trydydd sector er mwyn mapio’r asedau sydd ar gael yn yr ardal honno a’r gwaith ‘llywio’ sydd eisoes ar waith. Dylid datblygu cynllun ar gyfer cynaliadwyedd yr asedau hyn.

- Cydlynu Ardal Leol wedi’i gysylltu â’r Cyfarwyddiadur Gwasanaethau.

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- Galluogi ar lefel genedlaethol elfennau fel rhannu gwybodaeth (llywodraethu gwybodaeth a thechnoleg gwybodaeth), fframweithiau gwerthuso ar gyfer y mathau hyn o ymyriadau a datblygu safonau a diffiniadau cenedlaethol ar gyfer cysylltwyr/llyw-wyr cymunedol.

Gwneud i Bob Cyswllt Gyfrif - cyflwyno hyfforddiant yn systematig ar draws gofal sylfaenol ar sail dealltwriaeth o seilwaith cymuned leol (fel y caiff ei ddisgrifio ar lefel Bwrdd Partneriaeth Rhanbarthol).

Atal mewn lleoliadau clinigol - manteisio i’r eithaf ar fudd i’r boblogaeth ar sail ffactorau clinigol risg uchel (BMI uchel, pwysedd gwaed uchel, prawf glwcos yn y gwaed ar ôl ympryd, colesterol), ffactorau risg yn gysylltiedig ag ymddygiad (ysmygu, yfed alcohol, cyfradd gweithgareddh corfforol a deiet) sgrinio ac imiwneiddio.

Atal mewn lleoliadau anghlinigol (e.e. dull ysgol gyfan at atal ar gyfer atal a llesiant, risgiau cwympo).

Rhaglenni lleihau risg i’r boblogaeth– sy’n gysylltiedig ag atal mewn lleoliadau clinigol gan ddysgu oddi wrth raglenni fel Deddf Gofal Gwrthgyfartal ym Myrddau Iechyd Aneurin Bevan, Prifysgol Abertawe Bro Morgannwg a Chwm Taf.

Cymunedau Tosturiol neu gynlluniau cyfatebol e.e.

Canolfannau/hybiau iechyd a llesiant sy’n sicrhau bod y drefn iachusrwydd a’r model cymdeithasol o ofal yn nodwedd amlwg wrth gynllunio.

Cynyddu’r broses o gyflwyno rhaglenni cenedlaethol (e.e. Cynllun Cyfeirio Cenedlaethol ar gyfer Ymarfer Corff, Helpa fi i Stopio).

5.1.2 Model 24/7 Mae ‘Cymru Iachach’ yn datgan “gwasanaethau di-dor, sy’n cael eu darparu mor agos â phosibl at y cartref” gan nodi bod gofal sylfaenol a chymunedol yn greiddiol i hyn. Datblygwyd y model gofal sylfaenol fel model 24/7 ond mae wedi canolbwyntio yn bennaf ar wasanaethau o fewn oriau gwaith arferol yn unig. Gellir cymhwyso sawl elfen o’r model i wasanaeth gofal sylfaenol y tu allan i oriau, gan gydnabod bod rhai materion sy’n ymwneud yn benodol â gwasanaethau o fewn oriau arferol a’r tu allan i oriau. Yn ogystal bydd gwella cynaliadwyedd gofal sylfaenol a ddarprir o fewn oriau arferol a gwell mynediad yn helpu’r ddarparaieth y tu allan i oriau.

Gofal Brys – mae’n cynnwys gofal brys y tu mewn a’r tu allan i oriau. Mae’r ffrydiau gwaith yn cynnwys: adolygiad cymheiriaid o wasanaethau y tu allan i oriau y gweithlu dolen i Raglen Gofal Heb ei Drefnu gan gynnwys cynllunio ar gyfer y gaeaf canolbwyntio ar y prif lwybrau megis gofal diwedd oes, paediatreg ac iechyd meddwl cyfleoedd i fynd i’r afael â chapasiti ar amseroedd brig.

Prosesau Uwchgyfeirio – tra bod prosesau uwchgyfeirio wedi’u datblygu ac yn cael eu defnyddio’n rheolaidd mewn gofal eilaidd nid yw hyn wedi bod yn wir am ofal sylfaenol.

Yn fwy diweddar gwnaethpwyd gwaith yn y maes y tu allan i oriau ond mae anghysondeb yn yr adroddiadau sydd angen rhoi sylw iddo. Yn ogystal â hynny mae angen datblygu system graddio ‘RAG’ ar gyfer gwasanaethau o fewn oriau.

Hunanofal a chontractwyr proffesiynau gofal sylfaenol ehangach – mae angen gosod a mynegi’n glir gynnig “Dewis Doeth” a’r arlwy gan broffesiynau contractwyr er mwyn hybu newid ymddygiad ymhlith y boblogaeth (Sylwer: mae hyn yn gysylltiedig â’r ffrwd waith cyfathrebu a’r ffrwd waith atal a llesiant, yn benodol felly gwybodaeth i ddinasyddion).

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Ffôn / cyfeirio / brysbennu – yn seiliedig ar adolygiad manwl gan Hwb Datblygu ac Arloesi Gofal Sylfaenol a Chymunedol, mae gwir angen datblygu diffiniadau a safonau cenedlaethol, hyfforddiant cenedlaethol a fframwaith cymwyseddau.

Gwasanaethau yn y gymuned - mae angen sicrhau bod cysylltiad rhwng y gwasanaethau gwahanol yn y gymuned (e.e. nyrsio cymunedol, timau adnoddau cymunedol ac ati) er mwyn gwneud y defnydd gorau o adnoddau. Mae angen gwirio ymhellach y gwasanaethau sydd ar gael gan awdurdodau lleol a’r trydydd sector. Dylid hefyd ystyried ymhellach y defnydd o brofion diagnostig a phrofion pwyntiau gofal yn y gymuned.

Rheoli risg sy’n cynyddu – gweithredu dull wedi’i strwythuro (gan gydnabod bod ystod o offer ar gael ar gyfer hyn) er mwyn nodi risg a’r cysylltiadau ag ymatebion priodol (gan y system gyfan e.e. y Trydydd Sector, Awdurdodau Lleol).

5.1.3 Data a Thechnoleg Ddigidol Er bod y cynllun gofal sylfaenol cenedlaethol yn cydnabod rôl technoleg o ran gwella mynediad, nid yw gwaith blaenorol strategol ar ddatblygu gofal sylfaenol wedi canolbwyntio ar botensial technoleg newydd. Mae ‘Cymru Iachach’ yn nodi hyn fel elfen allweddol i alluogi trawsnewid er mwyn cefnogi modelau newydd o ofal. Yn y lle cyntaf bydd yn canolbwyntio ar ‘sicrhau bod y wybodaeth berthnasol yn gywir, yn gyflawn, yn gyfredol ac yn cael ei rhannu gan bawb sy’n gyfrifol am ofal yr unigolyn,’ cyn symud ymlaen at ddulliau newydd o gael mynediad at wasanaethau ac yna atebion digidol mwy datblygedig. Yn benodol bydd hyn yn cynnwys:

Ddefnyddio i’r eithaf y systemau sydd ar gael i rannu a defnyddio data a gwybodaeth. Er enghraifft Fy Iechyd Ar-lein, System Wybodaeth Gofal Cymdeithasol (yn enwedig y rhyngwyneb ar draws gwasanaethau) ac ymgorffori Cyfeiriadur Gwasanaethau DEWIS ac infoengine i wefannau practisau/clystyrau.

