North Yorkshire Council

 

Skipton and Ripon Area Constituency Committee

 

7 March 2024

 

Modality

 

1.0       PURPOSE OF REPORT

 

1.1       To provide Members with an update regarding concerns over Modality run GP practices.

 

 

2.0       BACKGROUND

 

2.1       At previous ACC meetings, Members have raised concerns over Modality run GP practices and so representatives from Modality were invited to the 7th of March 2024 meeting to answer questions. Unfortunately, the representatives were unable to attend this meeting due to prior commitments, but a written update has been provided and they have agreed to attend the 6th of June 2024 meeting.

 

2.2       The Modality practices that affect the Skipton and Ripon constituency most are Fisher Medical, Cross Hills, Silsden, and Steeton.

 

3.0       Modality Update

 

3.1       Ways that patients can book appointments –

 

The Modality GP Practices offer a variety of communication methods for patients to contact the practice with their medical or administrative query. All patient requests are triaged through the AWC Modality Patient Access system, but patients are able to submit their requests in three different ways:

1. Online: Patients can complete an online form via the practice website, providing as much information as possible about their query (https://access.klinik.co.uk/contact/modality-awc). Since launch, over 80% of patients now contact our practices in this way. For Fisher Medical Centre, this would equate to approximately 800 online submissions by patients per week.

2. Over the Phone: Patients can telephone the practice and speak to one of the Patient Services Team, who will complete the online form on their behalf. Since launch, we have seen a 50% reduction in the number of calls received by our practices and we have been working hard to reduce the call wait time for patients. The average wait time for patients is now around 18 – 20 minutes, but can be longer at peak times. However, we have introduced a call back function for patients and we are also working hard to train and recruit new staff to reduce the call wait time further.

3. In Person: Patients are able to visit the practice and speak to one of the Patient Services Team, who will complete the online form on their behalf or assist the patient to complete themselves using one of the in practice tablets (iPads).

 

 

 

 

 

3.2       Reasoning behind the online forms –

 

Why do patients have to submit an online form? Why can’t patients just book an appointment when they contact the practice?

In order for our practice teams to assess and prioritise the medical need or urgency of a patients query, we needed to implement a Patient Access system that was both safe and equal access for all. Prior to implementing the new system, patients were given access to care or services on a first come, first served basis - accentuated by the typical GP Practice 8am rush. This caused unfair and unsafe access for patients, especially for those patients requiring acute on the day care.

What happens when a patient submits a medical request?

Every medical request received is sent automatically by the system for GP review the same day as it is received, usually within 30 – 60 minutes of receipt. The GP will review and assess the medical need of the patient and follow one of the following processes:

1. Consultation / Advice – the GP will contact the patient either by phone or via an online consultation (using text message / video call) to consult / provide advice or treatment.

2. Further Information Needed – the GP will ask the dedicated Duty Patient Services Assistant (PSA) to contact the patient to obtain further information e.g. a photo

3. Same Day Face to Face / Telephone Appointment – if the GP assesses the medical query and decides that the patient needs to be consulted the same day, they will either book the patient into an appointment and send an SMS to confirm or ask the Duty Patient Services Assistant to contact the patient to book the appointment (dependent on the patients preferred contact method).

4. Routine Face to Face / Telephone Appointment - if the GP assesses the medical query and decides that the patient needs a routine appointment, they will assign the request to the routine waiting list. The Patient Services Team monitor the routine waiting list each day and contact patients to book into an appointment when they become available, usually within 2 weeks but the wait can be up to 4 weeks at busy times. Patients are sent a text message notifying them that their query has been assessed as routine and to let them know the approximate wait time for an appointment, together with asking the patient to recontact the practice if their condition worsens.

5. Other Clinician Appointment – if the GP assesses the medical query and thinks that the patient would benefit from a consultation from another type of clinician e.g. Physio / MSK Practitioner, Social Prescriber, Mental Health Worker etc. they will assign the request to be booked into the relevant clinic by the Patient Services Team. A PSA will then contact the patient via text message or phone to book them in for a consultation. 

What happens when a patient submits a nursing request?

All nursing queries are reviewed on the day of receipt by our Patient Services Team. The Patient Services Team will contact the patients via text message or phone to book a convenient time to attend for their appointment. This may be a telephone or face to face nurse consultation. If there are no appointments available at that time, they will be added to a waiting list for that particular type of appointment e.g. Cervical Screening, B12 injection etc. The waiting list is monitored and reviewed by the Patient Services team daily and the patient is send a text message or telephoned to confirm the process e.g. “Thank you for your enquiry to Modality AWC. We will contact you again as soon as a nursing appointment is available, usually within 1 – 2 weeks. Please contact us again if your condition becomes more urgent.”

