Do we truly appreciate what is possible when primary care entrepreneurship is unlocked? In this episode, Matthew Taylor goes behind the scenes at Thistlemoor Medical Practice, a pioneering general practice in Peterborough led by Dr Neil Modha. Serving an inner-city population of close to 30,000, the practice has radically evolved its approach to meet local needs.
Discover how the practice and wider primary care and system partners are working together to improve population health, reimagine the workforce, redesign pathways and adopt a more proactive approach to care. With the much anticipated workforce plan on the horizon, Dr Modha considers what it must enable and how, on the eve of the Fuller stocktake’s first anniversary, he is putting the principles into reality.
Dr Modha is also clinical director of the Central Thistlemoor Primary Care Network, chair of Greater Peterborough Network GP Federation and co-chair of the Cambridgeshire and Peterborough Integrated Care System North Place Board.
Shaping the future of primary care
With primary care at a crossroads, debate has turned to its future role within integrated care systems and the operating model for primary care.
The Fuller Stocktake set a welcome new direction of travel, focused on integrating primary care to improve access, experience and outcomes. With pressures on services mounting, the focus must now shift to turning the vision to reality – considering the contracting, commissioning and funding arrangements to enable change and the model to deliver it.
To support this, we are convening leaders and practitioners to turn ambition into action.
Five design groups and communities of interest will support solution-focused conversations about where next for primary care, designing practical resources, showcasing innovation and working with national and system leaders to influence change and share ideas.
Practical, problem-solving and peer-led, these networking spaces will shape the future of primary care.
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Health on the Line
Our podcast series offers fresh perspectives on the healthcare challenges of our time and ways to confront them. Tune in for interviews with the movers and shakers making waves across health and care
Hello and welcome to the latest Health On The Line. This week I'm on the road looking at some fantastic primary practice in Peterborough. So, do listen to that. But before I take you to Peterborough, here are some highlights from the last few days. First, I think you might be interested in the lecture I gave to the Royal Society of Medicine last week.
It was the annual Stevens Lecture. I tried to lay out a kind of vision of an NHS renewed and talked about what I thought were some of the key things needed to achieve that. I talked about the need for investment, but also, to understand that investment isn't just pouring money into a black hole; it’s investment in our economy, in our society.
I talked about the need to invert the pyramid to have an NHS where each level empowers and enables the level below, and ultimately, we empower and enable patients and the public themselves. I talked about the need for the leftward shift of resources. How do we get money proportionately out of the acute sector and upstream into primary, prevention, community?
Of course, it's impossible to do now because of the pressure on acute. But if we were to have more money, how could we tilt it more upstream? And I talked about the need for a new social contract with the public, emphasising the incredible importance of public attitudes, behaviours, the way the public uses the health service for the sustainability of what we're doing.
So, do have a look at that lecture. You can find the details on the Confed website.
You'll also, find on the Confed website information about ConfedExpo. It's now only three weeks away and if you haven't signed up, it's still possible to join over 4,000 other delegates in Manchester on the 14th and 15th of June. It's going to be the biggest and most significant healthcare conference of the year. And it will create a really strong point of focus for health and care leaders to come together at a time when we need to discuss both recovery and transformation.
And then a final point, in case you missed it. It's a year this week since the Fuller stocktake of primary care was published as the Confed’s own Primary Care Network has said this week Fuller stocktake contained a set of recommendations that were clear, practical, targeted.
One year on, we've seen lots of commitment and willingness from system and primary care leaders, but, as yet, we haven't had sufficient resource. And the speed and scale of transformation is limited because of the day-to-day pressures on primary care. So, we at the Confed are working with primary to help it operate at scale, to be a system and place player.
And I've seen some fantastic practice in terms of primary care, having that kind of ambition, focusing on population health, working with a range of other organisations. So, we'll be continuing to press hard both nationally and at system and at place level to drive forward the Fuller reform agenda. But talking about Fuller is also a great segway into what you're going to hear now on Health On The Line.
It's about a visit I had to the practice of Neil Modha in Peterborough. I was really impressed with what I saw. I hope you are too.
So, I've just arrived in a blustery Peterborough at Thistlemoor Medical Centre. I'm going to meet Dr Neil Modha who's head of this empire, but also, a key player when it comes to national thinking about the future of primary care. Really looking forward to talking to Neil and finding out what goes on in this amazing building.
Neil - hi.
Hi, Matthew, welcome.
Thank you. So, even from the outside, this is a very impressive set-up you’ve got here. So, show me around.
Yeah. Thank you. So, this is Thistlemoor Medical Centre. We now care for 30,000 patients. Our patients come from...
30,000? So, how many were you when you started?
