Written evidence submitted by the Middlewood Partnership (FGP0166)

 

1.       Introduction

1.1.   The Middlewood Partnership is a merged practice of 33,000 patients aligned with our PCN.  The organization and delivery of care has been fundamentally changed to be more organizationally resilient and provide better care to our patient population.

 

1.2.   This submission outlines some of the many issues facing general practice at present and how the Middlewood model can be one future blueprint for the survival and expansion of the Partnership Model of General Practice. 

 

2.       Challenges Facing General Practice

2.1.   General Practice is facing significant challenges.  Historically there has been resilience despite being buffeted by the particular political will of the time and regularly having to reform and adapt.  General Practice, more than ever is being challenged to the point of breaking.  We have a work force which is burnt out and demoralised.  The Profession feels under attack by all sides, with unpleasant and often inaccurate media attacks, often being validated by those in authority.  This has led to a narrative that GPs are to blame for many of the fundamental issues facing the NHS at present.

 

2.2.   The reality, as most working in the NHS know, is that General Practice has always delivered an extraordinary and efficient service.  Never has this been truer than over the last couple of years.  Whether it be the remarkable efforts in delivering over 75% of the initial waves of the COVID vaccinations or delivering to fundamentally change the way of seeing patients almost overnight.  When hospitals have been unable to provide face to face outpatient appointments or the waiting times are excessive, GPs have stepped in to provide the missing care.  The number of patients being seen in general practice has never been higher. 

 

2.3.   This unseen work has not been celebratedInstead an extraordinary narrative has been allowed to arise that GPs are somehow taking it easy and this has become a “fact” for a percentage of the population.  Headlines like “GPs are merely at the vanguard of the new war against work”1 quoting the “notoriously generous contract” and “If the GPs went on strike, would anyone notice?2 recently in the Daily Telegraph demonstrates how out of touch with the reality some are.  Constant attacks on “part time working” are part of this pattern and feed into the negative narrative.

 

2.4.   The cognitive dissonance of these media attacks, which are believed by a proportion of our patient population, and a workforce which is working far beyond the limits of any normal job is proving disastrous for the moral of our Profession. 

 

2.5.   When faced with these challenges it is easy to think we have passed the point of no return and general practice has no future.  At Middlewood we fundamentally believe this isn’t the case. We believe General Practice has a bright and important path ahead in which it will continue to be the beating heart of our NHS. 

 

2.6.   Any efficient health care system needs a thriving Primary Care Sector.  The amount of unseen work has led many to completely underestimate what is done in General Practice.  Even small shifts of work from General Practice into Secondary Care leads to catastrophic effects. 

 

2.7.   Ensuring that General Practice is stable and well-resourced stabilises the rest of the NHS.  There are few places were investment pays more dividends than in primary care.

 

3.       The Partnership Model

 

3.1.   Since its inception, General Practice has mostly existed in a different format to most of the NHS, being independent contractors mostly in small Partnerships.

 

3.2.   This has often led to conflict and confusion, as GPs are not direct employees of the NHS.  The intricacy of this model is poorly understood both by the general public, some Politicians and even Commissioners. 

 

3.3.   There are many significant benefits to the partnership model.  GP partners usually spend many years within their Partnership, adding to the continuity of care within populations.  GP Partners have a direct financial interest in their partnership and the efficiencies of their practice.  This has led to General Practice arguably being the most efficient part of the NHS.  GP partners who know their communities intimately are able to make informed decisions about local health care provision with all the benefits that brings.

 

3.4.   The Partnership Model is not without challenges, both for those within the system, and for partners themselves.

 

3.5.   Unfortunately, GP Partnerships are not as attractive as they once were.  I personally became a partner in 2009. When I applied for my role there were 80 applicants.  Now it is not unusual for partnerships to be left unfilled as GPs feel that the challenges of being partner outweigh the benefits.  GPs are increasingly drawn to more transitory roles, such as locums, portfolio careers with only a small component in practice.  Full time partners are increasingly uncommon.

 

3.6.   Incremental changes to the GP contract have had a direct negative impact on the attractiveness of partnership.  GP Partners are personally responsible for running the business, often with inadequate core funding, imperfect estates and a challenged work force.   Partnership allows the sharing of burdensHowever in small partnerships if one partner leaves, or becomes ill this leaves an unacceptable liability on the remaining partner/s. 

 

3.7.   GP Partners often end up working far beyond “normal” working hours, which an equivalent salaried doctor would not do, to ensure the practice continues to run smoothly.  New ways of working or alternative require funding resulting in a reduction in partners pay.  This appears to be “unseen” by the public and indeed the system.

 

3.8.   Changes to tax and pension regulations have further eroded the attractiveness of partnership and are directly related to the decisions of many partners to retire earlier than they would have done, leading to a loss of valuable colleagues at the end of their career.