What happens when a patient submits a prescription query or request?

Where possible, we encourage patients to request repeat prescriptions via the NHS App, SystmOnline Services or via our 24 / 7 automated telephone ordering service Voice Connect. These methods provide the patient with the quickest, most efficient way to request the repeat prescription as the request is sent directly into our clinical system for review and action. We continue to hold regular digital education sessions in practice and community locations to educate patients and promote the use of the NHS App and Voice Connect. Patients are able to send medication queries via our Patient Access system and these queries will be assessed using a similar process as a medical query i.e. reviewed by a Duty Clinical Pharmacist as to the urgency of the request and administered by the Prescription Administration team.

Other types of queries are handled in the same way as described above for both clinical and non-clinical requests.

Please note: If a patient submits a query using an incorrect pathway i.e. a non-clinical request is submitted for an urgent medical query, the request will be re-directed to the Duty GP Team for review. All pathways are monitored throughout our opening hours.

Why have we implemented this new way of working?

A common misconception is that GP Practice are providing fewer appointments that before the Covid-19 pandemic, in fact we are providing on average 20% more appointments each week. The reason patients feel as though we are providing less capacity is that demand continues to escalate and outstrip supply. We have continued to recruit additional GPs and Allied Health Care Professional (Paramedics, Physios, Physician Associates, Advanced Nurse Practitioners, Pharmacists, Mental Health Workers, Social Prescribers etc.) to maximise the number of appointments we can offer. For example, at Fisher Medical Practice during the week beginning 5th February 2024 we offered 2574 healthcare appointments.

To make sure we utilise the precious capacity we have available in the most efficient and effective way, we have implemented this new way of working to allocate care to patient based on medical need, rather than want. In making this change we have been able to dramatically improve our on the day acute care for patients, which resulted in a 2.4% reduction in our patients attending A&E within the first 3 months of implementation.

However, this change has resulted in us needing to manage the expectation of those patients needing to wait longer for a routine care. This change in process and higher demand has led to frustration for patients and a reduced patient satisfaction with GP access. Although on average a patient waiting for a routine appointment is seen within 2 weeks, we acknowledge that at busy times there can be up to a 4 week wait. We continue to innovate and transform our processes to maximise capacity to provide a consistent wait time for routine care of between 1 – 2 weeks.

Other Factors Affecting Patient Demand

The long wait times for patients to access procedures or services in secondary care continues to have a massive impact on GP capacity and services. Patients on waiting lists for secondary care frequently access GP services for advice, care and management of their ongoing symptoms – providing a big increase in demand on primary care.

What are GP Practices contracted to provide?

While NHS England measures GP workload based on simple appointment data, the work of primary care goes beyond that of patient consultations. Appointment data alone gives an incomplete picture of GP activity and fails to reflect the significant number of non-appointment patient contacts. That is, work undertaken in relation to repeat prescriptions, test results, referrals, targeted clinics, routine vaccinations, and support groups etc is not currently collected, although work on mapping activity is now underway.

Core general practice is funded through a national GP contract, with each practice being an independent contractor responsible for the recruitment, training and development, and individual terms and conditions of its staff. There is no specific standard within the contract that determines what workforce a practice should have in place other than that it is sufficient to deliver a safe core service as outlined in the contract.

The GP contract is funded to provide 2-3 appointments per practice-registered patient per year. For our current patient list of 87,000 patients that range is 14,500 to 21,750 appointments per month. In January 2024, there were over 59,000 appointments offered by the AWC Modality practices.

In May 2023, NHS England published the Delivery plan for recovering access to primary care, which has two key ambitions:

• Tackle the 8am rush and reduce the number of people struggling to contact their practice; and stop patients being told to call back tomorrow.

• Patients to know on the day they contact their practice how their request will be managed.

 

Our online forms are used to triage patients and allow us to tackle the 8am rush on the phones and ensures that patients know on the day how their request will be managed.  Previously the Patient Services Assistant would triage people based on what the patient had said to them in person or over the phone. This could mean that more vocal people, or people that are better at explaining their situation, may get appointments first. By having GPs triage using the forms in a controlled environment, it is more likely that the tirage system is efficient. The online forms are still reliant on people being able to accurately describe their situation in writing.