So, my mum actually started the practice in 1994 with 700 patients. So, a single terraced house, one clinical room, waiting room was the staircase before the days of the CQC and things like that. And now we've got over 60 clinical rooms, a massive team of doctors, 15 doctors, six trainees, 15 nurses, five paramedics, a massive clinical team, over 112 staff serving a population who don't speak English very much.
And so, 80 per cent of them speak other languages. And so, we've massively diversified our team to meet their needs. We try and think about our rota in reception to have people who speak different languages. So, we've got people who speak Polish, Russian, Lithuanian and Asian languages and so they serve the patients, and the building is split up into many zones.
So, we've got zones A now through to G. So, ABCDEFG and each zone has kind of a waiting room and then it serves kind of clinical rooms down the end. So, there'll be six or seven clinical rooms with a mixture of doctors, paramedics, pharmacists and, and different members of the team.
So, tell me about access, because I think I'm right that Peterborough is actually one of the most underserved places in terms of GPs per head of population. So, how are you tackling the kind of access issue?
Yeah, absolutely. So, the kind of key that we've had from the start has been to kind of consider what we would call ‘open access’. So, if someone needs us, we will see them. And so, I guess, the way that we did that up to the pandemic was that if any of our patients at that time, probably 27,000 patients, if anyone needed us, they would simply come, wait in a queue and we would see them.
So, we would, you know, we would kind of spread them out across this building according to their language preference, the clinical preference and things like that. Post-pandemic, now or during the pandemic, we moved to a digital triage. So, people like, you know, do digital forms and things like that or ring us up. And then we would aim to kind of help them within the 24 hour- or 48-hour period.
Obviously, if a person chose to want to come in on a Thursday or next week, that's obviously absolutely fine. But generally, if someone needs us, we want to deal with their case within 48 hours.
And do you think that that kind of obsession with two weeks is useful?
I think what's important is trying to personalise it to what people need.
So, actually, if people want it to be in two- or three-weeks’ time, that should be absolutely acceptable and fine. But I think as a responsive health service, giving people care, a majority on the same day or the next day is really important. But it depends on the problem. I guess the balance that we're always trying to strike is how much do we kind of have time for really good proactive medicine? So, not even the people contacting us, but the people that we should be contacting.
Right. So, ‘population health’ is what people would call it.
Absolutely. Yeah. Or ‘proactive care’ or whatever you want to call it. So, actually, how do I look through my list of diabetics, work out which ones have got the worst diabetic control, and make sure that I'm having conversations with them to make a difference to their lives.
And so, making sure that we can both meet the needs of people asking for our help, but also, we're prioritising through health promotion tools or health, you know, health prevention tools, the right population and having enough clinical capacity for that is really important as well.
Great, let's carry on with the tour.
This is Zone A and so, I work up here in an office alongside my practice manager.
What’s interesting, I guess about our clinical model is that we have healthcare assistants that support us. And so, I'm just going to introduce you to one of our healthcare assistants. So, Matthew, I've not warned Paulina, this is Paulina. Paulina you've been here now for...
Six, seven years.
Six, seven years. Yeah. So, Paulina is a great example of what is possible. So, Paulina joined us with no experience of healthcare. She went through a training program that was both kind of onsite kind of people mentoring and supporting her. Also, hard work that she did through her courses as well. And then she obviously speaks Polish fluently.
And so, when I'm working through my patient list in the morning, I'm working here alongside Paulina. So, although I've got my own room, most of the patients that want to see me will be first seen by Paulina. And so, for example, this morning we've done a number of diabetic patients who've got uncontrolled sugar levels. Four of them couldn't speak a word of English. And so, actually Paulina has helped communicate with those patients, explaining what needs to be done.
And also, while she was waiting for me, she's been doing things like foot checks, giving some health promotion prevention advice and then working with me to explain what the plan is with the patient.
So, did you have any health experience at all before you started the job?
To be honest, not at all.
Tell me why you applied for the job in the first place?
I just found this advertisement online and I was thinking that why not? Why not to try and, you know, to work here. And I was glad that I don't have to have the experience.
I'm really, really happy that they gave me opportunity to get this experience and basically to help people.
So, Paulina is part of the kind of health and data team. So, she works with Agnieszka who Agnieszka and Paulina basically look at, for example, all of our QOF registers, our performance targets basically, and they monitor these kinds of things and they use technologies.
So, even with a deprived and challenged population, we use a lot of digital technology, messages, System One annex, ways of communicating. And what we found with our population is very simple messages. So, if we send a really long questionnaire, 20 pages long, we will get none back. If we send a simple kind of, do you want to come in on a Saturday for a health check? Absolutely.
So, she's also been doing things on health promotion prevention, smoking cessation, exercise and diet. So, as well as then some of the helping me to consult she also, has got these other portfolios.
So, you have to become a technology expert as well as your medical your clinical skills.
Yes, that's true. Which isn't very easy. But with Agnieszka help. Yeah, I'm getting there.
