Community Infrastructure (CI) Programme tool

The Community Infrastructure (CI) programme is one of the four key strategic priorities of the Strategic Programme for Primary Care, and a core part of its 24/7 work stream. You can read more about the Strategic Programme for Primary Care here.

The CI ambition is to define the fundamental infrastructure required to deliver a place-based 24/7 integrated, multi-professional community model.

It focusses on how Primary and Community Care services work collaboratively together, delivering seamless, coordinated, effective, efficient, value-based, person-centered care and support closer to home.

The Community Infrastructure Programme recognizes the breadth of initiative-taking and responsive services that operate within communities, and support individuals over the age of sixteen. Its recognised though that this work often stands alone and has not had traction. This Programme provides the opportunity to build on, coordinate, and give profile to this work.

It will ensure proactive collaborative working across professions and organizations, to build greater community resilience and recovery for services.

Our ambition is enabling people to live well, closer to home through prevention, choice, well-being & independence by:

• Providing evidence-based guidance, frameworks, and quality statements to support multi-professional working
• Creating collaborative working across community professions
• Focusing on consistency, reducing variation, and building on good practice
• With the development & utilization of data to demonstrate its value and impact

Building on some of the principles outlined in the Primary Care model for Wales.

• Multi-professional teams working at cluster level
• Safe & effective systems to direct people to the right care in the right place and at the right time.
• Integrated team working ensuring a holistic approach to care
• Seamless 24/7 services
• Informed public with access to a range of community services

Read more on the Primary care model for Wales.

Background

Community services are very wide ranging, covering a number of agencies and a whole raft of services. Across Wales, each Health Board (HB), Local Authority (LA), Trust and Regional Partnership Board (RPB) area has, over time developed their historic community service offer in response to the challenges that they face within their specific health and care system. This has focussed on their local priorities and the means at their disposal, to support people to live and age well, be supported at home, and when required after a hospital stay be enabled to return home with support.

Earlier work undertaken by the NHS Delivery Unit (DU) Right Sizing Community Services provided each RPB with a view on how their suite of step down community services match against an expected norm / best standard.  This is complimented by data submissions about Intermediate Care as part of the NHS Benchmarking Network Intermediate Care Programme, led and co-ordinated by the National Collaborative Commissioning Unit (NCCU) since 2016.

It is now crucial that similar work is undertaken looking at the whole of community services, that enable the population to live well and be supported at home when in need of enhanced care. This work will help to support unnecessary access to secondary care or the need to require admission to a bedded care facility.

There is a need to create collaborative working across professions, agencies, organisations, and services within the community setting, to enable individuals to receive timely access to the right care and support for their needs, by the appropriate skillset, professional or service, in their preferred setting.

This work will support front line services in delivering the required care in the right place and at the right time. It will assist Health Boards / Local Authorities and key partners in being able to provide the required infrastructure to do so.

The Programme is aligned to:

• A Healthier Wales
• Primary Care Model for Wales
• The Six Goals of Urgent and Emergency Care
• Allied Health Professions (AHP) Framework
• Chief Nursing Officers priorities 2022-24
• Primary and Community Care AHP Workforce Guidance: Organising principles to optimise utilisation

and supports the SPPC Accelerated Cluster Development Programme (ACD).

The programme of work will focus on multi-professional working within community settings, developing, testing, and defining examples of evidence-based models of practice and their interfaces with and between primary and community care, social care, third sector and independent organisations such as care homes or domiciliary care.

Developing the programme in this way increases the emphasis on the way community and primary care colleagues work together across organisational and professional boundaries to provide inclusive services to all people who have health and social care needs within a cluster, including those who are the most vulnerable, such as residents within care home settings.

This collaborative programme will look to deliver upon 7 key outcomes, all focused on enabling people to live well, at home, through prevention, choice, well-being, and independence:

What good looks like infographic 

Process plan infographic 

Who is involved? Where to find out more?

A Key Stakeholder group has been set up to advise on the deliverability of the products/ proposals being generated by the CI Programme, in effect “critical friends” drawn from across Wales.

Each product / proposal is explored, informed and developed by a respective Task and Finish group.

