When I am not working with general practice I spend much of my time playing tennis.  It is fair to say I am something of an addict!  One of the key principles we use in tennis when learning something new (for example improving your backhand) is the idea of “progressions”.

Progressions are where you break down a complex task (your backhand) into a series of easier steps working up to the final result.  You start with something relatively simple, and then when you can do that task consistently you move onto something slightly more difficult, and then focus on that until you can do that well.  For example, first you hit a ball that is dropped next to you, then one that is fed to you from a coach’s basket, then one that is hit in a friendly, collaborative rally etc etc.  You continue to progress until ultimately you can hit your new improved backhand on a regular basis.

But if you start off by watching Roger Federer’s backhand on YouTube and then immediately try and hit it like Federer at full speed in a match situation you will inevitably fail, and revert to your old (not very good) backhand.  You have to work through the progressions so that you learn how the shot feels, what adjustments you have to make, and make them habits that you can rely on in a match situation.

This idea of progressions applies equally to PCNs and joint working between practices.  If a group of practices start off by trying to run a shared urgent care service across core hours without ever having worked together before it would most likely run into serious problems very quickly and the project would have to be shelved.

Instead the group of practices in the PCN need to learn how to work together by using a series of progressions, steps of increasing difficulty and complexity, so that they can learn ways of working together that will enable them to do more and more together.

What, then, might these progressions be?

There is no set answer to this question (the principle being only that it should be a series of actions of increasing difficulty where each progression is more difficult than the last).  An example of what these progressions could be is (and let’s assume here a PCN of 4 practices):

1. The 4 practices share a resource, e.g. a pharmacist. They adapt how they do this until they can do it in a way that means that all the practices feel they are benefitting from the shared resource, no practice is feeling hard done by, and the pharmacist is happy.
2. The 4 practices work together on a shared project that creates additionality for the practices, e.g. a first contact physiotherapy service. The practices find a way of working together so that they can agree on the location and operation of the new service, how it is organised, how they can use it, and how they can benefit from it.
3. The 4 practices work together on a project where there is individual accountability for each practice, e.g. delivery against a key IIF indicator. This is more difficult than the previous step because the practices have to work out how accountability and support will work across the practices, i.e. what happens if one practice is not able to fulfil its delivery requirements.
4. The 4 practices work together on a project that impacts how each practice operates, e.g. a shared document management hub. Here the individual autonomy of the practices has to be replaced with a standardised way of operating across all 4 of the practices, which creates a new layer of complexity and difficulty.
5. The 4 practices work together on a project that impacts how core clinical services are delivered in each practice, e.g. a shared in-hours urgent care hub. Now the practices have to work out how they can work together on the delivery of clinical services that have always historically been the domain of individual practices.

This is only an example set of progressions, but hopefully you can understand the idea.  As the 4 practices in the PCN work through the progressions they work out what clinical and managerial leadership they need for each type of new initiative, what communication across the practices is required, what the data and reporting requirements are and how these need to work, how support for individual practices within the group should best function, how to deal with differences of opinion without it derailing projects etc etc.

PCNs cannot expect to be effective at delivering core clinical services together if they have not worked through some progressions.  Just like we will revert to our old backhand because the new shot is too difficult, so the practices will simply try to find ways of continuing to work in their own autonomous ways if the starting point is too difficult.

Where PCNs are struggling to work together the starting point needs to be something that they can do together (however small) and then build progressions from there.