Thank you. Really nice to meet you.
Nice to meet you, too. Thank you.
Matthew (to Neil Modha)
You run this kind of empire now, and you're also, chair of the fed, which is a big Fed. How important is it that you still have time with patients?
Yeah, I think it's really important.
So, for me, I think clinical leadership comes from actually doing the job and sometimes it is difficult. It's been a really busy week this week and so I've done a lot less clinical time than I would be happy to do, but I try and get that balance. I was the CCG accountable officer and even as a CCG accountable officer I was doing three or four clinical sessions a week.
So, I try and keep that balance of clinical work that helps me connect with my people/my patients help me understand what the challenges are on the ground, but also, time to do the strategic work and think about the future, really.
Neil, this has gradually been built up. I mean, you must have been kind of adding bits to it almost every year.
Absolutely. I mean, we think that we provided a good service for our population. We tried to tailor our service to the needs of the people, and that's attracted people to come to our service. And as such, therefore, we've had to grow the infrastructure. Whenever we've seen, we've grown, we've just acted in our patients’ best interest, built on extensions and then had conversations afterwards with our commissioners to make sure that the space could be used and all of that kind of stuff.
I mean, this is an aspect I think of general practice, primary care at its best is that entrepreneurial element. You clearly have to be entrepreneurial.
Absolutely. I mean, let me be honest with you, Matthew. I came to Peterborough with my healthcare management degree, telling my parents how it should be done. Of course, you should get permission before you do anything.
And then I guess realising that it's quite challenging to do things in that kind of bureaucratic way because we've often had permission but then the timing to allow an extension to be done is so slow that it doesn't allow you to cater for your population. And I know in the Patricia Hewitt review, one of her recommendations is actually how do we move on from the way that people used to think about this to hopefully this organic patient-serving growth that we've managed to obtain here.
And I notice on the site, you also, have a pharmacy.
Yeah, absolutely. So, Graham Young's Pharmacy, one of the oldest independent pharmacies in Peterborough, we've owned it now since 2007 and since November we've taken full control of it. And I guess, you know, for me it's putting things like the Fuller stocktake into reality. If we're talking about primary care needing to work together, here we have the perfect opportunity to almost experiment - if we can work hand-in-hand with community pharmacy, where can we agree what where things need to be done?
So, rather than fighting over who does flu vaccinations, if we agree, flu vaccinations are done, for example, in the pharmacy that allows for surgery to focus on other things. And now with the changes in the pharmacy contract with blood pressures, pill checks and all of that kind of stuff, that's much-needed cavalry actually for my GP centre, because actually if that can be done, people can be served in a in a place that they will come to then that allows my GP centre to concentrate on different things.
And I also, notice people can get their prescription 24 hours a day.
Well, we're very proud of this. Let me come and show you a toy.
We're standing outside I guess you might describe them as kind of pick-up locker type devices that work 24/7. Now, I guess for me, the NHS is often about stories, and I guess the story behind Graham Young was he was a pharmacist that was dedicated to this population for 40 years.
The legend of him is that if, for example, you had a sick child and your GP had prescribed antibiotics, he would open up his shop at three in the morning. He'd come down in his white suit and he would serve you the antibiotics that you needed, or if you needed some Calpol or something and you run out, you'd knock on the door and that's 365 days a year. Christmas bank, holidays, whatever. That's what he would do.
And so, I guess in that memory we thought it was really important actually for our patients in our community who often do shift work, the ability to pick up medicines at three in the morning or five in the morning by simply putting in their PIN number and then releasing the medicine. You know, it's been a real game changer for the community.
And just to be clear, I'm standing here. There's a touch screen, presumably people get sent a PIN number through a text. They come along, there's a place for them to pay, put in the number and then the prescription like a vending machine just comes out. And it works!
You just look at the this and you think, why would you not have this everywhere in two or three years’ time? So, yeah, brilliant.
And we're on a journey of automation. So, this was one of the things that we were first very keen on. The second thing that's coming in in May, and I'm really hopeful that Amanda Doyle and Claire Fuller are going to come and christen the robots, but there'll be a robotic dispenser there and that will be able to do sort through 25,000 scripts.
And so, what that will do is it will enable the staff to focus on people. So, rather than getting medicines and putting them into a bag, the robot will do that and that's going to really dramatically free people up to actually focus on giving people care and attention.
And are you because you're your share of the federation.
So, that's greater Peterborough...
Greater Peterborough Network, yeah.
So, is this technology now something which is going to spread throughout the Federation area, do you hope?
I think the one that we're really keen on in the federation is, is actually almost how do we automate systems and processes? So, how do we free up clinical people or even HCAs, like we met earlier, to do people facing things and how do we use technology to do some of the filing, the automation, and things like that.