The Task and Finish groups consist of members from primary and community care, social care, third sector and independent organisations who work together to develop products, providing their specific lens or/and professional view. This is underpinned by the sharing work and good practice already existing in Wales.

Group members will work together to:

1. Identify good practice locally and sharing expertise.
2. Represent the voice (and perspective) of the organisation / profession / group they represent.
3. Ensure relevant information is communicated back to their organisation / profession / group in a timely manner.
4. Influence and engage with colleagues within area of practice to obtain feedback on work developed by CI programme

Ensure relevant information / feedback is communicated back to the group in a timely manner.

The Key Stakeholder group reviews the work of the Task and Finish groups. Products are also shared with Directors of Primary Care, Director of Planning and Directors of Finance to road test their content as well as colleagues in a number of Departments / Divisions in Welsh Government.

The CI programme is managed within the Strategic Programme for Primary Care and is accountable to the National Primary Care Board and through the Lead NHS Chief Executive to the National NHS Leadership team.

Vice Chairs play an important role within Health Boards with responsibility for primary care services.  There are also critical links with Regional Partnership Boards.

How can I get involved?

The CI work relies on engagement with professionals, teams, and agencies regardless of setting who work with people receiving care and support.

If you’d like to know more about a particular piece of work or join one of our task and finish groups, you can contact us via the Strategic Programme Primary Care [email protected] 

The Accelerated Cluster Development (ACD) Programme includes the introduction of Professional Collaboratives and Pan Cluster Planning Groups to broaden and strengthen clinical engagement and to increase the influence from the community up to the Regional Partnership Boards.

Professional Collaboratives (PCs) are networks of professionals, with shared expertise, working together to use their unique skills to assess the needs of the population where they work. PCs will capture the knowledge and experience of local professionals to map service provision, identifying gaps and development needs to inform decision-making and propose solutions.

Working together, members of the various Professional Collaboratives will use their detailed knowledge and expertise to consider the quality of service they offer, respond to national strategy and design local solutions using a multi-professional approach to meet the needs of individuals and their communities. This will help ensure that people’s needs are met by the right person, at the right time, in the right place

How will we achieve this?

The diagram below summarises the Vision to achieve the line of sight – with professional collaboratives ensuring local knowledge, skills, and expertise, inform the decisions made at each level of geographical operation – these being Cluster, Pan Cluster, or locality, and Regional Partnership Boards (RPBs).

Professional Collaboratives will ensure that the multi-professional voice influences practice and enables people to receive the best outcomes.

Each professional group has a particular perspective on aspects of service provision.  Professional Collaboratives provide a structure to support connection with peers to review the quality and safety of local services, share experience and good practice for the area of expertise and to advocate for service improvement.

The purpose of the Professional Collaboratives is to: –

• promote inter and intra-professional dialogue and cooperation to improve person centred collaborative care and experience and
• to gather professional and user experience of services to inform priority setting and planning.

Aims will include: –

• Improved population health and well being
• Increased value from the care and support provided
• Improved quality and safety of services
• Engaged and developed workforce

Nursing Professional Collaborative

The development of Professional Collaboratives offers Nurses working in the community for the first time, an opportunity to come together to influence how they and other professionals work collaboratively, for the individual and their family.

A Nursing Professional Collaborative crosses organisational boundaries, sectors, branches of nursing and places of care. It enables Nurses to provide compassionate leadership at cluster and pan cluster/locality level. In conjunction with other Professional Collaborative Leads, it supports the provision of high-quality care for individuals and their families, now and into the future.

The Nursing Professional Collaboratives support the Chief Nursing Objectives,

• By ensuring coordinated and strong Nurse leadership at cluster and pan cluster/locality level, through valuing our nursing workforce and the expertise and knowledge we bring
• By improving people’s outcomes and quality of services provided, and
• By bringing nurses together to look at the needs of their local population, influencing clinical pathways and addressing inequalities

To do this there needs to be a shared vision of what a Nursing Professional Collaborative is and to agree what support is required, to move from the concept of a Nursing Professional Collaborative into a functioning group, which influences at cluster and pan cluster level, high quality care and treatments for individuals and their families.

A National workshop was held on the 21st of June with nursing representatives across children and adult services to help start this work, focusing on what Nursing Professional Collaboratives may look like.

