What GP Federations can learn from the RCN

It might feel like getting a voice around the table is the hard part for general practice. It is not. It is just the beginning.

There is a salutary lesson for GP leaders from the experience of the Royal College of Nursing. They had a seat around the table of national pay negotiations for the NHS. Important for nurses, to ensure they are represented. But, under pressure from the government to “sell” the negotiated deal to their members they provided what an independent review described as “inaccurate” information to members, and presented the deal in a way “biased towards acceptance”.

When nurses opened their pay packets in July and found they were much lighter than they had been expecting, they called an emergency general meeting. The Chief Executive resigned, and a vote of no confidence was passed, following which the entire council will stand down.

In system meetings, just as general practice will want the hospital and the acute trust to make changes, so they in turn will want general practice to make changes. How does the federation leader, there to represent general practice as a provider, respond? If he or she is too inflexible, the chances of any system changes being realised are minimal. If too flexible, they could end up the way of the RCN.

The job of the leader is difficult. The real work is outside of the meetings. I have written previously about the importance of establishing a mandate with member practices. But this is not a one off event. Federation leaders need a strong, continuous, two-way flow of communication with their member practices. As situations develop keeping practices informed, listening to feedback, and understanding the mood amongst GPs is critical to being able to make the right decision in the meetings themselves.

It is neither possible nor desirable to go back to practices before each and every individual decision is made. Nothing is more frustrating in system leader meetings than individuals refusing to make any decisions without full Board/practice support. The federation leader must understand their practices well enough to know which decisions they can make and which they cannot.

The trap the RCN seemingly fell into was having agreed to something (even if they felt they had no choice), instead of being honest and transparent with their members they tried to “spin” it to make it more palatable. It didn’t work for them, and it won’t work for general practice.

The trust and support of practices, and the ability to maintain this through periods of changes, is at the heart of the leadership challenge. It requires honesty, transparency, and, probably above all else, a relentless commitment to communication. It requires clarity of purpose – of why general practice is around the table and what it wants to achieve. And it requires strength of character, in particular the ability to make unpopular decisions and to speak out when needed (because caving to pressure from above to agree, as we have seen, is a recipe for disaster).

Like I said at the start, getting a seat round the table means the real work is only just beginning…

Giving the Federation Voice Gravitas

We’ve all been in a meeting where someone (let’s say Peter) speaks and makes a relatively innocuous point. But then for the next 10 minutes everyone else who speaks starts with “I agree with Peter…”. You can’t help but notice the influence Peter has.

Later on in the same meeting you are listening intently, and suddenly have a flash of inspiration – you can see a way forward for the group. You build up your confidence, and make your point. You were kind of hoping for applause, but would have taken even some acknowledgement. But instead, nothing. The conversation moves on, as if you hadn’t even spoken. A few minutes later, Peter makes an almost identical suggestion to the one you had just made, just phrased slightly differently. Suddenly, we are back into “I agree with Peter”, the meeting swarms behind him, and it is as if you hadn’t said anything. You sit, bewildered, wondering what is going on.

Why is it, then, that some people have such influence in meetings when others do not? It is a really important point for those leading GP federations to consider, when thinking about how to ensure their voice has influence in system discussions.

As a young manager my mentors would encourage me to have more “gravitas”. It was hard to understand what they meant. It is something of a slippery, elusive concept. The word gravitas, according to Wikipedia, is used to describe someone whose words and actions have importance and weight. You know when someone has it or when they don’t, but it is difficult to understand why, or how you get it for yourself.

Part of it comes from positional authority. If Peter was the hospital CEO then some of his influence is a function of his position. In system discussions it is not because he is the boss, but because of the importance of what he represents (the hospital). For federation leaders, this brings us back to the question of mandate. The positional authority is much stronger if everyone in the room knows that you talk for 30 practices, and if you don’t agree with them they can’t go ahead with anything that involves those 30 practices.

Another part comes from relationships. If Peter has a set of good relationships with those around the table, they are more likely to listen to him. If they don’t know who you are, sometimes it doesn’t matter how good your idea is it is just going to get ignored.

