How Should Your Practice Respond?

It has been a difficult week for general practice.  The main source of the problem has been a letter from NHS England that panders to press criticism by mandating practices to “offer face to face appointments” (implying they have not), and to allow patients to choose whether they need to be seen face to face or not (“practices should respect preferences for face to face care unless there are good clinical reasons to the contrary”).

The widespread anger this letter has caused is not difficult to understand.  Many practices have been uncomfortable with virtual appointments for a long time, but the ‘total triage’ model was mandated by NHS England in the first place as a response to the pandemic.  To then be criticised on the front page of the Telegraph for using it is galling.

The workload itself in general practice has risen to unsustainable levels over the last few months, in part fuelled by the additional demand from the new routes of access.  Practices are already offering face to face appointments (the implication they are not is of itself insulting), but what this does is raise patient expectations to expect an appointment with their GP whenever they want one.  It is GP receptionists who often bear the brunt where these expectations meet reality, and in extreme circumstances can result in vandalism of practices.

This government’s biggest success has been the vaccination programme, the delivery of which has largely been down to general practice.  There is no mention of this in the letter, of the amount of additional work this has put upon practices, or even any acknowledgement of the contribution made.  Any lingering hopes that the role of general practice in the vaccination programme would change the public perception of GP practices have been sadly extinguished by this letter.

So where does this leave general practice?  What is the right way to respond?

The first thing to note is that the letter is overtly political.  The government is obsessed with access to GP practices (and has been for the last 10 years) because it understands the link between access to a GP practice (where so many of the NHS consultations take place) and the overall public perception of the NHS.

Equally the media understand this.  So a story that demonstrates there are problems with access to your GP is a story that demonstrates a government is failing in its handling of the NHS.  The Telegraph in particular has been trying to make a story about access to GP practices throughout the pandemic. Like it or not, GP practices are political footballs.

The temptation is of course to get drawn into working out how to influence the national debate.  Should there be a collective work to rule, a refusal to participate in any work beyond the core contract, or some other form of collective action?  The unfortunate reality is that for most of us engaging in the national politics around this is futile.  Clearly there is a role for the BMA and GPC in fighting the corner of general practice, but this needs to be done at a national level.  The worst outcome is to penalise your own patients and population because of national politicking.

For individual practices it is better to focus on those things you can influence, such as supporting staff, promoting thank you letters and the positive comments received, building positive local communications about the work of the practice as well as its role in the vaccination programme, and the impact you are making on local lives.  General practice remains one of the most trusted professions in the land, and local people will listen to you.

The bigger question is to work out how you will tackle the next 5 years.  The workload will continue to grow, patient expectations will continue to accelerate, and the number of GPs remains static.  Practices need a plan, because carrying on doing the same things will simply mean the pressure will get worse.  This will not be the last letter, or the last insult, or the last criticism of general practice.

Of course there is the temptation to simply walk away, and say enough is enough.  But not everyone has that option, and all that will do is make it even harder and more challenging for those left behind.  Even if that is what you want, it is better to leave with a clear plan in place so that those who remain have some hope and confidence in the future.

While the independent contractor model means there is limited protection from national and press assaults such as this one, it also means GP practices are businesses that can choose how they operate and organise themselves.  It is better to focus on what you can control and spend time working out what you can do to meet the challenges ahead.

There will always be national politics, and general practice will be part of this.  At times like this it is frustrating, disappointing and enraging.  However, channelling your energy into those things you can control, strengthening your own local communications, and planning for the future is the best way to respond.

5 Top Tips for Success as a PCN Manager

Despite no funding for a manager being included within the PCN DES, the PCN manager has quickly established itself as a crucial role.  As PCNs continue to grow in terms of staff and responsibilities, so has the importance of the PCN manager.  But the role does not come without its challenges, and many who have taken it on are finding the going tough.  How, then, can PCN managers make their role a success?

I recently spoke to PCN management expert Tara Humphrey, and out of that conversation distilled 5 important actions PCN managers should take to be successful in the role:

  1. Be Clear What Success Look Like

The challenge facing many new PCN managers is the PCN into which they are arriving has often not made explicit what actually constitutes success for the PCN.  Indeed, in many PCNs, success can mean different things to different people within it.  If the PCN is not clear what success looks like, it will be impossible for the incoming PCN manager to achieve it!

The trick for the PCN manager is not to assume that simply delivering the PCN DES requirements constitutes success.  If it is not explicit, ask those in PCN what success looks like for them.  Listen carefully to the answers.  Play back what you have heard and get sign up from the PCN as a whole.