We started by asking how as nurses, we could work together, recognising that we don’t always come together across our different organisations or areas of practice.

The group emphasised the importance of;

• Open and honest communication based upon a shared vison and objectives, enabled by protected time to work collaboratively together.
• A shared vison that needed to be inclusive, person centred, outcome focused and empower nurses to advocate for their local populations, utilising the strength of nurses skills and voice.
• Consistency in the key areas PC’s should focus on. These included amongst others, a focus on prevention, reduction in inequalities  and retention/satisfaction of nurses working locally.
• Clear structures, meaningful outcomes and opportunities for all nurses to have an equal voice and contribution.
• Leadership development and peer support.

The group were keen on increasing nurses understanding of what a professional collaborative was, so nurses could understand the value and opportunities the collaborative could bring.

Regional workshops were identified as a way of increasing understanding and engagement as well as identifying how PC’s could be developed within individual health boards.

Read the Nursing Professional Collaboratives National Overview Workshop Report.

AHP Professional Collaboratives

Allied Health Professions (AHPs) are 13 individual professions in Wales regulated by the  Health and Care Professions Council (HCPC)

• Art Therapists
• Dietitians
• Orthotists
• Podiatrists
• Speech and Language Therapists
• Music Therapists
• Occupational Therapists
• Paramedics
• Practitioner Psychologists
• Drama Therapists
• Orthoptists
• Physiotherapists
• Prosthetists

AHP Professional Collaboratives provide the architecture to explore and develop workforce plans that deliver the high quality and high value services needed to deliver seamless care and support population need by:

• Ensuring coordinated and strong AHP leadership at all levels of geographical operation from cluster and pan cluster/locality level, through to Regional Partnership Board.
• Bringing AHPs together to look at the needs of their local population, influencing clinical pathways and addressing inequalities
• Supporting a focus on how we look at our AHP workforce in totality, how we optimise its utilisation against informed and agreed priorities, and support these from a collaborative AHP perspective.
• Providing an understanding of the expertise, value, and impact AHPs offer, and in conjunction with other Professional Collaboratives, influence how they and other professionals work collaboratively, for the individual, their family, and the local community.

AHP Professional Collaboratives cross boundaries within organisations and all sectors related to health and well-being. To do this there needs to be a shared vision of what an AHP Professional Collaborative is and what support is required in order to operationalise the concept into a functioning group.

Following on from workshops as part of SPPC National ACD Launch Event, in June 2022 a National AHP Professional Collaborative workshop took place. To agree a shared vision and national agreement on how the AHP Professional Collaboratives will function.

Following the National AHP Professional Collaborative workshop, it was agreed that 7 Regional workshops would be held in each of the health board areas to develop the thinking around the introduction of AHP Professional Collaboratives. The agreed purpose of the workshops was to:

• Build on discussions in the national workshop and to further inform the national picture.
• Support local operationalisation of the AHP Professional Collaborative in each of the health board areas.
• Agree a plan and next steps to get the AHP Professional Collaborative in place, and to identify how the AHP profession will feed into the Clusters and Pan Cluster Planning Groups (PCPGs).

Key themes from the National AHP Professional Collaborative workshop:

• Influence: the way in which services are planned and delivered and the importance of being able to highlight the skills and roles covered by AHPs and how these can contribute to improved outcomes for our population.
• Collaboration: Across the 13 professions as well as collaboration with other primary care professions. Rebalancing so not one profession dominant
• Recognition:  benefit in bringing AHPs together and ensuring AHPs are seen as an equal partner around the table at cluster level.
• Engagement:  within the AHP family, and across the other primary care professions. Noting there can be professional AHP silos, and sometimes a lack of understanding each other’s roles in terms of value and impact. Also, consideration re inclusion of wider professions i.e., audiology, visual & hearing impairment rehab officers
• Equal voice: There is a need to work on the one AHP voice and consider the need for expansion in the number of generic AHP leaders to provide representation across Wales.

