Written evidence submitted by Modality Partnership (FGP0237)

 

 

 

About the Respondent

 

  1. Modality Partnership is an award-winning GP super-partnership that operates primary health care and community services nationally.  A super-partnership is made up of practices who come together to form one single business to deliver more efficiently and effectively at scale.

 

 

  1. We are a clear showcase of how the future of general practice can be when supported to embrace at-scale working, innovate and continue to play a leading role within the health system. 

 

 

What are the main barriers to accessing general practice and how can these be

tackled?

 

  1. The main barriers to access are caused by conflating demand and supply factors that will need to be tackled through a combination of both short and long term measures.

 

  1. It is well documented that demand in general practice has built up for quite some time.  The key drivers include:

 

4.1.             Changing population demographics: The increasing health needs of an aging population, combined with a younger sicker population in areas of socioeconomic deprivation, and rising levels of multimorbidity across the board has significantly increased the volume and complexity of encounters. These long term trends have been compounded and accelerated by the pandemic.

 

4.2.             Over-medicalisationAdvancements in medical sciences have done wonders but have also created a culture of seeking and reliance on medication.

 

4.3.             Changing public expectations:  Understanding the role of primary care as a provider of the needs of the population is often confused with catering to the wants of the patient.  We have observed a change in culture and attitude of our patients.  Aggression and complaints are regularly fueled by negative press reports and a lack of visible and timely support from the Government and NHS England.

 

4.4.             Scope creep:  We are seeing significant “overspill” of work due to issues in other parts of the system – e.g., the shift of almost all chronic disease management out of the hospital outpatient clinic at a time when an increasingly lengthy and complex array of monitoring and treatment options are available for all the major illnesses.  We also routinely receive requests relating to domestic / police investigations, social care and/or housing benefits. We are increasingly the “front door of the state” without the resources to match.

 

  1. From a supply standpoint, we are faced with a number of challenges:

 

5.1.             Recruitment and retention:  This is no longer just about GP shortages – there are challenges filling posts across all roles.  The profession does not feel valued.  The constant negative press, vilification of GP’s and exponential increase in abusive behaviours faced by staff is a strong deterrent to the recruitment of quality staff.  Existing pension rules and limits are encouraging experienced GPs to do less when we need them to stay and do more.

 

5.2.             Education and training: GP training is too short given the rising complexity and challenges of the role, whilst training, education and accreditation pathways for key primary care staff (e.g., practice nurses, healthcare support workers) and new roles (e.g., physician associates) is often under-funded and poorly defined.

 

5.3.             Ancillary support:  Reducing the reliance on GPs with alternate roles has  been insufficient to compensate for the shortfall of GPs given workforce shortages and mixed messaging from politicians. 

 

5.4.             Digital exclusionThe increased using of digital channels to access care has produced benefits but we also need to be mindful of the unintended consequence of excluding patients who do not understand and/or have access to technology.

 

5.5.             Estates and IT:  Substandard infrastructure continues to hamper service delivery.  Many existing estates are small, dated, not infection control friendly, and/or fails to support the sustainability agenda.  We are still working with desktops and applications that are years out of date.  Our servers and network connections are also slow and unreliable.


  1. No quick fixes but there are a set of key enablers we would recommend in the near term to lay the foundation to solve for access in the long run.

 

6.1.             Develop a shared understanding of the role of general practice and ownership of issues to enable more effective collaboration across the system.

 

6.2.             Change the current narrative about the role of General Practice with patients and the public.

 

6.3.             Reduce administrative burden by removing or simplifying requirements which are often disproportionate to the value and purpose it is intended to achieve (e.g., ARRS, local contracts management, CQC, appraisal processes).

 

6.4.             Unblock estates and IT infrastructure issues that are negatively impacting service efficiency and effectiveness.

 

6.1.             Remove existing pension limits (annual allowance) and disincentives (locums access to NHS pensions) to encourage experienced GPs to offer more sessions at a time many have less family commitments and could do so and more GPs to choose permanent employment.

 

6.2.             Reset the current GP contract as it is no longer fit for purpose

 

6.3.             Invest in at-scale exemplars particularly around innovative use of resources, data and digital to tackle workload, access and inequalities concerns.

 

6.4.             Invest in training on leadership, quality improvement and management to support GP development throughout their careers.

 

 


To what extent does the Government and NHS England’s plan for improving access

for patients and supporting general practice address these barriers?

 

  1. The current plans are well intended but show a lack of appreciation and insight into how general practice operates. 

 

  1. The level of funding is inadequate. For perspective, the additional £250m equates to circa £3.70 per patient, 2.5% of core contracts, or 0.4% of the planned injection of funds to support COVID recovery.  This is not proportionate given general practice is the first point of contact for more than 80% of all encounters coming through to the NHS.

 

  1. The proposals will create significant unintended consequences.  Demand for, and costs of, locums will be artificially inflated.  This will destabilise general practice because the existing workforce - particularly Salaried General Practitioners - will leave given the higher income opportunity working as a locum offers.

