Do you have a mandate?

The success of any at-scale general practice organisation is determined by the extent to which it has a mandate from its practices.  But if you have one how do you keep it, and if you don’t how do you get one?

Simply existing as an at scale general practice organisation does not automatically confer success, even when there may originally have been a contractual basis for its existence (e.g. a PCN) or even a financial buy-in (e.g. a federation).

There is a significant difference between a PCN that has a mandate to carry out activities and establish shared services on behalf of its member practices, and a PCN with no such mandate whose practices simply spend their time seeking to ensure they receive their ‘fair share’ of PCN resources.

A federation with a mandate can often speak on behalf of its member practices and even negotiate local enhanced services for local general practice, and practices will be grateful for what they have done.  But a federation without a mandate will be accused of undermining the local LMC, siding with the commissioners and top-slicing funding meant for practices when undertaking the exact same course of action.

Even LMCs experience this variation. Despite their statutory role some LMCs have very limited influence in the local health economy because they have no clear mandate from their practices, whereas others are hugely influential and commissioners would not dream of attempting to introduce new services without running them via the LMC first because they know of the extent of their mandate with their practices.

So how do at scale organisations establish this elusive mandate, and once they have it how do they hold on to it?

When new at-scale organisations are being set up there is generally a lot of communication and conversation as to what the new organisation is to do, how it will work, and what its mandate is.  But the mistake leaders commonly make is to underestimate the need to constantly and continually reaffirm both the mandate they have been given and their success in carrying it out.

Practices will quickly lose sight of the rationale behind the assignment of any mandate.  4 years on practices no longer remember the original conversations about the role and function of the PCN, and the PCN itself has evolved significantly over this time.  At-scale leaders have to keep this conversation alive.  This relies heavily on communication, the prime purpose of which is to maintain and strengthen the previously agreed mandate.

Mandate relies heavily on trust, in particular the trust that exists between the leadership of the at scale organisation and the practices.  When there is a change in leadership of the at-scale organisation, e.g. a new PCN CD or a new federation leader, the mandate is not automatically conferred onto the new leader.  Rather, the new leader has to ensure that they still have the mandate that previously existed and work hard to build the trust quickly to keep it in place.

There is a type of mandate common in general practice which is that of “silent assent”.  A practice silently goes along with the leadership of the at scale organisation, without ever really engaging.  This is fine while it lasts, but many PCNs are now finding this a problem because some of those practices who were previously giving silent assent have recognised the scale of resources tied up in PCNs and all of sudden want more involvement, and PCN leaders find the mandate they thought was in place no longer is.

If the mandate has gone, then what does the at scale organisation do?  There is no real choice but to work to rebuild the mandate.  As well as conversation and communication this requires a willingness of the at scale organisation to reduce the work it carries out on behalf of the practices, in order to then build it up in future once the required trust has been established.

Start with something small, build trust, and then scale up from there.

It is easy to forget but at scale organisations only exist as an enabler for their practices.  If they have no mandate from them they are not able to serve their primary purpose, and so priority must always be giving to securing this mandate and continually ensuring it is in place.

PCN Progressions

When I am not working with general practice I spend much of my time playing tennis.  It is fair to say I am something of an addict!  One of the key principles we use in tennis when learning something new (for example improving your backhand) is the idea of “progressions”.

Progressions are where you break down a complex task (your backhand) into a series of easier steps working up to the final result.  You start with something relatively simple, and then when you can do that task consistently you move onto something slightly more difficult, and then focus on that until you can do that well.  For example, first you hit a ball that is dropped next to you, then one that is fed to you from a coach’s basket, then one that is hit in a friendly, collaborative rally etc etc.  You continue to progress until ultimately you can hit your new improved backhand on a regular basis.

But if you start off by watching Roger Federer’s backhand on YouTube and then immediately try and hit it like Federer at full speed in a match situation you will inevitably fail, and revert to your old (not very good) backhand.  You have to work through the progressions so that you learn how the shot feels, what adjustments you have to make, and make them habits that you can rely on in a match situation.

This idea of progressions applies equally to PCNs and joint working between practices.  If a group of practices start off by trying to run a shared urgent care service across core hours without ever having worked together before it would most likely run into serious problems very quickly and the project would have to be shelved.

Instead the group of practices in the PCN need to learn how to work together by using a series of progressions, steps of increasing difficulty and complexity, so that they can learn ways of working together that will enable them to do more and more together.

What, then, might these progressions be?

