Priorities for Local General Practice

If general practice wants to influence the local Integrated Care System (ICS) then it needs to be clear what influence it wants to have.  If it doesn’t have priorities of its own then how can it expect these to be reflected in the priorities of the new system?

Last week I wrote about the importance of each area creating a local leadership group for general practice, including as a minimum the PCN CDs, LMC and federation (where there is one).  However, if an area puts such a group in place the risk is that this will simply be used by the rest of the system as a means of talking to general practice about what is on their agenda, and end up as yet another meeting that doesn’t help or extend the influence that general practice has.

Indeed, in some areas we are seeing these leadership groups attempt to be established by the system (as opposed to by general practice itself).  These are rooted in the need for the system to have one place that it can come to ‘do business’ with general practice – they are about making it easier for system partners, not about strengthening the voice and influence of general practice.

General practice needs to set its own priorities first.  But what are these priorities of?  If when generating priorities what comes out is a list that looks like more GPs, more money and less work for general practice then it is hard to see how this is going to help general practice increase its influence.  The system will not take the service seriously.

While these things are important, what the local leadership group needs is priorities that do two things: strengthen how GP practices can be supported by joint working; and identify the specific influence that general practice wants to have on the local system.

What type of things could these priorities be?  Each local area needs to decide this for itself, but it could be things such as:

  • Strengthening the resilience support for local practices (potentially pushing for resources for this to be transferred from the system to within general practice itself)
  • Supporting practices with the recruitment of hard to find staff groups
  • Practical steps to reduce the shift of work from secondary to primary care
  • Putting a local communications or media campaign in place to educate the public about the range and value of the roles that now form part of local general practice
  • Ensuring general practice plays a leadership role in the new Integrated Neighbourhood Teams as they develop

These are just examples, and won’t be right for your area, but they give you an idea of the type of priorities it could be helpful for local general practice to have.  They need to be translatable into practical actions that general practice can influence the local system to take. To be effective they also need to resonate at an individual practice level.

How do you set these priorities?  What is key here is engaging local practices in the process.  The local leadership team cannot just tell practices what the priorities are.  For them to have real value they need the support of all practices.

This could be done by asking practices what the priorities should be and building up from there.  The risk with this approach is that it could build expectations of the leadership team that may not be realistic.  A better option may be for the leadership team to identify a range of potential priorities and then involve all practices in the decision-making as to what constitutes the final list.  This process  would also provide an opportunity to explain to practices what the leadership group is, why it is needed, and what it is trying to achieve.

Once it has an agreed set of priorities in place the leadership group is in a much better place to control its agenda and how it spends its time, ensure that the primary focus of its energy is on delivering these priorities, and establish a real and productive influence in the local system.

Local General Practice Inc

I am going to write over the next few weeks a series of articles outlining the actions that general practice can take in a local area to be effective within the new integrated care system (ICS) environment.  This is the first of these articles, and is about putting a single board or leadership group in place for local general practice.

I have written previously on the potentially huge impact the loss of CCGs and the introduction of ICSs could have on general practice.  With general practice losing its system voice as a commissioner, it has to create one as a provider.  All signs from the Fuller report indicate that more of general practice funding will be channelled via ICSs (as opposed to the national contract) in future, so as a minimum local general practice needs to be organised to at least be able to negotiate effectively.

The first action that general practice needs to take is to put a single leadership board for local general practice in place.  As a minimum this needs to include the PCN Clinical Directors and the LMC Chair.  The system recognises PCNs, and the LMC has a statutory role to play.  If there is a local federation they also need to be included on it.

If general practice is not united it will be weak in the new system.  Different facets of the service will be played off against each other, as the system asks different people the same question until it gets the response it is seeking.  Equally, influence at system meetings is nullified when different parts of general practice argue against each other.  Strength comes from unity, and a single general practice board is the first step towards this.

There are a couple of important considerations to make about setting up such a board.  The first is one of scale.  Should this general practice board be at the level of the ICS, or of the local area (which more likely relates to the “place” area within the ICS)?  Whilst influence at an ICS level is important, the more natural grouping and ability for short term cohesion within general practice is at the local level.  One LMC, less than 10 PCNs and one federation feels both more manageable and more likely to be able to focus on common issues than one operating at an ICS scale.

Rather than having one large ICS group it would be much better for there to be several local place-based groups, and for the leaders of these to work together to influence at ICS level.

The second consideration is one of ownership.  There has been a tendency for local systems to try and set up these primary care leadership groups.  Groups set up in this way rarely work for a number of reasons.  First, the scale is often set at an ICS rather than local level, so there is little in common binding the members.  Second, the agenda is generally set by the system, and so becomes about an ability for the system to interact with general practice rather than general practice being able to influence the system.  Third, they quickly become just another meeting that busy PCN CDs and general practice leaders have to go to rather than being a place where important decisions are made, and so attendance and then influence of these meetings becomes poor.

