How to Create Effective Representation for your PCN

We are getting into the weeds a little bit this week, as we consider what action PCNs can take to ensure they are represented effectively at system meetings.

Regular readers of this blog will know that we have established two important principles when it comes to PCNs attending the wide range of system meetings that they are currently being invited to.  The first is to prioritise local PCN delivery over attendance at these meetings.  The second is that finding effective representation is difficult.

The way to think about this is not to consider first who should represent the PCN, but instead to start by considering how to create the representation the PCN needs.

One of the actions very few of us take (but is really important) is to determine what outcome we want from a meeting before we attend.  Why are we going?  If we are clear what outcome we want from a meeting we can in turn be clear with others who attend for us the outcome we are asking them to achieve.

A set of outcomes our PCN might be looking for in attending a system meeting might be:

  • To increase the resources and opportunities coming to the PCN and its member practices
  • To enable the appropriate shift of work (and resources) from secondary to primary care
  • To accelerate the alignment of community services with the PCN
  • To raise the reputation of PCNs and build confidence that they are an effective delivery vehicle

Whatever they are, they need to be ones appropriate for the meeting and for your PCN.  Of course, if your PCN has already taken the time to be clear about its purpose, then the outcomes may well be a version of the those stated in the purpose of the PCN.  Equally, if when you think about a meeting you cannot come up with any outcome you want to achieve by attending, that is probably a sign that you don’t need to go!

The reality is that all of us get invited to meetings when we are not clear what the meeting is or why we are needed.  For the time-poor PCN CD it is far better to spend time seeking clarity on exactly why attendance is required and the outcomes that attendance is seeking to achieve, as opposed to turning up and hoping that clarity will come during the meeting itself (it rarely does).

When we are clear on why we are attending a meeting, the question of representation becomes much easier to handle.  If you can be clear with your representative on the outcomes you are seeking to achieve, they can be much more confident in representing you in the meeting.  This will apply to a non-CD attending for the PCN, or for the CD of another PCN representing your PCN as well.

You can even go as far as being clear what they can or cant agree on your behalf.  For example, anything in line with the outcomes can be agreed, but anything that commits the PCN to additional work has to come back to the PCN for a discussion.  It is perfectly reasonable for a representative to gain rapid agreement after a meeting from those not present, and should not feel pressured into feeling they have to make decisions for others there and then.

We often get lost in the question of who should represent us at meetings (and whether we trust them or not).  But our time would be better spent on why attendance at each meeting is important, and as a result being clear on what the representation is we require.

Who can Represent my PCN?

I wrote recently about the importance of PCNs prioritising delivery over attendance at meetings.  The question that poses is how PCNs can ensure they are effectively represented at meetings if they are not there themselves.

First off I would just reiterate that given the limits of available PCN time, if a PCN is faced with a choice of either ensuring local delivery or attending a system meeting, I would always prioritise the former.  But how then do we ensure that the PCN influence on decision making is not completely abandoned?

This raises the thorny issue of representation.  While the idea is simple enough – one person goes to a meeting to represent a PCN or multiple PCNs – the reality is much more difficult.  How do I and my PCN know that the person who attends on our behalf is going to accurately represent us?  How can we be sure that by not attending the meeting we are not missing out on opportunities and/or resources?

Representation requires trust.  And the trust required for representation is hard to gain.  If I am to trust someone to represent my PCN I am not simply asking for the minutes of the meeting to show that my PCN turned up, or someone to spectate and then feedback afterwards.  I want, in addition to timely and appropriate feedback on the meeting and any relevant decisions made, to:

  • Know that my PCN is going to be represented accurately
  • Be confident that the representative is not going to put his or her own interests before that of my PCN
  • Believe that the reputation of my PCN will be strengthened as a result of my representative’s attendance
  • Trust that the representative will make an intervention where one is required, e.g. because the meeting is suggesting something inappropriate/absurd/potentially damaging etc.
  • Be sure that the opportunity to build relationships with other attendees will not to be lost

Given the challenge that effective representation presents, how is a PCN to find someone they can trust to represent them?

A commonly suggested solution is to use rotation, either between CDs of different PCNs, or between members of a PCN, where a group of individuals take turns to be the representative.  This stops everyone needing to go, and reduces the risk of any bias to a particular individual or PCN.  However, I don’t like this as a solution.  Meetings themselves are about relationships.  In any regular meeting the attendees get to know each other and find a way of interacting.  If my representative is always someone new they wont understand the dynamics of the meeting and as a result will almost certainly be less able to influence any outcomes.