But there is more to gravitas than positional authority and relationships. I remember as a federation leader there was one particular GP who wasn’t particularly well liked by other GPs (although he was respected), and who had no positional authority other than as a partner of a small practice. But when he spoke he always commanded the room. If he agreed with what we were suggesting as a federation (which he sometimes did) it really helped us to make the change happen with other practices. If he didn’t, he would articulate why and making the change from there was almost impossible. In the end we would run proposed changes by him to get his input before taking them forward.

His gravitas came from a really strong sense of values about what was right for his patients. His points never felt like a political manoeuvre, but more like an articulation of what was right. He was always consistent. He was always prepared to agree, and he was always prepared to disagree. He was never afraid to speak his mind. And when he spoke, everybody listened.

For federation leaders thinking about how to have a strong voice, this idea of gravitas is an important one, particularly when trying to shift the thinking from how to get a seat round the system table into how to make it a powerful one. Creating positional authority by developing a strong mandate from practices, building relationships with those around the table so they are receptive to what you say, and speaking consistently from a clear value base that determines whether you support or oppose proposals are all components of giving the federation voice gravitas.

Building Relationships to Strengthen the Federation Voice

We discussed in last week’s blog the importance of federations establishing a mandate from their practices, but that is only half of what is needed. To have influence, federations also need to build relationships with other organisations.

A common misconception is that attendance at meetings is the same as having a voice. It is not. If a GP sits through a meeting and has no impact on the outcomes then general practice has not had a voice. In fact it is worse, because other organisations can point to the fact that general practice was represented, even though it didn’t influence any of the decisions made.

This is not an uncommon situation. Understaffed federations, often reliant on the goodwill of a small number of individuals, are asked to attend a plethora of system wide meetings as the NHS works up a head of steam in its shift towards integrated care. It becomes a case of finding someone to go, and the poor GP who attends sits there, often without a clue what is going on.

The reality is, of course, that while meetings are often the end point of a decision making process, they are rarely the start of it. In a world of integrated care, the starting point is much more about relationships.

I was working in an area where the federation formed a strong relationship with the local acute trust. The Chief Executive of the hospital was supportive of the local GPs. They worked together on creating a primary care front door at A&E. When the federation needed someone to host the employment of the pharmacists to work in practices, the hospital stepped in. Then the CCG put community services out to tender. The hospital Chief Executive and the federation leadership had a conversation and decided to put a (ultimately successful) bid in, in a model whereby the hospital hosted the contract, but looked to primary care to provide leadership as to how it would be delivered in the local areas (which is exactly what the GPs had been asking for).

This change came about not because of what happened in meetings, but because the federation had built a relationship with the local hospital. To have a voice, to have influence, federations need to build relationships.

There are some really important relationships federations need to have in place. The LMC for one. Federations and the LMC need to work hand in glove together to ensure the voice of general practice is as strong as it can be. Practices are not going to trust the federation if the LMC doesn’t.

Other local federations in the same area are also key. Ultimately they are not competitors but collaborators seeking (more or less) the same thing.   Disagree in private, work out a way forward, and agree in public. If general practice is arguing with itself around the integrated care table, the power of any individual federation’s voice will be lost.

And as in the case of the federation who ended up being able to control the shape of community services in their area, a strong relationship with at least one local statutory organisation (whether it is the hospital, or the community trust or the mental health trust matters less) means when the bigger opportunities come along, the federation is in a realistic position to be part of the conversation.

These are the two foundations federations need to develop to create a strong voice: a mandate from their practices; and strong relationships across the health and social care economy. Next week we will explore how federations can turn these foundations into a voice which has impact.

How Federations Can Establish a Mandate from their Practices

Vineet Nayar is famous for what he stood for: “employees first, customers second”. He became CEO of HCL technologies and transformed its fortunes. He believed passionately that the firm itself did not add value to customers, but its employees did. The role of the firm was to build trust with its employees and empower them to make the changes that might at first sight appear impossible.

He was transparent about information and about the firm’s weaknesses with his employees in ways most companies would never dream of. He did this to build trust between the leadership of the firm and those who worked there. The firm was not telling its employees the answers, it was being honest about the challenges of the current situation, and enthusing, encouraging and enabling the employees to make a difference to it.

There is a 10 minute YouTube interview with Vineet about “employee first, customer second”. It is well worth a watch. I think it is entirely relevant to federation’s thinking about their role and the mandate they have from practices. What do federations stand for? Is it “practices first, patients second”?   Is the role of federations to transform patient outcomes directly, or to enthuse, encourage and enable practices to work together and do this themselves?

