Making general practice easy to do business with

Is general practice easy to do business with? The prevailing wisdom of the day is no, general practice is not easy to do business with. One of the big gaps identified in the Five Year Forward View was the one that exists between general practice and, well, everyone else. In a world of integrated care systems the NHS needs general practice to be easy to do business with. It needs general practice to be an active partner in the new arrangements because it recognises integrated care won’t succeed without it.

Being easy to do business with benefits practices as well as the system. It means more resources can be directed into primary care, aligned to the impact this investment will have on the system as a whole. It means general practice not only has a voice, but can shape changes to the system in a way that makes sense for its patients. It means the problems of distance from the community providers and the hospitals can be tackled not via fruitless arguments in a contracting room, but in practical changes that impact how services operate.

Why is general practice not easy to do business with? It is essentially a numbers game. The average hospital serves a population of about 300,000. The average practice serves a population of 8,000. So that is an average of 37.5 practices for each hospital to be doing busy with. It is an unsustainable number of relationships for a hospital to maintain. Community trusts serve population sizes of over a million, exacerbating the problem even further.

Enter general practice at-scale. Much of the drive for general practice at-scale is to solve this numbers problem. If general practice is organised into units of 30-50,000 there are only 6-10 relationships needed for an acute trust to be able to partner with general practice. If it is organised into larger federations of 200-300,000, then this number may be reduced to 1 or 2.

But there is a danger of being too greedy. The greater the distance of the general practice organisation from its practices (i.e. the bigger it is), the harder it is for it to really represent the views of its member practices. And of course with integrated care it is not just about presenting views, it is about changing models of care. If the system pulls the (newly created) general practice lever (in the form of the federation) but nothing happens, all we have really done is add to the complexity by increasing the number of organisations.

Hence the value of at-scale general practice lies in the strength of its relationships with its member practices. I write a lot about the importance of trust between practices and their network/federation leaders, but it is because it is so crucial. If these leaders sit around the integrated care table and cannot commit their practices to anything, and spend their time explaining how complex the general practice landscape is because practices are independent contractors, then the gap between general practice and the rest of the system has not really been closed.

But if these leaders can sit around the integrated care table and make decisions on behalf of their practices, firm in the knowledge that whatever direction they choose the member practices will follow on the basis of their belief and trust in them, it means general practice is, at last, easy to do business with.

Can you solve The Autonomy Paradox?

A paradox is, “a seemingly absurd or contradictory statement or proposition which when investigated may prove to be well founded or true.”

Try this one on for size… In order to retain autonomy GP practices need to give up autonomy. Is that absurd or true?

It is, in fact, The Autonomy Paradox!

The first question we need to consider is “why is operating at-scale of benefit to practices?” It is because, the argument goes, costs can be reduced, income can be increased, and new ways of working and new roles can be introduced to reduce workload.

But none of these things can happen without practices operating together as a collective. The group of practices working together “at scale” need to agree to a single way of doing things in order for any of the benefits to be realised.

For example, they all need to agree to move to a single accountant, or they all need to agree to a new paramedic-led visiting service, or they all need to agree to cross-refer their dermatology patients to one of the practices rather than sending them directly to the local hospital. Some practices will gain more than others from each change. One practice may have very cheap accountants, and my gain little or even lose out by the shift to one accountant across the group, but by that practice agreeing to it the group as a whole gains. Equally another practice may have a very low level of visits and so introducing the new paramedic model may feel like it is more trouble than its worth, but by participating the group as a whole benefits. The benefits of individual changes are rarely shared equally.

This, of course, is where difficulties set in. In my work with practices up and down the country, I am yet to go to an area that has introduced extended access without disputes about differential utilisation between practices. There is a deep seated reluctance for any practice to agree to a change that benefits another practice more, let alone one that might create a worse position for itself “for the greater good”.

But for operating at-scale to work, this is exactly what is required. For working together to deliver the maximum overall benefit, practices have to be prepared to make individual decisions for the benefit of the group, and trust that the overall benefit of working together will come to them.

Of course this is not the only option. Practices could fully merge, and then the single entity gains the benefit, rather than them being (differentially) apportioned across participants. But what is the cost of this for the original practice? In this (merged) scenario the practice has given up its independence altogether to become a new (admittedly independent) organisation. But it is no longer in its original state, with the freedoms that brought. The cost of receiving an equal share of the benefits was for the original practices to give up their independence altogether to form a new practice.

As the scale of the required changes grows, so does the problem. At what point, or at what size of practice, do we declare we no longer have independent general practice, but rather a group of (GP-led) corporations running the majority of services? Is this future worth it in order to ensure that at each point benefits are shared equally between practices?

In order to retain autonomy GP practices need to give up autonomy. If practices choose to cede some decision-making to the collective, so that benefits can be achieved at the group level rather than solely at an individual level, practices could retain their independence. They could avoid the need to either merge into larger and larger practices, or reach a dead-end when getting out is the only option remaining.

The choice is not either independence or dependence. Inter-dependence, and using federations, networks and the like to create this, is an option that allows practices to stay as separate units but enjoy the benefits of scale. But it requires practices to give up some autonomy in order to retain overall autonomy.

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

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