How to build trust with practices

The key success metric for at-scale general practice, the one I would be monitoring most closely in my own at-scale general practice organisation, is trust. Do the practices trust the federation/network/primary care home/insert local name here?

Why? It is because at-scale success, one that is to genuinely support GP practices, depends on practices giving up some degree of individual autonomy to the at-scale organisation. And this will only happen where there is trust. Without trust, practices will work to protect individual autonomy, not give it up.

So how can any at-scale general practice organisation build trust with its member practices? An interesting place to start is Charles Green’s trust equation. The equation is:

Trust = (credibility + reliability + intimacy) / self-orientation

This is summarised in a Harvard Business Review article (here). Credibility is the perception of credibility, and ultimately stems from whether practices think the organisation is honest and truthful, and whether they think what it says can be believed. Reliability is again a perception, of whether the organisation will do what it says it will do. Giving up any sort of autonomy means a practice needs to believe those to whom it is giving up autonomy can deliver on their promises. Intimacy is the willingness of a practice to trust the at-scale organisation with something. This needs a relationship between the two to exist.

But what strikes me as most interesting about this equation for at-scale general practice is that the denominator is self-orientation. This is the extent to which practices believe the focus of the at-scale organisation is on itself rather than on the member practices. The stronger the belief held by practices that the federation or network is primarily concerned with itself rather than its member practices, the greater the extent to which trust is lost.

How, then, can such an organisation reduce self-orientation? What can it do to build confidence with member practices that it is genuinely there to support them?

Create opportunities for practices to speak. Often communication between at-scale organisations and practices is one way. The federation or network will report back on what it is doing, and explain its plans going forward. But what is equally important is to enable practices to talk about what is important to them. Often the best way to do this is for leaders to visit individual member practices with the sole intent of listening to what the practices have to say.

Listen with intent. Creating the opportunity for practices to speak and then taking no action as a result is probably worse than not doing anything. It is simply lip service. The more practices feel you are listening to what they are saying the more they will engage, and the less they will feel you are simply carrying on with your agenda regardless of anything they have to say.

Take responsibility when things go wrong. A clear signal that organisations are oriented to themselves is when they blame others for failure. This might be the practices, the CCG, other federations, the government (the list can go on!). By taking responsibility, and by being transparent, practices can start to see that you have integrity. Avoiding the tendency to blame others shows you are committed to delivery, and that your focus is more on making things work for practices than your own reputation.

Trust is hard to win and easy to lose. Guarding against self-orientation, and actively keeping focus on the needs of member practices is one of the best ways for at-scale general practice organisations to build and maintain trust.

Guest Blog – It’s time to get the lawyers in!

In last week’s blog Ben suggested that spending time and money on lawyers whilst developing new federations might be a mistake. But Craig Nikolic, Chief Operating Officer of Together First (a GP federation in Barking and Dagenham) had different ideas. So this week he gives us his take…

Ben Gowland’s blog piece on the Perfect Governance Model for GP Federations hits the spot on most areas and is correct that Federations that overdo “governance” are setting themselves up to become cumbersome and inefficient. Where I disagree with Ben is in the commissioning of professional advice.

For the vast majority of the NHS, the statement “it’s time to get the lawyers in” means that something has gone wrong and it’s often far too late. Most NHS senior managers have only seen lawyers in outright firefighting mode where they’re trying to fix problems, and doing it expensively.

To someone like me who has spent most of their career outside the NHS, this is a strange phenomenon and makes about as much sense as refusing to spend £100 on fire extinguishers then later complaining when you call the fire brigade to stop your business burning down.

A good lawyer or accountant, or even both, brought in early can be a very positive event when you’re doing business transformation. The trick is understanding what lawyers can do for you. For most NHS folk, lawyers are there to help you get over negative legal problems, or to legally threaten someone else, and they’re expensive. On the positive end of legal advice, it can be substantially cheaper to get a lawyer in early than put it off then find out when it’s too late that you’ve got it all wrong.

In Barking & Dagenham, we’re undergoing substantial transformational change and there’s a few areas where we’ve had uncomfortable experience of things going the wrong way because of the standard NHS “gentleman’s agreement” or a vague MoU over a critical piece of our business. We brought in lawyers and accountants to make sure our new plans get it right first time.

I’ll give a few of examples:

  • Take a GP Federation that wants to hold APMS/GMS/PMS contracts yet has GP practices in its area that are corporate bodies, say other APMS practices. Do you know absolutely and beyond doubt how your Federation can hold those contracts and also have the corporate body as an equally represented Federation member?
  • Do you do business with other NHS organisations by MoU? What’d happen if the other organisation said tomorrow “sorry, but that’s it, we’re stopping this deal today and you have no comeback because MoUs aren’t contracts”. That happens far more often than you’d think in the NHS.
  • Could your Federation’s books cope with a substantial amount of delegated commissioning if it suddenly came from the CCG? How could you track the financial viability of each LIS or contract? Are you confident that your cash flow could keep up with the slow nature of centralised NHS payments or payments from other care settings such as acute Trusts?

