Is general practice easy to do business with? The prevailing wisdom of the day is no, general practice is not easy to do business with. One of the big gaps identified in the Five Year Forward View was the one that exists between general practice and, well, everyone else. In a world of integrated care systems the NHS needs general practice to be easy to do business with. It needs general practice to be an active partner in the new arrangements because it recognises integrated care won’t succeed without it.

Being easy to do business with benefits practices as well as the system. It means more resources can be directed into primary care, aligned to the impact this investment will have on the system as a whole. It means general practice not only has a voice, but can shape changes to the system in a way that makes sense for its patients. It means the problems of distance from the community providers and the hospitals can be tackled not via fruitless arguments in a contracting room, but in practical changes that impact how services operate.

Why is general practice not easy to do business with? It is essentially a numbers game. The average hospital serves a population of about 300,000. The average practice serves a population of 8,000. So that is an average of 37.5 practices for each hospital to be doing busy with. It is an unsustainable number of relationships for a hospital to maintain. Community trusts serve population sizes of over a million, exacerbating the problem even further.

Enter general practice at-scale. Much of the drive for general practice at-scale is to solve this numbers problem. If general practice is organised into units of 30-50,000 there are only 6-10 relationships needed for an acute trust to be able to partner with general practice. If it is organised into larger federations of 200-300,000, then this number may be reduced to 1 or 2.

But there is a danger of being too greedy. The greater the distance of the general practice organisation from its practices (i.e. the bigger it is), the harder it is for it to really represent the views of its member practices. And of course with integrated care it is not just about presenting views, it is about changing models of care. If the system pulls the (newly created) general practice lever (in the form of the federation) but nothing happens, all we have really done is add to the complexity by increasing the number of organisations.

Hence the value of at-scale general practice lies in the strength of its relationships with its member practices. I write a lot about the importance of trust between practices and their network/federation leaders, but it is because it is so crucial. If these leaders sit around the integrated care table and cannot commit their practices to anything, and spend their time explaining how complex the general practice landscape is because practices are independent contractors, then the gap between general practice and the rest of the system has not really been closed.

But if these leaders can sit around the integrated care table and make decisions on behalf of their practices, firm in the knowledge that whatever direction they choose the member practices will follow on the basis of their belief and trust in them, it means general practice is, at last, easy to do business with.

A paradox is, “a seemingly absurd or contradictory statement or proposition which when investigated may prove to be well founded or true.”

Try this one on for size… In order to retain autonomy GP practices need to give up autonomy. Is that absurd or true?

It is, in fact, The Autonomy Paradox!

The first question we need to consider is “why is operating at-scale of benefit to practices?” It is because, the argument goes, costs can be reduced, income can be increased, and new ways of working and new roles can be introduced to reduce workload.

But none of these things can happen without practices operating together as a collective. The group of practices working together “at scale” need to agree to a single way of doing things in order for any of the benefits to be realised.

For example, they all need to agree to move to a single accountant, or they all need to agree to a new paramedic-led visiting service, or they all need to agree to cross-refer their dermatology patients to one of the practices rather than sending them directly to the local hospital. Some practices will gain more than others from each change. One practice may have very cheap accountants, and my gain little or even lose out by the shift to one accountant across the group, but by that practice agreeing to it the group as a whole gains. Equally another practice may have a very low level of visits and so introducing the new paramedic model may feel like it is more trouble than its worth, but by participating the group as a whole benefits. The benefits of individual changes are rarely shared equally.

This, of course, is where difficulties set in. In my work with practices up and down the country, I am yet to go to an area that has introduced extended access without disputes about differential utilisation between practices. There is a deep seated reluctance for any practice to agree to a change that benefits another practice more, let alone one that might create a worse position for itself “for the greater good”.

But for operating at-scale to work, this is exactly what is required. For working together to deliver the maximum overall benefit, practices have to be prepared to make individual decisions for the benefit of the group, and trust that the overall benefit of working together will come to them.

Of course this is not the only option. Practices could fully merge, and then the single entity gains the benefit, rather than them being (differentially) apportioned across participants. But what is the cost of this for the original practice? In this (merged) scenario the practice has given up its independence altogether to become a new (admittedly independent) organisation. But it is no longer in its original state, with the freedoms that brought. The cost of receiving an equal share of the benefits was for the original practices to give up their independence altogether to form a new practice.

As the scale of the required changes grows, so does the problem. At what point, or at what size of practice, do we declare we no longer have independent general practice, but rather a group of (GP-led) corporations running the majority of services? Is this future worth it in order to ensure that at each point benefits are shared equally between practices?

In order to retain autonomy GP practices need to give up autonomy. If practices choose to cede some decision-making to the collective, so that benefits can be achieved at the group level rather than solely at an individual level, practices could retain their independence. They could avoid the need to either merge into larger and larger practices, or reach a dead-end when getting out is the only option remaining.

The choice is not either independence or dependence. Inter-dependence, and using federations, networks and the like to create this, is an option that allows practices to stay as separate units but enjoy the benefits of scale. But it requires practices to give up some autonomy in order to retain overall autonomy.