Instead these groups need to be owned and created by general practice.  General practice needs to set the agenda.  There can be some space allocated for others to come to talk to general practice, but this is secondary to general practice working together to influence the system.  It needs to be where local general practice works out where and how it will influence the place-based board, where it sorts out general practice issues (like extended access) together, and where it shares information about local system issues.  If the system is running the meeting for general practice, this is not what the meeting will achieve.

This raises the interesting question of who will chair the meeting.  I know of a series of different places across the country who are already running these local leadership groups, and the role of the chair varies significantly.  In one it is a PCN CD, in another it is the LMC Chair, and in another it is the senior manager from the local federation.  What all these people have in common, however, is that they are trusted and respected by the rest of the GP leadership team.  It is not about getting the right role as chair, it is about getting the right person, and each local area will need to work out who that is for themselves.

Putting a local general practice leadership group in place is important but it is only the first step.  If general practice is going to survive and thrive in the new system it will then need to develop this group so that it is effective and has real influence in the system.  In the coming weeks I will outline the steps such a board needs to take to build its impact.

5 Steps to Improve Joint Working in General Practice

Effective joint working is the key to successful general practice.  It may be joint working between the partners in a practice, joint working between the practices in a PCN, or joint working between the PCNs in an area.  Joint working is difficult, and where it is not effective individuals, practices and general practice as a whole all suffer.

The most important metric for joint working is trust.  How much do I trust my partners/the other practices/the other PCNs?  Where my trust is low I assume the intentions of others are poor, I avoid interaction where I can, and I am unwilling to be helpful because I do not believe there would be any reciprocation.  Life in a low trust environment is generally tense, unpleasant and often draining.

I spend much of my time supporting joint working within general practice.  Here are 5 steps that I have found to be extremely helpful in shifting from a low to higher trust environment:

  1. Stop communicating primarily by email. One clear indicator of poor relationships is where the majority of the communication takes place by email.  The problem with email is that it is one way and open to misinterpretation.  You are not there to correct any misunderstandings when the email is being read.

 

  1. Communicate by talking at least once a week. It is far better to have a short conversation of 20-30 minutes once a week than to have a (poorly attended) monthly meeting interspersed by heavy amounts of email communication.  Simply shifting the mode of communication from email to conversation in this way can have a huge impact.  It shows respect (people feel more valued when they are told things in person rather than by email), and allows questions and concerns to be answered and dealt with straight away, as well as preventing misunderstandings from festering.

 

  1. Communicate in person. Whilst there has been a huge time and convenience benefit to meeting and talking online, it is very difficult to develop and improve relationships in a virtual space.  It is too easy for individuals to simply disengage from the conversation (how often are we in meetings where the majority of people have their cameras off and are on mute?), rather than have their concerns noted and dealt with.  Online it is difficult to spend enough time understanding and valuing each other as people, as without shared coffee breaks or pre-meeting chat we focus only on the business.

I worked recently with a PCN that shift from monthly virtual meetings and email as the primary communication route, to weekly half hour virtual meetings and a monthly face to face meeting with far less reliance on emails.  The impact on relationships across the PCN was transformational.  Trust that had become low was restored.  There was a shared confidence in a new sense of transparency, and a new willingness to take actions together as a group of practices.

  1. Show vulnerability. The counterintuitive thing about building trust is that you build more trust by sharing your weaknesses than your strengths, and asking for help builds more trust than offering to help.  If I ask you for help I show that I respect you, that I believe you have strengths that I do not have and that I trust you enough to show you my weakness.  Conversely if I offer to help you I reinforce your belief that I think I am better than you, that I have no sense of my own weaknesses, and even that I may have a secret agenda to take you over – however well-intentioned the offer may be.
  2. Admit when you are wrong. We all make mistakes.  Sometimes we are convinced that a course of action is the right one to take, but with hindsight we can see the error of our ways.  But it makes a huge difference to other people if we are prepared to put our hands up and say we are sorry when we have made a mistake.

I worked with one federation who had a difficult relationship with some of the PCNs in its area.  But this all suddenly changed when in one meeting the federation acknowledged that it had made mistakes in the past, said sorry for the impact of those mistakes, and asked what it could do to put them right.  Almost immediately the relationships were changed and moved to a much more positive place.

While it is generally true that trust can be hard to gain and is easy to lose, my experience has been that by starting with a good intent and taking the right actions in line with these 5 steps trust can be rebuilt surprisingly quickly.

How Much Autonomy are GP Practices Prepared to Give Up?

Much of the strength of general practice comes from its autonomy.  While the rest of the NHS totters under the weight of being part of one of the largest centralised systems in the world, GP practices are free to operate as they choose to deliver the contracts they have agreed.  While this autonomy carries its risks (the practice is the business, not simply a part of the business), it also creates huge freedom for practices to operate exactly as they want.