There is no set answer to this question (the principle being only that it should be a series of actions of increasing difficulty where each progression is more difficult than the last).  An example of what these progressions could be is (and let’s assume here a PCN of 4 practices):

  1. The 4 practices share a resource, e.g. a pharmacist. They adapt how they do this until they can do it in a way that means that all the practices feel they are benefitting from the shared resource, no practice is feeling hard done by, and the pharmacist is happy.
  2. The 4 practices work together on a shared project that creates additionality for the practices, e.g. a first contact physiotherapy service. The practices find a way of working together so that they can agree on the location and operation of the new service, how it is organised, how they can use it, and how they can benefit from it.
  3. The 4 practices work together on a project where there is individual accountability for each practice, e.g. delivery against a key IIF indicator. This is more difficult than the previous step because the practices have to work out how accountability and support will work across the practices, i.e. what happens if one practice is not able to fulfil its delivery requirements.
  4. The 4 practices work together on a project that impacts how each practice operates, e.g. a shared document management hub. Here the individual autonomy of the practices has to be replaced with a standardised way of operating across all 4 of the practices, which creates a new layer of complexity and difficulty.
  5. The 4 practices work together on a project that impacts how core clinical services are delivered in each practice, e.g. a shared in-hours urgent care hub. Now the practices have to work out how they can work together on the delivery of clinical services that have always historically been the domain of individual practices.

This is only an example set of progressions, but hopefully you can understand the idea.  As the 4 practices in the PCN work through the progressions they work out what clinical and managerial leadership they need for each type of new initiative, what communication across the practices is required, what the data and reporting requirements are and how these need to work, how support for individual practices within the group should best function, how to deal with differences of opinion without it derailing projects etc etc.

PCNs cannot expect to be effective at delivering core clinical services together if they have not worked through some progressions.  Just like we will revert to our old backhand because the new shot is too difficult, so the practices will simply try to find ways of continuing to work in their own autonomous ways if the starting point is too difficult.

Where PCNs are struggling to work together the starting point needs to be something that they can do together (however small) and then build progressions from there.

Should System Clinical Leads be on GP Leadership Groups?

A common challenge that many areas are having is working out who should be on the local leadership group for general practice.  A specific question is whether this should include the (often newly appointed) system clinical leads, especially where they are GPs.  So, should they be included?

To answer this question we need to go back to our understanding of what an Integrated Care System (ICS) is.  As I am sure you know, an ICS is the new NHS infrastructure that aims to bring together providers from all areas including (but not limited to) primary care, secondary care, community care, mental health, social care and the voluntary sector, so that they can collectively agree how care is organised and how resources are deployed.

This is different from the previous system of Clinical Commissioning Groups (CCGs).  In this (old) system the CCG as a commissioning organisation, with a membership of all the local GP practices, was tasked with deciding how care should be organised and how resources deployed on behalf of the local population.

In the new system there is no commissioning organisation, and no special place for general practice.  General practice is simply one of the number of providers that have to work together to agree on how care should be organised and resources deployed.

The problem that general practice now faces is that the single membership organisation that could speak on its behalf into these system discussions (the CCG) no longer exists.  General practice is multiple individual organisations, along with a set of at scale organisations including PCNs, LMCs, and (in some places) federations, and so is left at something of a disadvantage when it comes to system discussions.  While the other organisations in an area are generally single entities with a clear leadership structure, such as the local hospital, general practice (and therefore its voice) is much more dispersed.

As a result general practice in many areas is creating a local general practice leadership group.  The role of this group is to provide a united general practice voice into these system discussions.

At the same time the ICS is working to find ways of bringing the different provider organisations together and organise pathways of care across these organisations.  To this end the system is appointing pathway leads (for areas such as planned care, urgent care, long term conditions etc etc) along with clinical leads for these areas.

These clinical lead roles could be taken on by any type of clinician from any type of provider organisation.  But of course the clinicians with the most recent experience of this type of work are GPs, particularly those who worked in CCGs.  So in many places we find that there are quite a number of GPs who have been appointed into these new system clinical lead roles.

While historically these same individuals may have been able to operate as system clinical leads on behalf of the commissioning organisation owned by GP practices (and so have a link into some form of leadership role for general practice), but now this is no longer the case.  The system clinical leads have to operate on behalf of the system as a whole, and not on behalf of one single provider part of the system (such as general practice).

There is a clear difference, then, between the GPs on the local general practice leadership group, working to ensure the voice of general practice is heard in the system, and the system clinical leads (even if they are GPs) who are working on behalf of all providers within the system.  When it comes to working in the best interests of general practice the system clinical leads are necessarily conflicted and should not be core members of the group.

There is of course a value to general practice of having GPs as system clinical leads.  It can be valuable for these leads to attend the GP Leadership group meetings to ensure the group understand the work that is being carried out, how partnership work is progressing and the context in which they are operating.

But this is different from them being core members determining the actions general practice should take as it seeks to partner effectively with the rest of the system.  This should be limited to those who operate on behalf of their practices, i.e. the PCN, LMC and federation leaders.

PCN vs Practice Independence

PCNs are not popular in some quarters of general practice primarily because they are seen as a threat to the independence of the individual practice.  But is there a bigger threat to practice independence than PCNs, and could it even be that PCNs may become key to maintaining practice independence?

Funding and resources are increasingly coming to practices via the PCN route (as opposed to directly via the contract).  Inevitably alongside any additional funding and resources are increased delivery requirements.  It is the lack of direct control of the resources alongside the additional work which is behind much of this growing practice resentment of PCNs.

But more changes are coming.