So, like a hospital would have a whole team of robotic coders. Why can general practice not have that? And actually, if we can create that for Thistlemoor in Peterborough, why couldn't we create something that then works for the whole of Peterborough or maybe the whole of the country? You know, that's certainly our ambitions going forward.
Today, Peterborough, tomorrow, the world.
So, here we are at the Endoscopy unit. So, tell me about the kind of background to that.
Yep. So, I guess when we built a lot of this infrastructure at that time, we were a 14,000-patient practice and I think people thought, why are you building such massive infrastructure? And I guess we always wanted to have a very modern pharmacy like we just saw now, we also, knew that we needed a bit of space for ourselves.
And at the top here we built some space that we thought could be apartments or something like that. And I guess the idea with this, the challenges that the NHS have sometimes difficult for people to see that vision until something is actually in place.
As we had built the building, we were approached by In Health, who are an endoscopy provider, and they were providing services elsewhere in another GP practice but were struggling because it wasn't the kind of purpose-built facility that they were after.
And so, they built the endoscopy unit here and that does all of the upper GI endoscopies and lower GI endoscopies. So, colonoscopy and gastroscopies for about 300,000 patients. So, it's linked to the hospital pathways. So, the hospital I guess are there to focus more on cancers or emergency cases and things like that, whereas more of the, I guess routine endoscopies or colonoscopies are done here.
So, so, what's the relationship with the consultants, for example, in the in the hospital, that kind of sense of teamwork running from acute through to primary. Tell me a bit about that.
Yeah, I mean, I have to say it's not perfect. And so, you know, some of it is because there are different silos and waiting lists in different places, trying to get that connection, because I think integration sometimes is also, about the IT, isn't it, and things like that.
But I think that's really good. You know, the hospital consultants appreciate having a pressure valve here that they can release into, and it is hospital consultants that provide the governance of this unit. So, some of the people that come here are GPs to do it, but the governance is through kind of the consultants basically supporting them.
Neil (talking to receptionist))
Hello, how are you?
So, we’re in yet another...I'm glad you're showing us around.
This is Zone D; this is kind of our nursing wing. So, we've got a team of nurses, between 12 and 15, at the moment we're closer to 15. But that's the range that we normally have. In that team, four of them are paediatric nurses.
So, in general practice we've got four paediatric nurses. Part of that is because we've got a young population and obviously the paediatric nurses love helping our children who are struggling. They also help with things like vaccine, you know, talking to people at vaccine hesitancy and things like that.
And we've also now got a midwife. It’s not that we want to deliver babies at Thistlemoor, but we want to get some of the skills of the midwife and, given we've got a very fertile population, how do we care for them better, but also, how do we take someone with those skills and how do we give them a platform to develop into general practice? I think is a really interesting concept.
And this story, which we'll talk about more, so many people here seem to be on a continuous journey of training and development that seems to be, if I had to choose a theme from all this, it wouldn't actually be the buildings and all that, which is amazing, and all the other things, it would be this sense that this is such a learning organisation.
One of the things we're most proud of, I guess, was in 1995, Sheffield University came here, spent five days because I guess a lot of the things and the platform that my parents created was controversial.
At that time, nurses were not doing what nurses do now. Even doing a blood pressure was controversial, you know, because actually that was a doctor's job, let alone getting healthcare assistants involved in consultations and all of this kind of stuff. And I guess Sheffield University was brought by the PCT chief exec at the time to, I guess, assess this model, and consider is it safe, is effective, is it well led?
And as part of that, then actually what the conclusion was, you're a learning organisation. And back to what you said, I think for us, we always love these hooks. If we were learning organisation in 1995, what does that look like in 2005? What does that look like in 2023? How do we build upon the platform that we've already set so, that we're not resting on our laurels, but we keep innovating and keep kind of extending that going forward?
So, here we are in the boardroom or the training room? It's kind of, you know, a big room, lots of photographs. I'm going to pick a couple of photographs Neil and ask you to tell them the story behind them.
So, I'm going to start with a picture of your mother, who I had the privilege meeting earlier. She's getting her MBE here and she built the foundation for all of this.
Yeah, absolutely. I mean, her story is an epic story of a Ugandan Asian coming over £50 to her name. She's still working here today. She's 70 years old.
She's here probably more than me, often seven days a week, thinking about clinical governance, safety improvements and things like that. But I guess the reason why she got an MBE, it was for services to the NHS. A little bit of it I guess was the story. And like you said, you know, the growth story and things like that. But I guess it's pushing back on some boundaries. So, it's taking nurses to the top of their game. It's importing a model of healthcare provision from America and applying it to England.
So, tell us, we haven't told you about the healthcare system story, which is which is amazing to me. And your mother started that story. We met Paulina - tell us about this kind of healthcare assistant model.