When you are clear what success looks like, use it as your guiding principle.  When faced with competing priorities or pressures on your time, use how it will impact on the success of the PCN as your way of making decisions.  This will also help you not to feel like a CCG manager or someone adding workload to the practices, but rather someone supporting them to achieve what they want with the PCN.

  1. Form a Strong Partnership with the PCN Clinical Director

The really successful PCN managers are those who have formed a strong partnership with their PCN CD, and are clear on what each of their roles are.  The two need to work as a team, playing to each other’s strengths, and compensating for each other’s weaknesses.  For example, one might be great at building relationships and communicating with the practices, while the other might be better at understanding and distilling the guidance as it comes in from NHS England and the CCG.

The PCN Clinical Director will always retain overall accountability for the PCN’s success, but what actions the PCN CD and PCN manager respectively take to ensure this success is up to them.  Key is that the two of them create a strong partnership and work together, and the better they do this the more likely success will follow.

  1. Build Strong Relationships with the PCN Practice Managers

The practice managers can make or break a PCN manager.  If a PCN manager can build strong relationships with and earn the trust of the practice managers in the PCN, and have open channels of communication through them into each of the practices, their chances of success are really high.  But if they fail to get the practice managers on side they will really struggle to be successful in the role.

I have already seen a number of instances where PCN managers have had to leave their roles because they lost the confidence of the practice managers.  If the practice managers are regularly complaining about the PCN manager to their GPs, who in turn pass on these concerns to the PCN CD, the position is more or less unsustainable.

  1. Decide Whether to Work With or Round the Difficult Practice or GP

There is always one!  I am yet to meet a PCN where there was not at least one GP (or more often than not a whole practice) who is at best disinterested in the PCN and at worst obstructive to whatever the PCN is trying to achieve.  For the PCN manager there are two choices.  Do they invest significant time and effort into getting this GP/practice on side, so that the work of the PCN can progress?  Or do they focus their attention on the other, more willing GPs and practices to ensure that any attempts to derail progress are not successful?

Each situation is different, and the right approach to take in any individual PCN will depend on the local circumstances, but what the PCN manager has to do is work out which tactic is best and then make that approach work.

  1. Communicate More Than You Think You Need To

For a PCN to be successful, it needs to do two things.  First, take actions and make progress towards its goals, and second communicate these actions and successes to its members.  Most PCN managers understand and do the former, but then completely underestimate the importance of the second.  The result is those in the PCN are generally not aware of just how much the PCN has achieved.

As a PCN manager your days are spent on PCN business.  It is easy to think everyone else has the same level of knowledge of what is going on as you do.  But others in the PCN have busy other jobs and are not as immersed in it as you are, and they quickly forget what the PCN is up to.

Communicating via a once a month PCN meeting is not enough.  There needs to be WhatsApp groups (or equivalent) and a regular email update/newsletter (probably weekly) as a minimum.  Some PCNs have gone as far as setting up their own podcast simply to communicate internally where they are up to.

Success breeds success, and using communication to ensure that not only is the PCN successful but that it is perceived as being successful is vital for future and ongoing success.

 

Does Your PCN have a Financial Plan?

As PCNs enter year 3 of their existence, they are growing in complexity.  Not only is the number of staff employed by the PCN continuing to increase, the expectations and requirements on PCNs is also going up.  The more the PCN becomes like a business in its own right (as opposed to a shared enhanced service across practices), so the importance of the PCN having a financial plan grows.

To date it has been easy enough to monitor the finances based on the individual funding streams associated with the PCN: the ARRS funding (which has pretty tight rules about how it can be claimed); the PCN CD funding (which generally goes to the PCN CD); the extended hours access payment (which generally goes to the practices who have provided it); and the £120 per bed care home premium (which is generally paid according to the beds managed by each practice).  I have not included the network participation payment as it is paid directly to the practices and by and large stays there.  That only really leaves the core £1.50 per head funding, and the PCN development monies (which are handled differently in different parts of the country) that have required any debate as to their allocation.

It won’t be so simple going forward.  This is for a number of reasons.  The first is that many PCNs have been managing the vaccination service which is highly unlikely to have exactly broken even, and so have to decide how any surplus is to be used.

The second is that the PCN CD money has once again been increased to 1 wte for the April to June period.  This creates a significant sum: a 50,000 population PCN will receive just over £26,700 extra for these three months.  Most PCN CDs do not have the capacity to work full time in the role (because of their clinical and practice commitments) so PCNs have to decide how they will make best use of this funding.

The third is the Investment and Impact Fund (IIF).  Not only will PCNs (eventually) receive payment for achievement against last year’s IIF (up to £21,534 for the average PCN), there is a small in year payment available for this year (£5,400 for mapping appointment slot types to national categories by the end of June), as well as the opportunity to earn £40.5k in total by the year end from the indicators announced.  The total IIF earning opportunity is due to rise to over £120k with the addition of the indicators not yet announced but set to commence in October.

