Is the PCN CD Model Reinforcing Historic Leadership Approaches and Cultures?

Introduction

In 1998 I completed an MBA. For my dissertation I undertook a triangulated study to identify the barriers to public participation in General Practice. I found culture, leadership and structure of General Practice to be contributory factors.  These terms were alien to NHS management language at the time. In the emergent purchaser provider split of the time, with the introduction of commissioning and competition into the NHS, there was a reliance on quantitative and empirical evidence, with little room for qualitative evidence. As a result, my dissertation sat on a shelf until I became a Practice Manager.

Finding my personal motivation and beliefs constantly conflicted in a toxic command and control environment, I found it increasingly challenging to function as a middle manager in commissioning. At the time, I thought academic leaning was my route to influence in the NHS. Heading towards a PHD I was head hunted to apply for a practice manager job. Taking it became the best decision of my career. More on that later………………

Fast forward to November 2019 when I was fortunate to attend a Kings Fund conference on “The Challenge of Culture Change in the NHS”.  Promoting a move away from the command and control culture, this event explored the type of culture (in alignment with the Interim NHS People Plan) that would make the NHS a better place to work in. The emergent words on the day included “collaborative and compassionate culture and leadership”. This brought music to my ears. Emotionally exhausted from hearing some very brave individual accounts of collaborative and compassionate leadership, I left the conference with renewed hope and personal ambition!! I had waited two decades for this.

Having dusted off my MBA dissertation and reflected on my findings, it becomes clear to me that the structure, culture and leadership style in individual practices not only prevented meaningful engagement with patients and the public, but may also be a contributing factor to the challenges we face in embedding PCNs and new models of care.

Leadership and Culture

Many GP practices aspire to a command and control leadership style and culture, aligned to a vertical organisational structure. This leadership style is authoritative in nature and decision making is top-down. Privilege and power are vested in the Senior Partner (the heroic leader) with limited opportunities for broader involvement and engagement. This leadership style facilitates a weak organisational culture, one in which core values are not defined or communicated. The absence of shared values results in individualistic compliant behaviour, with a greater need for policies, procedures and bureaucracy.  Employees are compliant with low morale. Staff are disengaged and disempowered.

 

A weak culture is associated with:

  • Incompatible vision, mission, goals, and a lack of understanding about the future direction of the organisation, which may lead to failure;
  • Lack of leadership, poor direction from senior managers, competition and poor role models, and;
  • Lack of quality of service provision, poor running of the organisation, and priorities externally perceived as being incorrect.

 

A strong positive culture is evident in practices where members within the organisation have deeply embedded shared values and beliefs. In this culture committed employees understand what is required of them and are empowered to act in accordance with the core values. Bureaucracy is reduced and there is high staff morale, engagement, and productivity. Internally, this positive culture provides the “glue” that binds the organisation together. Many practices with this culture and collaborative, compassionate leadership style are forging the way forward towards successful new models of care and scaled up General Practice.

 

The Practice Manager Continued….

Working at Oxford Terrace Medical Group taught me that command and control is not the only model available to general practice. There was no Senior Partner.  Leadership roles were distributed across the partnership.  Individual partners worked with the practice manager on management issues, taking an active role in running their business. At first there was limited involvement of patients and the broader Primary Health Care Team.

 

Equipped with my MBA and the necessary operational management skills, my first job was to co-ordinate a merger with a failing practice. It became very clear to me early in the process, that operational management skills alone, were not adequate for the culture change required to lead large scale transformational change. With three clear strategic priorities: improving access; transforming the workforce, and premises development, I embarked on a quality improvement programme. This provided structure for the merger project, through three modules:

  • Fundaments of quality improvement;
  • Human dimensions of change, and;
  • Facilitation Skills and developing a compelling narrative.

 

A focus on human dimensions of change and quality rather than finance, transformed engagement of patients and employees during, and after the merger, enabling us to achieve the first two priorities quickly. We developed new roles (Frailty Nurse, Older Peoples Specialist Nurse, Care Navigator and Occupational Therapy in GP) to meet population need, this helped us to manage the access issues. Tied up in the merry-go-round of the ETTF process, premises development eludes me to this day.

 

What I learned was that a distributed leadership model focused on engagement and collaboration could not only succeed but also make a real difference within the general practice environment.

