Allies or Neighbours? Practice relationships within a PCN

One of the key questions facing all practices is how much effort they should expend in collaborative working through their PCN, and how much they should strive to retain their independence and own way of doing things.  But the choice between the two is not as binary as it at first appears.

This Harvard Business Review article maintains that all work relationships fall into one of five categories:

  1. Collaboration (allies) – Merging self-interests with the interests of others
  2. Cooperation (friends) – Maintaining self-interests while also advancing joint interests
  3. Maximum possible independence (neighbours) – acting to neutralise the impact of others on self-interests
  4. Competition (rivals) – working to deter another in order to protect or advance self-interests
  5. Conflict (enemies) – trying to defeat or deny another’s interest

There are some important distinctions between these relationships.  Collaboration involves parties investing in the relationships to help each other.  The benefits of these relationships are the greatest for GP practices, because it means the maximum value can be derived from shared assets, such as ARRS staff and back office teams.  It means practices can potentially realise benefits beyond those that come simply from accessing PCN resources.  The drawback is that these relationships are hard to disengage from should interests change.

Cooperation is a step down from collaboration, where practices choose to work together on specific issues where interests (e.g. availability of PCN funding) align, but simply not to compete where they don’t.  This limits any potential benefits of joint working to those that come from (in our case) PCNs but nothing more.  Should PCNs end then there will still be things that need to be unravelled, but nothing too problematic.

Neighbours is where what practices are actually trying to do is maintain the maximum possible independence.  Practices deliberately reduce their reliance on others as much as they can.  This is where practices want control of their own ARRS staff, and don’t want them grouped into functioning PCN teams.  It limits the benefits that can be derived from PCN resources, but maintains practice independence.

It seems to me that in the vast majority of places now the challenges facing general practice have reached the point where practices no longer feel in competition or even in conflict with each other.  Maybe we sometimes still see it when APMS providers arrive on the patch, but other than that practices generally recognise that practices are in this together, and there is little value in making things even harder by fighting with each other.

The problem many PCNs face is that different practices within the PCN are at different places on this spectrum.  While some may be up for full collaboration, others are striving to maintain their independence.  It is very difficult for a PCN to be effective when what some of the practices are doing is rebuffing any attempts at cooperation, let alone collaboration.

What is needed is to try and get all the practices to agree on the same approach.

The critical point to understand here is that the independence question for GP practices is inextricably linked to the question of sustainability.  If a practice is not sustainable, ultimately it will lose its independence, at the point at which it is either forced to close or is taken over by another provider.  The best chance a practice has of being sustainable into the medium term is by collaborating with other practices, and making the most of the scarce resources that are available to practices.

While it feels counter-intuitive for practices, not to mention risky, the best way to maintain their independence is through collaboration.  For those leading PCNs and joint working initiatives across practices the starting point has to be building a shared understanding this is true, along with the trust needed to mitigate the risk.  How will the practice survive for the next 5 years? How will it navigate the challenges we know are coming down the line, on top of the rising demand and falling GP workforce?  How will it be able to maintain its independence within this context?  What role can the PCN and collaboration play in answering these questions?

Building a shared understanding that collaborative working is the key to maintaining individual practice independence, rather than a fast-track to losing it, is the starting point for successful PCN working.

What is General Practice Trying to Achieve?

For general practice there have been some important documents written this year.  The three that particularly stand out for me are: The Fuller Review; the Future of General Practice (Health and Social Care Committee (HSCC) Inquiry Report); and Side Effects by David Haslam.

I have written about the Fuller Review and the HSCC report, and had the good fortune to be able to interview David Haslam about his book for the General Practice podcast.

While Side Effects is about the system as a whole, it is extremely useful for general practice as it seeks to better articulate its role as a provider within Integrated Care Systems.  David Haslam’s key question for the health system as a whole is what is the healthcare system really trying to achieve?  This, he claims, is a question that most of those responsible for healthcare systems are unable to answer.  Infinite demand and limited resources means systems cannot be universal, high quality and comprehensive, so what is the goal of the system?

