8
dec
0

GP Partner Training – the Learning So Far

Posted by Blogs, The General Practice BlogNo Comments

Earlier this year myself and a group of colleagues decided that we should put in place the training for new GP partners that we had been talking about for such a long time.  The course finally started in September of this year, and we have already learnt some interesting lessons along the way.

I teamed up with Tara Humphrey, PCN management expert, Director of THC Consulting and presenter of the Business of Healthcare podcast; Robert McCartney, general practice governance expert and Director of McCartney Healthcare Associates; Dr Naj Seedat, GP, trainer, partner in a large North East London practice and LMC Chair; and Dr Farzana Hussain, GP, GP appraiser, mentor, trainer and lecturer.  Together we formed a really strong team, designed to be able to meet all the development needs of new and aspiring GP partners.

We designed the course into 20 sessions, broken down across three broad areas: understanding the business (i.e. what goes on within the practice); understanding the environment (i.e. what is happening around the practice that affects it); and understanding the risks (i.e. how do you build a strategic plan for the future).  Naturally the weighting of the first area is greater than the other two, as there is so much within the business of a practice for any new partner to get their head around!

We wanted the course to not be too demanding on GP time, which is why we went for the model of an hour a fortnight over a period of 9 months.  This has worked to the extent that it has made the course manageable in terms of time for participants.  The challenge, however, has been how to cover such huge topics as managing people or understanding premises in just an hour.

We have been working hard to do this well, but for some topics we just had to extend the sessions.  For example, when accountant James Gransby ran the session on understanding the practice finances we had to make the session an hour and a half.  Even then it was hard to cover everything for such a complex topic!

The other challenge we have experienced is how to make the sessions interactive when there is so much content to work through.  In an hour the scope for really interactive sessions is limited, but at the same time the more interactive the sessions are the more valuable they can end up being for participants.

Another lesson we have learned is that one of the biggest challenges new partners experience is taking on the role as a business owner and what this means in terms of how they lead and manage staff.  This is a really critical area for GP partners, as their leadership style really affects the culture of the whole practice.

As a result of all this we have made some changes to the programme, for the next cohort of new or aspirant GP partners who will be joining.  In the new format content will be delivered over six monthly half day sessions.  This will allow us to create longer, more interactive sessions where we can tailor the content to the specific needs of those on the programme.

We have also included core strengths training as standard, as it really helps new partners understand and develop their leadership style, and given over a whole half day session to leading and managing people.

We always knew developing this training would be a journey, and that we would be learning as we went along.  We are delighted with how the programme is going so far, and excited to make the changes to make it even better going forward.

The programme for our next cohort commences on the 1st February 2022.  We still have some places remaining, so if you or someone in your practice is interested you can find all the details here.  Alternatively get in touch and I am happy to talk through individually what we are doing so that you can work out whether it is right for you – I’m ben@ockham.healthcare.

1
dec
0

50 to 1

Posted by Blogs, The General Practice BlogNo Comments

I am spending some time working with a number of areas thinking through how to create and develop a strong, unified voice for general practice, that can be effective and influential within the new integrated care landscape.  It is a challenge that is harder than it sounds.

The problem comes because “general practice” in any given area generally consists of about 50 different, independent, autonomous organisations.  There are the 40 or so individual practices, 5 to 10 PCNs, maybe a federation, and the LMC.  How do you get 50 organisations to speak and act with one voice?

There is a framework that is quite helpful to consider in this context, called the Cynefin Framework.  Essentially it breaks problems down into different categories.  For our purposes what is helpful to understand is that there is a difference between simple, complicated and complex problems.

Simple is a problem that has a relatively straightforward solution, such as how do I lower my car window.  There is a specific, straightforward answer (press the right button).

Complicated is a problem that does have at least one solution, but which can be difficult to deliver.  An example that is commonly used is sending a rocket to the moon.  It is not a simple thing to do, and may well require multiple teams and specialised expertise.  But by really effective project planning, and using the experience of those who have done it before, it is possible to create a path to making it happen.