Yep. So, we're in a very sad family - everyone’s a doctor, married to a doctor. Their dogs are doctors. Their cats are doctors. It's a very medical family. And half the family are in England and half the family are in America. And my mum's dad had things like heart failure and, you know, medical problems.
And so, when she was over there and accompanying him to appointments, what she remarked upon was the difference between what happens in the NHS and what happened in America at the time. And what happened in America at the time was there were a lot more people providing care. The idea was the consultant's brain makes the plan, but actually there are so, many different people to do the various checks, organise the blood tests and things like that.
And so, what I guess they reflected on my mother and my father, my dad's also, a GP and they were working together, was if that can happen in one of the most litigious countries in the world, if they can have safe practices that allow this to happen, why could that not happen in the UK?
And so, what they went down to basics. So, what is the training? How does that work? What kind of sign offs do people need? They took all of that material from America, personalised it to the NHS, personalised it to primary care, and went on a journey that kind of backed giving people like Paulina the opportunity to train and develop to become healthcare assistants and then to apply that in practice to help patient care.
And how many healthcare assistants do you employ now?
So, now we've got 26 healthcare assistants. The traditional journey for a healthcare assistant is to start in reception. When we recruit, we are very clear to people that this is a healthcare organisation. Everyone has a role in healthcare. If you want to come here and have an administrative role, that's not going to work because everyone has to do something to do with helping patients and feel comfortable talking to people and patients.
As they start in reception they're taught some of the basics about kind of communication and things like that. They are taught how to do new patient medicals up to a certain point with guidance and supervision. They're taught a bit about the repeat prescribing protocols and things like that, just to give them a taster and check that they understand that. At that point they're doing their care certificates, they're getting the badge to be a healthcare assistant.
And then at the point that we're happy, which is normally about six months, they then go into a HCA training program. What we're always trying to drive is, you know, we're all here to provide people with a really good service. What would make us sad is if you came in for a diabetic check, we didn't look you in the eye. We didn't check your feet. We just documented that we had, you know, none of that is acceptable. We have got to have meaningful contacts with people. We've got to, as well as them helping us because they're helping us with our QOFs and things like that, we've got to help them a little bit. So, how do you get that ethos of improving the population and getting them to take ownership of their health as well?
Tell me a bit more about, because as we speak, we're awaiting, it probably won't be published by the time this is broadcast, the workforce plan. What are you hoping to see in that workforce plan in terms of the kind of principles you've established of new roles, The scope for people to develop in those roles, the kind of integration of roles, the flexibility that you've achieved.
I think you hit it on the head there: flexibility. I think we have bespoked our workforce to the needs of our population. I think every general practice or primary care centre, PCN, should be able to do that and empowered to do that, I think actually. So, what I believe is that for us to fly, we need to work in an environment that is allowing and enabling basically, those are the key words that are so easy to say, yet so difficult to do. And so, what I would love to see in the workforce plan is the ability to have more, more people, you know. I'd love to see the focus be on prevention. I think it's really important that often that can be the thing that people forget about, but that should be front and centre, you know, a proactive preventative self-care kind of part of general practice in primary care is really important.
And I think when we see the numbers and the statistics of people that work in different sectors, there is an opportunity for general practice. There is an opportunity if we can embed people that may leave the NHS, may leave the country, actually, if we can give them a home in an innovative centre, you know, that is general practice, then actually that can be really good because although people might fear we're already losing midwives, what happens if too many come over?
But actually, if we take the right amount over that, that can completely revolutionise someone’s career and the contribution they make to the NHS.
You talked earlier about four years ago, obviously pre-COVID, as you opened up new facilities, bringing together the community and the workforce and the local authority and others and talking about the priorities and that focus on prevention.
So, I guess the kind of 64-million-dollar question is, and maybe it's unfair because you've had COVID and the really tough winter, etc., but are you starting to see outcomes?
Yes, we are. I guess if I make it specific, I think the thing that it brought home to me was prevention is really important.
And I guess how my mindset changed with that by going through that process was even in this big building that you see before you today, if we're honest in 2019, we were very stingy in terms of who could use the building. The thought was we're a medical centre. Therefore doctors, nurses, my healthcare assistants, my team. That's what the building was for.
And I guess as we opened up the thoughts to, you know, the issue is prevention, one of the one of the most horrible bits of data that I see for my population, specifically Thistlemoor Road Surgery, the average age of an acute coronary event for my population is 47. The average age for an acute coronary event across Peterborough is 67.
Now when I've got populations that are having it at 47, I've still got people who are 80 having acute coronary events, so therefore I've got people in my thirties and forties having it and a lot of that is borne out of the population that I serve. So, it's not a lack of primary care, it's not a lack of general practice, it is genetic factors, it's cultural factors, it's behavioural factors.