Federations need to stand for something. To be the “voice” of general practice in the new world of integrated care, federations need a mandate from their practices. To gain that, they need to be clear what it is they are articulating on behalf of their practices. They cannot claim to be the voice of general practice without agreeing with practices what it is they are going to say on their behalf.

They will need some form of agreed vision/strategy with their practices. This will be some version of:

  • A strong and vibrant general practice with the registered list as the foundation of local healthcare delivery
  • Service delivery tailored to naturally occurring local populations of c50,000
  • Integrated primary and community care teams at a locality level
  • The removal of barriers between primary and secondary care, between health and social care, and between physical and mental health
  • A greater focus on health and prevention

You will have your own version of this. Whatever it is, the important part is that it is developed with the practices, not for them. But turning this into a mandate involves not only agreeing the what, but also the how – how will any agreements that are made actually be delivered? The lesson from Vineet Nayar is that it is not only ok for federations to stand for empowering, enabling and supporting general practice, it is what is needed because it is practices not federations that will make a difference to patient care. Federations are not around the table to get more for themselves; they are there to ensure practices get what they need to deliver change locally.

The important conversation with practices is to agree the nature of this relationship. The federation will use its “voice” to get the resources, the support, the infrastructure, the tools and whatever else practices need to make changes locally. But it is the practices that will make change happen. Change is done by the practices not to the practices. Ultimately, it is a two-way agreement, each side with its own part to play.

This is how federations can create a powerful mandate from practices, one where what they agree turns into action. This mandate is based on trust, the hard won and easily lost trust federations build with their practices. Without this mandate, even though it might be at the table, the federation does not really have a voice.

The Voice of General Practice

My first executive director role was at a hospital. I was very excited. Finally, I was going to get the chance to be part of the team who would make all the decisions about the running of the hospital. It was all new to me, and I wasn’t sure what to expect.

Some things, however, became clear immediately. When the Director of Nursing spoke (which was infrequently), her opinion did not carry weight and had little influence on the decisions the team made. But when the Director of Operations spoke (which was frequently), her opinion carried a lot of weight and frequently swayed the Chief Executive into decisions in line with what she had said.

In that same role I went to meetings of the hospitals across the local area. The same thing happened there: some hospitals had a much more influential voice than others. It happens everywhere.

The lesson, of course, is that simply being at a meeting does not mean that you have a voice.

General practice is seeking a “voice” around the table of providers who will be making decisions in the post-commissioner landscape of the NHS. GP federations are being established in many places to be the voice of general practice within this arena. But what exactly does this mean? I looked up the definition of voice (the meaning that we are thinking about here):

“A particular opinion or attitude expressed

  • An agency by which a point of view is expressed or represented
  • (in singular) the right to express an opinion

What particular opinion or attitude are GP federations seeking to express at the integrated care table? This is a more difficult question than you would think. If they are seeking to represent the views of practices, isn’t that the role of the LMC? Don’t they have a statutory role to do just that? What do the practices expect – are they expecting the federation to sign them up to new ways of working, or are they really expecting the federation to be representing the potential delivery of services outside of hospital rather than anything to do with what actually happens within the walls of their own practice?

And what do the other providers around the integrated care system table expect of federations? Do they think the federations are representing what happens in core general practice as well as the delivery of additional services? If the federation only represents the delivery of extended access (or the like) how influential a voice is it likely to have? Possibly more Director of Nursing than Director of Operations…

The aim of integrated care is not to hold meetings where representatives make the case for their individual areas, but rather that organisations partner with each other. This is why LMC representation at this level rarely works, because the other organisations see the LMC not as a partner but more as a trade union. It is hard for an organisation perceived as a trade union to persuade others it is there as an active partner.

So here is the challenge for federations to think through: how will they establish a mandate from practices that will enable them to be confident that when they speak at the integrated care system table they have the support of the practices behind them? And how will they deliver that voice within that arena in a way that influences decisions rather than is ignored? And when faced with making difficult decisions (which they inevitably will be) how will they keep credibility with both the practices and the system partners?

Over the course of the next few weeks I will consider this challenge in more detail. While there are no easy answers, having a clear approach and preparing effectively can reap significant rewards down the line.

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