What is a Primary Care Network for?

One of the best things about my job is I have the opportunity to speak to some of the leading practitioners and thinkers in general practice.  This week was no exception as I was lucky enough to interview Dr Robin Miller, the Deputy Director at the Health Services Management Centre at the University of Birmingham.  Robin has published two really important papers on transformation in general practice recently (you can access both of them for free here and here), and we discussed them for a forthcoming episode of the podcast.

The conversation really challenged some of my thinking.  We all understand the idea of a primary care network being about practices working together around populations of 30-50,000.  Where I had got to previously was that there are almost two options around this.  The focus could be on those practices working together to support core general practice.  The crisis in general practice is, and remains, real, and these networks form an opportunity for practices to find a way through this by introducing new roles, developing shared systems for managing demand, creating back office efficiencies, and introducing new technology.  Granta Medical practice is a fantastic example of using this population size to deliver these benefits.

The second option has more of a focus on the local community formed by the 30-50,000 population, and on making changes to impact health outcomes.  It includes a much stronger focus on prevention, on the wider determinants of health, and on integrating services across health and social care to better meet the needs of the local population.  This approach is beautifully illustrated by Dr Steph Coughlin and her colleagues in City and Hackney.

The first option is more internally-focussed on the practices themselves, working together to support their long term viability.  The second is more externally-focussed on the local communities, and developing the role of general practice to support them.

Back to my conversation with Robin Miller.  He has published a number of lessons about primary care transformation, from research into national and international primary care transformation initiatives.  Two lessons particularly stood out for me.  The first is that “transformation” of general practice requires more than an incremental approach.  It requires a more fundamental redesign based on its purpose and contribution to society.  In the transformation programmes Robin looked at the GP leads had to change how they viewed their role in local health and care systems.  The practices had to move beyond their individual histories and interests and put the interest of people and communities at the centre of their work.

The second lesson is that when practices move beyond their traditional practice boundaries it changes the role of GPs.  The role changes from one defined by the trusted relationship between the GP and the patient to one defined by the GP as contributor to the wider primary care team.  Moving outside a domain where GPs can dictate what happens (as the owners of the business) to one where GPs need to influence each other and other clinicians, individuals and organisations, also requires GPs to find new ways to communicate and interact.  It requires a more facilitative approach.

Back, then, to the role of primary care networks.  It seems there is a more fundamental question than I had previously realised sitting behind them.  Are they a vehicle, an enabler, for primary care transformation?  Or are they this year’s initiative, to be tolerated until the next one comes along?

If it’s the latter then, fine, use them as a way of enabling practices to gain some incremental sustainability benefits by working together.  But if it’s the former (and, given the parlous state of general practice, it does feel like a tremendous opportunity) then it is not the either/or choice I had originally envisaged.  It is a platform to widen the primary care team, shift the role of general practice within the local community, yes make practices sustainable but at the same time make a more fundamental impact on local health outcomes.

As with everything in life, it is not black or white.  In any area there will be GPs wanting the latter, those wanting the former, and a majority in the middle not really engaging with the question.  The leadership challenge is to set a direction locally and to galvanise practices behind it.  This may require an initial focus on incremental benefits to practices to lead them to the wider transformation possibilities.  The journey will inevitably be difficult (change always is), but maybe, just maybe, a primary care network is a vehicle for real transformation of general practice.

What is your story?

Persuading GPs to work together at-scale, in whatever form we prefer, is a challenge. It is difficult because people (all people, not just GPs) don’t like change. We all remain anchored to our past and the certainty that provides. We all have an aversion to loss, and are more concerned with losing what we have than the prospect of gain. And we all have a strong desire to hang on to what we have, because simply owning something makes it seem more valuable to us.

Why would GPs give up the certainty and security of working as an individual, autonomous practice, and start to hand over some of that autonomy and freedom to an at-scale entity? Why would they change the model that has barely changed in 80 years because suddenly someone else thinks the model needs to be different?

The leadership task of the at-scale organisation is essentially one of persuasion, of winning hearts and minds so that GPs and practices will decide to make this change. This act of persuasion is not about analysis, or a simple presentation of the facts. It is about inspiring people to implement new ideas in the future. And not just grudgingly but enthusiastically, because they believe in it.