We could apply this question to general practice.  Are we really clear as to what general practice is trying to achieve?  Are those leading general practice able to articulate clearly the purpose and role of general practice?

I remember even in my role as a CCG Accountable Officer that I was not crystal clear on the role of general practice in the system, and not fully able to articulate it effectively to acute trust Chief Executives and other system leaders.

It isn’t just me.  Ben Allen, a  Sheffield GP and Clinical Director, recently posted on Twitter,

The Fuller Review seems to distil the aim of general practice as to provide rapid access to care, to provide continuity of care for those who need it, and to play a role in prevention and tackling health inequalities (in partnership with others).

Is this right?  Is this what general practice is there to achieve?

The HSCC Report again is not explicit, but does use this quote, “[T]here are two characteristics of general practice which distinguish the GP from every other professional: first, access and, secondly, continuity of care. That is all there is and everything else supports that.” (p19).  The report broadly states that access has been over-prioritised over continuity of care and that this balance needs to be redressed.

So is the HSCC report right?  Is the role of general practice to provide access and continuity of care, and is the challenge to get the balance between the two right?

David Haslam did not explicitly address the question as to the role of general practice, but he is clear that the challenge for general practice is that much of what it does is not glamorous enough for politicians and the system.  The system does not value the heart attacks and strokes that general practice prevents, because it is not as glamorous as the service that treats a patient who has had a heart attack or stroke.  Even the patient whose heart attack or stroke has prevented does not know that general practice did this!

What he does say is that by investing in primary care health inequalities are reduced and health outcomes are improved.  Is this what general practice is trying to achieve?  And if it is, are we clear exactly how this happens?

Even now I am not sure I can fully articulate the answer myself.  However, the assumptions in the recent publications feel insufficient and inadequate to me.  I am sure that general practice as a profession is not articulating its purpose and role clearly enough.  I don’t even believe there is a shared clarity within the service itself on where the true value of general practice lies.

In the vacuum, the system and politicians just work with their own assumptions.  Acute trust leaders believe many of the patients in A&E are there “because they couldn’t get to see a GP”.  The assumption is that the prevention work of general practice is linear, that general practice stops the need for further care directly and only as a result of its accessibility.  Politicians believe that the aim of general practice is simply to be available when patients want it – hence the obsession with access.

We can´t let these misconceptions continue.  There is a pressing need for general practice, both at a local and national level, to be able to articulate the role of general practice in the system and what it is trying to achieve.  The advent of Integrated Care Systems means it is more important than ever that general practice is clear on the value it brings to the system and exactly how this is achieved.

Integrated Neighbourhood Teams: Where are we now?

Since the publication of the Fuller Report in May the idea of Integrated Neighbourhood Teams has come to the fore, specifically as the report indicated that Primary Care Networks would “evolve” into these new teams.  But what actually is an Integrated Neighbourhood Teams and what impact will they really have?

A helpful starting point is to consider the Integrated Neighbourhood Teams that already exist.  There are a number of different examples of these now working in practice, so what can we learn from them, their operation and their relationship with general practice?

This example from Manchester is typical in that it focusses on the bringing together and co-location of the social work and community nursing teams.  The link with general practice is less clear.  It seems a GP is the ‘locality director’ but the nature of the relationship between practices (and the PCN) and the Integrated Neighbourhood Team appears to be a voluntary one (they “work closely” together) rather than anything more formal.

Integrated Neighbourhood Teams also exist in Suffolk.  They are described here as staff working together from, “a number of different teams/ professions: social care for adults and children/families, health, police, mental health, district and borough teams, along with the voluntary sector”.  General practice are conspicuous by their absence, and in my conversation on the podcast with those behind these teams they explained that one of the things they want to work on is the relationship between the PCNs and the Integrated Neighbourhood Teams (i.e. it is not currently clear).