Getting formal legal and accountancy support on those items is not expensive, the trick is working with them properly. On lawyers especially, work with them, tell them in detail what you want to accomplish and how you’re planning to do it then put the open statement: “tell us the risks in what we’re doing”. It’s your plan, not theirs, you must put the hard work in first. Most NHS people dealing with lawyers give them nothing but vague statements and then say, “tell us how to do it”. You then get lawyers responding in the most risk-averse way possible with a contract that does nothing but lock people into onerous and negative terms. See the difference?

Imagine a GP referring a patient to a Consultant, you’d grumble at a GP just referring on and saying “patient is not well, tell us what to do” and giving nothing else, yet that’s what lawyers dealing with the NHS often get. Most of the money lawyers charge the NHS is spent doing their equivalent of “What do you mean by not well? Come on give us a clue, is it his leg? Maybe his arm?”

We did the positive work with our lawyers, we built a good relationship over overwhelmingly positive items and working through our already very robust plan. We got reassurance that most of the stuff we were doing was perfectly fine and had a legal opinion we could give to Commissioners and others to prove it. We changed track on a couple of minor points to address legal issues we simply didn’t know existed. We now have a clear idea of how to work well with other NHS organisations without having to get into regressive and negative protectionist contracts. Most importantly though, we know for sure that our plans are fit for a very flexible future that could go all the way from staying the same size all the way through to becoming a super-power Federation.

That’s it. Done. A simple, low bill to lawyers and we now have a clear foundation that’ll do us for years, protecting us from most negative events and giving us simple tools to help us do business more efficiently.

For me, that’s a no-brainer and I’d be in dereliction of my duty as a professional senior NHS manager to not take advantage of such an easily accessible resource.

The Perfect Governance Model for GP Federations

One of the problems I have been grappling with in recent weeks is trying to work out why there is no single, universally applicable model of governance that GP federations can adopt. I have seen governance models that have worked really well in one area be a real hindrance to progress in another, and I wanted to understand why.

What has helped me unpick this is thinking about organisational life cycles. If you are not familiar with these, essentially each organisation goes through a life cycle from creation through to termination. People who look at these things have found organisations do not progress through a series of random events, but rather through an expected sequence of stages. These are start-up, growth, maturity, renewal and decline[i].

Different organisations go through these stages at different rates. Some companies like Blockbuster Video and Boo.com (anyone?) came and progressed quickly through to decline, while others like Colgate and Cadburys feel like they have been around longer than most of us can remember. Some, of course, never make it out of the start-up phase.

This helps us understand why the ‘cut and paste’ model of federation governance doesn’t work because the governance needs of an organisation vary according to the stage of development it is at. In a start-up it is generally all hands on deck with everyone (including the board) doing what is needed to get the idea off the ground. During the growth phase the board is more focussed on plans and policies. And as the organisation gets to maturity the focus of the board is much more on strategy, risk management and holding the leader/CEO to account.

This means asking “what is the correct governance for a GP federation?” is actually the wrong question. The right question is “what stage in its organisational life cycle is the GP federation at?” Once that has been established, we can match the appropriate governance to it.

The trap I see many GP federations falling into is failing to match the appropriate governance with where they are in the organisational life cycle. In particular, many GP federations are in start-up – they have developed a shared vision/mission across the member practices, and there are a small number of leaders trying to maintain engagement and enthusiasm while at the same time getting projects off the ground to prove the worth and value of the organisation. But they spend their time investing in lawyers and developing complex governance arrangements that are appropriate for a more mature organisation.

It is hard enough being a start-up organisation. There are so few people trying to do so much, at the same time as having sceptics to convince. The precious limited resource that is the time and energy of the leaders needs to focus initially on getting ideas off the ground and turning them into action, and of convincing stakeholders that this really is the future. Spending it on creating overly complex governance structures at this stage diverts energy from where it is really needed (as well as being expensive!).

Meanwhile, the high performing federations have already been through the start-up stage. They may even have gone through rapid growth. So the governance they now have is of a mature organisation (looking at strategy, risk management and holding the leaders to account). This is appropriate for them now. But it wasn’t appropriate when they started, and simply because you aspire to be like them doesn’t mean that it is appropriate for your organisation now either.

There is no single perfect governance model for a GP federation. But being clear on where your federation is on its organisational life cycle is the best first step you can take to determine what the most appropriate form of governance is for you.

[i]  Lester, D., Parnell, J. and Carraher, S. (2003). Organizational life cycle: A five-stage empirical scale. International Journal of Organizational Analysis, 11(4), p.339-354

We need to turn the approach to solving the workforce crisis in general practice on its head

If I had an hour to solve a problem I would spend 55 minutes thinking about the problem and 5 minutes thinking about solutions” Albert Einstein

Why is all the effort being put into general practice workforce not working?  Two and half years after the publication of the GP Forward View GP numbers continue to fall, workload continues to rise, dissatisfaction continues to grow.  We are told the money is being invested.  So what is going wrong?