 

Quality Assurance and Quality Improvement

CQC further perpetuates the command and control leadership style and culture through target driven “quality assurance”, stifling opportunities for collaboration and the value of quality improvement. The Well Led KLOE, focused on transactional process is a clear indication of this.

 

There is a recognition now that the Well Led KLOE is limited, and there are plans to split the transactional (quality assurance) from the transformational (quality improvement) elements. A strong organisational culture requiring less bureaucracy, is better placed to facilitate quality improvement and collaborative, compassionate leadership with strong organisational culture.

 

Putting quality at the heart of the organisation, embedded though continuous improvement, involving all levels of the organisation working together to produce better services and care, through transformational processes and action. Quality improvement relies on the use of methods and tools to continuously improve quality of care and outcomes for patients. There is no place for command and control leadership in this environment.

 

PCN Leadership and Culture

Faced with changing demographics, people living longer with long-term conditions, with increasingly complex health needs alongside a shortage of GPs and nursing staff, the unprecedented pressures in primary care are well rehearsed. To date, workforce in general practice has remained simple with GPs, Practices Nurses, Health Care Assistants, Administrative staff and recent introduction of pharmacists in some practices. As new roles emerge, a different leadership style, culture and structure will become essential to enable safe embedding and sustainability of the new roles.

 

It is disappointing then, that the traditional leadership style and culture has been lifted and shifted from General Practice into Primary Care Networks in the guise of the Clinical Director role (The heroic leader).  Lip service is paid to management and non-clinical leadership, with only one paragraph in the PCN DES relating to administration support for CDs. The ensuing effects are already being felt by individuals and across the system.

 

Contracting of PCNs perpetuates financial incentives to passive engagement. This culture, with a focus on process, individual targets and transactional approaches to organisational and team development minimises the full potential of PCNs.  It limits the opportunities of active participation of individual practices. This will result in increasing performance management and bureaucracy for practices to maximise PCN income.

 

The rhetoric is around collaboration and integration, but actions are individualistic. The structure around practices is changing, but there are no incentives in the contract to influence and facilitate the necessary culture and leadership changes for collaboration and integration. The continuation of the existing culture, leadership style and levels of engagement across PCN practices will present significant risk to the introduction of new roles working across practices. Patient and staff safety will, therefore, be compromised.

 

To grow and flourish, PCNs will require a different leadership style and culture. A collaborative and compassionate leadership style, embedded in a strong positive, supportive and facilitative organisational culture. For PCNs to succeed we need Clinical Directors functioning as inspirational leaders, supported by a collaborative infrastructure with complementary skills.

 

Conclusion

My conclusions in 1998 were that the structure, culture and leadership style of general practice were barriers to patient and public involvement. My reflection now is that these are also contributing factors to some of the challenges we face in general practice, potentially including the move away from partnerships.

In his last address to the North East RCGP faculty: GP Reimagined conference in 2018: the late Sir Donald Irving (RIP) invited us to be brave, be accountable and be responsible in order to maximise the benefits and opportunities offered by new models of care. I believe, this is exactly what we must do to transform not only the structure of general practice, but also the leadership style and culture. It will take a brave leader to challenge the engrained culture that has endured decades of change in General Practice but maybe the time is nigh!

10 Challenges PCNs face introducing new roles

The majority of PCNs are experiencing difficulties as they recruit into these new roles.  Here are 10 challenges PCNs are grappling with:

  1. Understanding the Role

Just because a PCN has recruited a social prescribing link worker (for example), it does not mean the practices in the PCN understand what the social prescribing link worker should be doing, or that the new incumbent understands what they are to do in the new PCN environment.  There are a growing number of examples where this basic lack of clarity on both sides is leading to the early breakdown of new roles.

  1. Recruitment Capacity

Many PCNs are recruiting as many as 10 new roles all at once.  This involves creating job descriptions, developing different job adverts, shortlisting from maybe 100 applications, interviewing up to 50 applicants, negotiating 10 job offers, creating 10 contracts and putting in place 10 induction plans.  It is a huge amount of work for any PCN, and many PCN CDs are finding the scale of the required work simply overwhelming.