 

  1. Poor engagement and communications have disenfranchised many.  Trust between the Government, NHS England and the profession will need to be rebuilt.

 

  1. A plan for improving access needs to have the right time horizon that reflects the need to train, expand and develop the workforce and properly design and embed digital approaches – this is a 5-10 year project requiring long term strategic and funding commitments and not something that can be resolved with short term fixes.

 

 

What are the impacts when patients are unable to access general practice using

their preferred method?

 

  1. General practice is an integral part of the NHS and ideally placed to deliver Population Health Management (PHM) being:

 

12.1.         The first port of call for any health concerns for patients of all ages (from new babies to elderly people).

 

12.2.         Looks at each person as a whole covering physical, psychological, social, spiritual, cultural and economic aspects of care (whole person care approach).

 

12.3.         Provides continuity of care which is key to improving outcomes and reduce the burden of demand on other services.

 

12.4.         Housing a lifelong medical record from which data can be used to compile population and disease registries for population health management.

 

It is however not currently setup and/or resourced appropriately to fulfil this role.

 

  1. The NHS will fail if general practice fails.  A well-functioning general practice helps keep the health system stable and financially viable.  Patients who are unable to access their practice tend go to A&E, call 111, or both.  A backlog in general practice will also exacerbate inequalities.

 

What role does having a named GP—and being able to see that GP—play in

providing patients with the continuity of care they need?

 

  1. Strong evidence shows continuity of care leads to improved patient satisfaction, outcomes and reduced risk of missed diagnoses or treatment failures.

 

  1. A team approach, led by a named and accountable GP or GPs, will increasingly be necessary given the shortage, increasing complexity of patient encounters, and the diversification of workforce currently underway. We also expect continuity will be provided by a team member (e.g., health coach, social prescriber, practice nurse) rather than a GP in all cases.

 

  1. We need to accept that continuity of care cannot be universal but needs to be the norm for the segment of the population that requires this type of care long term or during episodes of illness. Intelligent management of patient lists and clearer segmentation into good access / lower continuity transactional care (often unplanned) and good access / higher continuity relational care (often planned) is required.

 

 

What are the main challenges facing general practice in the next 5 years?

 

  1. Rising demand at unsustainable levels. Changing population demographics and expectations have driven this pre-COVID, and the pandemic has, and will continue to, further compound this problem.  There are still many unknowns (e.g., long COVID, new variants, COVID vaccinations) but the increasingly unrealistic public expectations – stoked by political posturing - is a massive problem that needs tackling head on.

 

  1. Workforce challenges.  Physical and mental fatigue and the increasing amount of abuse we are seeing on site, over the phone and social media is taking its toll on both recruitment and retention.  In the past year, we have seen more and more cases of burnout and experienced GPs taking early retirement especially given existing pension rules and limits.

 

  1. Increasing administrative burden.  A common emerging theme whether it relates to Primary Care Network Additional Roles Reimbursement Scheme (ARRS), local contracts, CQC, and/or appraisal processes.

 

  1. Substandard estates and IT infrastructure continues to hamper service delivery and experience.

 

  1. Loss of GP voice.  It remains unclear where and how general practice will fit and be heard with the emergence of Integrated Care Systems (ICS).

 

  1. Contract no longer fit for purpose.  It needs a reset to rebuild the trust between the Government, NHS England and the profession.

 

 


What can be done to reduce bureaucracy and burnout, and improve morale, in

general practice?

 

  1. Explicit recognition of purpose and value:  GPs are the only clinicians in the NHS providing whole person care across all areas of physical and mental illness, close to peoples' homes and with a proper understanding of social context.

 

  1. Mindset shift from reactive to proactive care: Changing the emphasis providing reactive access for every problem, all of the time to high quality personalised planned care.

 

  1. Support mastery:  Creating space for GPs to operate at the "top of their license" by reducing administrative burden which is often disproportionate to the value and purpose it is intended to achieve.

 

  1. Digital automation:  Investing in better infrastructure particularly automation capabilities can significantly improve productivity and job satisfaction as much time is spent on tick-boxing bureaucracy.

 

  1. Improved autonomyThe current regulatory and appraisal requirements are too rigid and often inconsistently appliedA more robust risk-based approach where more focus can be applied to areas with major concerns whilst offering more flexibility for low risk areas is needed.

 

  1. Leadership development:  Investing in future leaders is key to future sustainability of the profession. 

 


What risks are there associated with the current workload and how could this be

addressed at local, regional, national and government/policy level?

 

  1. Current levels of workload are unsustainable.  Leaving this unaddressed will result in significant staff turnover and burnout, destablisation of general practice and in turn, other parts of the system (A&E, 111, etc).

 

  1. Modality are delivering 30% more appointments than pre-COVID time period.  In addition, we have also delivered 800K vaccinations.  The trend suggests this will not be changing imminently.