This then leaves the daunting prospect of me needing to find a single individual to represent me and my PCN at the meeting.  Who can I turn to?  Here we are talking primarily about system meetings, with potentially Board Directors of the CCG, hospital and community trust in attendance.  So in addition to being someone that I trust, I also need someone with an understanding of the system, someone who can hold their own in that company, and someone who can influence the outcomes in at least the same way as I believe I could if attended in person.

The horns of the dilemma facing many PCN CDs then is who can represent me and my PCN at these meetings that I simply don’t have time to attend?  And the default response is generally that there is no one, and that I will just have to find time and go myself.  But then, as I discussed last week, the PCN loses out because delivery suffers as there is insufficient time to both deliver and go to these meetings.

In many ways this brings us back to where we started.  If the choice is delivery versus meetings, choose delivery, and say no to the meetings.  But the real question is not is there someone who can represent me, but how can I create the representation that I need.  That is the question that I will explore in more detail next week.

Why attending less meetings will increase the influence of your PCN

It will come as no shock when I tell you that the NHS has a meetings culture.  The NHS loves meetings.  There is virtually no situation in the NHS where the default response will not be to organise a meeting.  When emergencies arise, ‘lesser’ meetings are cancelled so that the new, more important meeting can take place.

Integrated care is no different.  It is nearly six years since the Five Year Forward View was published, which was when the idea of integrated care became mainstream.  The idea was to close the divide between health and social care, between physical and mental health, and between primary and secondary care.

There then followed a tsunami of meetings to decide whether an MCP or a PACS (remember them?) would be the best model for integrating care locally.  Integrating care was the clear priority and so that was what filled the meeting schedule.

But 6 years later on it is not clear what impact all of those meetings have actually had.  Now of course the agendas of these meetings have moved on to integrated care systems and integrated care partnerships.  The default NHS response to any new initiative remains having meetings about it, and now PCN CDs are being asked to fill their diaries with these meetings.

The big question then is: should a hard pressed PCN Clinical Director spend any of their valuable time attending these meetings?  If a PCN CD has 2 or 3 sessions a week to carry out the role, how many of them should be spent attending system meetings about integrated care?

The problem with not attending these meetings is the nagging sense that somehow the PCN is missing out.  The concern is that the influence of the PCN will be less if they are not present at these important meetings, or that resources will be diverted elsewhere.

But the reality is that real influence comes from delivering change.  If the PCN is able to build relationships with the local community teams, to find a way of working alongside the local voluntary sector and social care, and to start to make changes happen that make a difference to the local population, not only will the time spent on PCN business become infinitely more worthwhile but also the local system will start to look to your PCN as a place to invest energy and resources.

When the wider system interacts with a PCN, they want to be able to ask the PCN to do something, and once whatever that is has been agreed, they want that to turn into real delivery.  If all PCNs do is turn up to meetings but never delivery anything (because attending the meetings has consumed all of the available time), any influence gained by being at the meeting is quickly lost.  Worse, confidence in PCNs as an enabler of integration is lost and the system starts to look elsewhere for a solution.

A PCN can diligently attend every meeting it is asked to go to and end up with very little influence because it has not had time to make any local changes, whereas a PCN can refuse to attend the majority of meetings it is asked to go to and yet be hugely influential because of what it has achieved.  In the end, delivery will always trump attendance at meetings.

Time is the most precious PCN resource.  PCN CD time and PCN meeting time are extremely limited.  One of the key leadership roles of every PCN CD is to determine how the time available can best be utilised to enable the goals of the PCN to be achieved.  If one of the goals is for the PCN to influence the local agenda, prioritise making change happen locally over attendance at meetings and trust that influence will follow.

Should PCNs Choose the Greater Good?

There are plenty of teams in every sport that have great players and never win titles. Most of the time, those players aren’t willing to sacrifice for the greater good of the team. The funny thing is, in the end, their unwillingness to sacrifice only makes individual goals more difficult to achieve. One thing I believe to the fullest is that if you think and achieve as a team, the individual accolades will take care of themselves.”  Michael Jordan

 

There is an interesting dilemma facing many practices right now, as they work out how to make the most out of PCNs.  Is it better to maximise the gains for your own individual PCN, or is it better to work together with other PCNs to maximise the gains for general practice as whole?

This manifests itself when a collection of PCNs in an area have to make a decision, and different PCNs have different views.  The decision could be for example whether one individual can represent all of the PCNs in a system-wide meeting.  If that individual can speak as a united voice on behalf of all practices then the overall voice of local practices is stronger.