Complex problems are ones that are impervious to a reductionist approach that strips the problem (however complicated) down to its core components to work out the solution.  The example commonly used is raising a child.  There is no handbook because each child is unique.

For a complicated problem you can use a project planning Lewinian style approach to solving it.  But for a complex problem the approach needed is an emergent one, using trial and review (like PDSA cycles for you NHS improvement fans, or probe, sense and respond which Snowden, who introduced the Cynefin framework, uses).

This distinction is useful because in healthcare we commonly describe complex problems as complicated ones and hence employ solutions that are wedded to rational planning approaches.  We look for business cases with defined outcomes as a default mechanism for moving forward, when this approach can only work for something that is simple or complicated, not for something complex.

Back to our problem.  How do we get 50 general practices organisations to operate as 1?  It is a complex problem.  There is no handbook, because everywhere is different.

That is not to say it is impossible.  What we can do, even operating in the domain of emergence, is understand what factors we need to build in order to give ourselves the best chance of success.  Two stand out.

The first is the need to build some capacity and capability at the collective general practice level.  If general practice is trying to operate as one then whatever forum or entity is trying to bring it all together needs to develop the ability to do a number of things.  It needs to be able to communicate with its 50 organisations.  It needs to be able to coordinate activities across those organisations.  It needs to be able to interact effectively with partner organisations.  These things don’t happen because the different parts of general practice simply meet together.  They need to put in place.

The second is the need to build trust.  Trust is the key ingredient.  If the 50 organisations don’t trust the 1, all is lost.  Here we get into the area of the prisoner’s dilemma, which explains why rational actors won’t cooperate even when it is in their best interest to do so.  Just because it makes sense for general practice to create a single unified voice it doesn’t mean they will do, and in fact without trust it is much more likely that they will not.

It is particularly challenging in general practice because we are all so instinctively independent.  That is why we have 50 different organisations in the first place.  We hate our independence and ability to act autonomously being in any way compromised.  We find working in PCNs difficult enough.  We instinctively pull away from any notion that we might get into scenarios where our practice or PCN has to act for the greater good rather than simply what is best for our practice or PCN.

As we move forward with the 50 to 1 challenge, our approach then needs to be an emergent one, i.e. one where we try things, see how they work, and then adjust accordingly.  We need to keep our eyes on the outcome (why are we doing this), and work hard to build trust and create some capacity and capability along the way.  It might make plan writers uncomfortable, but it is the way forward that will give us our best chance of success.

24
nov
0

The Inquiry into the Future of General Practice

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The Commons Health and Social Care Committee has announced a review into the future of general practice.  What does this mean, why would they do this, and what are the implications for the service?

The Health and Social Care Committee is a cross party committee charged with overseeing the operations of the Department of Health and Social Care and its associated agencies and public bodies (including NHS England).  It essentially has a scrutiny role.

The Committee chooses its own subjects of inquiry, which it then undertakes by reviewing written and oral evidence.  Once complete, the findings of the inquiry are reported by the Committee to the House of Commons.  The government then has 60 days to reply to the Committee’s recommendations.  The government does not have to accept them, e.g. the Environmental Audit Committee inquiry into disposable packaging recommended a 25p “latte levy” on disposable coffee cups; but the government rejected it, preferring for coffee shops to incentivise customers by offering discounts for the use of reusable cups.  However the cross party nature of the Committee, designed to build consensus across parliament, means its recommendations do still exert considerable influence.

This committee on the 16th November launched an inquiry into the future of general practice.  Its headline focus is to examine both the challenges facing general practice over the next 5 years, and the biggest and current barriers to access to general practice.  The committee is actively seeking evidence from anyone with expertise in the area (i.e. you, if you are reading this).  The deadline for submissions, which must be no longer than 3,000 words, is Tuesday 14th December.

It is one of 9 current inquiries the Health and Social Care Committee either has underway or that are complete and are awaiting a government response.  The others are workforce burnout, lessons learnt from coronavirus, children and young people’s mental health, treatment of autistic people and individuals with learning disabilities, supporting those with dementia and their carers, cancer services, clearing the backlog from the pandemic, and NHS litigation reform.