In Leicestershire the Integrated Neighbourhood Teams are described as operating in parallel and alongside primary care and Primary Care Networks.  The majority of care takes place, “working as individual practice or in networks (Primary Care Networks)”, but this is different to Integrated Neighbourhood Teams which are described as “multi-disciplinary teams of general practice staff, community nurses and therapists, social care staff and the voluntary sector” focussing on specific areas of care such as long term condition management and active management of at risk patients.

In East Lancashire the relationship between the Integrated Neighbourhood Team and the GP practice appears to be primarily one of the GP referring patients to the team.  GPs have been asked to share access to medical records when appropriate with health and social care organisations within the local neighbourhood team.  The way it works appears to be that a patient is assigned a single case manager whose role it is to develop and review the care plan for patients referred to the team and to “communicate with other people involved in your care and provide regular updates to your GP”.

What emerges from these examples is a pretty clear sense that Integrated Neighbourhood Teams, certainly in their current configuration, operate in parallel to general practice and Primary Care Networks, rather than as a replacement for them.  Indeed, taking the Leicestershire example, the Primary Care Network is a component of the Integrated Neighbourhood Team (one assumes it brings the practices and their shared teams together) but is clearly separate from it.

Increasingly it is looking not so much that PCNs will “evolve into” Integrated Neighbourhood Teams, but rather that they will contribute to them.  What we are probably to expect, then, are contractual specifications for PCNs as to how they need to support and enable the working of these Integrated Neighbourhood Teams, rather than a more fundamental change of PCNs.

This makes sense in that the timing for the introduction of Integrated Neighbourhood Teams in the Fuller report is April 2023 in the most deprived areas and April 2024 everywhere else, i.e. within the timeframe of the existing PCN DES (which we already know will run its course through to March 2024).  It could be that the recent update to the PCN DES anticipatory care specification (“PCNs must contribute to ICS-led conversations on the local development and implementation of anticipatory care working with other providers with whom anticipatory care will be delivered jointly”) is specifically intended so that PCNs will play their role within emerging Integrated Neighbourhood Teams.

Things may of course change, but for now it looks like Integrated Neighbourhood Teams may represent more of an opportunity for general practice to influence the deployment and effectiveness of local community teams, rather than pose any major existential threat to the future of PCNs or the independence of general practice.

Why System Primary Care Leadership Groups Do Not Work

In many areas the Integrated Care System has set up a Primary Care Leadership group.  These groups are purportedly to discuss and decide all things primary care, and include membership from PCNs and federations, along in many places with leaders from pharmacy, optometry and dentistry.  The problem with these groups is that they simply do not work.

Often these groups are chaired by senior GPs from with the ICS, and on paper have many of the people that you think would need to be there in order for it to act as a leadership group.  But that is not how they function, and in no way can they be described as providing leadership to primary care.

This will not be a surprising analysis for those who have attended such groups.  If the roots and tentacles of these meetings go up into the system, rather than down into front line primary care, it is not a surprise that those on the front line feel zero investment in any decisions that these groups make.

Where does the ownership of these meetings sit?  If it is sitting within the system it is not sitting within frontline primary care.  These groups end up as simply a meeting that certain PCN CDs and GP leaders attend once a month, with no actual leadership functionality.

The underpinning issue for general practice is that both its leaders and the system are struggling with its transition from commissioner to provider.

As a commissioner general practice had a clear leadership voice at the system table, where its role was to speak on behalf of the practice populations it serves.  It has done this in various guises for over 30 years, ever since the purchaser provider split was introduced, along with the notion of a primary care led NHS.

But the new model of care is different.  In an Integrated Care System each provider is responsible for working together to improve outcomes for the local populations.  Outcomes are no longer the sole preserve of primary care.  All providers need to work out how they can contribute in partnership with others to improving these outcomes.

