Is the system suffering from “Shiny New Toy Syndrome”?

If you are not familiar with shiny new toy syndrome, it is characterised by the sufferer wanting to own the latest toy and getting hooked on the intense but very temporary high of the ownership, before moving on to something else.  In the short term the new toy always seems to offer some sort of novel nirvana and the hope of short term gains, and the owner is blinded to the obvious shortcomings of that item.  But then, inevitably, disenchantment sets in, and the owner discards the toy and moves on to the next thing.

It seems to me that at present the wider NHS system is suffering from shiny new toy syndrome when it comes to Primary Care Networks (PCNs).  Whatever the current question, at present the answer is “PCNs”.  From “how will general practice be sustainable in the future?” to “how will we sort out out of hospital care?” and right through to “how will we deliver our ICP plan?”; the answer always seems to be “PCNs”.

As happens with shiny new toy syndrome, the system is apparently blinded to the obvious shortcomings of PCNs, most notably that they are brand new, they have very limited (if any) capacity to deliver, they have a large cohort of inexperienced leaders in place, and the relationships they have are very much in their infancy.  PCN development money is not, unfortunately, magic dust that can make these limitations disappear any time soon.

And it does not take someone with particularly well-honed psychic powers to predict that a year or two down the line widespread disillusionment with PCNs will set in, as they fail to deliver “what we expected”.  This will be followed by questioning as to whether the 30-50,000 population was really the right size, and then a new solution (or shiny new toy) will be put in place to replace this one, with equally unrealistic expectations upon it.

Success generally comes by staying focussed over the long term, and not getting distracted by whatever is new today.  The risk is that in the excitement of PCNs the recent good work that had been put in place to turn round the fortunes of general practice may get lost, including:

  • The GP Forward View and the releasing time for care programme
  • The support for individual practices to meet the challenges they face
  • The support for practices to learn to work together in different ways
  • The support for federations and other at-scale structures as enabling entities operating across multiple practices.

These were things making a difference, and you can feel the system losing its appetite to maintain its focus on them because PCNs are the shiny new toy in town.  Of course PCNs are an opportunity to build on the work so far, to enable further investment where it is needed into general practice, and to develop stronger relationships across general practice and between general practice and the rest of the system.  But it is going to take time.  The benefits will only come over the medium to long term, and they will require PCNs to build on the progress to the point at which they were conceived rather than starting all over again.

Right now what is important is that unrealistic expectations of PCNs are challenged both nationally and locally to give PCNs the chance to grow and develop.  The system needs to move away from shiny new toy syndrome and develop a long term commitment to PCNs as they have been configured, accept the real benefits will come some years down the line, and understand that the best way of accelerating this development is to build on the work already carried out rather than starting all over again.

Are you ready for Babylon?

Any reports of the demise of GP at Hand as a result of the new requirements on it from next year are, at best, overstated.  More likely is the threat to local practices will be greater.  The question, then, is how should practices react?

From April 2020 when the number of out of area patients in any CCG area reaches a certain threshold (1,000 patients) the GP at Hand contract will be split and a new practice list will be created with a new CCG contract, where the company will need to provide premises, be part of local networks, and meet all services requirements.

At present GP at Hand exceed the threshold in at least 17 of the 32 London CCG areas, and there are reports that it won’t be long until this is the case in all 32 areas.  And it is not just London.  In February this year NHS England approved plans for the expansion into Birmingham, and only a few weeks ago the company announced plans to expand into Manchester.

While the suggestion is that GP at Hand will need to set up under new APMS contract arrangements I think this is unlikely.  My sense is they will instead seek to “partner” with an existing practice in each of the relevant areas (and rumours abound these discussions are already taking place).  This removes the need for any set up costs, or any of the recruitment problems that new APMS contractors generally face.  And of course, the ‘local practice’ label could accelerate further the expansion of the service beyond its current rate by giving it a credibility that an anonymous national organisation wouldn’t otherwise have.  Patients not prepared to de-register from their existing practice to register with an on-line provider may not have the same qualms about shifting to the practice down the road.

Will GP at Hand be able to find local practices open to their advances?  Given the challenging environment general practice continues to find itself in, it is hard to imagine there won’t be at least some who will find the promise of silver too hard to resist.

The main challenge this creates for practices is they rely on risk pooling and cross subsidy, where the capitation fee for younger, fitter patients funds the cost of caring for elderly and complex patients.  The way GP at Hand operates, as Hammersmith MP Andy Slaughter describes it, “is distorting the way primary care is going to operate by sucking the most profitable parts into a parallel digital system”.

How, then, should general practice respond?  There is going to be limited political support, as the Secretary of State for Health proudly announced at the RCGP conference last week he was a GP at Hand patient.  If the argument isn’t going to be won at national level, it may well fall to local areas to take up the fight.