You know, a lot of my patients unfortunately start smoking at the age of 13. By the age of 23. They've got a ten-year history of smoking. Often that's two or three packs a day because of the nature of the jobs that they do, etc., etc. And that's not to blame them. That's the circumstances that they live in. And so, you can see how important that prevention agenda is. And I guess taking that data, you know, we've got a problem.
And so, the solution to that problem as we saw it by talking to the people that provide services was actually, you know, Dr Neil, why don't you why don't you let us have some rooms? And what about developing health and wellbeing coaches? Because that was coming out from Nikki Kanani and her team about a possibility. And so, we went big on health and wellbeing coaches.
We've got nine across our PCN with seven of them being here again in multiple languages and cultures and things like that. The council then said, well, we're doing that, we're doing the same agenda. We want access to your population. There are really hard population to get hold of and as a GP, I'm thinking, well, they're not that hard. They come into my surgery, you know, at that point there was a queue of 500 of them every single morning, 500 patients that used to queue up as they...
And of course, I don't want to interrupt, but an important part of that connecting elements is that your healthcare assistants have been appointed from that population. So, your workforce strategy and your population engagement strategy are mutually complementary.
And the reason for that, Matthew, is that what we found is that we would have consultations with someone in the morning. In an afternoon, they go to a walk-in centre, in the evening, they go to the hospital, and part of that was not because they were unhappy with the care, but I don't know how good your French is, but if I went to France and tried to explain to someone the medical problem that I had, I'd be left with a feeling that have I communicated? Have they really understood? And how much do I know about the French health system and what I should, which door I should go into and shouldn't go into? So, actually using that as a thought, how do you get someone from the community to actually explain things?
Because if I say to someone, oh, I'm really sorry, the NHS doesn't work like that, versus someone from their own community, from their own background saying, look, we know in Poland it's different, we know in England it's different. This is how England works. This is why the doctor's given you this advice and this is what they've explained you to do. That communication makes such a difference to people.
That takes me to another thing I wanted to ask Neil, which is I firmly believe that the future of the health service relies in large part on our capacity to have a different kind of relationship with patients and different kinds of conversations with patients. So, when it comes to ideas like shared care or anticipatory care, is that part of your story as well, that you're wanting to engage patients much more as partners, and that must be particularly challenging in a community like this with the language issues and the deprivation issues.
It's both challenging but a massive opportunity. And so, for example, when it comes to outcomes, which what you'd asked me about before, during the pandemic, we've really struggled with our diabetic outcomes. So, actually we had one of the we had some of the best outcomes for any population let alone our inner-city population before the pandemic because of the model of care that we had. You know, someone comes in with back pain, we grab them, do a diabetic check, take their bloods, do everything on the same day. And so, we would get hold of the population with really good access. In the pandemic, doors are closed, triaging everyone, minimal amount of footfall into the practice.
And so, we were being almost named and shamed in a friendly, competitive way in the system to say, look, Thistlemoor you were doing really well, what’s going on? And so, what we had to use was some of the people to use technology to actually send simple messages to people - are you free on Saturday to come in? - at that point, making sure we could do the whole of the diabetic check, do the blood tests.
And what we're really proud of is that we went from one of the lowest performers during the pandemic to one, and that's using data on Eclipse software that measures data and that has people from all around the country, by the end of that year, we were in the top ten in the country of people that came in, by adapting our approach.
And I think that's the key, isn’t it? Back to your question, how do you both as a service think on behalf of people and what they might need, but as part of that, test that out, get feedback? And so, one of the great things is because our population is so different and because they're from such a different background, it means that we feel that we have to ask them questions because actually we cannot simply think on their behalf, because we are we haven't lived the life stories that they have.
And so, we've got a natural resource in our healthcare assistants and our clinical admin team that we've developed from that population. But we've also, got these passionate people advocates that we can test things with and who will be very brutally honest about when things are not working.
And, you know, I help manage a lot of the patient feedback complaints and things like that and I always think that that's such a great opportunity to learn from people. You know, obviously there's a lot of negativity about the NHS and primary care and things like that. But actually, when people take the trouble to give you a complaint to explain exactly how they've been let down and what they would like to see for the future, that's a massive opportunity to make things better.
Do you feel that you can improve the health of your population despite the fact that so much of what drives the health is beyond your control? Or I guess maybe it your model to gradually be able to be more influential in terms of those things which influence their health?
Yeah, I think so, I mean, I love the concept of anchor organisations and being part of the community.
I really think that again, back to that difference in thinking, this building was full of doctors and nurses. Now this building is full of people, including doctors and nurses, but other people - social prescribers, health and wellbeing coaches, people in the voluntary sector utilizing the facility for drop-in clinics for the homeless or, you know, etc..
That's what I think the future is. The future is not just looking through the single lens of the medical model. It is about what how do we use the opportunity that a thousand people will contact me a day to enrich that population? We've been lucky on that journey.
