14
sep
0

5 Steps to Improve Joint Working in General Practice

Posted by Blogs, The General Practice BlogNo Comments

Effective joint working is the key to successful general practice.  It may be joint working between the partners in a practice, joint working between the practices in a PCN, or joint working between the PCNs in an area.  Joint working is difficult, and where it is not effective individuals, practices and general practice as a whole all suffer.

The most important metric for joint working is trust.  How much do I trust my partners/the other practices/the other PCNs?  Where my trust is low I assume the intentions of others are poor, I avoid interaction where I can, and I am unwilling to be helpful because I do not believe there would be any reciprocation.  Life in a low trust environment is generally tense, unpleasant and often draining.

I spend much of my time supporting joint working within general practice.  Here are 5 steps that I have found to be extremely helpful in shifting from a low to higher trust environment:

  1. Stop communicating primarily by email. One clear indicator of poor relationships is where the majority of the communication takes place by email.  The problem with email is that it is one way and open to misinterpretation.  You are not there to correct any misunderstandings when the email is being read.

 

  1. Communicate by talking at least once a week. It is far better to have a short conversation of 20-30 minutes once a week than to have a (poorly attended) monthly meeting interspersed by heavy amounts of email communication.  Simply shifting the mode of communication from email to conversation in this way can have a huge impact.  It shows respect (people feel more valued when they are told things in person rather than by email), and allows questions and concerns to be answered and dealt with straight away, as well as preventing misunderstandings from festering.

 

  1. Communicate in person. Whilst there has been a huge time and convenience benefit to meeting and talking online, it is very difficult to develop and improve relationships in a virtual space.  It is too easy for individuals to simply disengage from the conversation (how often are we in meetings where the majority of people have their cameras off and are on mute?), rather than have their concerns noted and dealt with.  Online it is difficult to spend enough time understanding and valuing each other as people, as without shared coffee breaks or pre-meeting chat we focus only on the business.

I worked recently with a PCN that shift from monthly virtual meetings and email as the primary communication route, to weekly half hour virtual meetings and a monthly face to face meeting with far less reliance on emails.  The impact on relationships across the PCN was transformational.  Trust that had become low was restored.  There was a shared confidence in a new sense of transparency, and a new willingness to take actions together as a group of practices.

  1. Show vulnerability. The counterintuitive thing about building trust is that you build more trust by sharing your weaknesses than your strengths, and asking for help builds more trust than offering to help.  If I ask you for help I show that I respect you, that I believe you have strengths that I do not have and that I trust you enough to show you my weakness.  Conversely if I offer to help you I reinforce your belief that I think I am better than you, that I have no sense of my own weaknesses, and even that I may have a secret agenda to take you over – however well-intentioned the offer may be.
  2. Admit when you are wrong. We all make mistakes.  Sometimes we are convinced that a course of action is the right one to take, but with hindsight we can see the error of our ways.  But it makes a huge difference to other people if we are prepared to put our hands up and say we are sorry when we have made a mistake.

I worked with one federation who had a difficult relationship with some of the PCNs in its area.  But this all suddenly changed when in one meeting the federation acknowledged that it had made mistakes in the past, said sorry for the impact of those mistakes, and asked what it could do to put them right.  Almost immediately the relationships were changed and moved to a much more positive place.

While it is generally true that trust can be hard to gain and is easy to lose, my experience has been that by starting with a good intent and taking the right actions in line with these 5 steps trust can be rebuilt surprisingly quickly.

7
sep
0

How Much Autonomy are GP Practices Prepared to Give Up?

Posted by Blogs, The General Practice BlogNo Comments

Much of the strength of general practice comes from its autonomy.  While the rest of the NHS totters under the weight of being part of one of the largest centralised systems in the world, GP practices are free to operate as they choose to deliver the contracts they have agreed.  While this autonomy carries its risks (the practice is the business, not simply a part of the business), it also creates huge freedom for practices to operate exactly as they want.

The pressures on practices mean that the sustainability of these independent, autonomous businesses is coming increasingly under threat.  Growth in funding does not keep pace with the growth in workload, and the staff required (especially GPs) in many areas simply cannot be found.

Here comes the challenge. In order to improve sustainability, practices have to find new ways of working.  These nearly always involve working with other practices.  These could be things such as creating a shared visiting team, building a staff bank, establishing a document management service, putting in place a prescribing hub, or any number of other things.  All of them will make a difference to practices, but all of them involve working with other practices.

If working together can make a difference to practice sustainability, particularly now when individual practice sustainability is under such pressure, why is that so few practices undertake these shared activities?

It is because working with other practices requires a ceding of some autonomy.  If five practices are working together to create a document management hub, they all have to agree to a single way of working for actioning and coding the incoming documents.  It doesn’t work if there are five different ways of doing things.  In order to gain the benefits of the shared hub, each practice has to give up its individual autonomy on how it does things and agree to the single collective way of doing things.