The key success metric for at-scale general practice, the one I would be monitoring most closely in my own at-scale general practice organisation, is trust. Do the practices trust the federation/network/primary care home/insert local name here?

Why? It is because at-scale success, one that is to genuinely support GP practices, depends on practices giving up some degree of individual autonomy to the at-scale organisation. And this will only happen where there is trust. Without trust, practices will work to protect individual autonomy, not give it up.

So how can any at-scale general practice organisation build trust with its member practices? An interesting place to start is Charles Green’s trust equation. The equation is:

Trust = (credibility + reliability + intimacy) / self-orientation

This is summarised in a Harvard Business Review article (here). Credibility is the perception of credibility, and ultimately stems from whether practices think the organisation is honest and truthful, and whether they think what it says can be believed. Reliability is again a perception, of whether the organisation will do what it says it will do. Giving up any sort of autonomy means a practice needs to believe those to whom it is giving up autonomy can deliver on their promises. Intimacy is the willingness of a practice to trust the at-scale organisation with something. This needs a relationship between the two to exist.

But what strikes me as most interesting about this equation for at-scale general practice is that the denominator is self-orientation. This is the extent to which practices believe the focus of the at-scale organisation is on itself rather than on the member practices. The stronger the belief held by practices that the federation or network is primarily concerned with itself rather than its member practices, the greater the extent to which trust is lost.

How, then, can such an organisation reduce self-orientation? What can it do to build confidence with member practices that it is genuinely there to support them?

Create opportunities for practices to speak. Often communication between at-scale organisations and practices is one way. The federation or network will report back on what it is doing, and explain its plans going forward. But what is equally important is to enable practices to talk about what is important to them. Often the best way to do this is for leaders to visit individual member practices with the sole intent of listening to what the practices have to say.

Listen with intent. Creating the opportunity for practices to speak and then taking no action as a result is probably worse than not doing anything. It is simply lip service. The more practices feel you are listening to what they are saying the more they will engage, and the less they will feel you are simply carrying on with your agenda regardless of anything they have to say.

Take responsibility when things go wrong. A clear signal that organisations are oriented to themselves is when they blame others for failure. This might be the practices, the CCG, other federations, the government (the list can go on!). By taking responsibility, and by being transparent, practices can start to see that you have integrity. Avoiding the tendency to blame others shows you are committed to delivery, and that your focus is more on making things work for practices than your own reputation.

Trust is hard to win and easy to lose. Guarding against self-orientation, and actively keeping focus on the needs of member practices is one of the best ways for at-scale general practice organisations to build and maintain trust.

In last week’s blog Ben suggested that spending time and money on lawyers whilst developing new federations might be a mistake. But Craig Nikolic, Chief Operating Officer of Together First (a GP federation in Barking and Dagenham) had different ideas. So this week he gives us his take…

Ben Gowland’s blog piece on the Perfect Governance Model for GP Federations hits the spot on most areas and is correct that Federations that overdo “governance” are setting themselves up to become cumbersome and inefficient. Where I disagree with Ben is in the commissioning of professional advice.

For the vast majority of the NHS, the statement “it’s time to get the lawyers in” means that something has gone wrong and it’s often far too late. Most NHS senior managers have only seen lawyers in outright firefighting mode where they’re trying to fix problems, and doing it expensively.

To someone like me who has spent most of their career outside the NHS, this is a strange phenomenon and makes about as much sense as refusing to spend £100 on fire extinguishers then later complaining when you call the fire brigade to stop your business burning down.

A good lawyer or accountant, or even both, brought in early can be a very positive event when you’re doing business transformation. The trick is understanding what lawyers can do for you. For most NHS folk, lawyers are there to help you get over negative legal problems, or to legally threaten someone else, and they’re expensive. On the positive end of legal advice, it can be substantially cheaper to get a lawyer in early than put it off then find out when it’s too late that you’ve got it all wrong.

In Barking & Dagenham, we’re undergoing substantial transformational change and there’s a few areas where we’ve had uncomfortable experience of things going the wrong way because of the standard NHS “gentleman’s agreement” or a vague MoU over a critical piece of our business. We brought in lawyers and accountants to make sure our new plans get it right first time.

I’ll give a few of examples:

• Take a GP Federation that wants to hold APMS/GMS/PMS contracts yet has GP practices in its area that are corporate bodies, say other APMS practices. Do you know absolutely and beyond doubt how your Federation can hold those contracts and also have the corporate body as an equally represented Federation member?
• Do you do business with other NHS organisations by MoU? What’d happen if the other organisation said tomorrow “sorry, but that’s it, we’re stopping this deal today and you have no comeback because MoUs aren’t contracts”. That happens far more often than you’d think in the NHS.
• Could your Federation’s books cope with a substantial amount of delegated commissioning if it suddenly came from the CCG? How could you track the financial viability of each LIS or contract? Are you confident that your cash flow could keep up with the slow nature of centralised NHS payments or payments from other care settings such as acute Trusts?