 

 

  1. Workload in general practice is not just about appointments.  Robust LMC and our own analysis indicates that around 70% of GP workload is administrative and rising.

 


  1. We have also seen an increase in complexity, safety risk, and variability in staff availability, all of which have contributed to staff turnover and burnout

 

 

  1. Our recommendations on way forward to improve access (Point 6) applies to improve workload as well.  Effective coordination across local, regional, national and government / policy levels will be essential.

 

 

How does regional variation shape the challenges facing general practice in

different parts of England, including rural areas?

 

  1. Practice populations and their needs can vary significantly across different parts of the country.  A younger multi-ethnic deprived inner-city population compared with a rural white, older population will require different models of care, access arrangements and the make-up of the general practice team.

 

  1. General practice does not operate in a vacuum and the available of local authority provided services (i.e., drug and alcohol services, social care, child health services) and strength and capacity of the voluntary and charitable sector varies significantly by region, with allocation of resources following a socially regressive pattern over the last 10 years. (i.e., Marmot Build Back Fairer Review)

 

  1. Much more needs to be done to address the inequitable funding delivered by the Carr-Hill formula, which disadvantages practices caring for younger, sicker urban populations and rural populations with low population density.

 


What part should general practice play in the prevention agenda?

 

  1. General practice is best placed to deliver personal illness prevention which is pivotal to enabling effective population health management.  However, it is not currently setup to perform this key role effectively.

 

  1. Proactive personalised care needs to move towards the whole person approach in place of protocol and tick box driven chronic disease / illness management.

 

 

  1. To deliver the above model will require funding, a radical change in GP training and in general practice’s operating model.

 

 


How can the current model of general practice be improved to make it more

sustainable in the long term?

 

  1. The immediate priorities will be around tackling access and workload issues as outlined in our recommendations above (Points 6 and 29). 

 

  1. General practice has a pivotal role in enabling effective population health management, underpinned by system level collaboration in analytics, pathways, workforce and finance.

 

 

Therefore, as ICSs and ICPs emerge and mature, it must ensure general practice has a strong, consistent and fully representative voice at system level.  Investment, time for continued development of PCNs and at-scale working will be needed to achieve this.

 

  1. We would also recommend potential changes to primary legislation around minimum list-size and enabling contracts to be held by alternative business models such as limited liability partnerships, mutuals or other employee owned entities.

 

 

 


Is the traditional partnership model in general practice sustainable given

recruitment challenges, the prioritisation of integrated care and the shift towards

salaried GP posts?

 

  1. The traditional practice model with a small list size and few partners will find it increasingly difficult (if not already) to sustain unless they embrace joint at-scale working with others to achieve more resilience.

 

  1. There are different business models that already exists and are sustainable options depending on local circumstances.  Whether it be super-partnerships, networks, companies, and/or federations, enabling at-scale working is what matters.

 

 

  1. From our experience, size has brought resilience and much needed stability for the serviceIt is by no means easy but the ability to flex and successfully tackle every challenge the pandemic has thrown our way so far has been invaluable.

 

  1. At-scale working has also enabled us to invest and build a fantastic work culture and workplace environment that affords every individual the opportunity to have rewarding careers.  We have focused on training and upskilling, sharing best practice, supervision, peer support and personal career developmentOur staff survey results are showing our efforts are paying off.

 

 

  1. Working at scale is also about encouraging innovations and contributing to system level working.

 

47.1.         Digital Transformation:  Embedding technology into service delivery effectively is no mean featOur long term ambition is to turn every service touch point into a digitally enabled learning front end to deepen our understanding of our patient populations and deliver more personalised care.

 

 

Our scale affords us the opportunity to experiment a wide range of approaches to apply new technologies to improve care navigation, patient experience and outcomes whilst reducing variation and administrative workload.  Our use of robots to support the administrative intake of email consultations and more recently, the filing of COVID test results have saved more than 40K hours in the last 12 months.

 

47.2.         System Leadership and Partnership Working:  Despite the pandemic, we were able to make tremendous progress in this area over the two years.

 

a)      Supporting non-Modality PCNs – two examples in point:  We helped setup and provide ongoing remote management support to a PCN in the North West where we do not have a practice.  We deliver remote structured medication review services from Hull to non-Modality patients in North Havering.

 

b)      Secondary Care Collaboration - We have also worked closely with local hospitals to help with elective care backlog recovery.  For example, in partnership with Sandwell and West Birmingham NHS Trust, we designed and delivered an integrated cardiology care model that enabled the Trust to maintain low outpatient waiting times throughout the pandemic.  Consultants, GPs with extended roles and other specialist staff such as Echo Technicians and Cardiographers would run these clinics91% of patients said they would recommend the service to their friends and family.

 

c)       Building Healthy Communities Significant positive impact can be generated by bringing 'Community into healthcare and healthcare into the Community'We have had great success linking in with local communities to co-design services innovations with our patients whilst proactively encouraging volunteering and creating alternate funding opportunities into the system.