Key requirements that were identified from the national workshop:

• Meetings with Purpose
• Clear structure, with clear and achievable outcomes as a result of collaboration
• Open and honest communication based upon a shared vison and objectives
• Work based on population needs assessments, with person-centred collaborative care at the centre
• Interventions and services backed up by evidence base and impact they have
• Being heard and influencing as a professional group with equal voice and contribution
• Inclusive representation – underpinned by leadership development and peer support
• Opportunity for AHP collaboratives across Wales to have some consistency in the key areas they should focus on e.g., prevention, reduction in inequalities and retention/satisfaction of AHPs working locally
• Developed and skilled workforce to participate in the collaboratives and cluster discussions
• Increasing AHPs understanding of what a professional collaborative is, so AHPs can understand the value and opportunities the collaborative brings

The Executive Directors of Therapies and Health Sciences (DoTHS) Peer Group was the point of contact for each regional AHP workshops’ membership, with nominations requested for AHP Leads across directorates and organisations, who will be supporting operationalisation of the regions AHP Professional Collaborative(s). Recognising the AHP Professional Collaborative is wider than Health Board AHP inclusion.

Guidance was provided concerning primary consideration for inclusion of the 13 AHPs regulated by the Health and Care Professions Council (HCPC), but that a flexibility of approach concerning additional professions based on localised need and what makes sense, would be appropriate. With regional workshops providing the opportunity to explore this.

Chairs of All Wales Heads of Adults’ Services Group (AWASH) and All Wales Heads of Children’s Services Group (AWHOCS) were contacted to raise awareness, engagement and support concerning their respective members. Recognising they are key stakeholders in AHP resource and activity, and their contribution to the development and operationalisation of regional AHP Professional Collaboratives is vitally important, in enabling them to inform decision-making and propose the most effective AHP solutions for the local context.

Regional Primary Care representative(s) with responsibility for coordinating ACD implementation, and Strategic Programme for Primary Care Fund implementation in each of the Health Boards were invited.

In addition to a representative from Health Education and Improvement Wales (HEIW) Primary & Community Care Education & Development Framework team. To ensure identified AHP learning, and development needs are included in the developing Primary Care Education Framework programme and the Gwella Leadership Resources specifically curated to support ACD.

• Read the AHP Professional Collaboratives National Overview Workshop Report. 
• Role Descriptor (for Professional Collaborative membership) – coming soon
• AHP Professional Collaborative ToR  – coming soon
• Proposed standardised AHP Professional Collaborative Agenda – coming soon

It is recognised that each area will progress towards the same end goal but at a different pace, with local knowledge and experience guiding this work to achieve the most effective solutions.

With the National Primary & Community Care AHP Leadership Group (AHPLG) providing opportunities for sharing early success, learning rapidly from challenges, identify and addressing barriers, spreading good practice, and identifying any further supportive actions required at a national and / or local level.

Additionally, the Primary & Community AHPLG communication network, hosted by Gwella, also provides the opportunity for timely communication and support concerning the progression of ACD.

The Accelerated Cluster Development toolkit explores Professional Collaboratives in more detail including model terms of reference and roles and responsibilities.

The Allied Health Professions (AHP) Framework: Looking Forward Together

This sets out the AHP strategic response to A Healthier Wales and utilises the Quadruple Aim as an organising concept to describe the transformation required aligned to the Primary Care Model.

The Six Framework Principles for Transformation of how AHPs must:

• be used more effectively
• be more easily and directly accessible through whole system planning
• contribute to population health, wellbeing, and resilience
• work at the top of their ability with visible and compassionate leadership, to transform services and apply the principles of prudent healthcare.

Read more on the Primary and Community Care AHP Workforce Guidance: Organising principles to optimise utilisation.

The Allied Health Professional (AHP) ambition in Wales is for well- integrated services, rooted in community, with full range of practitioner levels and prudent optimisation of AHP skillset.

With clear objectives to:

• Provide clarity around the evidence based AHP offer
• Look at the AHP workforce in totality from a collaborative AHP leadership perspective
• Inform and support planning to meet presenting population needs and regional priorities
• Ensure effective accessibility and utilisation of AHP skillset across Primary and Community Care
• Identify gaps and requirements from a well – integrated, whole system workforce planning basis
• Create sustainable models of delivery that support multiple stakeholders
• Deliver the high quality, high value services required to deliver person-centred support, within a place-based care model of care

This guidance provides the organising principles / actions required for the whole health and social care system, to optimise the Allied Health Professions (AHPs) offer across Primary and Community Care, ensuring we create sustainable models of delivery that support multiple stakeholders. Deploying AHPs from a well – integrated, whole system workforce planning basis to deliver the high quality, high value services required. Ensuring care and support is delivered closer to home, in the setting most appropriate for the individual.