Getting formal legal and accountancy support on those items is not expensive, the trick is working with them properly. On lawyers especially, work with them, tell them in detail what you want to accomplish and how you’re planning to do it then put the open statement: “tell us the risks in what we’re doing”. It’s your plan, not theirs, you must put the hard work in first. Most NHS people dealing with lawyers give them nothing but vague statements and then say, “tell us how to do it”. You then get lawyers responding in the most risk-averse way possible with a contract that does nothing but lock people into onerous and negative terms. See the difference?

Imagine a GP referring a patient to a Consultant, you’d grumble at a GP just referring on and saying “patient is not well, tell us what to do” and giving nothing else, yet that’s what lawyers dealing with the NHS often get. Most of the money lawyers charge the NHS is spent doing their equivalent of “What do you mean by not well? Come on give us a clue, is it his leg? Maybe his arm?”

We did the positive work with our lawyers, we built a good relationship over overwhelmingly positive items and working through our already very robust plan. We got reassurance that most of the stuff we were doing was perfectly fine and had a legal opinion we could give to Commissioners and others to prove it. We changed track on a couple of minor points to address legal issues we simply didn’t know existed. We now have a clear idea of how to work well with other NHS organisations without having to get into regressive and negative protectionist contracts. Most importantly though, we know for sure that our plans are fit for a very flexible future that could go all the way from staying the same size all the way through to becoming a super-power Federation.

That’s it. Done. A simple, low bill to lawyers and we now have a clear foundation that’ll do us for years, protecting us from most negative events and giving us simple tools to help us do business more efficiently.

For me, that’s a no-brainer and I’d be in dereliction of my duty as a professional senior NHS manager to not take advantage of such an easily accessible resource.

One of the problems I have been grappling with in recent weeks is trying to work out why there is no single, universally applicable model of governance that GP federations can adopt. I have seen governance models that have worked really well in one area be a real hindrance to progress in another, and I wanted to understand why.

What has helped me unpick this is thinking about organisational life cycles. If you are not familiar with these, essentially each organisation goes through a life cycle from creation through to termination. People who look at these things have found organisations do not progress through a series of random events, but rather through an expected sequence of stages. These are start-up, growth, maturity, renewal and decline[i].

Different organisations go through these stages at different rates. Some companies like Blockbuster Video and Boo.com (anyone?) came and progressed quickly through to decline, while others like Colgate and Cadburys feel like they have been around longer than most of us can remember. Some, of course, never make it out of the start-up phase.

This helps us understand why the ‘cut and paste’ model of federation governance doesn’t work because the governance needs of an organisation vary according to the stage of development it is at. In a start-up it is generally all hands on deck with everyone (including the board) doing what is needed to get the idea off the ground. During the growth phase the board is more focussed on plans and policies. And as the organisation gets to maturity the focus of the board is much more on strategy, risk management and holding the leader/CEO to account.

This means asking “what is the correct governance for a GP federation?” is actually the wrong question. The right question is “what stage in its organisational life cycle is the GP federation at?” Once that has been established, we can match the appropriate governance to it.

The trap I see many GP federations falling into is failing to match the appropriate governance with where they are in the organisational life cycle. In particular, many GP federations are in start-up – they have developed a shared vision/mission across the member practices, and there are a small number of leaders trying to maintain engagement and enthusiasm while at the same time getting projects off the ground to prove the worth and value of the organisation. But they spend their time investing in lawyers and developing complex governance arrangements that are appropriate for a more mature organisation.

It is hard enough being a start-up organisation. There are so few people trying to do so much, at the same time as having sceptics to convince. The precious limited resource that is the time and energy of the leaders needs to focus initially on getting ideas off the ground and turning them into action, and of convincing stakeholders that this really is the future. Spending it on creating overly complex governance structures at this stage diverts energy from where it is really needed (as well as being expensive!).

Meanwhile, the high performing federations have already been through the start-up stage. They may even have gone through rapid growth. So the governance they now have is of a mature organisation (looking at strategy, risk management and holding the leaders to account). This is appropriate for them now. But it wasn’t appropriate when they started, and simply because you aspire to be like them doesn’t mean that it is appropriate for your organisation now either.

There is no single perfect governance model for a GP federation. But being clear on where your federation is on its organisational life cycle is the best first step you can take to determine what the most appropriate form of governance is for you.

[i]  Lester, D., Parnell, J. and Carraher, S. (2003). Organizational life cycle: A five-stage empirical scale. International Journal of Organizational Analysis, 11(4), p.339-354

We discussed in last week’s blog the importance of federations establishing a mandate from their practices, but that is only half of what is needed. To have influence, federations also need to build relationships with other organisations.

A common misconception is that attendance at meetings is the same as having a voice. It is not. If a GP sits through a meeting and has no impact on the outcomes then general practice has not had a voice. In fact it is worse, because other organisations can point to the fact that general practice was represented, even though it didn’t influence any of the decisions made.

This is not an uncommon situation. Understaffed federations, often reliant on the goodwill of a small number of individuals, are asked to attend a plethora of system wide meetings as the NHS works up a head of steam in its shift towards integrated care. It becomes a case of finding someone to go, and the poor GP who attends sits there, often without a clue what is going on.