Defnyddio i’r eithaf systemau Meddygon Teulu a fferylliaeth newydd a’r cynnig i weithio fel tîm amlddisgyblaeth

Yn benodol ar gyfer fferylliaeth, symud ymlaen gyda Phrosiect Gweinyddu Rhagnodion Electronig, Fferyllfeydd a Meddyginiaethau Ysbytai Cymru, prosiect a fydd yn galluogi cyfrifiaduro’r broses o ragnodi, prosesu, rheoli cyflenwadau a chofnodi gweinyddu meddyginiaethau mewn ysbytai gofal eilaidd.

Symud ymlaen gydag atebion TG ar gyfer gofal y llygaid: yn benodol, gweithredu ar e-gyfeirio mewn gofal optometreg sylfaenol sy’n galluogi cleifion i gael eu cyfeirio at ofal eilaidd yn ddiogel, gweithredu system TG offthalmig dwy ffordd rhwng gofal sylfaenol a gofal eilaidd, gan ‘rannu gofal’ cleifion rhwng gwahanol weithwyr iechyd proffesiynol mewn lleoliadau gofal gwahanol.

Data sy’n dangos gweithgaredd a chanlyniadau.

Rhannu gwybodaeth ar draws clwstwr ac ar draws sefydliadau.

Deall yr anghenion ynghylch defnyddio dyfeisiadau symudol, gan gynnwys materion yn ymwneud â llywodraethu a’r gweithlu.

Systemau digidol sy’n hwyluso adnabod risg er mwyn hybu diogelwch cleifion.

Teleffoni – datblygu safonau cenedlaethol teleffoni.

Fideo a skype - fe’u cefnogir mewn egwyddor ond ni wneir defnydd digonol ohonynt. Mae angen ystyried llywodraethu, diogelu data, hyfforddiant ac integreiddio gyda gofynion cofnod iechyd.

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Mae angen ystyried y rhwystrau rhag defnyddio technoleg, gan gynnwys tlodi, a dylanwadu ar newid ymddygiad ymhlith y boblogaeth. 5.1.4 Datblygiad Sefydliadol a’r Gweithlu Mae ‘Cymru Iachach’ yn cyfeirio at ddull gweithio mewn tîm amlddisgyblaeth fel y nodwedd gyffredin yn y modelau newydd gorau sy’n datblygu yng Nghymru. Mae hyn yn hanfodol i Ofal Sylfaenol yng Nghymru. Arweiniwyd y gwaith hwn gan Grŵp Gweithlu Gofal Sylfaenol ac mae wedi cyhoeddi adroddiad terfynol sy’n tynnu sylw at y gwaith a wnaethpwyd hyd yma, gan nodi’r prif flaenoriaethau ar gyfer gwaith yn y dyfodol. Yn ychwanegol, mae’r adroddiad diweddar ‘Multi-Professional Roles within the Transforming Primary Care Model in Wales’ yn amlygu meysydd lle mae angen gwneud gwaith pellach. Wrth gyfuno’r argymhellion hyn mae’r canlynol yn brif themâu i ganolbwyntio arnynt:

Cynllunio a modelu’r gweithlu – datblygu model lleol sy’n seiliedig ar y boblogaeth ac ar ddadansoddi galw. Bydd hyn yn dylanwadu ar gymwyseddau angenrheidiol y gweithlu ac yn llywio cynllunio’r gweithlu ar lefel gymunedol a chenedlaethol.

Lle da i weithio - mynd i’r afael â recriwtio a chadw’r gweithlu, tâl a thelerau gwaith yn ogystal â chanolbwyntio ar lesiant.

Datblygu Rolau Penodol - mae meysydd blaenoriaeth yn cynnwys datblygu fframwaith a hyfforddiant cenedlaethol ar gyfer rolau llywiwr cymunedol a brysbennu.

Addysg, hyfforddiant a sgiliau – mae hyn yn cynnwys datblygu dulliau o gynyddu cyfleoedd addysg a hyfforddiant mewn lleoliadau gofal sylfaenol gan gynnwys anghenion mentora a goruchwylio a llwybrau gyrfa.

Rhannu arferion gorau – datblygu’r compendiwm o fodelau a rolau a gynhyrchwyd hyd yma gydag elfennau datblygu’r gweithlu wrth werthuso modelau newydd.

5.1.5 Cyfathrebu ac Ymgysylltu Er bod y model gofal sylfaenol i Gymru yn seiliedig ar fodel cymdeithasol o ofal, canolbwyntiwyd ar yr elfennau iechyd hyd yma. Yn ychwanegol, cydnabyddir bod yr iaith yn deillio o faes iechyd a bod angen ehangu hyn i sicrhau bod y naratif yn ddealladwy i bawb, a bod dulliau cyfathrebu cyson am y model gan yr holl randdeiliaid. I ddechrau bydd hyn yn canolbwyntio ar hyn:

Mynegiant cyfeillgar i ddefnyddwyr o ran holl elfennau’r model i randdeiliaid (e.e. gofal cymdeithasol, trydydd sector, gofal eilaidd). Mae angen ystyried sut y bydd y rhyngwyneb rhwng clwstwr/gofal sylfaenol gyda Byrddau Partneriaeth Rhanbarthol yn digwydd.

Datblygu’r sail ar gyfer y ffordd y bydd staff yn cael eu hyfforddi i reoli’r neges hon (e.e. swyddogaeth derbynnydd/llywiwr).

Ymgyrch ymwybyddiaeth a gwybodaeth/addysg gyhoeddus i hyrwyddo ac ymgorffori’r model gyda dinasyddion ledled Cymru.

Mae ‘Cymru Iachach’ yn dweud y bydd gan bobl ‘fwy o rôl a rheolaeth dros eu hiechyd a’u llesiant eu hunain, gan wneud penderfyniadau am driniaethau a rheoli cyflyrau hirdymor’. Mae hyn yn gofyn bod gwybodaeth ar gael i ddinasyddion a bod dealltwriaeth o fodelau gofal newydd er mwyn dylanwadu ar newid ymddygiad. Fel rhan o ‘Raglen Drawsnewid’ Llywodraeth Cymru, mae’n bosibl y bydd ffrwd waith drosfwaol ar gyfer gofal sylfaenol. Man lleiaf byddai angen i hyn gynnwys, ar lefel genedlaethol a lleol: - Ffyrdd newydd o gael gafael ar wybodaeth.