We often get tapped on the shoulder. So, we were tapped on the shoulder by the system to say, look, you are one of the most deprived practices, we've got this opportunity to do population health management. At the time, I was in the Fuller stocktake leading population health management while, alongside that, putting that into practice by doing a population health management project. And the project that we that we focused on was working with Optum, who basically did the data gathering and analysis for us.
And we targeted people that utilize our facility 20 times or more a year and also utilized A&E five times or more. So, that was the subset of population that we focused on. And those aren't people with medical needs. They don't have renal failure; they don't have cancer. They are on paper, on the surface, low-medical needs that some of that overlaps with mental health and other issues.
And I guess when I looked at the number of people and having worked here for 15 years, there were a lot of familiar names, as you can expect on that list. And I guess the design of that work programme was 1) to identify the people 2) to then think about how could we maybe impact on that?
Because actually, from a selfish way, if we can modify behaviour so it's not 20 times a year, it's ten times a year or five times a year, then actually that's going to make a difference to our clinical capacity. And actually, if we can identify what actually is the problem, what is the reason that they're contacting us and actually then look to solve those issues that seemed like the sweet spot.
So, over this winter at the place-base level, we set up incentives for not just my PCN or my practice, but all PCNs to think about what they could do to help their population. But also, that might have a difference - a measurable difference. And so, our work was focusing on that population. So, we did a motivational strength interviewing for all the people that were involved.
Those people were not necessarily just doctors some are doctors, GP trainees, for example, are involved in that, but also, health and wellbeing coaches, housing people and people from all different sectors interviewing all of those people to identify what actually is the problem. And the conversations that we're having with our ICB is we're asking them if three things can change in your life, what would they be?
So, we're gathering these lists of things that people want. And what we would love to do is where services exist, connect them and where services don't exist, think laterally, personalised care budgets, you know, what's the opportunity to maybe trial spending a little bit of resource on what matters most to an individual and doing an experiment to see well, actually, if that drives down A&E attendances, if that frees up general practice capacity, that's the kind of model that you could really build upon.
There's obviously a lot of focus, Neil, on the on the urgent emergency care pathway. You're working in an interesting way with your ambulance service, I think. So, tell me tell me about that.
One of our favourite projects is called the AMBO Project, as we call it.
And so, what we what we identified is through the winter pressures, the narrative is the ambulance service is swamped, there are people backing up into hospitals, etc., etc. We need to get upstream of that. And I guess if you look at that problem from a GP lens, I want to try and meet as much demand on the day as possible.
I want to kind of get the people that actually need to be in hospital and get them there. But the feeling was more could be done and the thought that we had was that actually if you look at the workload that an ambulance service has, there'll be some absolutely no brainers. You know, someone’s having a heart attack, someone is having a stroke absolutely the best port of call is not a GP going to see them or a paramedic from the GP service. It's someone who can go and quickly assess that situation and take that to where they need to go, which is normally one of the hospitals in our patch. However, we know that actually when you look then further downstream where ambulances are going, so, not categories one and two, but categories three, four and five, we know that there are many cases that when you monitor data, such as the time to call out, the time can be really long.
And that's not to insult the ambulance team because actually they are just really busy and cannot get to everyone in a speedy way. So, the thought was if we can be part of that pathway and if categories three, four and five could be triaged by our team instead of waiting two hours for a phone call, we can call them within five to ten minutes.
At that point, we can assess what the problem is and actually we can instead of the average time at the time it was set up was about 14 hours for an ambulance to get out there. If we assess them within an hour, we can then hopefully stop someone deteriorating and then around that, I guess the model that we've had with using healthcare assistants and things, that actually our I guess, null hypothesis, was that with these cases it needs to be safe.
It can't be we've just seen someone here and we decided not to take it to hospital. We need to follow that up and it doesn't need to be a doctor going around there to follow up. It could actually be a healthcare assistant who is trained up to do blood pressure, temperatures, pulses, the basic observations that give us the security check with the patient that they feel well and things like that.
If not, that gets escalated back up. But if they do feel well, we will continue to comfort call them or visit them over either a three- or five-day period and try and make sure that not only in that episode where they're not taken to hospital, but over the next, I guess, week that they're safe in their homes.
And I guess it's a really simple concept, but it's had some game changing results in terms of workload and workforce. And although we started that quite small over Peterborough, the ambulance service loves it, and that's back to what I think would be worse in the health system at the moment is competing against each other.
Things should be additive; it should be supportive. We have to understand that you might need some double running costs as you start projects and things like that to allow the ambulance to, you know, to keep the workforce that they've got. But I guess in that scenario, what the thought is, is that we don't necessarily want the ambulance services money. We want to free up the ambulance service to absolutely get to the heart attacks and strokes the cases that need to and not, I guess, be sidetracked by some of the lesser cases that our team can do and the hope being that then beyond the ambulance service, the hospital then are dealing with the cases that they need to deal with and not having to deal with some of the other cases that would have to come in because of that delay.