The reality is, of course, that while meetings are often the end point of a decision making process, they are rarely the start of it. In a world of integrated care, the starting point is much more about relationships.

I was working in an area where the federation formed a strong relationship with the local acute trust. The Chief Executive of the hospital was supportive of the local GPs. They worked together on creating a primary care front door at A&E. When the federation needed someone to host the employment of the pharmacists to work in practices, the hospital stepped in. Then the CCG put community services out to tender. The hospital Chief Executive and the federation leadership had a conversation and decided to put a (ultimately successful) bid in, in a model whereby the hospital hosted the contract, but looked to primary care to provide leadership as to how it would be delivered in the local areas (which is exactly what the GPs had been asking for).

This change came about not because of what happened in meetings, but because the federation had built a relationship with the local hospital. To have a voice, to have influence, federations need to build relationships.

There are some really important relationships federations need to have in place. The LMC for one. Federations and the LMC need to work hand in glove together to ensure the voice of general practice is as strong as it can be. Practices are not going to trust the federation if the LMC doesn’t.

Other local federations in the same area are also key. Ultimately they are not competitors but collaborators seeking (more or less) the same thing.   Disagree in private, work out a way forward, and agree in public. If general practice is arguing with itself around the integrated care table, the power of any individual federation’s voice will be lost.

And as in the case of the federation who ended up being able to control the shape of community services in their area, a strong relationship with at least one local statutory organisation (whether it is the hospital, or the community trust or the mental health trust matters less) means when the bigger opportunities come along, the federation is in a realistic position to be part of the conversation.

These are the two foundations federations need to develop to create a strong voice: a mandate from their practices; and strong relationships across the health and social care economy. Next week we will explore how federations can turn these foundations into a voice which has impact.

Vineet Nayar is famous for what he stood for: “employees first, customers second”. He became CEO of HCL technologies and transformed its fortunes. He believed passionately that the firm itself did not add value to customers, but its employees did. The role of the firm was to build trust with its employees and empower them to make the changes that might at first sight appear impossible.

He was transparent about information and about the firm’s weaknesses with his employees in ways most companies would never dream of. He did this to build trust between the leadership of the firm and those who worked there. The firm was not telling its employees the answers, it was being honest about the challenges of the current situation, and enthusing, encouraging and enabling the employees to make a difference to it.

There is a 10 minute YouTube interview with Vineet about “employee first, customer second”. It is well worth a watch. I think it is entirely relevant to federation’s thinking about their role and the mandate they have from practices. What do federations stand for? Is it “practices first, patients second”?   Is the role of federations to transform patient outcomes directly, or to enthuse, encourage and enable practices to work together and do this themselves?

Federations need to stand for something. To be the “voice” of general practice in the new world of integrated care, federations need a mandate from their practices. To gain that, they need to be clear what it is they are articulating on behalf of their practices. They cannot claim to be the voice of general practice without agreeing with practices what it is they are going to say on their behalf.

They will need some form of agreed vision/strategy with their practices. This will be some version of:

• A strong and vibrant general practice with the registered list as the foundation of local healthcare delivery
• Service delivery tailored to naturally occurring local populations of c50,000
• Integrated primary and community care teams at a locality level
• The removal of barriers between primary and secondary care, between health and social care, and between physical and mental health
• A greater focus on health and prevention

You will have your own version of this. Whatever it is, the important part is that it is developed with the practices, not for them. But turning this into a mandate involves not only agreeing the what, but also the how – how will any agreements that are made actually be delivered? The lesson from Vineet Nayar is that it is not only ok for federations to stand for empowering, enabling and supporting general practice, it is what is needed because it is practices not federations that will make a difference to patient care. Federations are not around the table to get more for themselves; they are there to ensure practices get what they need to deliver change locally.

The important conversation with practices is to agree the nature of this relationship. The federation will use its “voice” to get the resources, the support, the infrastructure, the tools and whatever else practices need to make changes locally. But it is the practices that will make change happen. Change is done by the practices not to the practices. Ultimately, it is a two-way agreement, each side with its own part to play.

This is how federations can create a powerful mandate from practices, one where what they agree turns into action. This mandate is based on trust, the hard won and easily lost trust federations build with their practices. Without this mandate, even though it might be at the table, the federation does not really have a voice.

Throughout August we’ve run a series of blogs where Ben has considered various aspects of the independence of general practice. In this fifth and final blog in the series he asks

Is operating at scale necessary to protect the independence of general practice?

There is something counter-intuitive about the notion that practices would operate at scale to protect their independence. Many GPs resist any notion of operating at scale precisely because of the restrictions they feel it places on their autonomy. The perceived wisdom is at-scale general practice is a step away from independence, not a move towards it.

But is it? I was struck by the tale of the practices in Wolverhampton. Recently a ninth local practice has handed over its list to the local hospital trust there, taking the total population now under the hospital’s control to 70,000. Now, I am not close to what is happening in Wolverhampton but local GP leaders said the GP partners were motivated by financial ‘non-viability’ and workforce shortages, with the move viewed as ‘handing over the problem to someone else’.