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- Dealltwriaeth o’r model ehangach ar lefel Ymarfer Cyffredinol e.e. Tîm ehangach Amlddisgyblaeth, rhagnodi cymdeithasol (neu atgyfeirio cymunedol) a chyfeirio at ymarferwyr eraill (ffisiotherapyddion, cynghorwyr, awdiolegwyr a gwasanaethau contractau presennol e.e. fferyllfa gymunedol ac optometreg).

- Cysylltu gydag ymgyrchoedd cenedlaethol fel Dewis Doeth a chynlluniau cenedlaethol fel Iechyd

y Llygad. 5.1.6 Trawsnewid a’r Weledigaeth ar gyfer Clystyrau Wrth i’r rhaglen drawsnewid ddatblygu (yn unol ag argymhellion ‘Cymru Iachach’) mae’n bwysig bod unrhyw ddysgu yn cael ei rannu ar fyrder ar draws gofal sylfaenol, gan ddylanwadu ar y weledigaeth i’r clystyrau. O bwys arbennig bydd unrhyw gynlluniau i gyflymu gweithredu’r model gofal sylfaenol mewn ar lefel clystyrau ac yn rhanbarthol. Gwneir cysylltiadau allweddol gyda’r Rhaglen Drawsnewid genedlaethol a rhaglenni trawsnewid lleol.

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5.2 Gweithio’n Ddi-dor 5.2.1 Trefniadau’r Bwrdd Iechyd i wneud y mwyaf o weithio’n ddi-dor Mae Arfarniad Beirniadol o’r rhaglen Pennu Cyfeiriad, y cyfeirir ato yn adran 3, yn nodi’r angen i Fyrddau Iechyd ystyried eu seilwaith lleol a nodi’r capasiti, y sgiliau a’r adnoddau sydd eu hangen i gefnogi’r broses o drawsnewid gofal sylfaenol. Ar sail argymhellion yr Arfarniad Beirniadol mae angen sylw ar y canlynol ar lefel bwrdd iechyd:

- Sefydlu trefniadau ar gyfer cynyddu proffil gofal sylfaenol ar lefel bwrdd iechyd.

- Sicrhau bod trefniadau ar waith i gefnogi cipio data er mwyn dylanwadu ar gynllunio ar sail galw/capasiti ar gyfer gwasanaethau sylfaenol a chymunedol.

- Sicrhau bod cynllunio tymor byr, canolig a hirdymor ar waith, wedi’i ddylanwadu gan glystyrau

a gyda thystiolaeth sydd yn y cynlluniau tymor canolig integredig.

- Dangos bod defnydd o’r mesurau gofal sylfaenol a phrif ddangosyddion y gwasanaethau meddygol cyffredinol wedi dylanwadu ar y cynlluniau hyn.

- Dangos bod y fframwaith ariannol yn cael ei ddefnyddio i gefnogi ailgydbwyso adnoddau ar

draws y system iechyd (Cylchlythyr Iechyd Cymru a gyhoeddwyd ym mis Gorffennaf 2018)

- Cydnabod maint y newid, gan sicrhau bod cynllunio’r gweithlu a chynlluniau datblygu sefydliadol ar waith i gefnogi hyn.

- Sicrhau bod gan y fframweithiau gwerthuso gymorth medrus i ddangos tystiolaeth o effaith

cronfa mentrau pennu cyfeiriad/model trawsnewid/trawsnewid er mwyn dylanwadu ar benderfyniadau am ddatblygu achos busnes a buddsoddi.

5.2.2 Gweithio’n ddi-dor ar draws yr holl system Mae ‘Cymru Iachach’ yn nodi’r angen i wasanaethau gan wahanol ddarparwyr gael eu cydlynu a’r angen hefyd i ddatblygu gwerthoedd a phartneriaethau ar y cyd. Felly o safbwynt gofal sylfaenol mae angen rhoi sylw i’r canlynol:

- Ystyried proffil gofal sylfaenol o fewn strwythurau bwrdd partneriaeth rhanbarthol yng nghyd-destun dealltwriaeth partneriaid o’r model gofal sylfaenol a chynrychiolaeth o fewn y strwythurau hyn.

- Sicrhau bod cynlluniau bwrdd partneriaeth rhanbarthol yn cael eu dylanwadu gan waith

cynllunio clystyrau.

- Ystyried blaenoriaethau a chynlluniau gweithredu Byrddau Gwasanaethau Cyhoeddus a’u cysylltiad â chynlluniau clystyrau yn lleol.

- Creu perthynas gryfach gyda phartneriaid allweddol.

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5.3 Sut y bydd Contractwyr Gofal Sylfaenol yn ymateb Mae’r adran hon yn ystyried sut y bydd contractwyr gofal sylfaenol yn ymateb i ‘Cymru Iachach’ o dan y penawdau canlynol,