The IIF funding has caveats not contained within the core funding and any funding earned from the vaccination service – “a PCN must commit in writing to the commissioner to reinvest any IIF Achievement Payment into additional workforce, additional primary medical services, and/or other areas of investment in a Core Network Practice” PCN DES 10.6.16.  It is the arrival of the IIF funding that means it suddenly becomes more sensible for PCNs to think about the finances in the round, as opposed to in terms of each individual funding stream.

If a PCN combines its core funding, any surplus generated from the vaccination work, the IIF funding, any unallocated PCN CD funding, plus any development monies it has been able to secure, then it can create a funding pot that it has relatively flexible use over.  There are some requirements governing some of these funding sources, but if a PCN can create an overall expenditure plan (i.e. how it wants to use the money it has), it can generally allocate the expenditure items against the different funding sources to ensure it complies with the rules.

So for example if a PCN is looking to reimburse GP time for clinical supervision of ARRS roles, or employ a PCN project manager, it may be better to allocate at least some of this out of the IIF monies rather than the core funding as it meets the IIF requirements and means the PCN then has total freedom for how it uses the remaining funding.

This financial complexity will continue to increase for PCNs moving forward.  The new PCN specifications likely to be introduced in October will have demands that require some sort of funding.  The IIF is due to be worth nearly a quarter of a million pounds to the average PCN by 23/24.  The commissioning of extended access via PCNs from next year will have its own financial (as well as operational!) challenges.

Now is the time for any PCN that has not created a comprehensive financial plan (as opposed to managing each of the PCN finance streams in isolation) to do so.  It is a good habit to create, and one that will reap significant dividends down the line.

How to be an effective PCN Clinical Director

Many PCN CDs describe a sense of uncertainty as to what exactly it is they are supposed to be doing in the role, and are concerned as to whether they are meeting expectations.  Often they are plagued by self-doubt, exacerbated each time they hear of another PCN achieving something that they may not have even thought of.

What makes a good PCN Clinical Director?  What is the role really about, and how do you know if you are being effective?

There are three things to understand about the PCN CD role:

The role is about making change happen.  Ultimately what will separate the successful PCN CDs from others will not be how many meetings they attended, how well they understood the PCN DES or the intricacies of the ARRS, or how many WhatsApp groups they were on.  It will be whether they were able to make change happen within their PCN.

But making change happen is not easy.  People do not like change (even the ones that say they do!).  We all gain comfort from our routines and ways of doing things.  Change means stepping out of these and doing things we are unfamiliar and uncomfortable with.  Naturally, we will all resist change.  Even when the new way of working is better, most of us will be reluctant to make the step away from what we are currently doing.  It is human nature.

The PCN CD role is about making sure the changes that are chosen are the right ones, and that those within the PCN make these changes.  Which leads us to the second thing to understand about the PCN CD role.

The role is primarily about people.  Making change is really about people.  It is about building relationships and trust so that when you ask those people to move in a certain direction, they trust you enough to follow.

This is not easy to achieve.  People within a PCN will not do what the PCN CD says, just because they have the title “Clinical Director”.  They need a reason to leave the comfort of where they currently are and what are they currently doing to move in the direction the PCN CD suggests.  An effective PCN CD is one who can make this happen.

The role is not about being popular.  Inevitably, different people within the PCN will want to do different things and to move in different directions.  The PCN CD ultimately has to make the decisions about what to do and where to go.  To be effective they can’t be seen to be favouring one individual or practice or group over others.  While others can seek support from their peers, no one else within the PCN will experience the same set of challenges that the PCN CD faces.

Those seeking popularity should not take on the role.  Not only is it lonely, but managing conflict is inherent within it.  There is always an individual or practice actively blocking any change that you are seeking to introduce.  Where the opposition is not vocal and overt, the leader’s role is often to seek it out and bring it to the surface so that it can be dealt with.  Constantly dealing with conflict makes sustaining positive relationships challenging, as well as being exhausting.

One of the best ways of dealing with this loneliness is to engage with peers who are in the same situation.  Other PCN CDs and primary care leaders are the best source of support, as they are most likely facing a similar set of challenges.

Dr Rachel Morris, GP and host of the You are Not a Frog podcast that focusses on resilience, has established a Resilient Team Academy.  This is an online membership programme for PCN CDs and busy leaders in healthcare that not only provides a community of like-minded colleagues, but provides coaching, productivity and resilience tools to support you in your role, and will help you as you lead and support your practices and team.