It describes whom the AHPs are, the current challenges in terms of progress to date and competing priorities, and focuses on the conditions conducive to optimising AHP utilisation. Providing clarity around the evidence based AHP offer to inform and support planning to meet presenting needs and regional priorities.

Ensuring effective accessibility and utilisation of AHP skillset across Primary and Community Care, which is paramount to the delivery of person-centred support, within a place-based care model of care.

It is fully aligned to Accelerated Cluster Development (ACD)  in order to achieve this ambition and informed by the principles of:

The Welsh Government’s ‘A Healthier Wales’.

The Primary Care Model for Wales

The Allied Health Professions (AHP) Framework: Looking Forward Together

Developing a Multi-Professional Framework for Wales:

• Creates collaborative working across community professions
• Focuses on consistency, reduces variation, builds on good practice
•  Utilises data to demonstrate value and impact to focus attention and resource

Multi-professional working is central to the CI programme and underpins the ambition of the Primary Care Model for Wales:

• Multi-professional teams working at cluster level
• Safe & effective systems to direct people to the right care in the right place and at the right time.
• Integrated team working ensuring a holistic approach to care
• Seamless 24/7 services

The aim of the Multi-Professional Framework is to support organisations to deliver joined up, outcome focused, evidence-based community services, through a place-based multi-professional working model of care.

Collaboration through place-based systems of care offers the best opportunity to meet the holistic needs of individuals and of the local population. This will challenge some of the traditional boundaries between professions and between services.

CI ambition is to define the fundamental infrastructure required to deliver a place based 24/7 integrated, multi-professional community model. Recognising that there has been of lots of really positive work in this space, but that it’s often stood alone and hasn’t had traction, this programme provides the opportunity to build on, coordinate, and give profile to this work.

The Multi-professional Framework is the key thread across all CI programme priorities and next steps. Supporting the focus on multi-professional working to deliver seamless, coordinated, effective, efficient, timely, integrated, value-based person-centred care and support closer to home.

The Multi-Professional Framework will include:

• A nationally agreed Framework for Multi-Professional working including nationally agreed Definition, Standards with underpinning Quality Statements
• Testing to demonstrate proof of concept
• A set of agreed outcome measures to demonstrate successful achievement of the framework

View the Multi-Professional Framework for Integrated Working.

View the Development Matrix for Multi-Professional Working.

This project is intended to contribute to, and not duplicate local initiatives and wherever possible align with existing work being undertaken within Health Boards Regions and other regional and national organisations.

The programme of work will focus on multi-professional working within community settings, developing, testing, and defining examples of evidence-based models of practice and their interfaces with and between primary and community care, social care, third sector and independent organisations such as care homes or domiciliary care.

Developing the programme in this way increases the emphasis on the way community and primary care colleagues work together across organisational and professional boundaries to provide inclusive services to all people who have health and social care needs within a cluster, including those who are the most vulnerable, such as residents within care home settings.

How will we achieve this?

Working collaboratively with a wide range of stakeholders through task and finish groups who consist of members from primary and community care, social care, third sector and independent organisations who work together to develop products, providing their specific lens or/and professional view. This is underpinned by the sharing work and good practice already existing in Wales.

Multi-professional Framework and Virtual Ward Task and Finish Group

Focused engagement regarding definition, standards and underpinning quality statement. Focus on understanding and mapping current practice.

Scoping Review

Literature review considering the role and key values, benefits and challenges of multi-professional working in the community.

Read the Multi-professional Working in the Community – Scoping Review.

Annex 1 – Table of Literature included in the scoping review is available on request

Group Concept Mapping

Read the Group Concept Mapping Findings. 

Online consensus building exercise to generate a common data set for community infrastructure.

National workshop

Triangulation of engagement and mapping, scoping review and group concept mapping, to support creation of a Development Matrix.