  1. Line management

There is a huge challenge introducing a new role into a practice, let alone a PCN.  The change process involved creates tensions within the practices in the PCN and inevitably for the new role incumbent.  These individuals require line management support, in addition to making sure their equipment, annual and sick leave is being managed.  Many PCNs initially underestimated the line management requirements of the new roles and are finding it difficult to create the additional capacity needed to support the new recruits.

  1. Location

General practice is not sitting on lots of empty space, and a huge challenge for PCNs as the new roles start is finding the clinic space for them to operate out of, as well as identifying desk space for their permanent base.  There is no obvious remuneration for this (there are only so many times you can spend £1.50), and so unsurprisingly it is creating internal disputes between PCN practices.

  1. Clinical Supervision

The new recruits come with varying levels of experience.  In particular the physician associates currently being recruited are often still to sit their final exams, let alone have any years of professional experience.  The clinical supervision requirements, particularly when these new roles first start, are significant, and PCNs are often relying on the goodwill of individual GPs from across their member practices to ensure these are met.

  1. Professional Development

Each of the new roles requires support and a plan for their continuing professional development.  There are pathways laid out for some of the roles, for example for the clinical pharmacists, which again require significant input from the PCN.  Health Education England is providing some resource to training hubs to support this, but in many areas this is not converting into the tailored, individualised support that PCNs require.

  1. Ownership

Who exactly do the new recruits into PCNs work for?  PCNs are not legal entities, and while they may comprise of the member practices, practices in general see the PCN (and so the new recruits) as separate to themselves.  New recruits often arrive but end up not really being owned by anyone, as they work for a PCN that no one really owns.  If a new recruit does not feel they belong anywhere, or that anyone really wants them, it will only be a matter of time before they start looking elsewhere.

  1. Additional Costs

The ARRS funding formula is rigid in terms of what PCNs can claim for.  Each additional role generates its own set of additional costs.  In some of the bigger urban areas this even includes salary costs, before we even get into some of the unfunded delivery costs.  Normally a business generates income to enable these costs to be met, but the nature of the PCN contract means there are very few ways PCNs can generate additional income (the potential impact of the Investment and Impact fund looks limited).  Given these costs it is hardly surprising that enthusiasm for additional roles from PCN member practices is often somewhat muted.

  1. Monitoring Impact

One of the key ways any new role establishes itself in a new environment is by demonstrating the value it is adding.  While there are some examples of some of the new roles starting to do this, e.g. first contact physiotherapists demonstrating a reduction in the number of GP appointments and secondary care referrals, for many of the roles there are no clear impact measures in place.  However they are funded, practices need to see the value the new roles are adding.  Otherwise it will be only a matter of time before discontent with the additional time and cost burden of the new roles reaches unsustainable levels.

  1. Retention

It is unsurprising given all of these challenges that even where PCNs have been able to recruit the new starters often do not stay for very long.  In part this is due to the huge number of additional roles being recruited by PCNs up and down the country and the seller’s market this is generating, but primarily it is because PCNs haven’t had the time, capacity or support to work through many of the challenges above.  The result is many new recruits are moving on quickly.

 

It is when you think about the extent of these challenges that the assessment of some GP leaders I have spoken to that we are still 12-18 months away from feeling the impact of these new roles starts to make sense.  It is going to take that long for PCNs to establish the systems, processes and ways of working that will enable these new roles to thrive and flourish.  In the meantime what PCNs need is support and assistance to help them get there as quickly as possible.

What is the Optimum Practice List Size?

The latest figures on GP practice size indicate that the number of GP practices has fallen from over 8,000 when the NHS England first published the statistics to 6,708 in September this year.  Fewer practices, as well as an increase in the size of the registered population, has meant the average practice list size has risen from 5,891 in 2004 to 9,007 now.

GP practice size has always been a (relatively) controversial issue. There are fierce defendants of small practice sizes and the relationship it creates between the practice and the population it serves.  At the same time there has been a move to larger (sometimes much larger) practices as a response to workforce, workload and financial pressures.

Research on the issue is generally inconclusive.  The 2014 study by the Institute of Fiscal Studies Does GP Practice Size Matter? GP Practice Size and the Quality of Primary Care, while it found that, “all three indicators of quality that we examined show that smaller practices are associated with poorer quality in primary care services”, it equally had to caveat, “The relationships between GP practice size and GP behaviour are not necessarily causal. This report controls for differences in the characteristics of the practice population, the local area and the GPs themselves in order to adjust for factors that may impact on both practice size and the indicators we examine. However, a considerable number of unobservable factors remain, such as the underlying health status of the practice populations, and could explain why smaller practices tend to perform differently.”

