Welsh Government Policy prioritises the delivery of care closer to home, seeking to improve outcomes through prevention, early intervention and supported self-management. The Primary Care Model for Wales (PCMW) supports local delivery through the organisation of care around local communities (cluster working). Moving care closer to home also supports the ambition of Net Zero Wales by redesigning the whole journey with care closer to home in a carbon-friendly primary care estate with a reduced need to visit hospital.
In response to this, the Strategic Programme for Primary Care developed the ‘Community by Design’ planning approach to transform the delivery of care through fully integrated systems thinking. The aim of the approach is to deliver services effectively and safely in the community and consider what system adjustments are needed, at local partnership and national levels, to drive such an ambition. This approach is grounded in ensuring that all resources along a health pathway should be directed towards to best outcomes and experience for service users.
A Community by Design approach drives service planning from the perspective of the service user and assumes, unless proven otherwise, that care can be provided in the community setting, utilising hospital-based care only when this is required by more complex or escalating clinical need. This approach requires engagement by all clinicians across the pathway, to understand needs in the population and to bring the most effective and proportionate solutions to the community, maximising the skills of the whole multiprofessional team.
Whist the principle of Community by Design should be universal, several areas can be used to promote and establish this approach. These may include:
Diagnostics
Advice and shared decision making tools that can be used in the community setting
Management of risk to support community care and to achieve a shared understanding of community needs
Clinical Intervention- expanding the availability of interventions that are already available in some areas
Rethinking periodic monitoring/reviews – prioritising community delivery and considering patient led reviews
Single patient record
Medicines management/Shared care
Full use of professional skills and scope of practice
Utilising the Community by Design methodology, work has commenced as follows:
Joint work with the Respiratory & CVD network on the breathlessness pathway
Joint work with the Diabetes network on the optimal diabetes care in the community
Joint work with the Strategic Programme for Mental Health on a place based approach to delivery of community mental health services
Other directorates are supporting this work including Digital, Technology, Innovation & Value, DTIV, Finance Planning & Delivery, Strategic Planning Team and Performance & Assurance.
Find out more about Community by Design.