Action Research and Community of Practice

This will enable us to test the Development Matrix and ‘narrate’ progress towards effective multi-professional working.

What’s included in this section:

1. Enhanced Community Care
2. Community Nursing vision and framework
3. Care Homes immunisation model
4. National Community Nursing Specification
5. Multi professional team models and support, to work with people to enable them to live well
6. Holistic long term condition reviews – coming soon
7. Workforce competence and knowledge framework for care homes – coming soon
8. Multi professional workforce models for care homes; to support care team around the person – coming soon
9. National District Nursing Dashboard – coming soon
10. Definition & measure of avoidable admission/attendance – coming soon

Enhanced Community Care

The aim of the Enhanced Community Care  model is to support organisations to deliver joined up, outcome focused, evidence-based community services, through a place-based multi-professional working model of care.

The Enhanced Community Care model will include:

• Nationally agreed definition of Enhanced Community Care and core principles and examples of good practice.
• Testing to demonstrate proof of concept
• A set of agreed outcome measures to demonstrate successful achievement of the model

This project is intended to contribute to, and not duplicate local initiatives and wherever possible align with existing work being undertaken within Health Boards and other regional and national organisations.

Read the Plan on a Page for Enhanced Community Care 

Read about the Enhanced Community Care framework

View the What is integrated community based health & social care? Infographic

The Primary Care and Community Nursing Framework

The aim of the Primary Care and Community Nursing Framework is to support organisations to achieve joined up, outcome focused, and evidence-based community nursing services.

The Primary Care and Community Nursing Framework has been developed by primary care and community nurses, and outlines how they will contribute to achieving the ambitions of A Healthier Wales and the Primary Care Model for Wales. The framework provides a vision for primary care and community nursing services that focuses on the person, what matters to them and how they are enabled to live well and take ownership of their health and well-being needs at all stages of their life.

Read the Primary Care and Community Nursing Framework summary paper.

The long read document is available on request via the Strategic Programme Primary Care (Public Health Wales); email: [email protected]

The Primary Care and Community Nursing Framework will include:

• A Nationally agreed Vision for Community Nursing
• A National Framework which outlines the ambitions of Community Nursing
• An action plan outlining how Community Nursing will achieve this ambition
• A set of agreed outcome measures to demonstrate successful achievement of the framework

This project is intended to contribute to, and not duplicate local initiatives and wherever possible align with existing work being undertaken within Health Boards and other regional and national organisations.

Care homes immunisation model 

The aim of the National Care Home Immunisations Model is to support delivery of specific (appropriate) immunisations within the Care Home’s with nurses, by Care home employed nurses.

Read the National Care Home Immunisations Model.

The work planned to achieve this National Care Home Immunisations Model will include:

• Developing a Nationally agreed Care Home Immunisation model for the administration of flu vaccines to.
  • Residents in care homes with nursing
  • Care home staff using a peer-to-peer model
• Identifying clinical governance, policy, and training requirements
• Identifying options for funding
• Testing the model to demonstrate proof of concept
• Making recommendations on the potential for other vaccinations to be delivered via a care home immunisations model

This project is intended to contribute to, and not duplicate local initiatives and wherever possible align with existing work being undertaken within Health Boards and other regional and national organisations.

If you’d like to know more about this piece of work, you can contact us via the Strategic Programme Primary Care [email protected]

National Community Nursing Specification

The National Community Nursing specification outlines at a strategic level the overarching principles, characteristics, and functions of Community Nursing in Wales for individuals aged 16 and over. The experience of individuals and families using or accessing community nursing services are at its centre, via the use of core principles focused on providing person centred, preventative, safe and effective services.  Its aims are:

• Standardise care where possible to reduce variation and raise quality
• Simplify systems and processes to make people’s experience better and nurses working lives easier
• Promote collaboration with other nurses and professionals around the person

The specification is not able to comprehensively cover all areas of practice and specialism that Nurses working in the Community provide. Therefore, this specification focuses on General Practice Nurses, Specialist Nurses and District Nurses and their teams.

Community Nursing Services do not work alone and are an essential part of the wider nursing team, multi professional team and health and care system.