- Gwytnwch unigolion/cymunedau

- Cyngor/mynediad pan fo angen

- Gweithlu sy’n cael ei gefnogi ac sy’n cyflawni 5.3.1 Gwasanaeth Meddygol Cyffredinol Gwytnwch unigolion/cymunedau – ochr yn ochr â’r ymrwymiadau i fynediad mwy cyffredinol, sydd yn Ffyniant i Bawb, a’r rhaglen ddiwygio sydd eisoes ar y gweill (ac sy’n ddull gweithio tairochrog rhwng Llywodraeth Cymru, Pwyllgor Ymarferwyr Cyffredinol Cymru a GIG Cymru), bydd diwygio’r contract Gwasanaethau Meddygol Cyffredinol yn ystyried beth yw’r ffordd orau o gontractio a chynnal gwasanaethau meddygol cyffredinol, cyflawni ystod o brif flaenoriaethau a chydnabod gwerth y model contractwyr annibynnol. Bydd diwygio’r contract yn ymchwilio i ffyrdd o barhau i wella mynediad at ofal sylfaenol, yn enwedig drwy glystyrau, er mwyn galluogi i’r Model Gofal Sylfaenol gael ei fabwysiadu a’i addasu. Mae’r polisi hwn, a gaiff ei ategu yn ‘Cymru Iachach’, wedi bod yn symud tuag at fwy o waith clwstwr ers peth amser. Yn ystod 2018-19 bydd Tîm Diwygio Contract Llywodraeth Cymru yn ystyried dull contractio newydd sy’n hwyluso clystyrau i aeddfedu ac ymgorffori proses well o gynllunio gwasanaethau sy’n canolbwyntio ar y boblogaeth ar gyfer Meddygon Teulu ledled Cymru. Gall y dull arfaethedig weld nifer o wasanaethau ychwanegol (fel Gwasanaethau Gwell a mesur ansawdd) yn symud i lefel clwstwr ac atebion ehangach o ran gweithlu clystyrau fydd yn rhyddhau capasiti mewn practisau Meddygon Teulu a chefnogi darparu gwasanaethau lleol i gleifion a galluogi cyflwyno a chynllunio gwasanaeth ar sail poblogaeth y clwstwr. Cyngor/mynediad pan fo angen - Fel rhan o drafodaethau contract y Gwasanaeth Meddygol Cyffredinol 2018-19 cytunwyd y dylai practisau Meddygon Teulu barhau i gynnig cymaint â phosibl o ymgyngoriadau yn ystod oriau craidd, cysoni negeseuon i gleifion y tu allan i oriau ac y byddai pob canolfan yn adolygu eu mynediad a chytuno ar elfennau o’r drefn ffôn yn gyntaf / cyfeirio / brysbennu. Mae dangos a datblygu methodoleg gwella ansawdd mewn Practis Cyffredinol yn flaenoriaeth arall allweddol, gyda golwg ar ddarparu gwell canlyniadau a phrofiad i ddinasyddion Cymru, gan ganolbwyntio ar y clwstwr fel y ffordd i symud hyn yn ei flaen. Gweithlu sy’n cael ei gefnogi ac sy’n cyflawni – Mae recriwtio, cadw ac arallgyfeirio’r gweithlu yn flaenoriaeth allweddol arall. Fel rhan o agenda diwygio gwasanaethau meddygol cyffredinol, bydd sawl maes yn cael ei ddatblygu ar draws y gweithlu Ymarfer Cyffredinol er mwyn cyflawni’r nod hirdymor o gael gweithlu cynaliadwy, a lleihau’r rhwystrau at ddod yn Feddyg Teulu a pharhau i weithio fel Meddyg Teulu. 5.3.2 Fferylliaeth Gwytnwch unigolion/cymuned: Mae fferyllfeydd cymunedol yn ased iechyd sy’n cyflawni swyddogaeth gymdeithasol a llesiant, yn aml mewn rhannau o Gymru ble mae’r heriau iechyd a chymdeithasol mwyaf. Mae fferyllfeydd yn cyfrannu at gyfalaf cymdeithasol ac yn creu gwytnwch ar y stryd fawr mewn trefi ledled Cymru, ond mae newidiadau mewn arferion defnyddwyr yn golygu bod yn rhaid i ni gydweithio â sector fferyllfeydd cymunedol i addasu a sicrhau bod modd cynnal y cyfraniad hwn. Rhaid i fferyllfeydd cymunedol barhau i ailddiffinio eu swyddogaeth a gwneud eu hunain yn ffynhonnell fwy hygyrch gydag ystod gynyddol o wasanaethau clinigol a chyngor wyneb yn wyneb gan weithwyr gofal iechyd proffesiynol, ac nid dim ond lle i ddosbarthu presgripsiwn. Mae’r prif flaenoriaethau yn cynnwys,

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Ailgydbwyso trefniadau contractau fferyllfeydd cymunedol i ysgogi cyflwyno gwasanaethau sy’n ymateb i anghenion y cymunedau y maent yn eu gwasanaethu ac nid dim ond dosbarthu presgripsiynau.

Fferyllfeydd yn parhau i dargedu eu gwasanaethau at y rhai sydd fwyaf ei angen a ble mae’r potensial gorau ar gyfer gwell iechyd a lleihau anghydraddoldeb iechyd.

Fferyllfeydd cymunedol wedi’u hintegreiddio’n llawn gyda chlystyrau gofal sylfaenol i sicrhau darpariaeth gwasanaethau effeithlon a theg.

Cyngor/mynediad pan fo angen: Mae fferyllfeydd cymunedol yn hygyrch, yn aml yn agored ar benwythnosau a gyda’r nosau ac yn cynnig amgylchedd cyfleus, llai ffurfiol i bobl nad ydynt yn gallu neu ddim am ymweld â gwasanaethau iechyd eraill. Mae’r prif flaenoriaethau yn cynnwys,

Fferyllwyr cymunedol yn parhau i wneud diagnosis a thrin ystod ehangach o salwch aciwt gan leihau’r pwysau ar rannau eraill o GIG.

Fferyllwyr cymunedol sydd â mynediad at Gofnod Meddyg Teulu Cymru yn genedlaethol ac ar draws yr holl wasanaethau er mwyn hwyluso gallu fferyllwyr i ymateb yn effeithiol i anghenion gofal brys a heb eu trefnu.

Cyfathrebu â’r cyhoedd a chamau gweithredu cyson gan wasanaethau iechyd eraill sy’n hyrwyddo swyddogaeth fferyllfeydd cymunedol fel man cyswllt cyntaf dinasyddion ar gyfer triniaeth am anhwylderau cyffredinol a chyngor am feddyginiaethau.

Gweithlu sy’n cael ei gefnogi ac sy’n cyflawni: Mae fferyllwyr cymunedol yn aelodau tra medrus o’r gweithlu gofal sylfaenol ac maent yn rheoli mân gyflyrau ac yn rhoi cyngor ar feddyginiaethau. Mae technegwyr fferylliaeth yn hanfodol bwysig o ran sicrhau bod fferyllfeydd yn gweithredu’n ddiogel ac effeithlon gan ryddhau amser fferyllwyr i ddarparu mwy o wasanaethau clinigol ac, yn gynyddol, darparu gwasanaethau clinigol eu hunain. Er mwyn cynyddu’r ystod o wasanaethau sydd ar gael mewn fferyllfeydd cymunedol byddwn yn parhau i wella cymhwysedd a hyder y gweithlu mewn meysydd fel ymgynghoriadau sy’n canolbwyntio ar y claf, gwneud i bob cyswllt gyfrif, gwella ansawdd, sgiliau clinigol uwch a rhagnodi. Mae’r prif flaenoriaethau’n cynnwys,

Pob fferyllydd cymunedol a thechnegydd fferylliaeth i barhau i gael eu cefnogi i ddatblygu eu sgiliau ar gyfer cynnal ymgynghoriad sy’n canolbwyntio ar y claf a “gwneud i bob cyswllt gyfrif”.

Gwell ymwybyddiaeth a dealltwriaeth o wella ansawdd wedi’i ymgorffori yn y timau fferyllfeydd cymunedol.

Parhau i gynnig cyfleoedd i hyd at 200 prentisiaeth fodern ar gyfer technegwyr fferylliaeth yn gweithio mewn fferyllfeydd cymunedol erbyn 2021.

Parhau i gynnig cyfleoedd i hyfforddi 100 o fferyllwyr cymunedol fel rhagnodwyr annibynnol erbyn 2020.

