Is this the same Jeremy Hunt?

You will recall that Jeremy Hunt was the Secretary of State for Health from 2012 until 2018, a period that marked some of the darkest years for general practice.  It was not until 2016 that the challenges general practice was facing were finally acknowledged, and the General Practice Forward View was published with the first cash injection into the service for over a decade.

But this was too late.  The great exodus of GPs from the service had begun (which had long been both predicted and ignored), and here we are over six years later with less GPs than the GPFV started with.  At no point in Jeremy Hunt’s tenure did general practice ever feel that its value was truly recognised.

So it was with a sense of real astonishment that I read the findings of the inquiry commissioned by Jeremy Hunt in his role as Chair of the Health and Social Care Select Committee.

When the inquiry into general practice was first announced it was hard not to be sceptical about why it had been called (you can read my thoughts from the time here).  One of the key questions was whether we could trust Jeremy Hunt, despite his motivation at the time to be a thorn in his own government’s side, which did seem to be working in general practice’s favour.

The report was published three days before Jeremy Hunt resigned to take on his role as Chancellor of the Exchequer, and it is without doubt one the most incisive and supportive government reports about general practice in recent times.

Don’t believe me? Here are some direct quotes from the report:

  • “In response to this Report the Government and NHS England should be clear in acknowledging that there is a crisis in general practice and set out in more detail the steps they are taking in response to this crisis in the short term, to protect patient safety, strengthen continuity, improve access and reduce GP workloads.” (p12)
  • “Continuity of care is beneficial for all patient interactions even if it cannot always be offered. It should not therefore be available only for patients with complex needs, because part of the purpose of a long-term relationship between a doctor and patient is to prevent chronic or long-term illness before it happens.” (p4)
  • “The Government and NHS England must acknowledge the decline in continuity of care in recent years and make it an explicit national priority to reverse this decline” (p25)
  • “Rather than hinting it may scrap the partnership model, the Government should strengthen it.” (p4)

The report contains a whole series of recommendations for government, nearly all of which are hard to argue with.  They include abolishing QOF and the IIF and reinvesting the finding in the core contract (p32), uplifting ARRS to include the costs of training and supervision (p15), limiting the list size per GP and committing to reducing this over time (p28), and allowing practices to operate as Limited Liability Partnerships to limit the amount of risk to which GP partners are exposed (p38).

There are more, and you can read the full list of recommendations on pp39-45 of the full report which you can find here.

What happens now?  Is general practice finally about to turn a corner?  Well, not quite.  The process is that the government has 2 months in which to respond to the recommendations made by the Health and Social Care Select Committee.  At that point we will find out which of the recommendations will turn into concrete action and which will disappear under the carpet, so let’s not get too excited just yet.

What will be fascinating to see will be the role that a certain Jeremy Hunt plays in the response to what is essentially his own report.  Of course by the time you read this he may no longer have a role in the cabinet, but assuming he does will he be prepared to put his money where his mouth is?  Has the leopard really changed its spots? Time will tell.

In the meantime I would fully recommend that you take the time to read the report (or at least the full list of recommendations in pp39-45 which reflect the report better than the summary document that goes with it).  If nothing else it feels like a recognition of where general practice is, the value that it adds and the need for action to be taken.

Can independent GP organisations operate as a collective?

The biggest challenge to general practice operating effectively within an integrated care system is gaining alignment across all of the general practice organisations (practices, PCNs, federations and GP providers and LMC).  As previously outlined, the first step is to create a local GP leadership group.  But what decisions can that group actually take?

The challenge such a group faces is that it has no formal authority.  If one PCN decides it doesn’t agree with a decision made by the group, and is going to plough its own furrow rather than toe the corporate line, what ability does the group have to enforce its decision?  Very little, because attendance and participation in the group is voluntary.

General practice’s ability to operate collectively is what will give it authority within an Integrated Care System (ICS).  If general practice signs up to a course of action through its leadership group but then a large proportion of the practices take a different course that authority will quickly slip away. Or if the federation or one of the PCNs is having side conversations this will undermine the leadership group and its value will be rapidly diminished.

What can general practice leaders do to build the authority such a group requires?

A common mistake at this point is to start by trying to create governance structures to establish this authority.  The thinking is that a hierarchy will enable the leadership to enforce its decisions, in a way that cannot be done with a voluntary group.  But the reality is that even within a governance structure PCNs or GP provider organisations will still go rogue if they are unhappy. A governance structure will just paper over pre-existing cracks, and while it may be a helpful end point once ways of working have been established it certainly is not the place to start.

