Ockham Healthcare: Supporting innovation in General Practice

Why scale isn’t the answer for General Practice

Ben Gowland argues that working at greater scale is not the panacea for General Practice that some would have us believe.

To many outside observers the problems facing General Practice seem quite straightforward. There are nearly 8000 small businesses, many of whom are finding their current business model to be unsustainable. Clearly what is needed is for there to be a consolidation of the businesses, so that there are fewer, each of a bigger size, with greater operational and financial resilience.

But is this really the answer? Reports have emerged recently about a federation in Doncaster going into administration after running into financial difficulties. Not only did operating at scale in this instance fail to provide the answer to the current pressures for this set of practices, but it also cost them as much as £20,000 each to find this out.

Operating at scale can help practices. But it is not a solution in itself. Rather it enables other solutions to be put in place. It means the practice can cope better with staff who want to work part time, it creates the critical mass to introduce new roles, and it enables the provision of sufficient management capacity for further change. Larger practices can access more capital, invest in buildings and technology, and play a much larger role in changes across the whole system.

But these benefits are not automatic. They are not delivered simply because the practice is now operating at a greater scale. If two or three practices merge or form a federation these benefits will not necessarily follow.

This is because the journey is often not straightforward. As one GP put it to me recently, “(these changes) have the potential to help the practice but if they are introduced badly they could also make things worse… Working as a group could definitely improve things if developed well, but could also drain effort and resources without giving enough benefits in return”.

Ultimately it is the way the change is made that is important. Not the practical legal governance issues (these are straightforward enough), but the engagement of hearts and minds, the development of a shared set of values, and the setting of common goals that will determine success or otherwise for those parties deciding to get bigger together.

The right question is not to ask whether operating at scale is an answer for General Practice. Rather it is to ask; are practices capable of changing the scale at which they operate? Does the expertise exist in General Practice to ensure the benefits of getting bigger outweigh the effort and resources required to get there?

In pockets the answer is yes but in general it is no. Some practices can, and have, made changes that have delivered huge benefits for them. But many practices are stuck in a vicious circle of increasing workload and worsening finances, and haven’t the capacity for a discussion about whether to make a change, let alone to implement anything significant. Telling them to operate at scale, or even employ a pharmacist, or introduce web-based triage simply is not going to help. And using a contract to try to force the change misses the point: the issue is capacity and capability to change, not resistance to trying something new.

Operating at scale is an answer for General Practice, but not the answer. The answer is headroom for practices to make changes to the way they operate; it is help with the process of identifying and making these changes; and it is resources to make these changes happen.

General Practice or CCG: Time for GP Leaders to switch?

I recently tried to persuade a GP leader (Dr S) to leave his CCG and spend his time helping core General Practice instead. Here is how the conversation went:

Me: The time has come for you, and GPs like you in leadership roles in CCGs, to step down from your CCG role and instead use the skills you’ve developed over the last 6 years to lead General Practice out of its current crisis.

Dr S: I can’t begin to tell you how bad an idea I think that is! First off, I don’t think it is my job to change General Practice.

Me: So whose job do you think it is? Seriously, if it is not your job, whose job is it? NHS England do not think it is their job, and you certainly cannot believe it is the Government’s! Only GPs really understand General Practice. You are now a trained system leader. General Practice needs you.

Dr S: But I‘m needed where I am. CCGs have to be clinically led, and need GPs like me to stay in place. Otherwise they will become just like PCTs.

Me: You yourself are always telling me how serious the crisis in General Practice is. If it really is in such a bad way, why are you not switching your efforts? What is more important, the badge of clinical leadership for CCGs, or the future of General Practice?

Dr S: I have invested a lot in the CCG. I want it to succeed. I don’t want to let down all those I work with in the CCG. I would feel like I am abandoning them.

Me: I understand how you feel, but at the same time you are letting down your GP colleagues, current and future, by not focusing your efforts on General Practice. It is the system’s job to look after the CCG – it is, after all, a statutory body. It is no-one’s job to look after General Practice.

Dr S: But I can do more benefit for General Practice here in the CCG. I control the money here and I can make real change happen.

Me: First, the CCG bureaucracy around conflicts of interest means the change you can effect in General Practice from within the CCG is extremely limited. Second, contractual change is not the answer General Practice needs. It needs to change from the inside, with leaders like you working across practices, winning hearts and minds, finding a way forward.

Dr S: Even if I wanted to leave I couldn’t because my practice needs the CCG money. I won’t get anything for working with General Practice. If I left the CCG I would just have to go back to full time clinical work.

Me: You are right that the incentives in the system encourage GP leaders to remain in CCGs rather than support General Practice to change. At Ockham Healthcare we make the case that the money you earn in the CCG should be transferred with you if you want to make this move, so that you are paid the same for carrying out work to support the development of local General Practice as you are in the CCG. (You can read the report here)

Dr S: But we are talking about over £70K per year. How would this work in practice?

Me: Your CCG could choose to fund you, or indeed any of the GP leaders in your CCG, to work in General Practice by seconding you on full pay on the basis of the benefit this would bring to the system as a whole. You don’t need anyone else other than the CCG itself to agree it.