5.3.3 Optometreg Gwytnwch unigolion/cymuned: Mae Optometreg Gymunedol yn weithlu hynod fedrus sy’n cyflawni swyddogaeth iechyd allweddol gan gyfrannu at gyfalaf cymdeithasol a chreu gwytnwch ar y stryd fawr mewn trefi ledled Cymru ac mae optegwyr cymunedol yn parhau i ddarparu'r gofal llygaid proffesiynol mwyaf hygyrch ac addas i gleifion. Mae angen codi eu proffil a chodi ymwybyddiaeth o’r cyfraniad y maent yn ei wneud. Mae pwysau masnachol i ddefnyddio gwerthiannau sbectol i ariannu profion golwg yn arwain cleifion i feddwl bod ymweliad â’r optegydd yn mynd i fod yn ddrud. Gall hyn leihau’r nifer sy’n manteisio ar wasanaethau gofal llygaid y GIG. Bydd symud y pwyslais i ofal iechyd y llygaid yn sicrhau bod optometryddion yn parhau i fod yn ased iechyd yn y gymuned ac yn gweithredu fel y man cyswllt cyntaf ar gyfer claf sydd â phroblem llygad. Mae mynediad rheolaidd a chyson at wasanaeth optometreg gyda chlystyrau gofal sylfaenol yn hanfodol wrth ddatblygu gwasanaethau integredig a sicrhau dealltwriaeth am y rhan bwysig y mae optometryddion yn ei chwarae yng ngofal iechyd llygaid cleifion. Mae’r prif flaenoriaethau yn cynnwys,

Optometryddion yn targedu eu gwasanaethau at y mannau ble y mae modd iddynt sicrhau’r enillion mwyaf – rhoi’r pwyslais ar ofal iechyd y llygaid.

Diwygio contract optegwyr cymunedol gan ail-gydbwyso’r angen i roi cymhorthdal i wasanaethau clinigol.

Optometreg gymunedol wedi’i integreiddio’n llawn gyda chlystyrau gofal sylfaenol i sicrhau gwasanaethau effeithlon a theg.

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Cyngor/mynediad pan fo angen: Parhau i gynyddu mynediad at ystod o wasanaethau gofal iechyd y llygad y GIG a darparu ystod ehangach o wasanaethau clinigol mewn canolfan optometreg. Mae optometryddion cymunedol yn hygyrch iawn, ac maent yn aml ar agor ar benwythnosau a gyda’r nosau. Mae’n hanfodol darparu cymwysterau ychwanegol I optometryddion cymunedol er mwyn iddynt allu darparu gwasanaethau gofal llygaid mwy integredig, gan symud rhwng gofal sylfaenol a gofal eilaidd, ar gyfer gofal llygaid wedi’i drefnu a heb ei drefnu. Mae’r prif flaenoriaethau yn cynnwys,

Optometryddion cymunedol yn parhau i wneud diagnosis a thrin ystod ehangach o lwybrau gofal y llygaid, yn benodol drwy ddatblygu canolfannau diagnosteg a thriniaeth.

Mynediad at system atgyfeirio electronig ac un cofnod electronig a rennir ar gyfer pob claf.

Cyfathrebu gyda’r cyhoedd er mwyn hyrwyddo swyddogaeth optometryddion yn y gymuned gan hyrwyddo’n gyson swyddogaeth optometryddion cymunedol - Meddygon y llygaid.

Gweithlu sy’n cael ei gefnogi ac sy’n cyflawni: mae optometryddion cymunedol yn darparu gofal llygaid cyffredinol. Mae’n bwysig parhau i wella’r gymysgedd o sgiliau sydd ei hangen i reoli a thrin ystod ehangach o gyflyrau’r llygaid yn y gymuned. Bydd hyn yn galluogi mwy o symud o wasanaethau eilaidd i ofal sylfaenol a hynny’n unol â pholisi gofal iechyd darbodus. Er mwyn cynyddu rhychwant y gwasanaethau sydd ar gael gan yr optometrydd cymunedol, mae angen ehangu’r gweithlu drwy hyfforddiant ac achrediad uwch yn ogystal â darparu strwythur gyrfa ar gyfer y proffesiwn optometreg. Mae’r prif flaenoriaethau yn cynnwys,

Cyflwyno optometryddion sy’n rhagnodi’n annibynnol ar draws clystyrau gofal sylfaenol.

Cynnig lleoliadau mewn adrannau gofal y llygaid mewn ysbytai er mwyn ennill cymwysterau mewn retina meddygol, glawcoma, rhagnodi annibynnol ac arweinyddiaeth.

Gwell ymwybyddiaeth a dealltwriaeth o wella ansawdd wedi’i ymgorffori mewn optometreg gymunedol drwy drefniadau contract.

5.3.4 Gwasanaethau Deintyddol Gwytnwch unigolion/cymuned; codi proffil y cyfraniad y gall gwella iechyd y geg ei wneud i iechyd a llesiant yn ehangach drwy rymuso cleifion a’u hannog i werthfawrogi, cynnal ac amddiffyn iechyd eu cegau eu hunain a’r rhai sy’n dibynnu arnynt. Mae cynnydd mewn dealltwriaeth o iechyd y geg yn bwysig er mwyn cyflawni hyn ac rydym am i gleifion ddeall sut mae eu hymddygiad yn effeithio ar y tebygolrwydd y byddant yn datblygu clefyd deintyddol. Rydym eisiau i dimau deintyddol bersonoli negeseuon allweddol gan gyflwyno cyngor cyson a chywir i helpu cleifion i leihau’r risg o glefyd y geg, er mwyn idydnt allu cynnal a gwella iechyd y geg. Mae’r prif flaenoriaethau yn cynnwys,

‘Disgwyliadau’ o ran cyngor ac ymyrraeth ataliol yn cael eu cyflwyno mewn ymarfer clinigol.

Pob claf, sydd mewn cysylltiad â gofal deintyddol sylfaenol yn cael asesiad o risg ac anghenion iechyd eu ceg a hynny wedi ei egluro a’i adrodd iddynt, fel eu bod yn deall statws iechyd eu ceg a sut y gall newid ymddygiad leihau’r risg o gael clefyd y geg.

Cyngor/mynediad pan fo angen: cynyddu mynediad at ddeintyddiaeth gofal sylfaenol y GIG a darparu gwasanaethau deintyddol (sylfaenol, eilaidd a brys) sy’n ymateb i anghenion cymunedau lleol. Dylai gofal fod ar gael i’r rhai sydd â’r angen mwyaf yn gyntaf - egwyddor Gofal Iechyd Darbodus. Yr ymrwymiad yw cynyddu mynediad at ofal deintyddol y GIG yn arbennig i gleifion nad ydynt wedi gweld deintydd yn y ddwy flynedd flaenorol (y flwyddyn flaenorol ar gyfer plant). Mae’r prif flaenoriaethau yn cynnwys,

Cynnydd o flwyddyn i flwyddyn yng nghyfran y bobl sydd wedi gweld ymarferydd deintyddol y GIG yn y 2 flynedd diwethaf (1 ar gyfer plant) ym mhob Bwrdd Iechyd.

Contractau sy’n cynnwys hyblygrwydd dyddiol o ran mynediad ac oriau agor ehangach.