The pressures on practices mean that the sustainability of these independent, autonomous businesses is coming increasingly under threat.  Growth in funding does not keep pace with the growth in workload, and the staff required (especially GPs) in many areas simply cannot be found.

Here comes the challenge. In order to improve sustainability, practices have to find new ways of working.  These nearly always involve working with other practices.  These could be things such as creating a shared visiting team, building a staff bank, establishing a document management service, putting in place a prescribing hub, or any number of other things.  All of them will make a difference to practices, but all of them involve working with other practices.

If working together can make a difference to practice sustainability, particularly now when individual practice sustainability is under such pressure, why is that so few practices undertake these shared activities?

It is because working with other practices requires a ceding of some autonomy.  If five practices are working together to create a document management hub, they all have to agree to a single way of working for actioning and coding the incoming documents.  It doesn’t work if there are five different ways of doing things.  In order to gain the benefits of the shared hub, each practice has to give up its individual autonomy on how it does things and agree to the single collective way of doing things.

Instinctively GP partners and GP practices resist any attempt to curtail their autonomy.  It is in the DNA of GP practices to be extremely protective of their own autonomy.  This is why joint working is hard, however rational and straightforward it might seem on paper.

There are two critical components to enabling collaborative working in general practice.  The first is a shared belief that continuing on our own is unsustainable and that joint working will make a difference.  The second is that practices trust those whom they are ceding autonomy to, most commonly the other practices that they are working with.  If we do not trust them, and in particular those leading whatever the change is, we are unlikely to go ahead no matter how clear the potential benefits.

As an aside, this is why PCNs are difficult.  The starting point of PCNs was not a shared understanding that joint action is required, but rather a contractual requirement.  The initial level of trust between the practices thrown together in a PCN was usually low, unless there had been some history of effective joint working previously.  So PCNs started with a set of practices who were supposed to work together, but all of whom were hugely protective of their own individual practice autonomy.

As the sustainability crisis worsens, the need for joint working gets greater.  The challenge for GP practices is whether they are prepared to cede some autonomy now to enable this joint working to take place and be effective.  The risk is that refusing to give up some autonomy now will lead to a complete loss of autonomy in future when the practice reaches a crisis point from which it is not able to recover.

What Should General Practice Do With PCNs?

There is a danger starting with a title like this that it will provoke many into further calls for general practice simply to abandon PCNs and have nothing more to do with them.  This was the call at the national LMC conference, and as I understand it has become BMA policy.  But as I have previously written, such a move has the ‘cutting off your nose to spite your face’ feel to it, and a more nuanced approach is required.  So what could this be?

The challenge is that all of the additional funding and resources for general practice over the course of the current 5 year deal comes via PCNs, and general practice simply cannot afford to do without this.  Any move away from PCNs will not result in the funding being transferred into the core contract, but in a loss of control of these resources to other organisations eager to take them on.

We know that the Fuller Report has laid out a direction of travel for PCNs to evolve into Integrated Neighbourhood Teams.  This means the focus of PCNs moving away from GP practices and towards multi-agency working across local neighbourhoods.

What will happen to the funding of PCNs after the existing 5 year deal for general practice expires in 2024?  The funding for them will potentially grow (neighbourhood multi-agency working is becoming more not less important to the system), and will most likely continue to consume any additional funding for general practice.  It is also highly likely to come via the local Integrated Care System rather than via the national contract.

So the additional money for general practice is, and will continue to be, tied up in PCNs, but the control of PCNs may start to shift away from practices.

I have written previously of the need for local general practice within each area to start to work together to create a collective voice and influence for general practice as a provider.  My question now is to consider what role PCNs should play in this collective action?

Should the voice of general practice in an area be channelled through the PCNs and the PCN Clinical Directors?  After all, it is the PCNs that the system wants to talk to.

Right now PCNs and PCN Clinical Directors should form part of any collective general practice voice, particularly as the Clinical Directors all come from general practice at present.  But in future the Clinical Directors of the Integrated Neighbourhood Teams may not come from general practice.  Some may come from the community trust, the acute trust, or the council.

Meanwhile general practice needs to create its own provider voice in the system, particularly as its commissioning voice is being lost.  But it needs to build this as the voice of the GP practices at its heart.  It needs to do this in a way that means it can both harness the resources for general practice that come via PCNs, but also when general practice in future has to negotiate its role within the Integrated Neighbourhood Teams it can do so because there is a clear enough separation between what is local general practice and what are the activities of these new multi-agency teams.

This means the local general practice leadership voice cannot be solely that of the PCN Clinical Directors.  The LMC and any local GP provider must also be involved, and there must be a way of ensuring that there is route for voicing the needs of practices, and negotiating on their behalf, that is separate from the needs of PCNs.

While this nuance is difficult, I think ultimately it will largely come down to leadership.  If local GP leaders can work together for the good of the practices and their populations, regardless of the role that they are in, then they can create a strong leadership voice that they can iterate with the changing environment.

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