The success of any at-scale general practice organisation is determined by the extent to which it has a mandate from its practices.  But if you have one how do you keep it, and if you don’t how do you get one?

Simply existing as an at scale general practice organisation does not automatically confer success, even when there may originally have been a contractual basis for its existence (e.g. a PCN) or even a financial buy-in (e.g. a federation).

There is a significant difference between a PCN that has a mandate to carry out activities and establish shared services on behalf of its member practices, and a PCN with no such mandate whose practices simply spend their time seeking to ensure they receive their ‘fair share’ of PCN resources.

A federation with a mandate can often speak on behalf of its member practices and even negotiate local enhanced services for local general practice, and practices will be grateful for what they have done.  But a federation without a mandate will be accused of undermining the local LMC, siding with the commissioners and top-slicing funding meant for practices when undertaking the exact same course of action.

Even LMCs experience this variation. Despite their statutory role some LMCs have very limited influence in the local health economy because they have no clear mandate from their practices, whereas others are hugely influential and commissioners would not dream of attempting to introduce new services without running them via the LMC first because they know of the extent of their mandate with their practices.

So how do at scale organisations establish this elusive mandate, and once they have it how do they hold on to it?

When new at-scale organisations are being set up there is generally a lot of communication and conversation as to what the new organisation is to do, how it will work, and what its mandate is.  But the mistake leaders commonly make is to underestimate the need to constantly and continually reaffirm both the mandate they have been given and their success in carrying it out.

Practices will quickly lose sight of the rationale behind the assignment of any mandate.  4 years on practices no longer remember the original conversations about the role and function of the PCN, and the PCN itself has evolved significantly over this time.  At-scale leaders have to keep this conversation alive.  This relies heavily on communication, the prime purpose of which is to maintain and strengthen the previously agreed mandate.

Mandate relies heavily on trust, in particular the trust that exists between the leadership of the at scale organisation and the practices.  When there is a change in leadership of the at-scale organisation, e.g. a new PCN CD or a new federation leader, the mandate is not automatically conferred onto the new leader.  Rather, the new leader has to ensure that they still have the mandate that previously existed and work hard to build the trust quickly to keep it in place.

There is a type of mandate common in general practice which is that of “silent assent”.  A practice silently goes along with the leadership of the at scale organisation, without ever really engaging.  This is fine while it lasts, but many PCNs are now finding this a problem because some of those practices who were previously giving silent assent have recognised the scale of resources tied up in PCNs and all of sudden want more involvement, and PCN leaders find the mandate they thought was in place no longer is.

If the mandate has gone, then what does the at scale organisation do?  There is no real choice but to work to rebuild the mandate.  As well as conversation and communication this requires a willingness of the at scale organisation to reduce the work it carries out on behalf of the practices, in order to then build it up in future once the required trust has been established.

Start with something small, build trust, and then scale up from there.

It is easy to forget but at scale organisations only exist as an enabler for their practices.  If they have no mandate from them they are not able to serve their primary purpose, and so priority must always be giving to securing this mandate and continually ensuring it is in place.