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At the heart of general practice since 1960

‘Joining a super practice means GPs can be themselves again’

The man in charge of one of the biggest super practices in the country talks to Alex Matthews King

dr naresh rati 3x2 2

dr naresh rati 3x2 2

The popularity of super practices is gathering pace across the country, particularly as GPs look to change their models of care to stave off closure.

Modality GP partnership is one of the largest and longest established with around 100,000 patients, 24 practice sites across the West Midlands and 65 GPs.

The organisation, that counts the chief inspector of general practice Professor Steve Field among its partners, is one of NHS England’s ‘new models of care’ and was awarded investment from the Prime Minister’s Challenge Fund.

And it is expanding. Modality recently welcomed three practices from Birmingham’s neighbouring town of Walsall and is working with three practices in west London who expressed an interest in joining the organisation.

Modality’s executive director Dr Naresh Rati is one of its founders. And the Birmingham GP is undoubtedly passionate about the model which he stresses is attractive to struggling practices, with a centralised back office and the ability to work on an economies of scales basis to offer a high quality, technology-led service to patients.

He has big plans for his organisation with his sights fixed on being the first GP organisation to offer seven-day opening. But is this the future for general practice and can it provide the solution for GPs desperate to be liberated from the bureaucracy hamster wheel?

How does being a partner in Modality differ from traditional general practice and do partners still own their own premises?

We give an option to incoming practices that either we’ll take the premises, if they want to sell, or make an offer, or take the lease on, on behalf of those partners.

Using London as an example, from Birmingham we will absolutely not be able to influence the way that general practice is delivered in west London. We have to have those partners that are vested in that vision.

But what we can do is solve some of the challenges GPs face: sorting out premises, so we’ve got a property company that can deal with leases; sorting out workforce and efficiency.

If you look at it from a lending perspective, for the bank, the covenant that you have from 30-40 partners as opposed to two or three partners is much greater, so the risk is spread.

Do GPs still have their own indemnity?

No, the partnership has a group policy, we pay for the indemnity for the partners and all the staff as well.

As a group policy, we get certain perks and discounts, which obviously is attractive to the individual. The premiums on an individual basis are lower than just with the MPS directly.

Has this helped Modality avoid general practice’s workforce crisis?

The GP shortage is consistent across the country - we still struggle to recruit - but because in Birmingham, we’re 85,000 patients and 19 practices, we can look at it as one organisation.

So we can employ pharmacists, physicians’ associates, advanced nurse practitioners, physiotherapists. We’re using some elements of what is traditionally general practice, delivered by GPs but delivered by other health professionals as well.

We’re getting our GPs to think differently and work differently, a typical patient journey would be if you’ve got an acute problem, you won’t necessarily see your GP, you’ll see one of the other health professionals, and our GPs are then freed up to deliver more proactive care in looking after those complex cases.

Does that mean you’ve managed to extend the ten-minute appointment?

We haven’t solved it yet, but the intention is that a traditional GP appointment will be moved out to 15 minutes, and we’re testing that model now as we speak.

How have you got to that stage?

By ensuring that we take a lot of the - if I can describe it as the administrative dross - that sits with general practice. A lot of letters or admin stuff that I, as a GP, doesn’t need to see can be dealt with by a trained administrator, that will free up my time or my team’s time to deliver care.

And you recently announced that 80% of your patient contacts were conducted remotely, through your app, or over the phone. Has that helped too?

Our offer to our patients is a wider choice of ‘modality’ to access their care, so we’re not restricting face to face, but a lot of patients - particularly for acute problems - are busy and so having a quick answer for those things, ‘Do I need to come in?’ or ‘Can I go to a pharmacist?’ - whatever it is - can be dealt with remotely.

When you survey our patients, of those that switched 70-80% of those surveyed wouldn’t switch back. It still means there’s a good 20-30% that aren’t quite happy with the full digital system, and they prefer the face to face. So it’s not 100%, and I wouldn’t expect that anyway.

Are you still grappling with how you can offer this level of access, but still provide continuity of care to patients?

As a society and as a profession, this is what we need to share with our patients - the choice; Access and convenience versus…[continuity]

The flipside is those patients that need to be seen from a continuity point of view will be seen by a GP but others may be seen by other professionals, not necessarily their GP.

It is a challenge as a profession and we are getting ‘push back’ from our patients, who are used to the traditional general practice model, but I think as more and more GPs start to adopt that sort of model, hopefully, society will start to shift as well.

So can you offer that continuity for patients with longer term conditions?

We’re in a transition phase. Patients are used to seeing their GP for every problem - whether it’s a sick note or a cold, through to a complex diabetic issue.

[In future] the GP will sit behind a pharmacist or a nurse practitioner or a physicians’ associate, so you’ll still be aware of the acute problems that patients present with, but won’t necessarily deal with them directly.

I’ll only need to see them when I intervene to make some changes from a medication point of view. And I’ll plan that appointment.

And do your GPs join Modality because they want this model, do they believe it lets them give better care to patients who need it?

There are two broad categories of GPs that want to be part of the Modality journey; those that absolutely see this as the future of general practice and want to be part of that and shape it, and those at the other end of the spectrum - struggling with the workload, can’t recruit, CQC issues or whatever it is, and want someone to just take all of that administrative burden off their shoulders so they can become GPs again.

Will you take up David Cameron’s voluntary contract for Multispecialty Community Providers?

We’re part of the six sites nationally that are pilot testing some of the thinking behind the new contract. So we’re hoping to get first sight of that [soon].

There are a number of issues we’re looking at with NHS England; the reality of seven-day access for GP services, what will that look like in practice? How do GP surgeries work at scale? In Modality we’ve got that figured out anyway, because it’s a single organisation, but other federations, how do they interact with each other?