However, there are two key actions that GP leadership groups can take.  The first is to ensure that decisions are made by consensus.

GPs, more than any other professional group that I have worked with, love a vote.  There is something clean about making a decision based on the democratic ideals of one person one vote.  The problem with a vote is that it creates winners and losers, and it is the losers that are prone to taking matters into their own hands and working against the group decision.

There is also a laziness around voting, because it often (not always) means that not enough time and energy has been put into creating a solution or a way forward that everyone is happy with.  Independent general practice organisations working together in one leadership group requires a commitment by all to working though issues until a solution that everyone can sign up to is found.  Whilst this is hard and time consuming, it is the only way the group can make effective collective decisions that everyone will stand by.

The second action is to create a golden thread from the leadership group through to the practices.  If core general practice has no idea that the leadership group exists or what its function is, it will struggle to have any real collective mandate.  Conversely, if each practice has a very clear sense of what the leadership group is, how it works, and why it is important, then the challenge for the leaders of groups sitting in between practices and the leadership group (individual PCNs, federations etc) of having to explain why certain decisions have been taken is significantly reduced.

This second action is also difficult.  It requires a level of over-communication that GP leaders have not historically been good at.  The general rule is that if you think you have communicated twice as much as you need to, you are probably just about hitting the minimum amount needed.  A direct connection and visibility between those leading the collective group and individual practices is required.  The group and its function must be simple to explain (one of the reasons CCGs struggled was because they could never really explain themselves in sufficiently simple and relevant terms to practices) and have buy in from the front line of general practice.

Establishing a mandate and an authority for the leadership group is probably the biggest challenge of all for general practice as it seeks to exert influence within an integrated care system.  But even though it is difficult, the good news is the ability to make it happen lies solely within the control of general practice itself.

Operating in an ICS: Single Point of Access

One of the reasons for general practice to come together in a local area is to so that it can be an effective partner in the new Integrated Care System (ICS).  But what it doesn’t want to happen is that it simply becomes easier for additional work to be foisted onto the service.

Historically general practice has been seen as difficult to do business with, because it is made up of a large number of individual practices in any local area (along with PCNs, federation, LMC etc) and because the primary route of engaging with general practice is via the national contract rather than any local mechanism.

Integrated Care Systems have been tasked with finding their own ways of engaging general practice as a partner.  What the Fuller Report made clear was that rather than any national solution being imposed, local areas would develop their own.  While this in part has averted the threat of nationalisation that loomed large earlier this year, bringing general practice directly into the NHS within local areas (ie putting practices under the auspices of the local acute or community trust) may end up being the ‘local’ solution if general practice cannot demonstrate that it can operate as a system partner.

I have written previously that the first step towards this is general practice creating its own leadership group.  A key function of this board is that it operates as a single point of access for the system into general practice.

For a single point of access to be effective a number of things need to happen.  First is that all the local general practice organisations (PCNs, federations, LMC etc) need to commit to making it work.  The system can (and does) use the plurality of organisations within general practice to play it off against itself.  If one PCN says no to something the system can usually find another that will agree to what it wants.

What a single point of access requires is that all organisations across general practice commit to redirecting any approaches back to this access point.  This means all approaches will be treated in the same way and that general practice can start to provide consistency of responses.

Second is that the leadership group needs to identify one, or at most two, people to control the process.  These are the people that anyone wanting to access general practice are redirected to.  By having a very small number of people controlling the process it ensures a consistent approach to requests is taken.

The single point of access needs to be people, not a meeting.  When it is a meeting there is no filter in place.  Whoever wants to come to talk to general practice can come, without anyone controlling whether it is appropriate or not or whether it is a valuable use of the limited time GP leaders have together.

What the person in charge of the process for general practice does is act as a gatekeeper, and decide whether attending the leadership meeting is appropriate, or whether a paper could be sent round, or whether it just requires a simple message on the WhatsApp group, or what further work might be required before any item can come to the group.

Operating a single point of access in this way means that general practice can operate as an effective partner with the system by providing consistent, coherent and unified responses to system requests.  At the same time it means that general practice can keep control of its own agenda, not allow its time to be wasted, and maintain a focus on its own priorities.

Getting Representation Right

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.

Priorities for Local General Practice

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.

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