One of the key questions facing all practices is how much effort they should expend in collaborative working through their PCN, and how much they should strive to retain their independence and own way of doing things.  But the choice between the two is not as binary as it at first appears.

This Harvard Business Review article maintains that all work relationships fall into one of five categories:

1. Collaboration (allies) – Merging self-interests with the interests of others
2. Cooperation (friends) – Maintaining self-interests while also advancing joint interests
3. Maximum possible independence (neighbours) – acting to neutralise the impact of others on self-interests
4. Competition (rivals) – working to deter another in order to protect or advance self-interests
5. Conflict (enemies) – trying to defeat or deny another’s interest

There are some important distinctions between these relationships.  Collaboration involves parties investing in the relationships to help each other.  The benefits of these relationships are the greatest for GP practices, because it means the maximum value can be derived from shared assets, such as ARRS staff and back office teams.  It means practices can potentially realise benefits beyond those that come simply from accessing PCN resources.  The drawback is that these relationships are hard to disengage from should interests change.

Cooperation is a step down from collaboration, where practices choose to work together on specific issues where interests (e.g. availability of PCN funding) align, but simply not to compete where they don’t.  This limits any potential benefits of joint working to those that come from (in our case) PCNs but nothing more.  Should PCNs end then there will still be things that need to be unravelled, but nothing too problematic.

Neighbours is where what practices are actually trying to do is maintain the maximum possible independence.  Practices deliberately reduce their reliance on others as much as they can.  This is where practices want control of their own ARRS staff, and don’t want them grouped into functioning PCN teams.  It limits the benefits that can be derived from PCN resources, but maintains practice independence.

It seems to me that in the vast majority of places now the challenges facing general practice have reached the point where practices no longer feel in competition or even in conflict with each other.  Maybe we sometimes still see it when APMS providers arrive on the patch, but other than that practices generally recognise that practices are in this together, and there is little value in making things even harder by fighting with each other.

The problem many PCNs face is that different practices within the PCN are at different places on this spectrum.  While some may be up for full collaboration, others are striving to maintain their independence.  It is very difficult for a PCN to be effective when what some of the practices are doing is rebuffing any attempts at cooperation, let alone collaboration.

What is needed is to try and get all the practices to agree on the same approach.

The critical point to understand here is that the independence question for GP practices is inextricably linked to the question of sustainability.  If a practice is not sustainable, ultimately it will lose its independence, at the point at which it is either forced to close or is taken over by another provider.  The best chance a practice has of being sustainable into the medium term is by collaborating with other practices, and making the most of the scarce resources that are available to practices.

While it feels counter-intuitive for practices, not to mention risky, the best way to maintain their independence is through collaboration.  For those leading PCNs and joint working initiatives across practices the starting point has to be building a shared understanding this is true, along with the trust needed to mitigate the risk.  How will the practice survive for the next 5 years? How will it navigate the challenges we know are coming down the line, on top of the rising demand and falling GP workforce?  How will it be able to maintain its independence within this context?  What role can the PCN and collaboration play in answering these questions?

Building a shared understanding that collaborative working is the key to maintaining individual practice independence, rather than a fast-track to losing it, is the starting point for successful PCN working.