For general practice this means it is now a partner as a provider, not as a commissioner.  As a provider its leaders cannot operate under the statutory authority that commissioning groups (in any of their guises) provided for them.  Instead its leaders have to connect directly with front line practices, work with them, engage with them, and act on their behalf in order to be able to carry out their role as a leader of general practice who can work in partnership with other providers.

System primary care leadership groups miss out this critical step, because they are still operating in the old paradigm of GP leaders having some sort of system-imbued power over their practices, when the reality is they do not.  Any primary care leadership group that is built top down rather than bottom up will not be effective in the new system, because it is built on sand.

Instead, a general practice leadership group requires the authority, support and mandate of its member practices.  It needs to be a group that connects directly with its front line teams.  It must have a focus on what general practice needs to survive and thrive in the new system, how its role in the system can practically be developed, and how its resilience an be strengthened.  It needs to be recognised by practices and have its roots and tentacles firmly within the practices. Only then can it operate as a leadership group that will add value to the system.

Creating a Local General Practice “Executive”

Integrated Care Systems (ICSs) require general practice to work together as a collective, if it wants to hold any kind of direct influence.  In recent weeks I have written about the need to form a single local leadership group for general practice, set priorities, put a single point of access in place, create a representation process, and establish a mandate from practices.  But to be effective all of these require something else.

Local general practice cannot realistically operate as a system partner if it takes the form of a meeting that happens once a week or once a fortnight.  There needs to be some form of dedicated executive capacity that can (amongst other things):

  • Set the agenda for leadership group meetings and ensure actions are carried out
  • Act as the single point of access
  • Drive the process required to set local priorities
  • Coordinate the representation of general practice at key meetings
  • Ensure effective communication with both practices and the system takes place

If the collective use of the shared general practice leadership team is to be optimised, then a dedicated smaller team is needed to make sure this happens and enact all of the things above.  Just as the Board of any organisation cannot function effectively without an executive, the same is true of general practice.

The key questions this presents are where will this capacity come from and will it carry the trust and support of general practice more widely.  These are not easy questions, and the answers will inevitably vary according to local circumstances.

There are two types of additional capacity required.  There is additional clinical leadership capacity, and dedicated management capacity.  I have seen the clinical leadership capacity take a number of forms, but most commonly it is a small group consisting of the LMC Chair, federation lead and a lead PCN CD.  What these have had in common is that these individuals have been able to use funding/time from their existing roles to avoid the need for the establishment of the executive creating an additional cost for general practice.  The last thing general practice needs right now is an additional overhead.  Instead those leaders choose to make this executive work a key part of their existing role.

Dedicated management capacity is harder to come by.  If an area is in the fortunate position of having a federation that sees its role as evolving to support local general practice, then the federation management support may be able to step in and provide this.  However, I suspect this limits the number such areas to less than a handful!

Some places use the system primary care lead (i.e. the person who used to be the CCG primary care lead), but this requires that individual to have a good relationship with, and be trusted by, wider general practice.  In some areas the PCNs have sought funding from the system to have a shared senior manager, who is then able to act into this role.  Bear in mind it is in the system’s interest for primary care to self-organise and so in the absence of any obvious local contenders it is worth seeking financial support from the system to find someone.

The other problem with establishing an executive function is that it concentrates power into the hands of a much smaller group of people.  It is very difficult to bring a multitude of general practice organisations together (practices, PCNs, federations, LMC etc), and I have written previously about the challenge of any leadership group establishing a mandate to make decisions.  This becomes even more difficult for a small executive group which contains less direct representation from all parties.

The key here is making sure that the delegated powers of the executive from the leadership group are clearly defined, and are reviewed and developed over time.  The authority of the executive, and its ability to act, comes via the leadership group.  It needs to ensure there are sufficient feedback mechanisms, and clarity on the decisions it can and cannot take on behalf of the leadership group.

Ultimately, putting such an executive in place will be key to how successful general practice is as it attempts to operate as a partner alongside the trusts within the integrated care system.  It is not without its challenges, but having it will ensure the proactive leadership that general practice requires is in place.

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