The Nuffield Trust 2016 report “Is Bigger Better? Lessons for large scale general practice” found that although, “larger scale has the potential to sustain general practice through operational efficiency and standardised processes, maximising income, strengthening the workforce and deploying technology”, the “evidence that these organisations can improve quality is mixed. Patients had differing views about the benefits of large-scale organisations. Some appreciated increased access, while others were concerned about losing the close relationship with their trusted GP.”

Overall the research is inconclusive.  A bigger practice feels more resilient, but brings with it concerns around quality and losing the ‘essence’ of general practice.

All of this research was of course before Primary Care Networks were introduced.  Before last year the range of at-scale options available to practices was essentially mergers, super-practices, and GP federations.  Each had varying losses of autonomy and potential associated benefits (ie merging meant changing the core functionality of the practice but with a huge possible upside, whereas joining a federation meant minimal change but with a much more limited upside).

Why PCNs are interesting is they signal a clear commissioner intent to drive the majority of investment in general practice through PCNs.  All previous movements towards at scale working were in the context of a core contract centred on the individual GP practice.  Now there is the PCN contract and all that entails to take into account.

If we add in the RCGP Fit for Future 2019 report, which basically establishes the future role of general practice as that attempting to be played by the PCN (an expanded multi-professional team, joint working across practices and collaboration with other local organisations to serve a local population), then it doesn’t take a huge leap of faith to think the PCN contract may ultimately become more important (in terms of financial and workload implications) than the GP practice contract.

PCNs are developing their infrastructure, staffing and delivery capability as we speak.  The obvious question, then, is whether it is sensible to have parallel practice and PCN delivery structures?  If one practice was the PCN, it would have the governance, be able to flex the utilisation of the staff, and be able to build on existing delivery capacity.

Is it really stretching the imagination for practices to start to consider whether the answer to what is the optimum practice size is actually that of the PCN?  I understand the resistance to this, why fears of exactly this is what fuelled the backlash against the PCN DES, but as a neutral observer looking at the strategic options for practices this is definitely the direction I would head if I was running a practice right now.

The PCN Investment and Impact Fund Explained

NHS England published a set of guidance last week in relation to the PCN DES.  One specific piece of guidance was detail on how the new Investment and Impact Fund (IIF) is going to work.

The IIF has the feel of one of those initiatives that probably started out as a good idea, but has been watered down so much in the making of it a reality that its impact is likely to be minimal.

For a start, the sums we are talking about pale into insignificance when compared to some of the other funds on offer to PCNs.  An “average” PCN can earn a maximum of £21,534 in this year’s IIF.  Compare that with the c£350,000 (£7.131 per weighted patient (pwp)) the average PCN has received through the Additional Role Reimbursement Scheme, or even the £75,000 (£1.50 pwp) core PCN funding.  These sums require very little effort from the PCN.

PCNs have already received  c£13,500 (£0.27 per weighted patient) for the six months up to the end of September as a Covid “support payment” for the PCN.  The question, then, is whether the £21,534 available between October 1st and March 31st is going to be sufficient to entice PCNs into action, particularly in the context of everything else that is going on.

It depends to some extent on how achievable the targets are.  The scheme is designed like a QOF scheme, but at a PCN rather than practice level.  There are 194 IIF “points” available, each worth £111 each (adjusted for list size and prevalence).  These points are divided across 6 indicators.  For each indicator there are limits outside of which practices either earn zero or the maximum, with a sliding scale applied in between:

Indicator No of points Upper limit Lower Limit £ available
% patients aged 65+ who received a seasonal flu vaccination 72 77% 70% £7,992
%patients on the learning disability register aged 14+ who received an annual learning disability health check 47 80% 49% £5,217
% patients referred to social prescribing 25 0.4% 0.8% £2,775
% patients aged 65+ currently prescribed a non-steroidal anti-inflammatory drug (NSAID) without a gastro-protective medicine 32 30% 43% £3,552
% patients aged 18+ currently prescribed an oral anticoagulant (warfarin or a direct oral anticoagulant) and an antiplatelet without a gastro-protective medicine 6 25% 40% £666
% patients aged 18+ currently prescribed aspirin and another antiplatelet without a gastro-protective medicine 12 25% 42% £1,332

It will be hard for any individual practice to achieve the 75% flu vaccination target, let alone 77%.  It will be even more difficult for a whole PCN to achieve it. A non-guaranteed incentive payment of less than £8,000 is not going to change behaviour.  PCNs may well work very hard to achieve as high a vaccination coverage as possible for their local population, but it will be because they want to protect their local population, not because of the IIF.