One of the practices put this on its website as it announced it was joining the hospital, “Without the help of The Trust we would definitely have left and would have had no option but to close the practice and split our list up amongst other local Practices. The Trust have been able to find us new Partner GPs, a new site and the funding to refurbish it into a modern GP Practice.”  The local practices, it seems, felt like there was no alternative.

I am sure everyone reading this is aware of the pressures currently facing general practice. Those pressures are not going away. There are no new GPs. Demand is continuing to rise. The financial pressures remain significant. At some point, almost inevitably, practices (like those in Wolverhampton) will reach the point where they decide to hand over the pressure of running the practice, to let someone else take on the responsibility, and to simply focus on the patients in front of them.

In a period of sustained pressure on general practice, where salaried doctors are increasingly earning more than the GP partners, more and more practices will reach this ‘enough is enough’ point. And if the local hospital, or community trust, or whoever, offers to take on the responsibility, increasingly practices will make the decision to trade their independence for the relative security and simplicity of salaried life.

If we take the practices in Wolverhampton back 3 or 4 years, would they have made the same decision then? Could they have envisaged then that things would get to the point where this was the choice they would make? And if they had known this would happen would they have chosen to do things differently?

But what could they have done? Well, the opportunity that practices working together (“operating at scale”) presents is for practices to support each other, and to work together to tackle the workforce, demand and financial pressures all are experiencing.

Here is the irony: practices resist operating at scale in the name of keeping their autonomy, but by doing so are keeping themselves on a track that is taking them to the ‘enough is enough’ point when they will hand their list over to whoever will take it. The status quo is unlikely to remain an option for much longer. However counter-intuitive it feels, it is choosing to work together with other practices that is most likely to protect the independence of general practice.

There is something difficult, elusive even, about the concept of governance. It should be straightforward. According to the universal fount of all knowledge (Google) the definition of governance is, “the action or manner of governing a state, organisation etc.” Yet somehow in the NHS, governance has drifted into becoming a stick managers wield over clinicians to drive compliance.

Am I overstating it? I am not sure. The first time I really saw evidence of this was when CCGs were first formed. Keen, eager and green, groups of GPs worked together determined to use NHS money to make a difference to local populations. But then these fledgling organisations were subjected to an “authorisation” process, where the focus was on governance and the ability of CCGs to operate as stewards of public money.

Whatever your views on the rights and wrongs of the authorisation process, the result of it was that it sucked the life and spirit out of nearly all of the CCGs. The model constitution, non-executives, multiple committees (etc. etc.) all contrived to create organisations too unwieldy to make any real change happen, to diminish trust between the organisation and its member practices, and to sap any sense of organisational pride or identity.

Last week we published our four step guide for practices working at scale. The real point of this was to encourage practices wanting to work at scale to think about why they wanted to work together and what they wanted to do before getting bogged down in questions of governance.

Don’t get me wrong, governance is important. But it is not more important than having a clear purpose for the at-scale general practice organisation, or more important than working out the guiding principles that will determine how the organisation will operate (its values). It is not more important than building trust between the new at-scale entity and the member practices, or more important than achieving the goals the organisation has set itself. Focussing on these things makes good governance an enabler, rather than governance existing for governance’s sake.

In the days when CCGs were being established, the key cry from practices was that it “did not become like the PCT”. Now the concern from practices about the development of new at-scale general practice entities is that they “don’t become like the CCG”. Yet the pressure “to have good governance” is often forcing some of these newly-emerging organisations down the same route. This is the tyranny of governance.

But things can be different this time. The cycle can be broken. At-scale general practice organisations are not statutory bodies in the same way that CCGs are. They do not have to hold population-based budgets (which will take them down the CCG route), and it is perfectly feasible for them to partner with other organisations (with the required governance) to enable that to happen. They can be whatever the member practices want them to be.

This means there is no ‘right’ model of governance for them. There is no checklist they have to adhere to.   Appropriate governance will depend on exactly what it is they are trying to achieve and do.

New at-scale GP organisations have choices. First they must determine why they exist, then decide what they want to do and the way they want to do it, and finally choose what governance they need to enable them to do the things they want to do in the way they want to do them. Governance in its place is an amazing enabler, but out of place can create a fast track to failure.

Many practices are considering the benefits of working at greater scale. But, from our experience at Ockham, we see so many approaching it from the wrong direction; by considering what form this expansion will take before even reaching agreement on why they are seeking to get bigger. So we have put together a simple and helpful guide on the steps practices should take to help them successfully navigate this journey.

When I was about 5 years old my brother and I became supporters of Liverpool Football Club. No-one told us we had to. Our parents were not football fans. We did not have to sit in a class to learn about Liverpool Football Club, or pass an exam before we could watch them play. No-one forced us to learn the names of all the players, or their shirt numbers, or the endless statistics from the previous decade. We learnt about the club because we were passionate about it which created our energy and enthusiasm to find out as much as we could, whenever we could, and to pester our father constantly to take us to matches.