Bydd unrhyw un gyda phoen deintyddol sy’n effeithio ar ei fywyd bob dydd yn cael triniaeth ddeintyddol effeithiol a chael cynnig amserol i ddychwelyd a chael asesiad risg o iechyd y geg.

Bydd pob claf sy’n ymweld â gwasanaethau gofal deintyddol sylfaenol y GIG yn cael asesiad risg y geg ac asesiad o angen, o leiaf unwaith y flwyddyn gydag adolygiadau dilynol yn dibynnu ar y canfyddiadau.

Gweithlu sy’n cael ei gefnogi ac sy’n cyflawni: datblygiad yn y defnydd effeithiol o’r gymysgedd o sgiliau mewn timau deintyddol a gwasanaethau arbenigol drwy gynnydd yn nifer yr hylenyddion, therapyddion a nyrsys deintyddol sydd â sgiliau ychwanegol, wedi’u hyfforddi a’u cadw yng

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Nghymru, ac yn gweithio i’w heithaf o fewn cwmpas eu hymarfer. Bydd hyn yn creu tîm deintyddol effeithiol sy’n canolbwyntio ar waith atal. Bydd ehangu mynediad i gyfleoedd gwaith yn cynnig rhagolygon gwaith i unigolion o gymunedau lleol, ysgogi timau deintyddol a’u cefnogi i gyflawni eu nodau proffesiynol a phersonol drwy gynnig llwybr gyrfa. Mae’r prif flaenoriaethau yn cynnwys,

Sefydlu Cyfadran Broffesiynol Gofal Deintyddol a chyflwyno rhaglen Making Prevention Work in Practice yn 2018.

Cronfa arloesi sy’n cefnogi ehangu Gweithwyr Gofal Deintyddol. 6. Casgliad Mae’r papur hwn yn darparu ymateb gofal sylfaenol i ‘Cymru Iachach’, gan ddisgrifio safbwynt ar ddatblygiad gofal sylfaenol a chan nodi’r prif feysydd strategol y mae angen rhoi sylw pellach iddynt. Mae hyn yn sail i raglen strategol ar gyfer gofal sylfaenol. Bydd hyn yn ddull cyflawni a gwerthuso sy’n cefnogi’r rhaglen strategol a bydd yn rhoi manylion am gamau gweithredu, cerrig milltir a chanlyniadau ar lefel clwstwr yn ogystal â lefel ranbarthol a chenedlaethol. Dylid nodi y bydd rhai meysydd gwaith yn parhau yn unol â’r arfer o dan arweiniad Cyfarwyddwyr Gofal Sylfaenol a Chymunedol y Byrddau Iechyd.

Elfennau Model Trawsnewidiol ar gyfer Gofal Sylfaenol a Chymunedol

Mae rhaglen drawsnewidiol o newid i wasanaethau gofal sylfaenol a chymunedol ar y gweill i ddiogelu iechyd a lles pobl Cymru, gan adeiladu ar y gwasanaethau ardderchog a ddarperir ar hyn o bryd gan weithwyr proffesiynol, ar hyd a lled y wlad. Mae’r model newydd yn defnyddio dull system gyfan o ymdrin ag ail-ddylunio, wedi’i lywio gan safonau ansawdd cenedlaethol ond gyda’r hyblygrwydd i ymateb i anghenion cymunedol lleol (gweler y diagram yn Atodiad 1). 1. Egwyddorion Model Trawsnewidiol Gofal Sylfaenol a Chymunedol Y dinesydd sy’n ganolog i’r model newydd, gan gynnwys pob oedran a demograffeg. Bydd defnyddio’r model yn sicrhau bod y gofal cywir ar gael ar yr adeg gywir o’r ffynhonnell gywir, yn y cartref neu ger y cartref. Mae’r model yn seiliedig ar:

Datblygu gwasanaethau ar sail anghenion y boblogaeth, gyda gwaith cynllunio a thrawsnewid yn cael ei arwain drwy glystyrau gofal sylfaenol lleol

Hyrwyddo byw’n iach a dadfeddyginiaethu lles

Canolbwyntio ar boblogaeth fel sail ar gyfer cynllunio a darparu gwasanaethau mewn cymunedau lleol

System fwy ataliol, ragweithiol a chydgysylltiedig o ofal sylfaenol sy’n cynnwys darpariaethau practisau cyffredinol a gwasanaethau cymunedol drwy dimau adnoddau cymunedol (CRT) neu wasanaethau eiddilwch

Dull system gyfan drwy integreiddio gwasanaethau iechyd, awdurdod lleol a’r sector gwirfoddol, wedi’i hwyluso gan gydweithredu ac ymgynghori

Gofal cyfannol i ddinasyddion, sy’n ymgorffori lles corfforol, meddwl ac emosiynol, wedi’i gysylltu â dewisiadau byw’n iach

Gofal integredig, syml ar sail 24/7, yn canolbwyntio ar y cleifion salaf y tu allan i oriau

Gwell gwydnwch cymunedol drwy rymuso dinasyddion a’r gallu i gael gafael ar amrywiaeth o asedau cymunedol

Cyngor a chymorth ar gael i helpu pobl i aros yn iach, o fewn cyrraedd rhwydd i wasanaethau gofal lleol pan fydd pobl ei angen

Arweinyddiaeth gryf amlbroffesiynol ar draws y sectorau a’r asiantaethau i lywio’r broses o wella ansawdd