I have teamed up with Rachel and we have created a 6 module online course on how to get people and practices to work together across a PCN.  In the course we provide practical advice on what PCN leaders can do to be effective in the role, and how to avoid the common mistakes that are made such as forgetting it is about people, and taking things personally.

Rachel’s Resilient Team Academy only opens a few times a year for new members.  If you want to join you can do so now, but only until Monday 3rd May.  If you join using this link you can receive a 15% discount on the joining fee, and receive the online course on joint working across practices for free.  It is risk free, because if you change your mind once you have joined, there is a 90 day no quibble money back guarantee.

An effective PCN Clinical Director is one that can make change happen, and can build the relationships needed to achieve this.  It is one of the most challenging jobs there is right now in general practice, and I would strongly recommend that anyone wanting to make a success of this role makes sure they put the support they need in place.  The resilient team academy is a great place to start!

Do you really trust your team?

If I were to ask you this question directly, your knee jerk reaction may be, ‘Of course, why else would I work with them?’.  But for many of us, this question raises some uncomfortable truths.

 

Yes, I may have ‘competency-based trust’ in my colleagues. I know they are capable of practicing safely, have good clinical knowledge and go above and beyond in the care of patients. I also know they are honest, good upstanding citizens and unlikely to nick my car…

 

But do I really trust that I can speak up, raise difficult issues with them, give them some feedback about the way they behaved in that meeting, challenge a decision they have made about a patient or disagree with something they have done? AND that our relationship will be totally fine afterwards?

 

Do I know that they always assume I have a good intention towards them? Do I know they will forgive me if I get it wrong or fail at something – even if I should have known better?

 

This is a different level of trust – vulnerability-based trust.  It is what makes teams work – or not. It is a key ingredient of psychological safety – essentially a climate in which people, ‘are comfortable expressing and being themselves…in which they are comfortable sharing concerns and mistakes without fear of embarrassment and retribution and…they are confident that they can speak up and won’t be humiliated, ignored or blamed.’ Amy Edmondson, The Fearless Organisation.

 

Unless we have this sort of trust within our teams, we are effectively trying to drive a high-performance car in first gear. The team won’t even be the sum of its parts, and certainly won’t be able to conflict and disagree well, which will lead to artificial harmony, lack of commitment, accountability and ultimately poor results.

 

One of the major reasons why PCN Directors and other leaders in healthcare struggle to get projects off the ground is an absence of trust in the team between the individuals from the different practices or organisations.

 

Teams with high levels of trust and good psychological safety have less medical errors, better outcomes, more engaged staff and better performance, so building trust in your team should be a priority for any PCN Director. The problem is that so often we focus on tasks and processes rather than building relationships and trust. Whilst doing a task together is a good way of beginning to build trust (if you do it right!), neglecting to work on the relationships can have dire consequences and can de-rail the whole thing.

 

So how do you build trust within your teams?

 

  • Really get to know one another. This doesn’t actually take too long. It is possible to make a deep connection in less than a minute if you ask the right questions. Show genuine interest in the other person (and then remember their answers!). Find some ‘uncommon commonality’ (perhaps you have children at the same school, or you’re both origami enthusiasts) or something about their past that shaped them and affected them deeply. Don’t forget to create times where you can have informal interactions (admittedly much harder online – it can be done but you’ll have to plan it more).
  • Model vulnerability. Tell people when you’re worried about something, share where you’ve made mistakes and ask for help. Self-disclosure is a powerful way of building a deep connection with people and it shows you trust them if you’re asking for help.
  • Assume good intent from others. Assuming that someone has your best interests at heart and that they are saying that thing because they are genuinely concerned, want to learn from mistakes, make things better and that they care about you too is a powerful mindset and the basis of psychological safety. It will allow teams to address all sorts of things in a non-judgemental, open and curious manner. It will help people speak up, recognise problems and challenges before they happen and save a whole load of hassle and heartache.
  • Seek first to understand before giving your opinion. Not only will you build trust but you’ll come across as wise too.

 

Leading teams in healthcare is ultimately about people, not about process. Focus on building trust within the teams in which you work and you’ll reap the rewards several times over.

 

For more about how to build trust when working across teams in practices and networks, check out the brand new BONUS spotlight course from Ben Gowland and Rachel Morris  ‘How to work together across practices and networks: 6 mistakes leaders in healthcare make and how to avoid them’ available free to you when you join the Resilient Team Academy – a membership for busy leaders providing monthly Deep Dive Masterclasses, ‘done for you’ team resilience building activities, teaching you how to use the Shapes Toolkit coaching and productivity tools with your teams and giving you a likeminded community of peers. Find out more here.

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