Even if a PCN does examine the scheme and thinks the rewards could be worth the effort, there are further barriers to overcome.  To earn any IIF funding, a PCN must first “commit in writing to the commissioner that it will reinvest the total achievement payment into additional workforce and/or primary medical services” (2.15).

I find this astonishing.  The IIF funding is not recurrent (it has to be re-earnt each year) but the cost of any additional staff or service delivery is, so how is this supposed to work as an incentive? Equally, if a PCN invests in extra resources to achieve these targets it does not seem as if they can refund their own outlay with any money earned.

We will have to wait and see how these restrictions are applied in practice (e.g. whether any earned IIF funding can be applied retrospectively, whether it can be used to fund on-costs of additional staff not covered by ARRS funds etc).  Hopefully common sense will prevail.  Either way, it seems that either the policy should be to create incentives and allow PCNs the freedom to innovate to achieve them, and the freedom to use those incentives as it sees fit, or it should abandon any notion of payment for performance (which is what this scheme at its heart is) and stick with fixed payments for expected deliverables.  As it stands, this scheme neither promotes investment nor looks like it will have much impact.

The Growing Influence of PCNs

We are just over a year from the formation of PCNs and, despite the pandemic, their importance and influence is growing.  Could this incarnation of general practice be the one that finally starts to shape the NHS around the needs of local populations?

The voice of general practice has long been sought after.  Right back from the days of GP fundholding, different regimes have tried different ways to enable general practice, the “gatekeepers” of the NHS, to have a bigger say in how the service is organised.

It would seem the main problem, however, is that this has been done throughout any extremely long NHS experiment with the purchaser provider split.  Each attempt so far (fundholding, primary care groups, primary care trusts, practice based commissioning and clinical commissioning groups) has been hampered by the inability of any of these incarnations (or indeed any form of purchasing) to make its mark on the shape of healthcare provision.

As the purchasing model is finally put out of its misery, and CCGs simultaneously reduce in number and influence, the new order is starting to take shape.  Centre stage are Primary Care Networks.

The NHS already knows that merging organisations makes no difference.  Integration is not about the merger of providers.  We used to have merged community and acute providers.   Back then the argument was that resources were being stripped from community services to fund hospital services.  What was needed was to make community services organisations independent in their own right.  We have just come back full circle.

Merging or not merging organisations is not what integration is about.  Integration is about doing things differently.  About working in different ways to change the experience and outcomes for local people.  The only chance integration, and integrated care systems, has of making this difference is at the level of the Primary Care Network.

This is really important.  Integrated care systems and integrated care partnerships are dependent on PCNs to be successful.

PCNs may only be just over one year old, but we already have groups of practices almost universally working together to provide care for their local populations.  The work to deliver enhanced care into care homes, and to deliver a social prescribing service, has already begun.  Practices are building relationships with voluntary organisations, local authorities, and care and nursing homes in ways not seen before.

We are less than one month away from PCNs finding ways to deliver structured medication reviews to those who need it most, and to support early cancer diagnosis.  With each new service we will see new relationships form, new ways of delivery develop, and new benefits for patients and local people result.

PCNs are not purely conceptual (the problem with many of the purchasing constructs).  An army of new staff who will actively deliver care are currently being recruited.  PCNs up and down the land are building teams of pharmacists, physiotherapists, physician associates and more.  About 10,000 new staff are being put in place this year to provide the energy and impetus to make this work.  Thousands more are to follow next year, and the year after, and the year after that.

PCNs worry about their voice at the “top table” of integrated care.  But the reality is the power sits with them, because they are the ones who can effect real change.  This power will only grow, as their resources grow and they deliver more.  This really could be the opportunity for general practice to finally make the difference it has been seeking to make for so long.

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