Instinctively GP partners and GP practices resist any attempt to curtail their autonomy.  It is in the DNA of GP practices to be extremely protective of their own autonomy.  This is why joint working is hard, however rational and straightforward it might seem on paper.

There are two critical components to enabling collaborative working in general practice.  The first is a shared belief that continuing on our own is unsustainable and that joint working will make a difference.  The second is that practices trust those whom they are ceding autonomy to, most commonly the other practices that they are working with.  If we do not trust them, and in particular those leading whatever the change is, we are unlikely to go ahead no matter how clear the potential benefits.

As an aside, this is why PCNs are difficult.  The starting point of PCNs was not a shared understanding that joint action is required, but rather a contractual requirement.  The initial level of trust between the practices thrown together in a PCN was usually low, unless there had been some history of effective joint working previously.  So PCNs started with a set of practices who were supposed to work together, but all of whom were hugely protective of their own individual practice autonomy.

As the sustainability crisis worsens, the need for joint working gets greater.  The challenge for GP practices is whether they are prepared to cede some autonomy now to enable this joint working to take place and be effective.  The risk is that refusing to give up some autonomy now will lead to a complete loss of autonomy in future when the practice reaches a crisis point from which it is not able to recover.

24
aug
0

What Should General Practice Do With PCNs?

Posted by Blogs, The General Practice BlogNo Comments

There is a danger starting with a title like this that it will provoke many into further calls for general practice simply to abandon PCNs and have nothing more to do with them.  This was the call at the national LMC conference, and as I understand it has become BMA policy.  But as I have previously written, such a move has the ‘cutting off your nose to spite your face’ feel to it, and a more nuanced approach is required.  So what could this be?

The challenge is that all of the additional funding and resources for general practice over the course of the current 5 year deal comes via PCNs, and general practice simply cannot afford to do without this.  Any move away from PCNs will not result in the funding being transferred into the core contract, but in a loss of control of these resources to other organisations eager to take them on.

We know that the Fuller Report has laid out a direction of travel for PCNs to evolve into Integrated Neighbourhood Teams.  This means the focus of PCNs moving away from GP practices and towards multi-agency working across local neighbourhoods.

What will happen to the funding of PCNs after the existing 5 year deal for general practice expires in 2024?  The funding for them will potentially grow (neighbourhood multi-agency working is becoming more not less important to the system), and will most likely continue to consume any additional funding for general practice.  It is also highly likely to come via the local Integrated Care System rather than via the national contract.

So the additional money for general practice is, and will continue to be, tied up in PCNs, but the control of PCNs may start to shift away from practices.

I have written previously of the need for local general practice within each area to start to work together to create a collective voice and influence for general practice as a provider.  My question now is to consider what role PCNs should play in this collective action?

Should the voice of general practice in an area be channelled through the PCNs and the PCN Clinical Directors?  After all, it is the PCNs that the system wants to talk to.

Right now PCNs and PCN Clinical Directors should form part of any collective general practice voice, particularly as the Clinical Directors all come from general practice at present.  But in future the Clinical Directors of the Integrated Neighbourhood Teams may not come from general practice.  Some may come from the community trust, the acute trust, or the council.

Meanwhile general practice needs to create its own provider voice in the system, particularly as its commissioning voice is being lost.  But it needs to build this as the voice of the GP practices at its heart.  It needs to do this in a way that means it can both harness the resources for general practice that come via PCNs, but also when general practice in future has to negotiate its role within the Integrated Neighbourhood Teams it can do so because there is a clear enough separation between what is local general practice and what are the activities of these new multi-agency teams.

This means the local general practice leadership voice cannot be solely that of the PCN Clinical Directors.  The LMC and any local GP provider must also be involved, and there must be a way of ensuring that there is route for voicing the needs of practices, and negotiating on their behalf, that is separate from the needs of PCNs.

While this nuance is difficult, I think ultimately it will largely come down to leadership.  If local GP leaders can work together for the good of the practices and their populations, regardless of the role that they are in, then they can create a strong leadership voice that they can iterate with the changing environment.

10
aug
0

Making the Transition from Commissioner to Provider

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The impact of the formal establishment of Integrated Care Systems and the abolition of CCGs may not have been felt straight away, but there is no escaping the huge consequences this has for general practice.  The question is whether general practice can shift from influencing as a commissioner to influencing as a provider quickly enough to prevent any real damage being done during the transition period.

For the last 30 years, ever since the introduction of the internal market, the influence of general practice has grown through the commissioning route.  It started slowly at first, with the initial forays of GP fundholding, but then steadily grew until Clinical Commissioning Groups were established built around a membership of GP practices.

While the influence of general practice grew through the commissioning route, its influence as a provider steadily receded.  A strong provider voice for general practice has not been needed because GP leaders were already at the system table via the CCG.  Indeed, GP provider representation was actively discouraged because of concerns around conflict to interest.  At best we had GP federations and GP provider organisations purporting to be the voice of general practice provision, but in reality they represented additional provision undertaken by these organisations above and beyond core general practice.

