One of the areas that initially feels quite straightforward but turns out to be relatively complex is representation.  How general practice is represented in system meetings and system discussions, and how this is done effectively, is an area that insufficient thought is given to, and as a result is an area in which general practice is currently faring badly in most areas.

It seems easy.  A GP representative is needed for a meeting and someone needs to go.  In the end someone volunteers/is volunteered and job done, general practice is being represented.

But who is this GP representing?  Themselves? Their practice? Their PCN? The whole of local general practice?  If they agree something in the meeting does that mean that the whole of local general practice also agrees to it.  Probably not.  So that means they are not representing local general practice.  Instead they are most likely giving a view.  Which means that general practice is not actually being represented at the meeting.

The complexity comes because as a disperse group of practices, PCNs and general practice organisations we are generally not clear that anyone can represent us if we are not there ourselves.  Indeed sometimes we feel the need to attend simply because a colleague is attending and we either don’t agree with their views or are concerned that they will use their attendance to exploit the best opportunities for themselves or their practice/PCN.  Even if we agree someone can represent us we rarely agree what it is they can or cannot sign up to, or what outcome we want them to achieve.

The starting point for this process is establishing a single leadership group for local general practice (which I have written about here).  I have also written about establishing priorities for general practice, which will help any representative understand what they may want to achieve.  But the leadership group need to be clear how representation will work in practice.

The first question is who will do the representation.  The choice tends to be between whether one or two key individuals carry out most of the representation on behalf of general practice (like the Chief Executive or Medical Director of the acute trust would), or whether it is shared out amongst multiple colleagues so that the burden of meeting attendance is distributed and more manageable.

My preference is for the former option.  The reality is that much of the system decision making happens not at the meetings themselves, but as a result of the relationships between those at the meetings.  If a small number of individuals are cultivating these relationships on behalf of general practice the influence is likely to be much greater than if a different GP is attending each meeting.  It also means there will be a consistency to the views given by general practice, and different GP representatives cannot be played off against each other, unaware of what their colleagues have said in other meetings.

Available time is the enemy.  In some places a senior manager (such as a federation Chief Executive) is used to carry out this representation as they have the time and skills to be effective in this role.  Where a dispersed model is used then there needs to be one or two leads with overall responsibility for representation who can both brief and receive feedback from the representatives so that all of the system information and dynamics are held in one place.

The second question is what process will be put in place for representation.  The first instinct here tends to be to create a very prescribed framework where what people can or cannot agree is explicit, with clear guidelines on what must be brought back to the wider group for sign off.  The problem is that it emasculates the representative in the meeting as they are not able to agree what others in the meeting can.  The real world is also unpredictable, and so what actually happens rarely matches any predetermined framework.

The process has to be built on trust.  The group has to trust their representative that they will have the skills and experience to agree/not agree to the right things and to bring the right things back for wider discussion.  What is helpful to put in place is a regular review process so that the wider leadership group can feedback to the representative(s) what is working or what is not (e.g. where they may have overstepped the line and agreed something they should not have, or where the feedback could have been more detailed) so that representation develops and becomes more effective over time.

There are two areas where GP representatives generally fall down.  The first is communication back as to what is due to be discussed in a meeting, what has happened in the meetings and what has been agreed (most often due to lack of time).  A process for ensuring this communication takes place needs to be agreed and put in place.  If not, the lack of communication leads to an erosion of trust, and the whole representation process can collapse.

The second area is that of action.  In many of these meetings actions are required as a result of whatever has been agreed.  GP representatives often do not ensure these actions are carried out (again generally because of a lack of time), which in turn means general practice can lose its influence and any gains achieved during the meeting.  Key here is putting some management or administration support alongside the representative(s) to ensure that any actions are carried out.

Getting representation right is not easy.  An early challenge for GP leadership groups is working through how this will happen, and then refining this process over time so that it builds and strengthens the influence general practice is having on the system.

If general practice wants to influence the local Integrated Care System (ICS) then it needs to be clear what influence it wants to have.  If it doesn’t have priorities of its own then how can it expect these to be reflected in the priorities of the new system?

Last week I wrote about the importance of each area creating a local leadership group for general practice, including as a minimum the PCN CDs, LMC and federation (where there is one).  However, if an area puts such a group in place the risk is that this will simply be used by the rest of the system as a means of talking to general practice about what is on their agenda, and end up as yet another meeting that doesn’t help or extend the influence that general practice has.

Indeed, in some areas we are seeing these leadership groups attempt to be established by the system (as opposed to by general practice itself).  These are rooted in the need for the system to have one place that it can come to ‘do business’ with general practice – they are about making it easier for system partners, not about strengthening the voice and influence of general practice.

General practice needs to set its own priorities first.  But what are these priorities of?  If when generating priorities what comes out is a list that looks like more GPs, more money and less work for general practice then it is hard to see how this is going to help general practice increase its influence.  The system will not take the service seriously.

