Increasing access to lifestyle management and support services

Modality Partnership (Modality) is an NHS GP super-partnership with 130 partners, providing primary healthcare to 450,000 patients and community services across nine regions of the UK. It provides community services for trusts, promoting out of hospital solutions during increased pressure in secondary care.

A significant volume of patients requiring personalised care planning, goal setting, management and support can be seen by highly skilled non-clinical roles. At scale working presents opportunities to adopt a population health approach, drawing on wider primary care teams to prevent ill health and improve patient outcomes.
Modality has implemented a new strategic approach to workforce planning and increasing patient access and support.

An international, remote health coaching service

Modality has collaborated with a market leading provider in Mumbai to design and implement an innovative remote coaching service that offers personalised care to patients requiring lifestyle management and support. This could relate to diet, physical activity, mental wellbeing, and long-term conditions.

The international coaches, working across multiple time zones to provide patients with a flexible and convenient service, have been trained, inducted and developed locally to align with NHS pathways.

The team of 22 qualified multi-lingual coaches work to provide a flexible and convenient service to patients, with one whole-time equivalent coach providing around 400 appointments per month.

Referrals are taken from GPs and other clinical team members working in primary care. Patients are proactively monitored and reviewed to ensure progress and support are in place, supervised remotely by an experienced clinician.

Through targeted engagement with both practice teams and patients, the key focus has been to break down barriers and foster acceptance of a 'new' workforce, demonstrating agile working, flexibility, role redesign and innovation.

The new model has alleviated day-to-day operational pressures and provided workforce resilience, increasing staff satisfaction and reducing administrative burden for practices. It has freed up time for GPs to offer appointments for more complex patients with multiple conditions and needs. For patients, it has improved health and wellbeing outcomes and GP access, with medication use reduced in 85% of patients accessing the coaching service.

A longitudinal review of A&E attendances throughout the coaching service suggests that presentations by frequent attendees were reduced, indicating the opportunity for system-wide savings and the reduction of pressure on secondary providers.

By focusing on preventing issues such as social isolation and poor mental health, the project has demonstrated how at scale working can contribute to population health management approaches and provide out of hospital solutions for people with long-term conditions.