But that individual may not fully represent the views of “our” PCN.  What if we don’t fully agree with what they say, or don’t trust them to put our point across?  We end up feeling the need to represent ourselves and our own PCN.  But now there are two voices of local general practice.  And if we contradict each other, the overall voice and impact of general practice is diminished.  But at least we know that our individual view and has been represented, and our views fed accurately into the system-wide discussion.

Or maybe we need to decide whether our PCN should use the federation to deliver extended access services, or whether we deliver these directly as a PCN.  If all the PCNs agree to the same model, the overall costs and administration to general practice are likely to be cheaper.

However, an individual PCN may be able to develop its own model which delivers greater retained profits for its member practices.  It may have access to capacity or management capability which mean the cost of delivering directly for that PCN are less than going with the federation model.  In doing so, the costs of using the federation model are likely to go up for the other PCNs and practices (because the fixed costs are then shared between fewer practices).  But at least our PCN has maximised the potential of the opportunity presented.

Should, then, individual PCNs make decisions based on the direct interest of itself and its member practices, or on the greater good of the wider group of local general practices?

The fates of PCNs and practices in an area are actually intertwined, whether PCNs and practices like it or not.  How much a system invests in local general practice overall will be determined by the extent to which general practice is able to both agree amongst itself and collectively deliver.  A system is not going to choose to invest in the medium to long term into one PCN over and above the others in an area, because it will want gains to be delivered to all of its population not just parts of it.

Choosing to take decisions based on maximising the gains of short term opportunities for an induvial PCN is short sighted, particularly when this comes at the expense of neighbouring practices and PCNs.  Operating in isolation will ultimately come at a cost to overall general practice.

What Michael Jordan said applies directly to practices and PCNs within a local area, “If you think and achieve as a team, the individual accolades (gains) will take care of themselves”.

Go Back to the Purpose

We are a year down the line with PCNs.  Recent months have been overshadowed by covid, but there were significant PCN developments in that period.  In particular, the agreement by NHS England to pay 100% rather than 70% cost of the new roles, the rowing back of the service specifications so that now only three (relatively light) specifications need to be delivered this year, and the sign up to the 2020/21 PCN DES by almost all practices.

Last year I don’t think it is unreasonable to say a number of practices, and even whole PCNs, took a ‘wait and see’ attitude towards PCNs.  It was a case of cautious sign up without making any significant commitment.  But now practices are in a whole new position – the role reimbursement scheme funding is significant, the delivery requirement is greater this year, and the extended access funding is around the corner (April next year).  The relative importance, particularly financial, of PCNs to practices is starting to feel different, and so the attitude of practices towards PCNs is beginning to change.

What we are starting to see (understandably) in some areas as a result of this is more unrest within PCNs.  The move from practices taking a relatively passive attitude to one that is more active is inevitably starting to create friction.

This is primarily because GPs and practices often want different things from the PCN.  Should the PCN appoint first contact physiotherapists or more pharmacists?  Should the PCN spend its £1.50 on management support or retain as much of that money as possible for practices?  Should the PCN use the local federation or should it manage its own finances and employment?  There are often different answers to these (and similar) questions within the members of a single PCN.  Moving forward can be difficult.

So how does a PCN move forward in this situation, where practices seem to have differing views on nearly every issue?

The key priority here for PCNs is to work on a shared purpose for the PCN across member practices.  Even if PCNs did this in the early days it may be time now to revisit this given how the landscape has started to shift.  Once there is a clear, shared purpose this can be used as the framework for decision making by the PCN.

Easier said than done.  How exactly do practices develop a shared purpose?  How can practices agree what they want the PCN to achieve?  The key part of this is taking time to sit down together and for each practice to share what they want from the PCN (what we assume is often different to the reality), and then work hard to identify where the common ground lies.

This process may take some time.  The key is to create a framework within which the practices can make decisions together, and criteria to assess any decision against.  If the practices, for example, want the PCN to reduce practice workload, increase the voice of general practice, and improve outcomes for the local frail elderly population, these can become the criteria for assessing any decisions against.  But this will only work if all the practices are agreed and sign up to the framework in the first place, which is why it takes time.

A shared, agreed purpose will not end debates and arguments within a PCN.  There are very few PCNs where the practices agree on everything.  But as the responsibility, funding and influence of PCNs grows, the importance of having a clear direction and a framework to make decisions and settle disputes is greater than ever.

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