Methven Forbes, CEO and Owner of Fuller and Forbes Healthcare, discusses the issues facing healthcare’s front door
What was it that made you want to pursue a career in healthcare?
Back in 2002, I was looking for a position, and I found my feet in primary healthcare management. It offered an attractive combination of varied responsibilities, opportunities for innovation, working with people, and using the business and finance skills I had developed through previous positions and education. Two years later, I moved to Leeds due to a change in personal circumstances and took on the role of Practice Manager at a large medical centre there. Two years after that, I was made a Partner, and I remained there until 2017, when I left to found the Fuller and Forbes Healthcare Group.
One of the things that I love about primary care is the scope for innovation and the opportunity to explore new things. The UK has a very complicated primary care system, and there are a lot of moving parts, so there are always unintended consequences from decisions and actions, whether at a service or national policy level. I often describe primary care as a tapestry of interweaving strands. You can pull on what you perceive to be a loose thread at one end, and suddenly it snags at the other end. It’s a very interesting field, as I love multi-faceted environments and working within complexity, particularly when it comes to setting standards and processes and figuring out how to make them work without unintended consequences. Primary care is about as complex as you can get within an industry, I suspect.
How have you achieved operating primary care centres at scale?
We have 17 medical centres located around the country from as far north as Gateshead to Plymouth in the south. We provide a full range of primary care services, delivered by a multidisciplinary team made up of General Practitioners, Advanced Nurse Practitioners, Advanced Clinical Practitioners, Clinical Pharmacists, Physiotherapists, Social Prescribers, and Specialist Nurses. Our services include everything from undifferentiated and undiagnosed healthcare problems to the ongoing management of patients with long-term conditions. We also run additional services, including a city-wide intermediate care service for patients who are able to be discharged from hospital but not quite able to return home, and a region-wide special allocation service for patients not suitable for normal primary care services due to challenging personal circumstances.
Do you think that you have a point of difference from other primary care organisations?
There is considerable variety in UK primary care, ranging from small independent GP practices to groups of medical centres working as single units or collaboratively. Most medical centres are still single-unit entities operating under an unlimited liability partnership model, though this is slowly changing. Variety also arises in governance, service models, and culture.
I am not convinced there is a definitive working definition of primary healthcare, especially when considering what is commissioned, by whom, how services are delivered, and how to handle healthcare problems with non-medical determinants or situations where medical providers are the only option for non-medical issues. This issue is a greater problem than most realise, especially as countries seek to develop primary care systems.
Our point of difference is twofold: the first is our worldview, and the second is the structure, process, and delivery mechanisms. We are a bottom-up organisation. Both Mark and I began working in primary care on the ground at individual sites more than 20 years ago, so we have a practical, hands-on perspective. We have also been involved in commissioning and working collaboratively with other medical centres, which has given us a sense of what works and why, and what does not work and why. We have travelled extensively, learning from others and sharing our own learning, avoiding the trap of simply talking at a high level, instead aiming to understand the details that matter. All this experience influences our worldview and has shaped our development.
In terms of structure, processes, and delivery mechanisms, we have 17 medical centres, all owned by myself and my business partner which makes decision-making far simpler. It does come with risks, which is why we have developed a board of experts made up of committed, passionate people from across the organisation. We work hard at reviewing all the processes of the organisation at an individual site level, taking into account local factors, such as social demographics or culture.
In terms of delivery mechanisms, we have significant experience in multidisciplinary teams and innovative models. For example, I first employed a Clinical Pharmacist in general practice in 2004, over a decade before it became national policy. I have done the same with Practice Matron roles, smartphone apps, and many other innovations in primary care.
What makes us different or unique?
Ultimately it’s a tapestry of components that gives us an understanding of primary care that is as deep as it is wide, and we make this an ethos across our leadership team. The UK context is a complex environment – we often hear people talking about ‘working at scale’, when they mean ‘working at quantity’ or working collaboratively, which is not the same thing. To work at scale, you need to have a depth of understanding to maximise the value of local delivery and local knowledge alongside centralised support and effective governance across all levels.
The result is reflected in our growth from one medical centre covering 4,500 patients to 17 covering 120,000, in the unique governance systems we have set up and the teams we have developed. It is reflected in our innovation, including proprietary solutions we have developed, such as e-consultations and our care navigation tool that supports front-line staff to triage patients so that they see the right person at the right time, given that there are over 55,000 different diseases (according to the WHO) and thousands of medically recognised symptoms. It is reflected in our ability to respond to national programmes. For example, during the pandemic, we became a national COVID vaccination centre (even though we only had three medical centres in Leeds) and yet were able to deliver over 100,000 vaccinations not just to our patients but to patients registered at more than 2,000 medical centres. Finally, it is also reflected in our culture and relationships with patients, staff, and stakeholders. People make a difference, and the right people make all the difference.
How do you align outcomes across different regions?
We align outcomes across different regions through a standardised framework of clinical governance, quality assurance, and performance metrics, while allowing for local adaptation to meet the specific health needs of each community. Our approach involves localised leadership teams that can understand and leverage population health data, develop relationships with local stakeholders and promote a culture of support and learning amongst front line staff. Our scale enables us to support our local leadership team by giving them the training, support and tools to do their job, whilst taking away work that can be done centrally.
Primary care is first and foremost a community-based service rooted in undifferentiated and undiagnosed healthcare problems, and local knowledge is key. But our approach to scale ensures that local teams are the defining feature of our organisation, not a nameless tool for organisational aims. This balance between standardisation and flexibility, local empowerment and corporate governance enables us to maintain high-quality care and align outcomes across all our Medical Centres.
How do you approach the concept of value-based healthcare or VBH?
I have a UK primary care perspective, so my answer is that it depends on your definition of value-based healthcare and the prevailing national institutional culture. The national institutional culture refers to how society has decided healthcare should be funded and provided. VBH is fundamentally about motive and control. Insurers are answerable to shareholders, governments to voters, and clinicians to their patients. Everyone wants value for money but for different reasons. But how do you get value when, as a funder, you are not in control of the delivery process, and when the providers are aware of your duty to shareholders? In a capitated system such as the UK, how do you manage unlimited demand when healthcare is free at the point of need? Can a GP ever deliver enough appointments to achieve patient satisfaction?
I am cognisant of finite resources, and so we must look at it more systemically in terms of value-based healthcare systems and their related dependencies. Training, education, clinical audits, peer review, benchmarking, adherence to clinical guidelines, and HR/contractual processes are the real levers of clinical behaviour. But value-based systems will also recognise the role of public health, patient education, social determinants, and other factors that impact activity.
At a site level, we recognise that everyone deserves a base salary. But we also recognise that different types of incentives have value in terms of productivity and efficiency, so we have introduced schemes for different types of staff.
Do you see a solution to this conundrum?
Focus on being clear about what needs to be delivered, using the best available evidence, understanding the limitations, identifying what can and cannot be controlled, and recognising the resources available. We also need to acknowledge that people’s lives are complex, influenced by a wide range of social determinants that impact their health. Primary care is on the receiving end of these complexities, making it impossible to determine a definitive figure for what VBH actually costs. Instead, we should remain aware of all the factors outlined above and ensure we are positioned to continually evolve, adapt, and learn. This requires both a system view (value-based healthcare system) and a local view where people make the difference.
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