The NHS England workforce plan is pretty simple: increase the number of GP training places; attract overseas doctors; provide financial incentives for GPs in hard to recruit areas; recruit an additional 1500 clinical pharmacists; co-locate an additional 3000 mental health therapists; introduce 1000 physician associates to general practice.  All the individual elements of this plan are reportedly on track, so why is it not working?

In short, it is because we have jumped to solutions without spending enough time understanding the problem or thinking about the change process required to make solutions successful.

Do practices want clinical pharmacists, mental health therapists and physician associates?  Some do and some don’t.  Practices are independent businesses; creating roles that practices don’t want isn’t going to help.  Each practice ultimately has to choose to pay for any new roles.  The problem isn’t insufficient physician associates.

It is too big a jump to move from a case study of a practice, or group of practices, who have developed a solution to their specific workforce challenge, to then assuming this solution will work for all practices.  Making it national policy, and performance managing each area on delivering it is a change management approach that won’t work with GP practices.

Each area is different.  Each practice is different.  The workforce problem manifests differently in each area and each practice.  Where the problem is different, the solutions needed, and how they are implemented, will be different.  For a solution to work, it needs to be owned by the practice not imposed from above, yet this is where we currently are.

What, then, is the alternative?  Each area should work out how they want their specific challenges to be addressed.  Practices need to work out what they want to do about their problems, and own their own solutions.  They need to set the agenda.  The majority of practices are now in some form of primary care network.  This is an ideal grouping for practices to work together to identify the changes they want to make, such as employ paramedics to undertake a joint visiting service, build GP-led clinical teams for populations of c5000, create a multidisciplinary team to manage the on the day demand etc etc.  Each area should identify the solutions that will work for them.  This should then drive the workforce plan, not the NHS England targets.

Each local area currently has to justify how it is complying with the national workforce plan.  This approach is never going to work.  The whole approach needs turning on its head.  Local groups of practices should be shaping the agenda.  The available funding should be focussed on helping practices to work out the solutions that will work for them, and on helping them implement them.  Regional workforce organisations should be accountable to these group of practices, not to national organisations.

If we are going to start making inroads into the workforce crisis in general practice, we have to accept the current approach isn’t working, and start doing things differently.

Never mind the models, it’s the mind-set

Back in the dark mists of time, I used to work in the national emergency care team. Our job was essentially about applying service improvement to improve the delivery of emergency care. As part of the role myself and others would visit many different A&E departments and hospitals. What struck me most about these visits were the different mind-sets of those we visited.

They generally fell into two camps. There were those who were very warm and welcoming. They wanted to show us every part of their system and explain how it worked. They were eager for our feedback, and were keen to understand how they could make it better.

Then there were those who were not welcoming, who would make us wait, and restrict access to the areas they wanted us to see or to a certain amount of time because of how busy they were (i.e. had more important things to do). They were defensive to any reflections made about their practice, dismissed innovations developed elsewhere, and were not open to doing things differently.

We were not there to judge these departments, only to help. But it was clear from the outset which ones were actually open to any help and which ones were closed to it.

This phenomenon of having an “open” or “closed” mind-set is not limited to emergency departments. It is also prevalent in general practice. There are practices who are keen to learn from others, eager to try new things, and who want to find out where they can improve. Then there are practices who will tell you they have already tried everything that is out there, that it “didn’t work” for them, and that it is the system that needs to change, not them.

Possibly the leading international thinker on this subject it Carol Dweck. She talks about an open mind-set as a growth mind-set, and a closed one as fixed. She says,

A fixed mind-set doesn’t easily allow you to change course. You believe that someone either has ‘it’ or they don’t: it’s a very binary frame of mind. You don’t believe in growth, you believe in right and wrong and any suggestion of change or adaptation is considered a criticism. You don’t know how to adopt grey thinking. Challenges or obstacles tend to make you angry and defensive.”

The tricky part of all of this is that most people and practices will say they are open to new ideas, and that they have a growth mind-set. But saying it doesn’t make it so. Some people and some places maybe were open to new ideas once, but no longer are. Years of relative success breeds a confidence in what you do and how you do it. It creates a mind-set that challenges and difficulties are driven by external forces and that making changes to meet them and learning from others is disrespectful to how they do things and unnecessary.

This is the difficult place that general practice finds itself in. Some practices are open to new ideas and to making changes, and are developing rapidly. But others are not. Their mind-set remains closed. This is where the real challenge for general practice lies. Primary care networks, operating at scale, technology, the introduction of new roles, creating John Lewis style ownership models (etc.) will only help practices if they have an open mind-set, if they want to learn from others, and if they want to make changes.

Creating a new future for general practice is not really about creating a new partnership model. At its heart it is about developing a new mind-set.

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