So how do we do this? How do we take our own hypothesis (that by working together we can make general practice a better place to work, able to deliver better care for patients, and have more influence on decision-makers) and persuade GPs and practices to give up some degree of local autonomy, and maybe some of their own money, to test it?

It is all about the story we tell. To win hearts and minds we need to tell a compelling story. Where management is concerned with how we deliver the goals we set for ourselves, leadership is concerned with establishing those goals in the first place. It is about creating a consensus about the goals to be pursued and how to achieve them. Storytelling is not a replacement for analytical thinking, but it enables us to imagine new perspectives and so is ideally suited to communicating change.

The best stories to spark action are what Stephen Denning[i] describes as “springboard stories”. These stories are based on actual events, where someone else (preferably a similar group of GPs or practices) has made a change that has been successfully implemented. It includes an implicit alternate ending of what would have happened had the change not been made. It is told in a way that allows the listener to create an analogous scenario for change in their own practice (“what if we did this here?”).

Sparking action is only the beginning. But thinking about how we inspire practices to work together and make the possibilities come alive through the stories we tell is an important starting point. Doing it because we feel we have to, or because everyone else is, or because the CCG/system wants us to means we can have the names and structures in place but lack the energy or commitment to make any real change happen. Sometimes we need to go back to the beginning to move forward.

What is your story?

 

[i] The Leader’s Guide to Storytelling, Stephen Denning, 2005

What does the cut in CCG running costs mean for general practice?

It was announced last week that CCG running costs are to be cut by 20%. CCGs are being asked to do this by “exploring mergers and joint ways of working”.

It all seems a long way from the days when CCGs were being set up. The argument then was about the “right” population size for a CCG. Small would allow a close relationship between the practices and enable clinically-led local change. Large would give CCGs a stronger voice, allow economies of scale, but risk creating distance to member practices.

While the backdrop to that particular discussion was a huge cut in management funds for CCGs (as compared to their predecessor PCTs), this latest cut ends any remnants of the historical debate. CCGs will no longer be vehicles for local clinically-led change, as they take a more strategic role across a wider area.

At the same time the system moves away from the commissioner provider split and towards integrated care systems. So whose responsibility is local clinically-led change in the emerging world? The size and role and funding of CCGs suggests it will no longer be their responsibility. In the realm of integrated care it is for local providers to work together to drive local change. Part of the drive for primary care networks is to have some form of infrastructure to enable this to happen at a local population level. Without them it is very hard to see anyone able to do this.

But what we haven’t seen happen is the corresponding shift of any resource to primary care networks for this redesign work. If the redesign responsibility is being taken away from CCGs and primary care networks are expected to pick this up, then resource surely needs to follow. Maybe it will in future, but nothing has been announced so far.

And in this in-between world where CCGs retain their statutory responsibilities but are increasingly starved of the resources to deliver them, then the change model seems to be shifting from one of co-design with local practices (that might actually work) to one of large scale schemes being universally implemented by CCGs across a large (and diverse) area, without any local tailoring. Not a recipe for success.

In future the new strategic commissioners will (hopefully) outline the outcomes they would like to local providers, who will then come up with ideas for how to make this happen, and schemes will be developed with local ownership that are likely to work. But what is missing at present (apart from any sense of a bottom-up mindset) is the shift of resource to the local areas to do their part of this work. And so instead we drift further and further into a world of top-down imposed models that has been proven many times over not to work in the NHS.

What are GPs to do? I would suggest three things. First, de-prioritise the investment of GP time into CCGs. If CCGs are no longer about clinically-led change for local areas, at a time when there is a real shortage of both GPs and GP leadership capacity, that time would be better focussed elsewhere. Second, resist calls to implement unachievable top down schemes, and argue for both the opportunity and the resource to develop locally-workable alternatives. Third, push for recurrent investment in primary care networks and at-scale general practice as an enabler of locally driven change for the system.

Making general practice easy to do business with

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.

Can you solve The Autonomy Paradox?

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.

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