 

3.9.   The system appears reluctant to invest in General Practice as they seem worried that the money would not be invested in patient care rather than go into increased profits for the partners.  The false narrative being pushed by certain parts of the media reinforce this view.  The 2003 GP Contract still seems to hang heavily over the profession despite being nearly 20 years old and negotiated before most of the current workforce became GPs.  The idea of General Practice paying a penance for it is, I believe still real. 

 

3.10.                      Practices where partnerships have been taken over by either Hospital Trusts, Health boards or other Private companies use a purely salaried model.   The fear is that this leads a more transitory workforce, less clinical ownership within that population and a decline in efficiency. 

 

3.11.                        I believe that the partnership model is something to be proud of and to cherish rather than attack.  The “system” needs to reset their relationship with General Practice and begin to celebrate and augment the extraordinary work being down within Partnerships.

 

3.12.                      For some the smaller model of partnership will continue to the right one.  However, there is an alternative. There is a different, transformed model of General Practice which has Partnership at the centre and fundamentally addresses some of the challenges of Partnership, whilst treasuring its benefits.   We hope that the Middlewood Partnership can be considered as a new way forward for General Practice.

 

4.       The Middlewood Partnership Merger

 

4.1.   The Middlewood Partnership was formed from the merger of four successful GP Partnerships in the Towns of Bollington, Poynton and Disley in Eastern Cheshire in 2019The four individual Partnerships were high performing practices with good or outstanding CQC ratings, performing well on all permanence matrixes and had a good standing within the local community. They ranged in size from 4000 to 12,000 patients in size.

 

4.2.   Although superficially achieving, and sustainable, the individual partnerships were struggling with the same challenges felt by other GP PartnershipsThere were issues with estates, with workforce and individual partners having to shoulder significant personal responsibilities.  There was a feeling that collectively more could be achieved than by continuing individually.

 

 

5.       Aims of the Merger

 

5.1.   In creating the Middlewood Partnership, the partners set out a clear ambition and objectives that would create a larger organisation with a wider skill-base to establish real transformation, backed up by robust organisation-wide policies and procedures. These were to:

 

 

6.       The Middlewood Care Model

 

6.1.   It was felt that to truly maximise the benefits of merger a new care model was needed to change the way in which people who contacted Middlewood were managed. 

 

6.2.   This was a significant undertaking.  At the time this was introduced the same model of care had been used for the last 20 years.  We decided to look at this afresh and see if we could create a new way of consulting. 

 

6.3.   In many mergers the individual partnerships continue to work within their previous practice boundaries, but we felt we truly needed to look at the population as a whole and work across the entire population. 

 

7.       Digital Triage

7.1.   We decided that the introduction of a digital triage model would be fundamental to delivering this aim and we started using a digital triage model in 2019.  This allowed us to more effectively triage patients and direct them towards the most appropriate clinician.

 

7.2.   This has proven extremely popular with the majority of our patients.  We receive between 600 and 1000 requests a day.

 

8.       Establishment of the Middlewood Hub and Urgent Care Centre

8.1.   In order to deal with the urgent presentations, we established our Urgent Care Hub.  This is in effect a Primary Care Urgent Care Centre.  A weekly rota of GPs, physician associates and advanced nurse practitioners is supported by a team of permanent care co-ordinators. Together, they manage up to 1000 requests a day, reviewing, prioritising, and allocating to the most appropriate team member – this is the very heart of the clinical model.  70% of requests are dealt with on the day.

 

8.2.   The team are co-located in a single room alongside consulting rooms which allow clinicians to choose whether remote or face to face appointments are appropriate for the patients they are dealing with.  There is also a “hot room” with a separate entrance to allow the review of patients with infective diseases such as suspected Covid-19. 

 

9.       Integration with our Community Team

9.1.   One of the key features of the change is the integration with our community team allowing a truly multidisciplinary approach to our most complex patients.  Our team can have real time multidisciplinary team meetings with therapists or district nurses or other team members whilst providing immediate medical support. 

 

9.2.   This approach has transformed the care of our most vulnerable patients and data is showing a reduction in our hospital admission rates.

 

10.   Base Sessions

10.1.    Continuity is fundamental to General Practice.  The long-term therapeutic relationship with patients with their GP is vital to their care as laid out in this RCGP report, “Continuity of care in modern day general practice”3There is a significant danger in larger organisations that this can be lost to the detriment to both GPs and their patients. 

 

10.2.    We have tried to combat this by all GPs having dedicated sessions to deal with patients who would benefit from having that continuity with a specific GP. 

 

10.3.    Our care navigators are asking the question when allocating a patient, “would this patient benefit from having a GP who knows them deal with their case”.  When the answer is yes then this is facilitated.