 

The length of the form is dependent on the patient’s concern, but it normally would not take longer than 15 minutes to complete (usually a lot less time). There is a fine balance between collecting enough information to accurately triage someone, and having the forms be too long. There is an option to put ‘I have a new or ongoing medical condition’ which covers most grounds if patients are unsure of what to select.

 

AWC Modality is progressing with NHSE’s NHS England » Modern general practice model in order to provide a service that can provide equity of access to patients across Online, Telephone and Walk In access routes. Constantly refining and adapting the new system according to a wide range of feedback from patients, staff and other stakeholders in the health system, is an integral part of this process. To adopt the Modern General Practice Model requires an appropriate process of triaging and assessing demand to offer the right balance of appointments to best meet patient needs. This also supports practice demand and capacity at a time where GP services are experiencing significant pressure nationally Pressures in general practice data analysis (bma.org.uk).

 

AWC Modality consistently delivers above the national average number of appointments each month based on the national GP Appointments Data publication. December 2023 data shows Modality deliver 463 appointments per 1000 patients in comparison to the national average of 409 per 1000 patients (data quality caveats apply and volume of appointments should not be considered indicative of quality).

 

Klinik, the software customised by AWC Modality and used as our Patient Access system, is referenced as a case study recommendation for GP Online Consultation / Online Access Tool in NHSE’s Delivery plan for recovering access to primary care (england.nhs.uk) (p25) and is compliant to the relevant national Digital Toolkit frameworks for GP Online Access tools.

A representative from the NHS Bradford District & Craven ICB can be made available for comment, but was not available to provide an official comment within the timescale required.



Who are Modality Partnership?

Modality Partnership comprises of over 50 GP surgeries across the country, with 10 divisions (regions) and these all operate under an NHS General Partnership structure. Each division is broadly aligned with the NHS England regional structure. This is important as it is the NHS regions, known as Integrated Care Boards or ICBs, which determine how much funding is provided to meet its local population needs. This process is known as commissioning. If we take AWC Modality as an example, NHS Bradford District & Craven Integrated Care Board determines the amount of funding which is available to each practice. AWC Modality has circa 87,000 patients and is provided with circa £164 per patient per year by the NHS Bradford District & Craven. Under a general partnership model, partners are required to accept unlimited liability for the services they provide. This liability is joint and several which means that each individual partner can be liable for the actions of all the other partners in the organisation and is a huge responsibility. Within this organisation Modality has organised a number of centralised shared services teams that provide HR, payroll, finance, legal, IT, websites, cyber security, training, compliance support to the divisions. This is designed to increase overall efficiency as the alternative would require each practice to hire and retain its own expertise in these areas. Naturally these shared services cost money to run and each practice provides 3% of the annual £164 per patient per year to cover this. The Modality divisions operate all of the activities above under a legal framework known as an Unlimited Liability Partnership, as do most GPs across England. There are no external owners or shareholders expecting to be paid dividends from profits etc.

AWC Modality operates using a partnership model and is owned by GP Partners (the same GP Partners as prior to joining Modality Partnership), as is the structure of most individual GP Practices in England. Instead of Fisher Medical Centre being part of a partnership of six GPs, it is part of a partnership of over 130 GPs across England. However, each Modality division has its own divisional (regional) board which has autonomy over the decisions it makes for it’s practices.

 

3.3  Time to get an appointment –

Patients who require acute care are usually seen on the same day, unless a particular clinician or service is better suited to provide care or it is not convenient for the patient to attend on that day. Routine appointments will be allocated within 2 – 4 weeks (sooner, if available and with the aim to get this lead time down to within 2 weeks), as per the process outlined earlier in the report.

We have worked hard to meet are acute demand, with 85-90% of our incoming demand for GP appointments being dealt with on the same day. The remaining 10-15% is managed via our routine waiting list.  We are aiming for patients on this list to be seen within 2 weeks and were achieving this during the summer, but have understandably found it harder to maintain during the winter due to the significantly increased demand. 

For comparison latest NHS Digital Data (Microsoft Power BI – May 2023) for the West Yorkshire ICB for GP appointment booking showed that locally only 61% of GP appointments were being booked the same day and 12.2% had to wait more than 2 weeks (12.6% nationally). One in 20 patients in England wait at least four weeks to see GP, figures show | GPs | The Guardian – so longer waits for routine appts are not a Modality problem – this is a national problem.

Are elderly / vulnerable patients being disadvantaged?