The inquiry into general practice will cover a range of issues (you can find the full terms of reference here), but it includes regional variation in general practice, general practice workload, and the partnership model of general practice.  The specific question in relation to the latter of these points is, “Is the traditional model of general practice sustainable given recruitment challenges, the prioritisation of integrated care, and the shift towards salaried GP posts?”.   There is also a question about PCNs, “Has the development of PCNs improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?”.

What can we make of the announcement of the inquiry into the future of general practice?

The first point to note is the timing of the announcement.  It has come at a point where there has been considerable media and public attention to the challenges around access to general practice, and is also hot on the heels of the announcement of a ballot for industrial action of GPs by the BMA in response to NHS England’s recent publication on improving access and support for general practice.  It does not seem unreasonable for this to have been picked up as a point of concern by the Committee at this point in time.

The second point to note is that the Chair of the Health and Social Care Committee is Jeremy Hunt.  Jeremy Hunt appears to be enjoying his role as a backbench GP, able to chair this committee from a position of considerable knowledge, particularly in terms of how he can make life as uncomfortable as possible for the government.  His own response to the NHS England document was that it “won’t turn the tide” for GPs, and this seems to be reflected in some of the wording of the terms of reference, e.g. “to what extent does the government’s and NHS England’s plan for improving access for patients and supporting general practice address these barriers” (to access to general practice) when it is already clear to everyone that it does not.

There will be the more cynical who assume this is a back door attempt to end the independence of general practice and shift practices into the main body of the NHS, or conversely to privatise things further by shifting all remote and telephone consultations to digital first providers to “reduce pressure” on practices.  And while it does seem odd to want to look at the partnership model of general practice only a few years after the 2019 review by Nigel Watson, the cross party nature of the committee, along with the methodology of collating evidence from as wide a group of experts as possible, does make this seem unlikely.

Whilst it is hard for anyone in general practice to trust anything led by Jeremy Hunt, my sense is the best course of action would be for as many of those working in general practice as possible to give evidence and provide their views on the questions asked and what is needed going forward.  It feels like a genuine chance to be heard, and is a welcome change from the recent policy directives received from NHS England which have had little or no consultation at all.

17
nov
0

3 Reasons to be Concerned about the Newly Announced Review of PCNs

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The NHS announced last week that  they would be undertaking a review of primary care networks and how they will “work with partners across newly formed integrated care systems to meet the health needs of people in their local areas”.  The review will report by March 2022, ahead of ICSs going live as statutory bodies.  Whilst it might all appear very anodyne on the surface, it does set alarm bells ringing.

There are three reasons for concern.

  1. The perceived need for greater national direction

What the announcement of the review signals is that NHS England, in what is now customary NHS England style, is seeking greater control over PCNs and how they operate.  The initial language used around PCNs was that they how they operated was for local determination by local practices to best meet the needs of local communities.

That, however, now appears to be going out of the window.  NHS England clearly wants to set more guidance and rules on PCNs and how they work.  The contractual constraints of PCNs are already suffocating for many, and so it is hard to see how extra national directions will be helpful.

What we have with this review is a signal that someone somewhere high up is not happy with how PCNs are progressing, and has put this review in place to change where they are headed.  This review has also been announced hot on the heels of the BMA motion for industrial action and mass resignations from PCNs.  This may be unrelated, but it does lead on to my second concern.

  1. It signals a shift in ownership of PCNs away from practices

If you read the announcement from NHS England you will notice it has a very clear focus on joint working.  It talks about how PCNs “will work with partners”, how they can “drive more integrated primary, community and social care services at a local level”, how they can “bring partners together at a local level” etc etc (it carries on like this throughout).

If you recall when PCNs were first announced there was quite a number of references made to how PCN Boards would be expanded over time to be more than simply the member practices.  Whilst some PCNs have widened their PCN Board membership, most have not.  Given the language in this announcement it would be astonishing if the recommendations made were not about a shift of PCN ownership away from practices and towards a much wider ownership.

