Partners involved in this collaboration:
- Airedale, Wharfedale and Craven (10 GP practices)
- Sandwell and Birmingham (13 GP practices)
- East Surrey (3 GP practices)
- Hull (4 GP practices)
- Lewisham (3 GP practices)
- Mid Sussex (4 GP practices)
- Walsall (10 GP practices)
- Wokingham (2 GP practices)
Modality Partnership brings together 49 GP practices that operate primary health care and community health services across the country. It started with two GP practices in West Birmingham merging to create Modality Partnership in 2009. Modality now serves more than 400,000 people2 and has been at the forefront of at-scale development in primary care since they began.
Naresh Rati, a founding partner of Modality Partnership, tells us about the partnership and how they collaborate with secondary care providers – mostly focusing on Sandwell and Birmingham, where Modality was initially founded.
Setting up the partnership
Naresh says that "there was a like mindedness" among the two founding GP practices who began to see "there was something more to this than doing it on our own" back in 2009. It initially began with the intention to streamline processes and reduce duplication, for example they would share intelligence about meetings they attended to help manage their workloads and began to share back-office functions.
They started out by developing solutions to help struggling GP practices and over time, as their impact and benefits became more recognised, the partnership grew to what they have now. They became more innovative and proactive in their approach, which eventually led to them becoming one of the new care model vanguards in 2015. This enabled them to get further funding to build on their collaboration.
"So, progressively the partnership grew from two sites to five and then to six and so on…We started to be more innovative and eventually became a vanguard which propelled us to a whole different mindset."
The partnership also started to think about sustainability and diversifying their business model. Naresh says "we started to think about what else we could do to add value to the system. And that's when the outpatient business was born”. Exploring the role of GPs in an outpatient setting, as part of the 'GP plus' programme also provides more diversity to GPs' roles and is "breaking down the walls between primary and secondary care". Both primary and secondary care clinicians enjoy working across different settings, and these kind of portfolio careers provide a more attractive employment offer.
Naresh says the goal of the partnership now is to become more resilient and shift the focus towards population health and address challenges facing the primary and secondary care workforce.
The impact of COVID-19
Because they have been collaborating for a while, Modality practices were more prepared to manage the pressures and uncertainties brought about by the COVID-19 pandemic. The partnership was able to open specific practices up as COVID-19 hubs and produced uniform infection prevention and control guidance across all practices to streamline the process into a consistent approach. "Being an at scale provider means we have a lot more Lego pieces to work with."
During the pandemic, they also modelled different scenarios to help them to forecast demand throughout its duration and beyond, and this prepared them to manage the second virus surge collaboratively. While waiting times have rapidly increased overall in the NHS, Naresh feels that collaboration has made this significantly more manageable and has made their services more "COVID proof". They continue to use modelling to predict future demand and account for potential new variants, future spikes and the potential increase in patients presenting with mental health issues.
He also notes that while they haven't been on the frontline dealing with the pandemic in the same way that hospitals have, the COVID-19 vaccination programme has helped them play an important part in the broader response.
The case for change
Naresh uses a case study example of Modality's community-based specialist cardiology service in Sandwell and Birmingham to explain the benefits of collaborative working during the first wave of the pandemic.
The inner-city population is known to have a high burden of cardiovascular disease, so it was important that they set up a COVID-19 secure environment to give patients the confidence to attend their appointments, receive the care they needed and reduce the number of patients presenting late.
The integrated cardiology care model delivered by Sandwell and West Birmingham Hospitals NHS Trust and Modality enabled them to maintain low outpatient waiting times throughout the pandemic. While hospital consultants and other staff were redeployed to support the pandemic response, which meant backlogs were building up in outpatient services, they were able to increase capacity within community clinics so patients could continue to access the care they needed within four weeks of referral. Consultants, GPs with extended roles and other specialist staff such as echo technicians and cardiographers would run clinics, often at evenings and weekends to keep on top of the outpatient cardiology demand and prevent big backlogs from developing.
Naresh says, "there's no question that collaboration has eased the pressure, because we're on the same team, helping each other out". This partnership model has meant Sandwell and West Birmingham Hospitals NHS Trust has managed to maintain a low wait time throughout the pandemic as patients felt more confident attending a community-based clinic than going into the hospital environment during the pandemic, with 91% of patients saying they would recommend the service to their friends and family.
Sharing lessons learned
Naresh says that relationships and trust between partners is so important for developing effective partnerships, but this all takes time and effort to build. Having these good relationships makes it easier for partners to feel they can be open and transparent about sharing issues and challenges and "removes some of the worry about losing a service to another provider".
Naresh also notes that because of the history of competition within the NHS, it is difficult to shift to a culture of collaboration. He says, the new care models vanguard programme helped build trust between partners and shift to a more collaborative culture. "Setting ourselves up as a vanguard really helped pave the path because it really did bring people together…it was this little piece that connected us". As a vanguard in 2015/16 they started piloting services with a local trust who sub-contracted work to them, and this really helped pull them together and benefits have been realised for both parties.
Next steps and national policy to support provider collaboratives
Naresh touches on tensions that could arise as provider collaboration develops, particularly around collaborating at scale and having a seat at the table, so this will be something to work through. Naresh also hopes that the national policy changes to provider collaborative arrangements won’t impact the successful collaboration already taking place within Modality Partnership and with their partners, as primary care’s role at system, place and neighbourhood level is essential to achieving the ambitions of integrated care.