While these things are important, what the local leadership group needs is priorities that do two things: strengthen how GP practices can be supported by joint working; and identify the specific influence that general practice wants to have on the local system.

What type of things could these priorities be?  Each local area needs to decide this for itself, but it could be things such as:

• Strengthening the resilience support for local practices (potentially pushing for resources for this to be transferred from the system to within general practice itself)
• Supporting practices with the recruitment of hard to find staff groups
• Practical steps to reduce the shift of work from secondary to primary care
• Putting a local communications or media campaign in place to educate the public about the range and value of the roles that now form part of local general practice
• Ensuring general practice plays a leadership role in the new Integrated Neighbourhood Teams as they develop

These are just examples, and won’t be right for your area, but they give you an idea of the type of priorities it could be helpful for local general practice to have.  They need to be translatable into practical actions that general practice can influence the local system to take. To be effective they also need to resonate at an individual practice level.

How do you set these priorities?  What is key here is engaging local practices in the process.  The local leadership team cannot just tell practices what the priorities are.  For them to have real value they need the support of all practices.

This could be done by asking practices what the priorities should be and building up from there.  The risk with this approach is that it could build expectations of the leadership team that may not be realistic.  A better option may be for the leadership team to identify a range of potential priorities and then involve all practices in the decision-making as to what constitutes the final list.  This process  would also provide an opportunity to explain to practices what the leadership group is, why it is needed, and what it is trying to achieve.

Once it has an agreed set of priorities in place the leadership group is in a much better place to control its agenda and how it spends its time, ensure that the primary focus of its energy is on delivering these priorities, and establish a real and productive influence in the local system.

I am going to write over the next few weeks a series of articles outlining the actions that general practice can take in a local area to be effective within the new integrated care system (ICS) environment.  This is the first of these articles, and is about putting a single board or leadership group in place for local general practice.

I have written previously on the potentially huge impact the loss of CCGs and the introduction of ICSs could have on general practice.  With general practice losing its system voice as a commissioner, it has to create one as a provider.  All signs from the Fuller report indicate that more of general practice funding will be channelled via ICSs (as opposed to the national contract) in future, so as a minimum local general practice needs to be organised to at least be able to negotiate effectively.

The first action that general practice needs to take is to put a single leadership board for local general practice in place.  As a minimum this needs to include the PCN Clinical Directors and the LMC Chair.  The system recognises PCNs, and the LMC has a statutory role to play.  If there is a local federation they also need to be included on it.

If general practice is not united it will be weak in the new system.  Different facets of the service will be played off against each other, as the system asks different people the same question until it gets the response it is seeking.  Equally, influence at system meetings is nullified when different parts of general practice argue against each other.  Strength comes from unity, and a single general practice board is the first step towards this.

There are a couple of important considerations to make about setting up such a board.  The first is one of scale.  Should this general practice board be at the level of the ICS, or of the local area (which more likely relates to the “place” area within the ICS)?  Whilst influence at an ICS level is important, the more natural grouping and ability for short term cohesion within general practice is at the local level.  One LMC, less than 10 PCNs and one federation feels both more manageable and more likely to be able to focus on common issues than one operating at an ICS scale.

Rather than having one large ICS group it would be much better for there to be several local place-based groups, and for the leaders of these to work together to influence at ICS level.

The second consideration is one of ownership.  There has been a tendency for local systems to try and set up these primary care leadership groups.  Groups set up in this way rarely work for a number of reasons.  First, the scale is often set at an ICS rather than local level, so there is little in common binding the members.  Second, the agenda is generally set by the system, and so becomes about an ability for the system to interact with general practice rather than general practice being able to influence the system.  Third, they quickly become just another meeting that busy PCN CDs and general practice leaders have to go to rather than being a place where important decisions are made, and so attendance and then influence of these meetings becomes poor.

Instead these groups need to be owned and created by general practice.  General practice needs to set the agenda.  There can be some space allocated for others to come to talk to general practice, but this is secondary to general practice working together to influence the system.  It needs to be where local general practice works out where and how it will influence the place-based board, where it sorts out general practice issues (like extended access) together, and where it shares information about local system issues.  If the system is running the meeting for general practice, this is not what the meeting will achieve.

This raises the interesting question of who will chair the meeting.  I know of a series of different places across the country who are already running these local leadership groups, and the role of the chair varies significantly.  In one it is a PCN CD, in another it is the LMC Chair, and in another it is the senior manager from the local federation.  What all these people have in common, however, is that they are trusted and respected by the rest of the GP leadership team.  It is not about getting the right role as chair, it is about getting the right person, and each local area will need to work out who that is for themselves.

Putting a local general practice leadership group in place is important but it is only the first step.  If general practice is going to survive and thrive in the new system it will then need to develop this group so that it is effective and has real influence in the system.  In the coming weeks I will outline the steps such a board needs to take to build its impact.

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.