Vertical integration - the answer to effective patient care?
18 Mar 2019
In January 2019, our non executive director and lay member discussion panel explored vertical integration (VI) between GPs and secondary care providers.
What is vertical integration?
With VI, the Trust brings together partners to blur the line between primary, secondary and community care; breaking down the barriers between them for the benefit of all.
This is an exciting option for GPs at a point where most people agree that the structure of primary care needs to change. VI could be the answer to the provision of effective patient care, removing issues of scope, responsibility, funding or differing objectives through better coordination of healthcare delivery.
We invited Sultan Mahmud to discuss his experience at Royal Wolverhampton NHS Trust, where he is director of integration.
Sultan’s work has seen the integration of doctors and staff from nine former practices, now employed by the Trust, which went live on 1 June 2016. These nine practices provide primary care to over a third of registered patients in the area (approximately 262,000 people).
VI In Wolverhampton
The initiative was conceived because the Trust recognised that GP practices have an amazing capacity to support improvements in healthcare. An excellent example of where VI can improve services is in multi-morbidity, where patients may move from one pathway to another. This can quickly become chaotic and difficult to manage, with multiple appointments, diagnostic tests and other interventions that could be delivered much more efficiently.
The GP’s name remains attached to the surgery in this form of sub-contracting, but the GP is effectively an employee of the Trust, which also handles Care Quality Commission (CQC) registration. This means practices remain active members of the Clinical Commissioning Groups (CCG). There are additional benefits for GP practices in the area not employed by the Trust, including access to the innovative Integrated Data System.
The Trust recognised that combining data with that of GP practices would provide better information on public health.
This approach has exciting potential. Significant positive impacts are already showing in Wolverhampton, with patients having better access to their GPs and primary care professionals like physiotherapists and pharmacists. Vertical integration also gives patients a voice in practice meetings.
Trust assessments provide valuable insights. For example, the Trust found that 5% of patients will use 60% of the practice budget, and as a result GPs have been able to put longer appointments in place to deal with complex cases.
For GPs, this system provides support where it is most needed. In Wolverhampton the GPs were running small businesses, with all the distractions of practice management instead of practicing medicine. Through VI the Trust offered business development, access to its HR department and a space to do things with the data.
GPs are seeing record attendance, but funding has remained relatively flat. Since this shows no sign of improving, there is definitely an appetite for a new way of working.
The big question now is how to deliver and scale VI into other areas, and how it would work in various scenarios. The Trust has a very clear view of how to approach VI: “You start with one practice and get them up and running before you move on. If it grows organically, you adapt as you go on. Every health economy is different, and this should not curtail or prevent progress which directly benefits the patient and the public purse.”
The Trust has developed a manual to support other health economies setting this arrangement up, saving considerable costs (like legal advice) in implementation. The Trust is confident that this model is scalable and is working with other health economies on their plans.