So, Neil I’ve got a last question for you, and I'm just going to spit it out and I'm sorry if it upsets some people listening, but, you know, I'm fascinated by primary care. Some of the most inspiring people I've met in this in this job with the Confed have been GPs. But I'm going to be honest with you, when I speak to groups of GPs together at the moment for reasons that are completely understandable generally the tone is one of pessimism and kind of fatalism. I've met you before, you're often kind of wheeled out because you're so positive and because of what you've achieved.
Do you have a kind of message for your colleagues about how it is they can have hope and optimism and entrepreneurialism in this really challenging environment where and let's face it, you know you're in a city which I think is one of the most underserved by GPs in the country.
When I talk to GPs who are pessimistic, they often say, well, with there aren't enough of us, but you're in a city that hasn't got enough GPs. So, what would be your message to your colleagues about how it is they create positivity in these challenging circumstances?
I mean, I have to say that for me to continue working, I find that I need to be positive. So, what I need to be doing is working in an empowering environment, and it's not always empowering, but take the rough with the smooth. Actually, what we continue to achieve here is amazing. And so, although I can remember the negatives of that journey, I should also, remember the positives. I think a lot about it is how do we frame the problem; how do we frame our situation and frame the problem?
And I guess I've grown up in a household where I've had two massive advocates in my mum and dad who continually have reinforced that general practice is one of the best jobs in the country. It's challenging - you cry with patients, you go through journeys with patients, and you know, you hear some horrible things, but you've got such an opportunity to have really in-depth conversations, problem solve, take people through Some of the most challenging times of their lives.
And so, the nub of the job is a brilliant job. And I think for most people it's thinking through if you are feeling that the situation is bad now, what are you going to do personally? What is your organisation going to do to make things better? And for me, it's always that balance of how do I make it better for my patients, but how do I make it better for my staff and my team?
And I value those equally, if I might, before the pandemic, I put patients up there higher during the pandemic. And with all of the kind of, you know, challenges that staff have, mental health, financial, all of that kind of stuff, I think they're on the same platform. We should look after our staff and patients as one, you know, and as part of that, how do you keep improving things?
And I don't want to work in a system that, for example, gets the same money for doing the same thing each year. I think getting that sweet spot of looking at the opportunities, picking two or three things that you want to do and be proud of what you achieve. Learn when you fail but be prepared to experiment.
And when you do experiment, be honest about it, when it doesn't work, but when it does work, celebrate that. For me, a lot of it is trying to get my colleagues alongside me locally, but also, I'm very happy to do that regionally or nationally to look at the situation that they're in and reframe that, reframe that as a position of opportunity.
I think what's great with all of these reviews, with all of these commentaries, with all of these, do we need 5,000? Do we need 6,000? do we need 8,000 GPs? We need more GPs. The point is people value general practice, people See the need of the function of general practice to expand, to do more, to be there, more for population.
How do you use that as an opportunity? How do you use the data which tells us we've not got enough GPs? What is the solution? Now, one of the areas that we're thinking about being involved with at the moment is the primary care doctors’ pilot, actually thinking about people moving who have been in the hospital sector, or other things, over to general practice.
And although people could see that as a negative that actually, why are you robbing Peter to pay Paul, but actually it's an opportunity, if you've got someone that's disenfranchised wherever they are, if they've got the opportunity to stay in the country, stay in the NHS and add value to another sector, why wouldn't we allow and enable that to happen?
As I go around the country, Neil, speaking to system leaders, trust leaders, primary engagement is the big, I would say is the single biggest variable. So, I think part of your story is that you've got involved in the place conversation, the fed conversation, and now that's not for everybody. But it is important that primary care does get engaged in that system, place and system conversation, isn't it?
Absolutely. I mean, I think people look at my diary and think how, you know, how do you manage this, you know, alongside having two kids and all of this kind of stuff. The truth is it nourishes my soul. I get benefit from being a GP in the practice I also get benefit in learning at place level, federation level and looking at how scale can get there. And I think each area should be looking for the people that do those things and I guess do it with the right ethos.
So, what a lot of this is not about is how do I use these agendas to make it better for Thistlemoor. A lot of it's about how do I use these platforms and these opportunities to create the space to make it better for any GP practice, PCN place level organisation to flourish, because I believe there's room in the NHS for leadership, there's room for clinical leadership and there's room for service providers as long as they're focused with the right principles. And so, that I think is our job.
I completely agree with you. Neil, thanks So, much for your time. It's been inspirational.
Thank you for coming down to see us in Peterborough.