Whilst not a football fan, my mother was a catholic. So when we were the same age every Sunday she used to make me and my brothers go to church. We never asked to go, and we went because we had to. We didn’t pay attention, got out of going whenever we could, and spent our time when we were there daydreaming about Anfield and whether Liverpool would win when they next played, as well as generally causing trouble. Eventually, we made life so miserable for my mother that she stopped making us go.

Now I am older, things are not much different. I spend my time doing the things I am passionate about and enjoy doing. There are some things I have to do (chores, shopping etc.), but, as my wife will no doubt attest, I do them as quickly as I can (or try and get out of them!) so that I can focus my efforts on the things that matter to me.

My brother is the same. In fact, we all are. We all want to spend time doing the things we want to do and care about, and avoid doing things we are doing because we have to. GPs are no different. Most GPs want to spend their time in the practice, focussing on making a difference to patients and the things that matter, not doing the things they feel they have to do (but hate) like preparing for a CQC inspection, or attending yet another CCG meeting.

For GPs, where does operating at scale fit in to the spectrum, where “doing it because we have to” is at one end, and “doing it because we are passionate about it and the difference it can make” is at the other?

Looking around the country, it varies.

Some GPs are really passionate about operating at scale. They believe it is key to the sustained future of the profession, to ensuring GPs have a strong voice around the system table and to giving them the best chance of making a difference to the lives of their patients. They seemingly work 24 hours a day on making it happen, putting all their spare time into it, and do so with boundless energy.

But many GPs are doing it because they feel they have to. They feel the weight of system pressure pushing them in that direction, and go along with it because even if they recognise there is some logic to it, their heart is in small, independent general practice. Unsurprisingly, they rarely turn up to meetings, they contribute only what they have to, and are often negative and disruptive.

GPs working at scale because they want to, not because they have to, is what will create the energy to make something great happen. It is what already differentiates those really successful examples of working at scale from the rest. Getting the majority of your colleagues to agree to doing something they do not believe in is storing up problems for the future. Jumping into a federation or a network without even knowing why is a mistake, because you won’t invest of yourself in it.

Spend time on why. Spend as much time as it takes to generate energy for a movement, and only then move forward. That investment of time will repay itself multiple times in the future, because it won’t feel like (your equivalent of) going to church, but instead like going to Anfield!

Did you ever have a mullet? Regularly wear flares? Decide tattooing your eyebrows was a good idea? I suspect not (or not that you would admit to!). As we all know, things come in and out of fashion, and sometimes there is a real art to avoiding something popular in the moment that later we might come to regret.

A common question I get asked is whether the move to working at scale in general practice is just a trend. The profession has been burnt before (think PMS contracts, fundholding, even CCGs), and it is reasonable to consider whether operating at scale is just another in a list of initiatives that demand energy and time but leave little or no lasting benefit.

It could be a short term trend. It feels like there is pressure in the system on practices to operate at scale, and yet history suggests that changes practices have made because others want them to (like the move to PMS contracts) are often best ignored, because the fickle nature of health policy is such that there is likely to be an opposite policy (PMS reviews) a few years down the line.

When we look at joint working between practices we find the benefits are not always that great: purchasing gains can be limited; extra services can be time limited or put out to tender with little or no margin included; and the additional overheads of working at scale can quickly absorb any financial gains made leaving little or no benefit for the member practices.

Bigger practices can create bigger problems. Communication can be difficult (poor), practices become impersonal and it can feel like the soul of general practice has been removed. Individual disputes do not disappear, and where they are not tackled divorce can follow quickly on the heels of the marriage.

Working at scale itself has now been around for some time. Average practice size has grown steadily from 6250 in 2005 to 7860 in 2017, and according to the Nuffield Trust three quarters of GP practices are now in some form of collaboration with other practices. Could, then, we be heading in the wrong direction? Could working at scale be just a trend, something we will inevitably later regret?

The best way to determine whether something is likely to be a short term trend or something more permanent is to consider the causal factors affecting the change.

There are, as you are no doubt fully aware, some long term trends impacting general practice. Demand is rising. There are more patients, more GP visits per patient, more over 85s and more patients managing one or more long term conditions. This demand is highly likely to continue to rise. The supply of GPs to meet this demand is going down. In the time period from September 2015 to December 2017, the total number of GPs decreased by 720 full time equivalents, despite the national pledge to increase the number by 5000. Less and less GPs want to work full time, or to be partners.

Funding for general practice has fallen from 11% to under 8% of the NHS budget. The promised extra £2.4bn in the General Practice Forward View is hardly touching the sides. The recently announced 3.4% growth for the NHS means no windfall for general practice is coming any time soon. The national policy is towards integration, and providers working together. A 10 year plan for the NHS is expected this year, built on exactly these principles. 7,435 practices operating independently in this environment are unlikely to be able to articulate their need for resources as well as, for example, the 135 non-specialist acute trusts.

Ultimately, working at scale is a reasonable response to these long term trends impacting general practice. Simply deciding to work at scale will not in itself deliver benefits (for all the reasons outlined earlier), but using the opportunities that scale provides to find new ways of managing demand, to expand the workforce and incorporate new roles, to deliver efficiencies and respond to the opportunities that the new integration agenda presents is one of the few things practices can proactively do to meet the challenges they face.