How far-fetched is it to suggest that this report will end up “recommending” a place for councils, community trusts (and no doubt others) on PCN Boards? Maybe a direct accountability into place-based partnerships will be imposed on them.  Whatever comes, it is hard to envisage a positive outcome of this review for practices.

  1. It further widens the gap between PCNs and the sustainability of general practice

At a critical point in time, just over half way through the 5 year GP contract that introduced PCNs, when general practice has reached such a desperate place that it is prepared to consider strike action, this review is announced.  In the announcement general practice or GP practices receive only one mention, and that is about the need to improve partnership working between GP practices and other organisations.

This report will not be looking at how PCNs can better support the sustainability of GP practices, despite the majority of the additional funding for general practice coming via PCNs.  It is hard not to see the announcement of this report as part of NHS England’s response to the GPC’s threat of industrial action, and if it is it spells more bad news for general practice.

I am not generally a pessimist or a conspiracy theorist, but everything about this report sets alarm bells ringing.  Time will tell whether these are unfounded concerns, or whether it is the first signal of yet more challenges to come for general practice.

10
nov
0

Is General Practice Making the Most of the Opportunity of PCNs?

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It is a difficult time for general practice right now. The pressures of workforce and workload are higher than ever, exacerbated by the media and their impact on patient expectations and overall morale.  How can general practice move forward?  How can it shift from the place that it is now into a more sustainable future?

In 2016 the GP Forward View, a 5 year “rescue package” for general practice, announced an extra £2.4bn for general practice by 2021.  This was then somewhat usurped in 2019 with the new 5 year GP contract that announced an additional £2.8bn for general practice by 2024.

What we have known for a while is that more resources on its own are never going to be enough for general practice.  We don’t feel £2.4bn better off than five years ago.  The reason for this is the growth in resources will never be able to keep up with the growth in patient demand and expectations.  There need to be changes alongside the resources.  These changes need to be in how we manage demand and how we organise ourselves.

Here we get into problems.  No one really likes change.  Look at how certain sections of the public and the media have reacted to changes to the management of demand in general practice where only those who actually need to be seen (as opposed to those who want to be) are seen face to face.  Whether the government likes it or not we will end up there, but it helpfully reinforces the point that no one likes change.

When you examine what options are available for changes in terms of how general practice organises itself (which we did in our 2016 book) they are broadly around staffing, operating at scale, using technology and working in partnership with other organisations.

This is where PCNs come in.  What stands out for me about PCNs is that they offer an opportunity for practices to be able to make virtually all of these changes, and to be able to do so in a way that protects the independent contractor model.  Prior to PCNs it was all about mergers and super practices, but what PCNs do is provide a construct that allows practices to access the benefits of scale while at the same time protecting their own individual identities.

But delivering the potential benefits does not happen by itself, or as a function of signing up to the PCN DES.  It requires practices within a PCN to commit to using the PCN construct to drive change in the way the practices operate to realise the benefits.  Change does not become easy because you call it a PCN.  It remains difficult, but what PCNs provide is a framework for practices to use if they choose to do so (in addition to providing a huge source of resources – £1.8bn of the additional £2.8bn announced in 2019 is coming via PCNs).

I have no idea whether this was the original idea behind PCNs.  I suspect it wasn’t.  Certainly the contractual nature of PCNs, the tick box style of the IIF, the push to recruit more and more new roles with hardly any support for transformation alongside these roles, and the continual attempts by the system to hijack the PCN agenda are not conducive to practice transformation.  But at their core PCNs do provide practices with the chance to broaden their staffing model to reduce the pressure on the GPs and to build relationships with other practices and other organisations to create shared service models that work better for everyone.

However, at present it feels like PCNs are an opportunity for general practice that is not really being grasped.  Many practices choose to keep PCNs at arm’s length.  The BMA is trying to use PCNs as a mechanism for pressuring government and NHSE.  Others want to use PCNs for their own ends.  But PCNs are a huge, well-resourced opportunity to make change that can be a huge force for good and for creating a positive future for practices.  Practices just need to choose to take it.

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