So how does GMS or PMS fit in and does it get ring-fenced as a unit within that voluntary contract, so that elements of the voluntary contract are built above it, or is it morphed into that voluntary contract? That’s what we’re working on at the moment.

And is the aim of this contract still to deliver seven-day working? You’ve said in the past that patients don’t go for Saturday morning or Sunday appointments.

We’re committed to seven-day working - absolutely - and I’ve gone on record to say we want to be the first GP organisation that offers 24/7 opening for its patients.

I think the requirement for urgent access at weekends may need to be looked at differently. If you open up access across the week and make it convenient through digital technology, then your weekend opening can focus on those vulnerable elderly patients and keeping them out of hospital, and going out and visiting them to stop them from getting admitted. It may be that sort of model rather than just acute.

That’s our experience, we’ve been doing the challenge fund seven-day working for nearly two years now, but others have had different experiences.

Are super-partnerships the only future for general practice?

dr naresh rati 330x330 2

dr naresh rati 330x330 2

It’s an interesting question. How do you keep that uniqueness of the individual doctor-patient relationship, which is agile, absolutely purist at a small practice level, but also accept that society has changed, and convenience, access and quality are non-negotiable commodities now?

The way we’ve tried to address it retains that individual doctor-patient relationship. When that patient gets into that consulting room, what happens between them and their GP, we don’t interfere with.

But across all the practices, what I describe as the unwarranted variability that exists across general practice - referral patterns, quality metrics around QOF, or public health targets across our geography - there shouldn’t be any variability or at least you need to understand why.

How other models - looking at a federation for example - can achieve that, I think that’s the challenge for federations.

And will Modality remain an independent GP organisation?

Modality’s partners are considering a number of options around the future organisational form that will hold an MCP contract. One of the options could be an employed model through a limited company, moving to LLP and moving to employment within the MCP vehicle itself, as consultant GPs. No decisions have been made and we are developing these ideas as part of shaping our new model of care.

Professor Field is a Modality partner, how have your experiences fed into the new proposed inspection regime?

We’re not exempt from anything. I guess there is an advantage in that some of the frustrations, we can feed directly back to him around the process.

Like the inspection methodology for super practices? The plan is to inspect the practice leadership and a sample of the practice sites, instead of inspecting each site individually.

There’s got to be a better way. If we have 19 practices, it’s not necessarily a good use of time and resource from a CQC perspective as well as from our perspective, if a lot of the systems and processes are the same.

CV

Age

47

Education

Qualified in 1993 from University of Manchester Medical School. Awarded DRCOG, DFFP and DPD diplomas.

Fellow Royal College of Practioners (2015)

Career

  • 1996-97 Doctor at Wollongong Hospital, Australia
  • 1997-98 GP Registrar
  • 1998 GP. Locum
  • 1998-present Laurie Pike Health Centre GP Principal, Partner
  • 1998-present Dept. General Practice University of Birmingham Hon. Senior Clinical Lecturer
  • 1999-2005 University Hospital Birmingham Clinical Assistant, Dermatology
  • 2001-present Birmingham Skin Services Group GPwSI Dermatology
  • 2002-present Laurie Pike Health Centre GPwI Substance Misuse
  • 2004-present Laurie Pike Health Centre GP Trainer
  • 2008-present Executive Partner Modality Partnership

Other interests

Dr Naresh Rati volunteers every Sunday at his local temple, and makes best efforts to get to the gym every morning, he also enjoys travelling.

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Readers' comments (20)

  • there is no difference between what you are doing and the Hurley group, practice PLC etc. once the existing partners leave/retire, you are looking to replace them with PA etc. on a serious note you will have the same failures as the other organisations.

    you are creating a future vision of general practice, that does not have doctors at its heart and that is why it will fail.

    - anonymous salaried!

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  • I think it sounds horrible. Do you not fear that essier (virtual) access will lead only to increased unnecessary demand? I wonder if there is any correlation between the 70% you say wouldn't change back and their reasons for consulting - are these the relatively fit who just want immediate answers for minor/self-limiting conditions and the other 30% who are unhappy the ones who need a GP? By the way, we all offer 24 hour access to a GP - we just don't offer unaffordable, unfunded, unsustainable and unnecessary routine 24 hour access.

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  • These models are efficient and maximise profit. Continuity is however a thing of the past and health fuel inequalities because of the reliance on digital technologies thereby restricting access to the most vulnerable.

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  • According to his practice website Dr Rati only works one session a week in GP. He does more session in his private facial aesthetic clinic.

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  • This comment has been moderated.

  • However many partners there are unless you are on the board or whatever it is you are essentially an employee with all the problems of partnership none of the control and none of the protection of salaried.
    This is touted as the way forward for GPs - well no it isnt it's the way forward for a micromanaged salaried GP model ripe for takeover.

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  • Ghastly response to deliberate underfunding. Beware ye who enter here......

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  • 9.39am entry

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  • "It is a challenge as a profession and we are getting ‘push back’ from our patients, who are used to the traditional general practice model, but I think as more and more GPs start to adopt that sort of model, hopefully, society will start to shift as well."
    I wonder how Prof Steve reconciles this with 'patient-centred care' that the college bang on about. It is doctor-centred care (you could paraphrase it as 'the patients will just have to adapt')

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  • would you want this care for a loved one? I am sure that doctor's here make much money and that it provides a mechanism for partners to become part time and focus on their private work/CCG/NHSE work etc. is this what we became doctors for?

    - anonymous salaried?

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  • Dear CQC, we "flex" to the patient "push-back" - how "outstanding" is that?

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