Working at scale is a trend. But it is a trend that is a response to underlying changes affecting general practice. Sometimes working at scale becomes the change itself (which is where problems set in) rather than understanding that its function is to enable the continued challenges to be met. Because the demand, supply, financial and policy changes are all continuing to move in the same direction, my view is that working at scale won’t go the way of mullets and flares, but will continue long into the future.

Joining federations is currently de rigueur in general practice. But is it right for everybody? For federation leaders, is it important that practices join for the right reason, or is it more important that as many practices as possible join? And for a system trying to push for general practice at-scale, does the underlying motivation of practices to work together matter, or should we be pursuing the goal of scale regardless?

As someone who has led a federation in the past, and now works with practices and federations up and down the country, my view is there are good and bad reasons for practices to join a federation. When federations form with practices joining for “good” reasons, federations can fly quickly. Initiatives can get off the ground rapidly, a powerful voice for general practice can be formed, and partners can find the group easy to do business with.

Conversely, when practices have joined a federation for the “bad” reasons, progress can be painfully slow. The group can be beset by internal arguments and in-fighting from the start. Gaining practice agreement for any, even minor, initiative can be extremely challenging and the leaders are often disconnected from their members; unable to speak with any real authority for them.

Here are my seven “good” and “bad” reasons to join a federation:

In the second of his blogs looking at the questions that will determine the future of general practice Ben asks

At What Scale Will General Practice Operate?

I find the answer “general practice needs to operate at greater scale” often precedes the question. Indeed, in many cases there is no sign of a question, it is simply presented as a statement of fact, as though 70 years of effective working at the current scale counts for nothing and there is no need to even make a case to support the statement.

As I have previously been at pains to point out, scale does not, of itself, automatically generate benefits for general practice. We only need to look at the graveyard of federation failures to know this to be true. Equally, the Nuffield Trust report “Is Bigger Better?” found instances where the quality of general practice reduced with increased size.

The authors of that report ultimately felt scale was better for general practice, but only where it is led by high quality leaders who understand the value general practice provides and work hard to preserve it. I have been fortunate enough through the podcast to be able to discuss with some of those leaders the rationale that sat behind their move to scale. What is striking is how different those rationales are. This is important, as it means there is not a single basis for general practice operating at scale. Further, it is the rationale for operating at scale that ultimately determines the answer to the question of at what scale general practice should operate.

There are seemingly two ends of the spectrum. At one end, the question is, “how do we create the efficiencies, voice and shared infrastructure to preserve and strengthen independent general practice”? This, for example, is broadly the question the super-practice Our Health Partnership (OHP) is seeking to answer.

They believe the optimum population coverage for their model is c500,000. This is based on each member practice contributing £2 per head, which creates a £1m budget to fund a management team. This is the size they believe is necessary to deliver real value. What is impressive about the model is it is maintaining a focus on working for the member practices (efficiencies), while at the same time creating a strong position within the local STP (voice).

At the other end of the spectrum, proponents of NAPC’s primary care home model advocate strongly for a population size of 30-50,000. Here the question is, “How can general practice really understand and best meet the specific needs of local communities, and retain and build on the sense of belonging that local communities have”? They believe if general practice operates beyond that size it cannot maintain the personal relationships fundamental to its success. Local needs vary so much that a service providing an average of the needs of two communities is in fact not meeting the needs of either.

Of course these two perspectives are not mutually exclusive. OHP want to build their organisation around specific geographical localities. Nav Chana, GP Chair of the NAPC, is clear a bigger population size might be required to create the infrastructure needed for these individual primary care home sites to deliver.

Futures are journeys not destinations. Beacon Medical Group is a great example of a practice on a journey. Already at 30,000, they have plans to scale significantly beyond that. But they understand what is important about general practice is continuity of care, and the ability for local areas to tailor services to the needs of their local population. So as they grow they are building on units of around 30,000, each with some degree of local freedom. Imposing a one size fits all operating model is not, in their view, going to work, even within a single practice.

General practice may be heading to a place where it operates at a large scale (over 100,000 population, maybe higher than 500,000) to create the new infrastructure it requires, while at the same time finding a way to retain some level of autonomy at individual locality level (30-50,000 population). But this concept of the journey, like the one that OHP and the Primary Care Home sites and Beacon Medical Group are all on, is the one that Rebecca Rosen and the authors of the “Is Bigger Better?” report believe to be critical. The most important question is not what size general practice is going to be, but rather how it is going to get there.

If you’d like to find out more about the future of general practice and meet some of the key voices in contemporary general practice (including Mark Newbold from OHP, Nav Chana Chair of the NAPC and Jonathan Cope from Beacon Medical Group) then why not buy a ticket to our first General Podcast LIVE event? For more information including a full programme and how to buy tickets visit our website here.

The BMA has found GP practices with a higher CQC rating earn more income. My PhD wife regularly pulls me up for mistaking correlation with causation, so I wonder whether outstanding practices earn more income (i.e. the cause is that they are outstanding), or whether they are outstanding because they receive more income (i.e. the cause is that they receive more income).