Dr S: But in the CCG I have a clearly defined leadership role, and everyone understands what it is. What would my role be if I If I left the CCG? Would there even be a role?

Me: There won’t be a marked out role, but there is a huge leadership challenge. You will have to establish your role and gain acceptance from your peers for it. No-one said this would be easy!

Dr S: The problem is I have burnt bridges with many of my colleagues as a result of my CCG role. I am not sure my GP colleagues want my help!

Me: First and foremost you are a GP. You understand General Practice. The fact you have made tough decisions in the past and stood by them in the face of peer resistance shows you are a leader of courage and integrity. You are exactly what General Practice needs. General Practice has to make some difficult decisions about how it is going to change and adapt going forward. Some are not going to like it and the challenge is going to be taking everyone with you.

Dr S: That is very generous, but I am not sure however hard I try that I will be able to persuade my GP colleagues to change.

Me: If you don’t believe that General Practice can get out of the situation it is currently in, do not expect anyone else to. Everyone can change with the right leadership, resources and support. If anyone is capable of helping your colleagues to change, it is you.

Dr S: But where would I go? What would I do? I am not sure I would even know where to start.

Me: You could do worse than following the advice of John Kotter. You would start by listening to your colleagues and really understanding their problems. You would share the experiences and ensure everyone understood the urgency of the situation and the need for change. You would create a change team around you. You would build a vision for the future. You would make sure everyone bought into it, and you would communicate it over and over and over again. You would move to action, creating quick wins to develop momentum. You would build on early successes and make bigger and bigger changes. Eventually you would embed these changes in the way that General Practice operates, completing the transformation.

Dr S: Maybe the idea is not as ridiculous as I first thought! I am not sure what to do

Me: Either General Practice is in trouble or it isn’t. If it is, it needs your help. Don’t leave it to others. Don’t take the easy route of staying put. Take up the challenge. Make the move. Use the skills that you have developed in the CCG to give General Practice a chance. Don’t do it for yourself, do it for your colleagues, do it because you believe in General Practice and the role it plays in the system and the difference it makes to patients. Do it because it is the right thing to do.

Should GP Leaders be leaving CCGs and supporting core General Practice? Let me know what you think: email ben@ockham.healthcare or via twitter @BenXGowland

Give us our daily bread

I am a bread maker. I know which ingredients I need to make the perfect loaf. I know how long it takes. I know how much the ingredients cost, how much of my time I need to put in, and how many loaves I need to sell at what price to make a living.

As a bread maker, I know my customers. I know if I make really great bread I can sell at a price higher than that in the supermarkets because my customers appreciate great bread. If the cost of the ingredients goes up, I can raise my prices and my customers might not like it but they will understand. I can still make a living.

In the NHS the life of a bread maker is much more complicated. When I sell my bread to the NHS, I am not selling it to my customers (the people who eat my bread). I am selling it to “commissioners”, who are buying that bread on behalf of patients. The job of commissioners is to make sure patients get the best possible value for the money invested by the government in the NHS, and they take this very seriously indeed.

Problems arise when the cost of my ingredients go up. I say to the commissioners, “the cost of flour has gone up, and so I will have to raise my prices”. But according to the commissioners this is my problem. They insist that I make more bread for less money, despite the rise in the cost of ingredients.

So what do I do? I can either make lower quality bread, putting less care and attention into each loaf. Or I can work longer and longer hours making bread, and pay myself less and less money to offset the rise in the cost of ingredients. Eventually, I have to do both.

I go back to the commissioners and say that I can’t carry on. My bread is no longer of the same quality and I am close to burnout.

Finally, they listen. They say they understand the problems I am facing. They say they are going to give me more money for my bread. On one condition: that I make bread 7 days a week. Patients should have fresh bread 7 days a week they tell me, and that is what they want in return for the extra money.

I say, “But I need the extra money because my costs have gone up. My costs will go up even more if I have to make bread 7 days a week. My business will still be in trouble”. “Money is tight for everyone” the commissioners reply, “we need a return for the extra money we are investing”.

I don’t understand this logic. If flour costs more, I need more money to make bread. I cannot absorb the cost and still make great bread and still make a living that will support my family. Sometimes costs go up. Sometimes people have to pay more for the exact same thing. When I sell directly to customers they understand this.

I agree with commissioners that patients should have fresh bread 7 days a week. I am happy to work with my fellow bread makers to work out a way that we can do this between us, and as long as we are reimbursed for the costs of doing it then we can provide it. But not now. Not while my business is facing such severe challenges. If commissioners paid more money so that I could meet the costs of making bread, and I could get my business back on track, then I would be at a point where I could work out how to make fresh bread available 7 days a week. But not right now.

I would be happy to agree to change the way I make bread in return for extra money. I would be happy to explore how I could find different types of labour, work with other bread makers and other organisations, and find ways that would enable me to still make great bread at lower costs. If the commissioner would invest extra money to help me make these changes I would be up for the challenge.

But if nothing changes, I do not think I will be able to make bread for the NHS any more.

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