One of our GP Partners, Dr Sukhdip Jhai,  conducted an audit in September 2023 which showed that the over 65 years patient population across AWC Modality was 17,808 patients in Sept 22 and 17,740 patients in Sept 23 (20.5% of our total population in both years). This patient cohort was found to use 36.3% of our appointments in 2022 and 36.1% of our appointments in the same period in 2023. This audit provides reassurance that our elderly patients are not being disadvantaged or struggling to access us in the way that some feared.

Has there been an increase in AWC Modality patients attending A&E?

According to data from the NHS Bradford District & Craven ICB AWC Modality have reduced our A&E attendances since implementing our new patient access system (compared to the same period last year) by nearly 600 in 9 months (2.4%) while the Bradford District and Craven figures for the whole patch are only 0.4% reduction.

AWC Modality have reduced our GP Out of Hours (OOH) attendances by about 800 in the same time (9.7%) compared to 6.9% for the whole of Bradford District and Craven.

This refutes comments from individuals that “patients are being forced to resort to accident and emergency just to get seen” and suggests our patients are finding us easier to access than prior to the change.  It also refutes the comments such as that “Something is going badly wrong I think the GP service in general is in trouble however I think Modality are even worse” given our numbers compared to rest of district.

 

 

 

3.4       Providing feedback or complaints regarding the process –

 

Before launching the new patient access system in April 2023, AWC Modality conducted a large programme of system development, co production  and education events both online and face to face in a large number of practice and community locations. Pre-launch over 1000 patients took part in these sessions. The education sessions have continued since implementation, with a recent sessions running weekly at a series of local practices and community venues. For example, last week we attracted  over 30 patients to attend at our Long Lee Surgery. Sessions are planned in each locality in a variety of venues  over the coming months.

Example of Facebook Live post implementation - https://www.youtube.com/watch?v=6wbDwfCzRGI

Patients can provide feedback on the system using the online patient complaint / compliment contact forms via our website and using a paper-based form in practice.

 

After-care services –

As AWC Modality is one practice operating across 11 practice locations, patients can receive care at any of our practice locations. Every patient is allocated to their nearest practice location, where the majority of their care will be provided. Exceptions to this could be Covid and Flu vaccinations which we have historically run out of a number of locality hubs e.g. Skipton, Silsden, Haworth and Long Lee practice locations, together with community venues. If a patient wishes to be seen sooner and this can be facilitated at a site which is not their usual location, this will be offered to the patient but equally the patient can choose to attend at their usual location. Some patient choose to attend a location for care which is for example, nearer to their place of work for convenience.

Continuity of care for Patients

Patients  can also request a particular GP or care practitioner and we will always endeavour to meet these request if appropriate.


Why are after-care services not always delivered in the Modality practice?

Practices across Craven Airedale and Wharfedale provide certain specialist services that won’t be replicated at every GP practice site. It is common practice for patients to be referred to the service at the site it is provided which may not be their regular practice site. For example, we have the pre diabetic service running from Fisher practice this year and patients from a wide range of practices will be referred to the service at Fisher. Another example would be - patients who are referred into the MSK service may be offered an appointment at an Ilkley practice (along with AWC Modality locations) and be seen by a Modality GP, but this is due to that GP working as a GP with Special Expertise within the MSK service (MSK is not a AWC Modality commissioned service).

 

 

 

4.0       ALTERNATIVE OPTIONS CONSIDERED

 

4.1       Not applicable as this report is just for noting.

 

5.0       IMPLICATIONS

 

5.1       There are no financial, legal, equalities or climate change implications.

 

6.0       REASONS FOR RECOMMENDATIONS

 

6.1       This report is just for noting.

 

6.2       Members should decide whether they wish to invite Modality to a future meeting.

 

7.0

RECOMMENDATION(S)

 

 

i) Note the report.

 

ii) Decide whether to invite Modality to a future meeting.

 

 

APPENDICES:

 

Appendix A – Modality’s latest CQC report – for reference only 2.5% of GP practices in the UK are rated as outstanding.

 

Appendix B – The delivery plan for recovering access to primary care – pages 19-25 highlight the way Modality are working and delivering on this plan.

 

Appendix C – The GP access report for Bradford and Craven – section 5 gives data and section 6 explains what the data means. Bradford and Craven is rated no.2 out of 110 areas in England in this report.

             

 

Report Author – Modality Representatives and David Smith, Democratic Services Officer.

 

Note: Members are invited to contact the author in advance of the meeting with any detailed queries or questions.