Since October PCNs have taken over responsibility for enhanced access.  We are seeing a mixed picture of delivery across the country.  Some PCNs have taken over this delivery from the local provider, others have simply come to their own arrangements with the local provider and yet others have created all sorts of hybrids in between with mixed models of delivery and even whole new providers in place.

Now, we know from the Operating Framework that a “General Practice Access Recovery Plan” is on its way.  While we don’t know what will be in it, there are some elements we can predict.  Most likely is the number one action outlined in the implementation plan from the Fuller Report, which was to:

Develop a single system-wide approach to managing integrated urgent care to guarantee same-day care for patients and a more sustainable model for practices.  This should be for all patients clinically assessed as requiring urgent care, where continuity from the same team is not a priority” p34.

Specifically, the report says that it is for, “primary care in every neighbourhood to create single urgent care teams and to offer their patients the care appropriate to them” (p11).

Very quickly, it appears, we may be in a place where PCNs are expected not just to offer extended hours across all of its member practices, but also a system for delivering all urgent appointments across core practice hours.

Let’s leave aside the mechanics of how the centre might expect to impose a system that takes away activity that is core contract activity (and, one assumes, also the funding that goes with it), and for arguments sake assume that this is what happens.  In this situation does a PCN really want to be outsourcing the delivery of these appointments to a third party provider?

It is one thing for a third party to be providing additional appointments on top of those that a practice has traditionally been expected to provide.  But it is another for such a provider to take on responsibility for delivering in hours appointments that have always been part of the core contract.

Even putting aside the impact this would have on the practices’ ability to deliver effective continuity of care, the threat to practice independence at this point surely becomes much more real.  If a practice is not responsible for one aspect of its population’s core primary care, what is to stop other responsibilities being taken off it?  Where does that road end up?

Meanwhile, the PCN remains a contractual entity owned entirely by it practices.  While individual practices may not be able to retain control of this agenda, groups of practices working together as a PCN can.  If the group can work together they can find a way through this that protects their collective independence.

So while there is a loss of control at an individual practice level in operating across the PCN, the group of practices can retain collective control by working together.  What the PCN provides is additional running costs, staff and resources to enable this joint working to be effective.   Now may well be the time for practices working together as PCNs to start considering how they can ramp up their in-house delivery abilities and reduce any reliance on external providers, as a means of protecting their collective independence.

The End of Independent General Practice?

The Labour party has launched an offensive against general practice in recent days.  First the Shadow Health Minister Wes Streeting says he wants to “tear up” the “murky, opaque” GP contract, and now Labour leader Keir Starmer has doubled down on the comments and said he wants to take away the GP contract and make GPs direct employees of the NHS.

Now we are in the odd position of the Conservative party defending the GP partnership model.  In Prime Minister’s Questions on 11th January Rishi Sunak said, “‘I’ll tell you what the NHS doesn’t need. What they don’t need is Labour’s idea – Labour’s only idea – which is for another completely disruptive, top-down, unfunded reorganisation buying out every single GP contract”.

Maybe Labour’s position is not surprising.  They wanted to nationalise general practice back in 1948, and only reluctantly agreed to the current situation in order that they could push ahead with introducing the NHS.  Since then GPs have maintained such huge popularity ratings with the general public that it has been impossible for them to challenge the independent contractor model, and to press ahead with any plans to nationalise general practice and bring it in line with the rest of the health service.

But now things have changed.  The popularity of GPs has fallen sharply as access challenges have risen and the media campaign demanding immediate access to an in-person appointment with a GP has continued largely unchecked.

Labour has pounced on this opportunity and is now portraying GPs as money-grabbing private contractors, who undertook the vaccination programme for no other reason than personal financial gain, in an attack that they would have not even considered only a few years ago.

Of course, this flies in the face of any reasonable analysis of what is going on.  The recent Health and Social Care Committee Inquiry Report into general practice (an all party document!) reported that, “Historically one of the key drivers of innovation and improvement in general practice has been the GP partnership model, which gives GPs the flexibility to innovate with a focus on the needs of their local population. We know there are significant pressures on GP partners at the moment but the evidence we received was clear that the partnership remains an efficient and effective model for general practice if properly funded and supported… Rather than hinting it may scrap the partnership model, the Government should strengthen it” (p4).

There is a belief amongst some that others (“professional NHS managers”) would be able to manage general practice better than GP partners.  But only last week a hospital in Swindon returned the contracts of two GP practices so that they could have “more opportunities to draw upon shared learning and best practice” from nearby practices.  It turns out running practices needs its own expertise, and this is not one that currently exists in other NHS organisations.

The idea that introducing the very NHS bureaucracy to the service that the government has consistently said it is trying to cut from the health service would be somehow a solution to the challenges facing general practice can only be described as political, and never as either pragmatic or realistic.

But ultimately the NHS is political.  General practice at a national level is not functioning as an effective political operator.  So while the logic of Labour’s political position is not intellectually defensible, unless general practice gets its act together nationally it may well be that the GP partnership model will end up as a political casualty, should Labour maintain its current lead in the opinion polls and win the next election which will take place within the next two years.

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