This has been of little concern to the profession because the main representation of general practice takes place nationally via the negotiation of the national contract.  It is this contract that has been pivotal to the sustainability of the service, much more important than any additional local income.

But now this is a problem for two reasons.  First, the representation of general practice at a national level is finding it difficult to secure an effective deal for the profession.  This is encapsulated by the self-defeating policy to promote the withdrawal of practices from the PCN DES, despite all the agreed additional resource for general practice over the last 5 years coming via this route.  This creates a huge risk for general practice, because it relies on a premise that this funding will be reinvested into the core contract instead, when a much more likely outcome is simply that practices will lose control of the PCN resources.

Second, all the signs are that much more practice income will come via the local route rather than via the national contract in future.  This was signalled strongly in the Fuller Report, and backed up by a letter from all 42 ICS Chief Executives.  If this is the case, how organised is local general practice to negotiate as a provider with its local system.  Are LMCs up to the job?  Is the infrastructure of LMCs sufficient for the size of what may be required? While some clearly are, there is a huge variation amongst LMCs across the country.  The system is going to want more ‘integration’ by general practice in return for more resources, so how are PCNs going to play into these discussions?  Will PCNs and LMCs be joined up, or will they be played off against each other?

For the first time in over 30 years local general practice needs to establish its voice and influence as a provider in the local system.  The support that has historically been in place from commissioners will quickly recede in the new system.  Much of the responsibility that has sat with national leaders and the national contract will become the responsibility of local leaders.  It will be up to general practice in each local area to support itself.  LMCs, PCNs, federations and practices will need to work together to ensure local general practice is unified.

27
jul
0

Can GP Federations Continue to Stand Alone?

Posted by Blogs, The General Practice BlogNo Comments

The world is moving quickly and the need to take a step back and consider how everything fits together is becoming more and more frequent.  For GP federations the move into Integrated Care Systems (ICSs) is creating one of these moments.

Historically GP federations have been set up in local areas often by a relatively small number of enthusiastic GPs.  They generally began with high expectations, and then over time relationships with member practices have waxed and waned, particularly as it has been challenging for federations to fulfil the delivery requirements needed to establish themselves as a provider and at the same time carry out the amount of communication necessary for practices to feel engaged and part of the organisation.

Then along came PCNs.  Up until that point it had been easy for federations to describe themselves as the ‘at-scale’ arm of general practice, as there were only individual practices and the federation.  But with PCNs came a mandated at-scale operation of general practice in every local area.  Now there are practices, PCNs and a federation, and it has made it more difficult for federations to articulate their role in the system.

The preference has generally been to describe themselves as the at-scale provider across any given area, as their remit tends to mirror old CCG areas and hence be larger than nearly all individual PCNs.  The mainstay of many federations has been the delivery of extended access, and recently federations and PCNs have been undertaking a round of relatively strained conversations to agree what the federation will do and what PCNs will do, now that responsibility for the service has shifted to PCNs.

But it is the emergence of ICSs that is bringing things to a head.  General practice needs to be able to operate as a collective entity within an ICS “place” area.  Within such an area there is often a number of PCNs, an LMC and (if one exists) a federation.  The question is whether, in such an environment, a federation can stand alone as a GP provider organisation, separate from core general practice?

This is problematic because the system wants to do business with general practice as a whole (not a limited company that can access GPs to deliver services).  Whereas in the past federations could point to their practice membership as a proxy for working across all practices, with PCNs in place this is no longer the case as they have a much clearer practice membership.  Federations were never really set up as a way of other organisations being able to do business with general practice, so now federations have a problem.

The most obvious way forward would seem to be to strengthen the federation/PCN relationship.  If federations can be the glue that holds PCNs together they would be perfectly placed to continue to provide at-scale services, provide support for PCNs and practices, and by including the LMC could start to be able to talk with authority in the system as local general practice.

But while some federations have been bolder in taking steps towards taking on the provision of support for PCNs as a new part of its core business, many have shied away from this (often because of emerging PCN/federation tensions, and because of the costs involved).  While PCNs are funded by the PCN DES, federations rely on funding from the delivery of services.  The need to breakeven/fund the federation infrastructure and even generate a return for shareholders has often created a tension in terms of what federations have been willing or able to do in terms of support for PCNs.

The irony is that federations are highly unlikely to be able to generate any kind of sustainable financial return if they maintain their separation from PCNs.  They will increasingly rely on the PCNs for the work (like extended access), and if federations are not the support provider for PCNs then whoever takes this on will end up being better placed to take on any at-scale work.

Without the protection of CCGs the ICSs are not going to tolerate small-scale provider organisations with no real remit.  If federations are not providing the scaled up support the new integrated neighbourhood teams are going to require, and don’t become the organisation that holds general practice together in an area, it is hard to see how they will survive beyond the next few years.

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