Atebion technolegol i wella’r ffordd o gael gafael ar wybodaeth, cyngor a gofal a chefnogi hunan ofal 2. Cyhoedd Gwybodus Mae rhannu’r ddealltwriaeth o ran yr achos dros newid, nodi sut mae rhywbeth da yn edrych ac esbonio’r manteision, yn hanfodol i sicrhau llwyddiant. Mae angen gwybodaeth, addysg, ysgogiad ac ysbrydoliaeth i sicrhau newid diwylliannol y cyhoedd er mwyn grymuso pobl i gymryd perchnogaeth o’u hiechyd. Mae angen ffocws cryf ar ofal sylfaenol a chymunedol ar gyfer strategaethau cyfathrebu er mwyn rhoi gwybod i’r cyhoedd a gweithwyr proffesiynol am y modelau newydd a datblygiadau mewn gwasanaethau. Efallai y bydd angen dulliau gwahanol er mwyn newid ymddygiad mewn ardaloedd daearyddol lle mae gwahaniaethau diwylliannol. Mae cynnwys plant a phobl ifanc mewn deall pwysigrwydd hunan-gyfrifoldeb yn allweddol ar gyfer newid yn y dyfodol. Mae gweithwyr proffesiynol gofal iechyd yn defnyddio dulliau ac ymyriadau byr, gan gynnwys gwneud i bob cyswllt gyfrif, er mwyn effeithio ar ymddygiadau a dewisiadau o ran ffordd o fyw 3. Dinasyddion Grymus Mae cynnwys pobl yn y gwaith o gynllunio eu gwasanaethau lleol, defnyddio adborth ar brofiadau defnyddwyr a rhoi rolau pendant i bobl yn y broses o newid, yn hwb i rymuso’r cyhoedd. Gall hyrwyddwyr lleol rannu gwerth arloesedd gofal sylfaenol a chymunedol drwy eu profiadau cadarnhaol eu hunain. Canfuwyd bod cyfweliadau ysgogol a thechnegau hyfforddi wedi bod yn effeithiol wrth gefnogi newid ymddygiad. Caiff cleifion a defnyddwyr gwasanaethau eu hannog i wneud dewisiadau hyddysg gyda’i gweithwyr iechyd a gofal cymdeithasol proffesiynol. 4. Cefnogi Hunan Ofal Cefnogir pobl i gymryd cyfrifoldeb dros eu hiechyd drwy ddatblygu eu gwybodaeth, meithrin sgiliau a magu hyder. Mae hunan ofal a chymryd cyfrifoldeb yn allweddol i newid trawsnewidiol, gyda chyfranogiad penodol pobl a gofalwyr mewn penderfyniadau am eu gofal, ac amrywiaeth o adnoddau lleol ar gael i hyrwyddo hunan ofal a hunan gyfeirio. Mae technoleg glyfar yn cynorthwyo gyda monitro, hunan ofal a chyfathrebu. 5. Gwasanaethau Cymunedol Mae’r model yn ymgorffori gallu gweithwyr proffesiynol gofal iechyd mewn practis cyffredinol i gyfeirio at amrywiaeth ehangach o wasanaethau a llwybrau cymunedol, gyda’r wybodaeth ddiweddaraf a chyngor ar iechyd a lles. Mae’r model hefyd yn cynnwys gofal a chymorth nad yw’n glinigol yn ogystal â gwasanaethau clinigol. Mae amrywiaeth gynyddol o opsiynau cymorth a chyngor yn cynnwys sgyrsiau â thimau iechyd lleol dros y ffôn, e-bost neu alwad fideo. Mae systemau wedi cael eu cynllunio i gefnogi penderfyniadau a sicrhau

ei bod yn bosibl cael gafael ar y person neu’r gwasanaeth proffesiynol gorau pan fydd angen. Gellir cael gafael ar adnoddau cymunedol drwy hunan gyfeirio neu drwy system flaenoriaethu ar y ffôn sy’n gweithio fel dull rhagnodi cymdeithasol, gan ddefnyddio Gweithwyr Cyswllt, Rhagnodwyr Cymdeithasol a thechnoleg i gefnogi’r gwaith o gyfeirio. Mae’n hanfodol bod y gwasanaethau lleol hyn ar gael yn rhwydd, eu bod yn gynaliadwy a’u bod yn diwallu anghenion y gymuned. 6. Gweithio mewn Clwstwr Mae cyflogi staff i weithio ar draws clystyrau yn gwella effeithlonrwydd ac yn sicrhau bod y boblogaeth leol yn gallu cael gafael ar arbenigedd clinigol, cymdeithasol a rheoli. Mae timau clwstwr yn recriwtio gweithwyr proffesiynol gan gynnwys fferyllwyr, ffisiotherapyddion, gweithwyr cymdeithasol, parafeddygon, cydymaith meddygol, therapyddion galwedigaethol, cwnselwyr iechyd meddwl, deietegwyr, gweithwyr y trydydd sector a staff eraill yr awdurdod lleol i wella capasiti ar gyfer rheoli anghenion y boblogaeth leol o ddydd i ddydd. Sefydlogrwydd mewn practis cyffredinol sydd wrth wraidd y model newydd ac mae’n hanfodol i sicrhau bod gwasanaethau iechyd lleol yn gynaliadwy ac y gallant ymateb i alwadau yn y dyfodol. Mae cymorth lleol gan fyrddau iechyd yn cynorthwyo i sefydlogi practisau meddygon teulu sydd mewn perygl a bydd cynllunio gweithlu lleol yn effeithiol yn sicrhau cynaliadwyedd yn y tymor hwy. Mae timau clwstwr yn cael gwared ar y rhwystrau ffug mewn systemau iechyd a gofal cymdeithasol lleol er mwyn hyrwyddo gofal integredig mewn cysylltiad ag anghenion y boblogaeth leol. Caiff gweithio integredig a newid diwylliannol eu hwyluso drwy gontractau ar y cyd, rhannu sesiynau dysgu, cyd-leoli staff a chyfleoedd i weithwyr proffesiynol symud rhwng gwahanol sectorau. Mae dyfodiad modelau amrywiol sy’n hyrwyddo cydweithredu clwstwr, megis Ffederasiynau, Mentrau Cymdeithasol a’r Canolbwynt Gofal Sylfaenol, wedi’u halinio i’r dull amlbroffesiynol integredig hwn. 6. Blaenoriaethu Clinigol / Systemau Ffonio Gyntaf mewn Practis Cyffredinol Bwriad systemau trin galwadau a blaenoriaethu clinigol diogel ac effeithiol fer y fynedfa i ofal sylfaenol yw cyfeirio pobl at y gwasanaeth neu’r gweithiwr proffesiynol mwyaf addas, gan symud oddi wrth y system bresennol lle mae meddyg teulu yn blaenoriaethu’r mwyafrif o gysylltiadau â chleifion. Mae cyngor dros y ffôn yn briodol ar gyfer cyfran sylweddol o geisiadau pobl ac, os rhoddir y cyngor hwnnw gan weithiwr proffesiynol profiadol addas, gall leihau nifer yr ymgyngoriadau personol yn ddiogel ac yn effeithiol. Mae gan y model hwn o ffonio gyntaf, sy’n ymgorffori trin galwadau (neu gyfeirio gofal) a blaenoriaethu gofal, y potensial i gyfeirio pobl y tu hwnt i’r bobl amlbroffesiynol o amgylch y meddyg teulu. Mae’r model ffonio gyntaf / blaenoriaethu hefyd yn sicrhau cael gafael ar y gofal cywir gan y gwasanaeth cywir ar amser, gan gyfeirio pobl at:

Weithwyr proffesiynol clinigol sy’n integredig o fewn y tîm clwstwr amlbroffesiynol lleol, gan gynnwys gweithwyr optometrig a deintyddol proffesiynol i reoli problemau’n ymwneud â’r llygaid, y dannedd a’r geg; fferyllwyr cymunedol i reoli mân anhwylderau a phroblemau’n ymwneud â meddyginiaethau a ffisiotherapyddion i reoli problemau cyhyrysgerbydol

Gwasanaethau cymunedol nad ydynt yn glinigol, pan fydd hynny’n briodol, gyda chyfeiriadau’n cael eu cynorthwyo gan weithwyr cyswllt neu ragnodwyr cymdeithasol sydd wedi’u hintegreiddio o fewn y tîm amlddisgyblaethol lleol