But can local areas do anything with the prospect of such a juggernaut looming large?  Even though the situation might feel hopeless to some, there a number of factors working to the advantage of local practices:

  • Consistently over 90% of patients say that they trust their GP, and there is not a clamouring from patients to move to a new service. If practices can keep patient satisfaction high, it is unlikely patients will leave en masse.
  • The opportunity now exists for practices to put their own digital arrangements in place. In the new contract practices have to offer online consultations by April 2020, and so practices can significantly reduce the differential between the local offering and the GP at Hand offering.  Practices working together in Primary Care Networks (PCNs) provide the opportunity for practices to do this collectively, in a way that is tailored to the specific needs of their local population.
  • Local practices are embedded in local communities. PCNs provide an opportunity for practices to strengthen these links further, and to create more reasons why being part of a local service is better than being part of a corporate, national service.
  • LMCs have a role to play. There may not be national opposition to the roll out of GP at Hand, but practices need to be making sure their local LMC is mobilising opposition locally. GP at Hand may come in the package of a local practice, but it is up to the local GP leaders to ensure the local population is fully aware of the reality of the new situation.

There are probably lots of other factors that I have missed.  My point is that Babylon is coming, and it is important practices understand what is on the way, and think proactively about what they can do to minimise the impact on their own practice.  The head in the sand approach is unlikely to be the best one, and now is the time for local practices to get together and come up with their own plan to mitigate the forthcoming challenge.

What single thing can have the biggest impact on GP resilience?

I was talking recently to Dr Rachel Morris (who as many of you will know is a Red Whale presenter, coach, and specialist in resilience) as part of a conversation for her new podcast “You are not a frog” (which focusses on how to build resilience and thrive in challenging environments).  General practice is certainly challenging, and the question Rachel asked me was what can GPs do in such an environment?  What “quick wins” are there that GPs can take?

I reflected on all of the guests we have had on the General Practice podcast, and what is clear is that there are no magic bullets for general practice.  Changes that have worked for some have not worked for others.  Some practices hate telephone appointments, some swear by them.  Some love new roles, some think they simply add to the overall burden of work.  Some like to give the admin team more of the GP workload, but others find the lack of control adds to rather than reduces their stress levels.

There is, however, one thing that GPs who are working in practices that are thriving in the current environment have in common: the ability to make change happen.  I don’t think it is over-stretching it to say that a key part of developing resilience for GPs is the ability to make change happen in their own practice.

I recently interviewed Dr Liz Phillips on the podcast, and she talked about the transformational impact being able to make changes (for her as a partner, compared to 12 years previously as a salaried GP) has had on her.  Longer time listeners to the podcast may also remember the inspirational Dr Farzana Hussain talking about how learning how to make change happen using quality improvement techniques had given her the strength to carry on when she was left as the sole partner in her practice.

Resilience comes from the sense of control that when things are not working, they can be made better.  When problems are being faced, there is a way out.  When making change feels impossible, it is easy to understand why individual GP resilience can suffer.

Recently on the podcast Paul Deffley (in a must-listen episode) described his experience of making changes across multiple practices.  However, it was in his first appearance on the podcast that he described an experience of two practices introducing the same pharmacist to do exactly the same things.  One had made it work really well, one hadn’t.  The pharmacist was the same, and what the pharmacist was doing was the same.  The variable was the practices.  Why would one practice be able to introduce the change successfully and the other not?  Ultimately it came down to ability of the practices to make change happen.

Making change is difficult.  But it is not impossible.  Learning how to make change is a skill, and it is one that it is worth investing in developing because the benefits are so wide-reaching.  I remember my own ‘a-ha’ moment many years ago, when suddenly after 5 years of “managing” in acute hospitals I learnt the role was not simply to keep things going, to do the heavy lifting for a period of time until it was someone else’s turn, but to actually make things better.  I learnt the skill of making change happen, and it completely transformed my own experience of being a manager.

So when Rachel asked me what can GPs and practices do that will make the biggest difference in the challenging environment of modern day general practice, my response was to learn how to make change happen.  Whatever the challenges a practice might face, if it knows how to implement change effectively it will always have a route to overcoming them.

Guest Blog – Karen Castille – 10 things coaching can do for you

When your car won’t start you probably call out a mechanic. And when your drain is blocked it’s likely you’ll need a plumber to help you unblock it. But when might you require the help of a coach? Whilst it’s hard to describe what their role is, it is certainly not to fix things for you!

As it is notoriously tricky to explain what a coach does, it is probably better to flip the question and, instead, describe how the process of coaching might help you.

The coach’s job is to help you move closer to achieving things you want for yourself. However, most of us have a natural tendency to focus on problems rather than on bigger more strategic and longer-term goals that will help us to grow and learn. So I use the mnemonic ‘A.C.E.’ as a reminder of the three possible areas of focus if you work with a coach:

A – an Aspiration, goal or dream that you have

C – a Challenge, problem or issue that you need to rise to or resolve

E – an Experience or event that you want to make sense of

The ‘A’ is future focused; the ‘C’ is mostly present focused; and the ‘E’ focuses on the past.

Based on many years of coaching, here are ten things that most of my clients ask for help with and which usefully describe how a coach might help you.

