Vertical integration: How and why it works | Sultan Mahmud

Sultan Mahmud

The Royal Wolverhampton NHS Trust’s work on vertically integrating its services with GP practices continues to gather attention and, here, Sultan Mahmud, director of integration at The Royal Wolverhampton, reflects on the shared values that have underpinned new contractual relationships they have developed, and without which the new partnership arrangements would fail.

We believe that we have started to reframe the relationship between primary and secondary care. If we’re all on the same side, we can think differently and work differently.

Our integration work in Wolverhampton starts in the same place as everyone else. Our efforts to manage the inexorable growth in demand were not working, the system was becoming less and less sustainable and we felt we needed to think outside of the box. The Dalton Review was the start of a mood shift towards system thinking, the visionary Five Year Forward View and the work of the Alzira Group in Spain. The latter showed a quantum leap in progress when they engaged the GP community in an authentic way. Previous attempts for service redesign across England had taken us so far, and as a trust board we felt that if we genuinely wanted system change then we as the largest player in the system, needed to lead, facilitate and parhaps be held accountable for a new way of working.

As we engaged local GPs in Wolverhampton and South Staffordshire they described the feelings of isolation that they sometimes felt, and workforce issues that they faced, inexorable demand and some wanted to try something completely different, namely full integration with the NHS trust. We were really clear in these discussions that our primary focus was to listen, to understand and not to push an agenda. This original conversation led to a series of others with GPs in the area, all of whom described the same issues, and the pressure that their practices were facing.

This is where the idea of vertical integration came from. The idea of linking primary, secondary and community care in one single organisational structure for those who wanted to. Our whole relationship is based on trust, and a shared ambition to address the issues that primary care, acute and community trusts face together.

We approached NHS England and the local clinical commissioning group to see how they would feel about our organisation working with GP practices and delivering a vertically integrated service, and received permission to proceed. We took legal advice, and found that actually there was a clever contractual workaround, and that’s what we have done.

The arrangement we designed allows GPs to retain their contracts with NHS England, but at the same time now to be directly employed by the trust. We’ve taken on a lot of the worry of running a business. We cover staffing, contracts, finance, CQC, payroll and everything that sits behind the scenes allowing GPs to concentrate on what they do best - support patients. And GPs now use our management information systems and an unrivalled set of live patient data to track patients as they move from primary to community and hospital services.

We believe that we have started to reframe the relationship between primary and secondary care. We are also working constructively with non-VI GPs in our patch as part of the Integrated Care Alliance (ICA) which is our local placed-based arrangement.

Directly we work with nine practices within The Royal Wolverhampton Trust family. We’ve delivered in excess 80,000 new appointments for patients. We are able to offer GPs portfolio careers where they can work in the hospital as well as in general practice, building specialisms and helping to inspire and retain this key part of the workforce. Our information system is delivering excellent insight that’s helping us to work on population health solutions based around a whole system understanding of where patients are and how pathways work in practice. We have GPs in key positions now across the trust’s management committees, offering perspectives we’ve not always had before and securing the broader relationship with general practice on an equal footing. We have a population health unit of public health professionals embedded and employed by the trust which is also reframing our thinking. We are working towards becoming the NHS trust of the future and while the work is not complete the key building blocks and the attitudinal shift are in place .There are several other economies who have also taken this and similar approaches and it is mushrooming all over the country.

Primary care networks (PCNs) are a great opportunity for all concerned. I think they will surface existing issues for primary care as they mature- workforce challenges, employment risk, financial risk and community services redesign will need to be tackled head on for PCNs to succeed. This will all come out but I don’t think our model does anything that will affect this discussion apart from offer an alternative way of working that is entirely complimentary.

Our patients are very supportive of the integration. The ability to share information seamlessly and have clinicians working together because we are part of the same organisation is a massive benefit to patients, many of whom assume that the NHS is just one organisation already!

We’re really happy to share the learning behind our model, the contractual learning that underpins the relationship between us, the GP practices and NHS England/Improvement. We’re also exploring slightly different affiliate relationships with practices - where we get some of the benefits of working without all of the contractual obligations. As an anchor NHS organisation we have a responsibility to work with all of the GPs in the city.

The Royal Wolverhampton Trust model only works if all partners demonstrate integrity, tolerance, emotional intelligence and a shared ambition to do the best for their communities. If trusts approach this as a way of “taking over primary care” then this arrangement will not work; it completely misses the point. Both sides must be committed to the best outcomes for their communities and incentives to do so must be aligned. Values are at the heart of our partnership and innovation underpins everything we do - these two things have been the mantra of our chief executive, David Loughton CBE, right from the outset.

Sultan Mahmud is director of integration at The Royal Wolverhampton NHS Trust. Follow the trust on Twitter @RWT_NHS

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