The Primary Care services are split in to 3 localities: Vale of Glamorgan, Cardiff North & West and Cardiff South and East. Each locality is further split into 3 Clusters as shown below.
Vale of Glamorgan
Cardiff North & West
Cardiff South & East
Cardiff South West
Cardiff South East
City & South Cardiff
The GP surgeries will be linked to one of these 9 Clusters and should have a nominated Member of staff to act as a Cluster Lead for the Practice. Each Cluster has an employed Clinical Director (CD) to act as overall lead for the Cluster. Below are some examples of the exciting work the Cardiff and Vale Practices have been up to and are planning for the future. If you are interested in getting involved it is worth speaking to the Practice Cluster lead in the surgery you are working in or speak to the CD Cluster lead. Contact details should be available on the CAV Clinical Portal. Who's Who (wales.nhs.uk)
Central Vale cluster.
There’s more to Barry than the beach, amusement park and Gavin and Stacey. There is also a burgeoning independent food and retail scene, and to top it all a cohesive and forward thinking cluster! The central vale cluster comprises 7 practices from the Barry and Sully area. We have developed many innovative projects, some of which have spread beyond our cluster (the first point of contact physio model in place in Cardiff in the Vale was started in the central vale cluster). We have a solid ethos of supporting each other’s practices, which particularly developed during the pandemic. Sustainability for primary care is at the core of what we do, and all of our projects are developed with this aim included. We currently have projects running to support mental health, MSK, phlebotomy, and wellbeing, with new projects including paramedics and a pain clinic due to start shortly.
Additionally we are deeply involved as a pathfinder for national work on acute unscheduled care, and have attracted additional funding from WAG to set up and develop an MDT model of acute unscheduled primary care. We have designed and set up an acute unscheduled care hub in Barry, which has been running for 18 months now and is being used as an example that may shape the future direction of acute unscheduled primary care in Wales in the future.
Dr James Martin Cluster Lead
Cardiff North Cluster.
North Cardiff cluster is the largest in Wales, serving a population of 105,000 at present, with expansion up to 120,000 over the coming years.
We are composed of 10 very friendly practices.
We have cluster pharmacists, PCNOPs (primary care nurses for older patients) are looking to employ a couple of paramedics to help with house calls, a HF ANP as well as trialling a FeNO project to diagnose respiratory problems.
We are actively engaged in diagnosing and managing AF and dementia and have established excellent links with PHW to promote public health matters.
Dr Angharad Trigg Cluster Lead
Cardiff South West Cluster.
Cardiff SW cluster prides itself on being at the forefront of an innovative and collaborative approach to patient centred care. Strong links have been developed across health and social care together with the third sector, with health and wellbeing as a central vision for all who live and work in our community. Our cluster development plan has key priorities which focus on social prescribing, multidisciplinary team working, streamlining care across the primary secondary care interface and supporting the more vulnerable members of our community. The cluster has been at the forefront of the accelerated cluster model and is soon to form a community interest company which will allow a more agile approach to delivering cluster initiatives.
Dr Karen Pardy Cluster Lead
Cardiff City and South
Cardiff City and South! People often remember the Senedd building, Millenium Centre or drinks by the bay. Alongside the bustle of the city, however, lie the vibrant, ethnically diverse, and multicultural communities of Grangetown and Butetown. 50,000 people across areas are served by the seven practices of our cluster. As our population stretches across the social strata, from working class families associated with the docks to white collar workers attracted by the fashionable accommodation of Cardiff Bay, this is a challenging, demanding, and satisfying area in which to practice and improve health outcomes.
We are committed to delivering outcomes that matter locally. Practices are reasonably connected with their communities but an important cluster focus is to improve this engagement. Much good work has been achieved in the area of diabetes management but this, and identifying pre diabetic patients, remain important foci. We have a team of diabetic specialist nurses helping practices improve the care of their complex patients. Similar to other CAV clusters we are maximising benefits from the MSK triage model, frail elderly care at home, and social prescribing / mental health support models. A valuable local variation has been the innovative gardening project which tackles exercise, social isolation and learning valuable skills. We have also pioneered a useful partnership between public health and general practice to increase HIV screening uptake which is likely to be spread wider as part of the fast track cities initiative. Good relationships have been developed between practices and local health visiting teams to tackle the generally low immunisation rates.
Dr Richar Baxter Cluster Lead
Primary Care One
Primary Care One Wales website is a central online resource for primary care clusters. Primary Care One Wales promotes cluster collaborative working, signposts to relevant resources and facilitates sharing of innovation and practice.
Quality improvement in Cardiff and Vale PCIC
As a health board, CAVUHB is committed to continuous quality improvement. Within PCIC we recognise that delivering this can be challenging amidst the pressures of general practice and process variations between practices. Consequently our approach is to celebrate successes whilst supporting and encouraging all practices to adopt a similar focus on continuous improvement.
Dr Baxter is CD for Quality improvement and clinical innovation and links in closely with the wider health board Innovation team.
Over the last two years we have supported practices with QI training. Evidence and our experience suggest that QI training is more effective when delivered in conjunction with specific projects. We are now identifying specific improvements with measurable benefits that we can encourage and support practices to implement in conjunction with further training. Birthday aligned chronic disease recall and structured demand management are currently our focus in this regard. However wherever practices have individuals or teams engaged in QI projects we are happy to help identify and address their training needs.
We would love to hear from any practices with quality improvement ideas they would like help developing or which they consider are worth shaping up to scale across CAV.
Clinical Directors CDs
Clinical Directors (CD) are not just in post as Cluster Leads. GPs who work with the Health board for a variety of reasons are referred to as CDs. There are CDs for Clinical Governance, Medicines Management, Research & Development, Out of Hours, Quality Improvement, Training and Practice development & Sustainability. There are also CDs linked to Clinical specialities such as Diabetes, Respiratory, Mental Health, Surgery, Palliative Care, Cancer Care, Gastroenterology and Paediatrics.
Getting involved with the Health board is hugely rewarding work. We all know that things can be better and It is very worthwhile to get involved and try and be part of the solution. There are vacancies for CD roles available over time on NHS jobs. If you are interested in and want more information you can contact Anna Kuczynska: Anna.Kuczynska2@wales.nhs.uk or Helen Kemp: Helen.Kemp@wales.nhs.uk