 

10.4.    More can be found on our care model including our video showcasing our care hub on our website here  https://middlewoodpartnership.co.uk/middlewood-clinical-model/

 

11.   Work Force in Middlewood

 

11.1.  General Practice has changed, and the workforce has changed considerably over the years.  We are proud to have a diverse team which reflects a new model of General Practice.  This includes:

 

 

11.2    The inclusion of this diverse workforce underpins our new care model and if continued investment allows, will lead a more sustainable workforce in the future.

 

11.3  We have introduced a mentoring service within our organisation to support this workforce both clinically and pastorally.

 

12          The role of the PCN and Middlewood

 

12.2    Prior to merging we were a Primary Care Home and after merging we felt that the PCN was a logical extension. 

 

12.3    The practice and PCN are aligned.  We are convinced that this provides the best model for realising the benefits of the Primary Care Network.  The governance of the PCN is better and staff employed within the PCN work within the Practice footprint.  It has allowed us to employ a more diverse workforce who add real value to caring for our practice population. 

 

12.4    Because the finances of the PCN is separate to the practice by investing in the PCN for Middlewood this allows further investment in General Practice in a way which could allow confidence for the “system” to invest into General Practice with full confidence that money would be invested into patient care rather than to Partner “profit”.

 

13          Medicine Management Team

 

13.2    The management of medication prescriptions both acute and routine prescriptions is a huge part of the work of general practice.  We have created a team of clinical pharmacists, pharmacy technicians and prescribing support administrators who with GP support to manage this specific work.  This has improved the safety and management of prescribing.

 

14          Non-Clinical Team Members

 

14.1. The merger of the practice has allowed us to look at changing the way in which our back-office staff work.  Prior to the merger there was duplication within the administration team The volume of work meant it was difficult to spend as much time as needed on individual areas. Since the merger we have created the following:

 

14.2.  By having a specific area to lead on it allows managers to build up specific knowledge whereas before they were trying to juggle all of the different aspects of a practice manager job.

 

15.        Case study – first-hand account of impact of the clinical model

 

This short case study was submitted by one of Middlewood’s salaried GPs who returned from maternity leave after the merger of the four practices.  When she returned the new clinical model had been introduced. This provides a first-hand account of the impact of the clinical model on a GP member of the team.

'I left to go onto maternity leave in October 2019. At this time, I was working at Priorslegh Medical Centre as a salaried GP where my days consisted mainly of 2 face to face clinics (with a few telephone slots) plus home visits, lab reports to file, prescriptions to sign and Docman to work through. I occasionally did sessions on-call, mainly on triage alone trying to deal with overwhelming numbers of patients.

 

When I returned in September 2020, a lot had changed and, in my opinion, generally for the better. I now work as part of Middlewood, a collection of 4 practices. Whilst I remain based at Priorslegh, my days are very different. There is a 2-week Rota which offers some consistency but with in-built variety - I do fortnightly sessions with the medicines management team (MMT) and in the Hub, plus weekly coil clinics. This gives me the opportunity to do other things I enjoy and the Hub, particularly, is a great supportive environment which eliminates some of the isolation typically felt in general practice. The visits are mainly done by our community paramedic and patients are now better managed by the integrated Middlewood and community/social care team (Team Bollington, Disley and Poynton) which offers a central point. This is much easier than speaking to lots of different people as we did previously, and it appears a lot more joined up as a result. My paperwork is less as the scripts are managed by MMT and Docman is filtered which results in more time spent on patients.

 

General practice remains an incredibly important but stressful job and whilst that stress has not been completely eliminated, I feel that the move to this way of working, including the single digital pint of access system, makes it more sustainable. Despite being 4 practices, I now feel more of a team and able to get more involved and contribute (I managed to redesign the coil clinic from scratch and was given permission to do what I needed to get it established for which I am grateful). Overall, I feel that it is a supportive, innovative and dynamic place to work, and it is exciting to see how it will continue to grow as more services get reintroduced and developed'

 

 

16.        Summary

 

16.2.  It is not possible, within the word limitation, to fully describe the transformation of our organisationWe would welcome members of the committee to visit Middlewood to see for themselves an effective 'future for General Practice

 

16.3.  General Practice is faced with a perfect storm of challenges which create a variety of significant risks both for Practices and the patients which they serve. 

 

16.4.  Meaningful change is needed, and we hope that we have demonstrated a way in which the partnership model can not only survive but thrive

 

Dr David Ward

GP Partner and Chair of the Partnership Board

The Middlewood Partnership

 

References

  1. https://www.telegraph.co.uk/news/2021/09/11/gps-went-strike-would-anybody-notice/

 

  1. https://www.telegraph.co.uk/news/2021/10/11/gps-merely-vanguard-new-war-against-work/

 

  1. file:///E:/Downloads/Continuity%20of%20care%20in%20modern%20day%20general%20practice1.pdf

 

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