More research is required to test these hypotheses, but my money would be on the former. I know many areas where the opportunity for income is equal across practices, yet the better practices earn more (through better recovery of QOF income, through delivery of a wider range of enhanced services, and through private income streams).

So in the independent world of general practice, the practices that provide a better service to patients earn more money, while the less well run practices earn less. Independence, of course, means there is no bail out. The risk sits squarely with the GP partners as business owners. Compare this with those leading statutory bodies, such as CCGs. They will earn the same amount of money regardless of how well the CCG does. Salary is not linked to performance. There is no meeting with the accountant where the slow realisation descends on all of the partners that they are going to have to take a pay cut. Instead the CCG goes into deficit and money is spent on management consultants to “help” the CCG get back into balance.

I was fortunate enough recently to spend some time learning about how the system of general practice works in New Zealand. There, a key component is that each practice is part of a network. These networks are not statutory bodies. They were formed by practices nearly 30 years ago, essentially as a protectionist manoeuvre by practices, and their purpose is to strengthen and improve general practice.

The great thing about non-statutory bodies is that they cannot be abolished or reorganised. While in this country we have seen PCGs, PCTs and now (probably) CCGs come and go, in New Zealand over the same period the networks have been constant. They have been able to adapt and thrive over that time, and provide better and better support to their member practices. Indeed, the government has even channelled the contracts for practices through the networks, enabling the networks to take on the role of improving quality across their member practices.

I was the Chief Executive of Nene Commissioning, one of the leading practice based commissioning groups. We were a non-statutory body, but we worked with the PCT, with our member practices, and with many others to drive some impressive innovations across the system. With the advent of CCGs we transitioned into a statutory body. There is no doubt in my mind that becoming part of the NHS system, hounded by layers of hierarchy and regulation, strangled the innovation out of the organisation. It is because CCGs are statutory bodies that ultimately they have not been able to fulfil their promise.

Meanwhile the networks in New Zealand have thrived and continued to innovate. Pinnacle, one of the leading New Zealand networks, has developed an improvement programme for its member practices. It funds it itself, it tests it on practices that it directly manages (the equivalent of our APMS contracts), and is working with its members to make them fit for the future. Not because it has to, not in response to a government initiative, but because its role is to strengthen and improve general practice. It only answers to its member practices, and because it is independent it cannot be abolished or reorganised.

This is an important lesson for us. Moving to at-scale general practice in many areas is the right thing to do. But finding ways to do it that maintain the independence of general practice, and the independence of any at-scale organisations it creates, is absolutely critical. Independence rewards success, and penalises failure. It fosters and encourages innovation. Most important of all, it creates stability and strength for the long term.

In the first of a short series of guest blogs, Robert McCartney warns that the marriage of two practices will only be a success when there is a healthy pre-nuptial agreement between both parties.

Mergers are the ultimate form of marriage between GP practices. When they include the consolidation of the contract into a single patient list it becomes incredibly difficult, maybe impossible, to separate them again. As a consequence, the parties must understand the commitment they are entering into as there is no easy divorce.

During my recent podcast with Ben Gowland at Ockham Healthcare I stated that spending the time understanding and sharing a common vision of the future is essential. This applies to the relationship analogy. The most successful marriages are built upon a shared vision for their future, an understanding that there may be challenges but they will be overcome together and a trust that your partner will support you despite the occasional disagreements.

If the ‘soft’ merger elements linked to developing the relationships, like creating a shared vision and building a framework for the future of the partnership are rushed, the ‘hard’ formal merger steps may still happen but it increases the likelihood that the merger will fail.

Practices are currently under immense pressure and time is not a luxury many GPs have. Whereas a corporate merger may take months or even years to achieve, GP practices are looking to complete the process within a few months.

Fortunately, unlike a marriage there are some firm, definable objectives that all practices will be working towards. By ensuring that the parties focus on these at the earliest possible opportunity the ‘dating’ process can be accelerated with a reduced degree of risk.

The parties need to be willing to be forthcoming and ‘lay their cards on the table’ at an earlier stage than they may otherwise want to do. This openness is essential. In the past year, I have seen proposed mergers fall apart for a range of reasons based on people not being open until far too late in the process. This includes; forgetting significant funding repayment plans on properties; an unrealistic expectation as to equivalent sessional pay; and, despite comments to the contrary in the initial discussions, a complete refusal to consider using allied health professionals.

I have found that practices considering mergers have benefitted from having an independent third party facilitate and structure these discussions. This is especially important where time is of the essence. They are the pre-marriage counsellors focused on ensuring the merged practice is built on firm foundations.

For more information or if you would like support in any merger process you are considering or undertaking please do not hesitate to contact me.

Robert is Managing Director of McCartney Healthcare Associates Limited. He is an expert on practice mergers and this is the first of a short series of blogs he will be writing for Ockham Healthcare. If your practice needs a helping hand with its fledgling relationships, you can contact Robert via e-mail at rm@mccartneyhealth.co.uk or call 0203 287 9336.

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.