Standardising key elements of Community Nursing Services will promote greater collaborative working between nurses and understanding of community nurse’s role and value within the wider multi professional team. This will be important as traditional role boundaries change and nurses increasingly work in new models of care to meet the challenges of our health and care system.

The specification promotes Community Nurses to come together to review the way they work across pathways for people aged 16 and over. It encourages nurses to think about different models of working, how to share and learn from one another and advocates for a move towards a preventative population-based approach to support the people they care for.

Recognising the value Community Nurses offer, the specification outlines how nurses should be enabled to lead and support research and service improvements, have clear development and career pathways and be supported via access to regular clinical supervision.

Community Nurses offer strong clinical leadership and governance to their services and the wider health and care team. This, alongside a consistent approach to the way they work, will enable nurses to further lead, develop, and/or support current and new services, to meet the ambitions of the Primary Care Model for Wales.

National Community Nursing specification

Appendix 1 – Self-assessment form which covers all key aspects (i.e., sections 4 – 12) of the National Community Nursing Specification

Data is core to demonstrate the value and impact of enabling people to live well, closer to home through prevention, choice, well-being and independence. To support practice, it is imperative that data is collected with purpose, collected once and used multiple times.

With data brings the opportunity to learn from every individuals’ interaction to continually improve practice, better understand health and care needs, develop new ways of working, support advances in data-driven technology and enable more efficient and person-centred care.

Data is being collected every day but ensuring what is being collected is accessible, relevant and accurate is crucial to its use. Good data ensures you have good evidence to base decisions on and can support operational and strategic decision-making, in turn making prudent use of resources and improving outcomes and experiences.

Data needs to be used with context and reviewed in conjunction with subject matter expertise to derive the critical information from it and make its use as meaningful as possible.

How will we achieve this work?
Through the recruitment of two Demand and Capacity Improvement Managers the CI programme aims to work collaboratively through the task and finish groups, understand best practice in data collection, standards and analysis and ensure this is incorporated into the vision and framework.

We aim to expand and share this information across areas of practice and the professional collaboratives.

There are several data focussed pieces of work linked to the CI programme:

• National district nursing data set and dashboard for Civica (Malinko) scheduling information:
  • Plan on a page in draft, proof of concept for district nurse dashboard
  • Further work with Digital and Healthcare Wales (DHCW)

View the Plan on a Page for District Nursing.

• Multi-professional working models and Virtual Wards thematic analysis of existing teams/pilots and how AHPs are working in these areas. Engagement with AHP’s to specifically scope out data sets:
  • What data can be used to quantify Demand, Capacity and Activity for AHPs?
  • What data can be used to assess patient outcomes and the impacts of multi-professional working?
  • What is the point of contact? How are people escalated to multi-professional teams (standard criteria)?
• Connected to University of South Wales:
  • Literature Scoping Review
  • Group Concept Mapping Exercise
  • EOI Action Research Maturity Matrix
• Care home immunisation
  • Linking with National Immunisation Framework

Monitoring refers to setting targets and milestones to measure progress and achievement and check whether the inputs are producing the planned outputs i.e., it determines whether implementation is proving consistent with design intent—implying we can tweak our approach during the monitoring period. Evaluation is not just about demonstrating eventual success; it also provides insights into why things don’t work (as learning from mistakes has equal value). Monitoring and evaluation is not about finding out about everything (which is intimidating) but are focused on the things that matter.

CI monitoring and evaluation plan – Coming soon 

Communicating and engaging with stakeholders to co-produce new or changing services is an important task for all teams. Communication is the successful conveying or sharing of ideas and feelings, therefore any information imparted or interactions with others are forms of communication.

The CI work relies on engagement with professionals, teams, and agencies regardless of setting who work with people receiving care and support.
If you’d like to know more about a particular piece of work or join one of our task and finish groups, you can contact us via the Strategic Programme Primary Care [email protected]

This toolkit will remain a live resource and we will continue to add information here which we hope will help and support you.

For informational videos on CI please visit:

What good looks like infographic 

Logic model

Coming soon

Events

To keep updates with any future events please visit: Event and Information Videos

Timeline

View the Plan on a page

Welsh Government Communications

Letter from CNO and Alex Slade – National Community Nursing Specification