7. 111 a Gofal y Tu Allan i Oriau Mae’r Gwasanaeth 111 ar ei newydd wedd yn sicrhau bod pobl ag anghenion brys yn y cyfnod y tu allan i oriau yn cael eu rheoli’n briodol, gyda systemau cyfathrebu da i sicrhau bod y timau proffesiynol yn gallu cael gafael ar gofnodion clinigol cyfoes. Mae hyn yn hanfodol ar gyfer gofal di-dor o fewn oriau arferol ac y tu allan i oriau, yn arbennig o ran cleifion â chyflyrau cymhleth a / neu ar ddiwedd oes. Mae 111, gyda chefnogaeth cyfeiriadur rhithwir cenedlaethol o wasanaethu, hefyd yn gweithredu fel dull rhagnodi cymdeithasol i gyfeirio pobl at wasanaethau lleol a ffynonellau cymorth drwy’r dydd bob dydd. 8. Mynediad uniongyrchol Gall pobl gael gafael yn uniongyrchol ar amrywiaeth o wasanaethau iechyd lleol sy’n cynnwys fferyllwyr cymunedol, i gael cyngor a thriniaeth ar gyfer amrywiaeth o anhwylderau cyffredin; optometryddion i gael cyngor a thriniaeth ar gyfer problemau llygaid arferol a phroblemau brys; deintyddion ar gyfer ddannodd ac iechyd y geg; ffisiotherapyddion ar gyfer problemau cyhyrysgerbydol; awdiolegwyr ar gyfer problemau clyw. Efallai nad yw’r gwasanaethau hyn ar gael ym mhobman eto, ond maent yn datblygu ac yn trawsnewid drwy’r amser.

9. Pobl ag Anghenion Gofal Cymhleth O ganlyniad i flaenoriaethu effeithiol a gweithio’n well fel clwstwr amlddisgyblaethol, mae gan feddygon teulu ac Ymarferwyr Uwch fwy o amser i ofalu’n rhagweithiol am bobl ag anghenion mwy cymhleth yn y cartref neu yn y gymuned – yn aml yr henoed ag amryfal gydafiechedd. Mae angen amser ymgynghori sylweddol hirach i asesu, cynllunio a chydgysylltu’r gofal a ragwelir. Gellir cefnogi pobl a ddaw gydag anghenion gofal iechyd a chymdeithasol gan ofal di-dor gan dimau adnoddau cymunedol, timau eiddilwch neu iechyd a gofal lleol integredig eraill. Gellir rheoli trafferthion cymhleth sy’n deillio o broblemau lles, tai a chyflogaeth yn well drwy system gyfan amlbroffesiynol. Mae’r tîm clwstwr mewn lle da hefyd i gefnogi gofal am y rhai â salwch aciwt o fewn Wardiau Rhithiol a Chanolbwynt Cymunedol, gan weithio gyda chydweithwyr arbenigol i ofalu am y rhai a fyddai, fel arall, yn cael eu derbyn i’r ysbyty ac mewn perygl o golli eu hannibyniaeth. Gall timau cymunedol o’r fath, hefyd, hwyluso rhyddhau o’r ysbyty yn brydlon. Felly, mae’r model amlddisgyblaeth cyfannol hwn yn cynnig dull mwy rhagweithiol ac ataliol o drin gofal, a phobl yn cael eu trin yn gynharach ar eu llwybr gofal wrth iddynt ymateb yn well i addysg a chefnogaeth ynghylch hunan ofal. Y canlyniad yw gwell canlyniadau a phrofiadau i bobl a gofalwyr. Mae gan y model y potensial ar gyfer amrywiaeth ehangach o ofal wedi’i gynllunio i’w gynnal yn y gymuned, gan gynnwys apwyntiadau a thriniaethau cleifion allanol, a phrofion diagnostig. Gallai hefyd leihau’r achosion o gyfeirio i ofal eilaidd a derbyn i’r ysbyty ar gyfer gofal heb ei drefnu, gan ganiatáu i staff ysbytai ganolbwyntio eu hadnoddau ar y bobl sy’n sâl iawn ac ar ofal arbenigol wedi ei drefnu.

10. Seilwaith i gefnogi Trawsnewid Mae’n rhaid i’r Model Trawsnewidiol ar gyfer Gofal Sylfaenol gael ei gynnal gan seilwaith sy’n addas i’r diben ac sydd wedi’i gynllunio i hwyluso gwaith tîm amlddisgyblaethol. Mae’n rhaid i gyfleusterau iechyd lleol, gwasanaethau gwybodeg a theleffoni fod yn hyblyg ac yn ymatebol i newid yn y dyfodol, gan gefnogi gwaith amlbroffesiynol a chydrannau ffonio gyntaf/blaenoriaethu. Mae’n rhaid i opsiynau digidol ar gyfer chwilio am ofal a derbyn gofal ddod yn gyffredin. Mae cael gafael uniongyrchol ar wasanaethau diagnostig yn y gymuned, gan glinigwyr clwstwr yn hanfodol ar gyfer darparu gofal o safon yn nes at y cartref. 11. Canlyniadau Disgwyliedig Mae gwaith ymchwil cenedlaethol a rhyngwladol, ynghyd â thystiolaeth sy’n dod i’r amlwg o’r Rhaglen Pennu Cyfeiriad, yn nodi manteision posibl y model trawsnewidiol ar gyfer gofal sylfaenol a chymunedol:

Gwell iechyd a lles dinasyddion Gwell gwydnwch cymunedol Gwell moral, ysgogiad a lles ymysg ymarferwyr Gwella recriwtio a chadw staff gofal sylfaenol a chymunedol Modelau gofal cynaliadwy

Jane Harrison, Cynghorydd Ymarferydd Cyffredinol Arweiniol, Canolbwynt Gofal Sylfaenol (Iechyd Cyhoeddus Cymru)

Chwefror 2018

Modelau GofalCynaliadwy

Gofal

Sylfaenol

Sefydlog

Modelau

Clwstwr

Newydd

Gweithwyr

proffesiynol

ysgogedig

Llai o achosion o

dderbyn i’r

ysbyty/ Achosion

Brys y gellir eu

hatal a’u hosgoi

Dull Systemau Cyfan

Integredig

Gofal Cymhleth

ac Arbenigol yn y

Gymuned

Adnoddau Cymunedol

Cynaliadwy

Gwella

lles

dinasyddion

Hyrwyddo

Byw’n Iach

Adnoddau

Hygyrch

Amrywiaeth Eang o Adnoddau

Cymunedol

Cefnogaeth i

Hunan Ofal

Gwell

Gwydnwch

Cymunedol

Cyhoedd

Gwybodus

Dinasyddion

Grymus

Gwell

mynediad at

ofal

o ansawdd

DULL SYSTEM GYFAN CYMRU GYFAN

Notes/Nodiadau

Notes/Nodiadau

Notes/Nodiadau

Notes/Nodiadau