Aspirational Things (hopes, dreams and longer-term goals)

1. Provide clarity about what you want, then create a tangible plan of the steps you will take to get there.

2. Work out what’s most important to you (rather than focus on the urgent things in front of you now), especially those things that will help you create a more positive future.

3. Determine what success looks like (for you) and embed this into your longer-term goal.

4. Create excitement, momentum and focus to help you move closer to your goal.

Challenges

5. Build confidence and competence in solving your problems and making decisions about things that are troubling you or keeping you awake at night.

6. Help you to stand outside of the problem, rather than being in it, by questioning your assumptions and helping you think about it from different perspectives so that you can consider different solutions.

7. Work out your options – especially if you feel stuck or that the challenge is impossible to overcome – then create commitment to acting on one or more of your ideas.

Experiences or Events (either negative or positive)

8. Reflect on and make sense of past experiences or situations. This can help you to learn from mistakes and let go of things that are out of your control.

9. Help you discover things about yourself that you may not be conscious of such as:

  • Your leadership style and preferences
  • How you deal with challenging behaviour or conflict situations
  • What works for you (and what doesn’t!)

10. Build positive and productive relationships – even with people you don’t get along with – by reflecting on their behaviour as well as your own.

People who have undergone coaching often talk about it being a life changing or transformational experience. But don’t misunderstand me. It is certainly not a cosy chat over a comforting caramel latte! It requires hard brain work and for you to take responsibility for your life and your future. It needs courage to try new things, and commitment to make changes to the way things are.

This said, when the coach and coachee work well together, it is certainly worth the effort.

Unfortunately, you’ll still need to call out a mechanic for your car, or a plumber for your blocked drain. But with coaching, futures get sharply defined, careers get changed, problems get solved, work-life balance can be restored and, importantly, sleep comes more easily!

Dr Karen Castille O.B.E, Executive and Leadership Coach, Author The Self-Coaching Workbook, @karencastille

Are PCNs the new unit of GP improvement?

The question of whether Primary Care Networks (PCNs) are to replace individual practices as the focus for improvement in general practice is an important one.  If the answer is yes, it potentially represents a direction of travel whereby the focus on the individual practice could be significantly reduced, and (conversely) the opportunities for practices through PCNs could increase way beyond the level set out in the contract.

I asked Robert Varnam, Head of General Practice Development at NHS England, in a recent interview for the General Practice podcast whether PCNs are the new unit of GP improvement.  His response was that while there is a focus on the unique and individual needs of each practice at present, we are in a period of “transition” from practices to PCNs, and are moving increasingly towards working with practices as a group within their individual networks.  The rationale is that when practices collaborate they can generate more ideas more quickly, they can build shared resources that prevent things being done multiple times (e.g. training, directories of service etc) and networks create a route to accessing resources like new roles, that for some practices have been out of reach while working on their own.

Within such a transition, how will the focus on the specific needs of the individual practice be maintained?  This responsibility is likely to fall to the PCN itself.  The ‘system’ will support the PCN, and it will be the role of the PCN to support its member practices.

The question then for the PCN is how it intends to support its member practices.  There are two potential routes open.  One is to use the PCN as an exercise in collaborative improvement for its member practices (and the populations they serve).  The second is to treat the PCN as a bureaucratic hurdle to be overcome to secure resources for member practices.

It is the role of the practices in each PCN to decide what the right balance is for them, and which of these routes they want to go down.   I suspect the assumption made in some STPs and in some quarters nationally that all practices are opting for the former rather than the latter of these two routes is unlikely to be right.  The differing attitude of PCNs to the £1.50 running costs is illustrative of this, as some PCNs are spending as little as possible to maximise the resources that remain for practices, and some could have easily already spent the £1.50 twice over as they embark on a series of different local change initiatives.

Underneath this choice is a question each practice needs to grapple with on its own, which is in light of this overall national direction and given the challenges we face how will we make improvements to our practice?  Will we do it on our own, using the (increasingly limited) resources that will be available?  Or will we do it through the PCN, using the opportunities that brings?  Is it to be done at a practice level whenever we can, and a PCN level when we have to?  Or PCN level whenever we can, and practice level only when we have to?  The mindset here is key.

The PCN route brings resources such as new staff and new investment, as well as the opportunity to make bigger, bolder, more impactful changes.  But as ever there is a trade-off, as individual practice autonomy is reduced, there is less individual control on changes happening across a larger group of practices.  And, inevitably, the more GPs that are involved, the more difficult introducing any change can be.

So far PCNs have been largely about set-up and getting the fundamentals in place, and the opportunities for improvement have not yet been widely exploited.  What remains to be seen is whether practices will choose to use PCNs as a collaborative opportunity to create a general practice that can thrive into the future, or whether PCNs end up as a largely administrative exercise that serve a wider purpose but do not really help core general practice.  PCNs may be the perceived unit of general practice improvement going forward, but ultimately it is up to practices to decide whether this is a route they are prepared to travel down.

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