The trouble with conflict in General Practice? There’s just not enough of it.

A busy practice is wondering why it is struggling to recruit more doctors.

The team is lovely, ‘we all get on really well, never a cross word’.  The practice manager agrees, ‘the partners are just really nice’.

The problem is they’ve been trying to get their document management workflow right for years but no-one’s on the same page. The doctors are staying later and later just to get everything done and even though they’ve been offered half a clinical pharmacist by the PCN they’re a bit unsure about how it will work for them.  When they tried it before, the person they appointed moved on after three months.

In this day and age, being ‘nice’ just won’t cut it for your team.

You see the problem I’ve seen the most in practices is not out and out war between the partners (though that definitely exists!) but the problem of people being too nice and a fear of conflict, which produces artificial harmony.

We all know that destructive conflict can cause untold damage to teams and organisations and is to be avoided at all costs.  However we are in danger of throwing the baby out with the bathwater when we are so frightened of destructive conflict that we avoid having any constructive conflict that will help us to debate and solve problems and ultimately work better together.

If we avoid conflict, what happens? People ignore changes that are being implemented, don’t use the new systems and processes designed to improve things and carry on with business as usual. Bad behaviour is not addressed, groupthink happens and often the loudest and most senior (though it doesn’t always have to be) voice in the room gets their way.

For good ideas and true innovation, you need human interaction, conflict, argument, debate.’ Margaret Heffernan

How many ideas have been lost, initiatives gone untried, and changes failed because we didn’t have the constructive debates and disagreements needed to come up with better solutions?

With artificial harmony it’s not that people don’t disagree, it’s that they disagree and just don’t tell you. Then, if a decision is made that they disagree with, they simply won’t commit to doing it. (Think about how many times something was discussed and ‘agreed’ in a partnership meeting that people just don’t do).

So this fear of conflict leads to a lack of commitment – the second and third dysfunctions of a team as described in Lencioni’s ‘5 Dysfunctions of a Team’. This in turn leads to avoidance of accountability and inattention to results which will affect workload, performance and even patient outcomes.

So how exactly do we increase the amount of constructive conflict in our practices?

You need to start with building vulnerability-based trust. This is where you can trust that if you disagree over something, the relationship will still be OK. Trust that you can fail, do something wrong or just have a bad day and you’ll be forgiven. In short, it needs to be SAFE to speak up and to disagree. This is the basis of psychological safety.

 

Here are some suggestions about how you can increase the constructive conflict in your practice:

  • Mine for conflict. In every meeting, in every discussion, ask every person to tell you 3 reasons why what has been suggested won’t work, or 3 potential problems / barriers or challenges they can see. Constantly ask people ‘what am I missing here? What are the downsides to this?’
  • Assign different roles in a meeting – make one person ‘Devil’s Advocate’ (to disagree about everything!). Make one person the ‘Unconditional Supporter’ (to agree), and one person ‘Switzerland’ (to be completely neutral). Make sure you swap these roles around regularly so that one person doesn’t get stuck as the Devil’s Advocate all the time!
  • Listen and ask questions. Give people ‘permission’ to disagree. Thank people for their contributions
  • Build up trust within your team. Get to know people, have coffee together, understand where they’re coming from. Model vulnerability; admit when you’ve failed and when you’re having a bad day.

So next time you’re feeling frustrated and stuck, ask yourself, are we being ‘too nice’ here? How can we help everyone feel able to get their ideas and opinions on the table? You might just get a pleasant surprise.

 

Dr Rachel Morris, April, 2021

Further resources:

 

Want to learn more about how to increase trust and psychological safety within your team? Would you like to get a happy, thriving team at work without burning out yourself? Join Rachel in the Resilient Team Academy – a membership for busy leaders providing monthly Deep Dive Masterclasses, ‘done for you’ team resilience building activities, teaching you how to use the Shapes Toolkit coaching and productivity tools with your teams and giving you a likeminded community of peers. PLUS gain exclusive access to Ben and Rachel’s very special bonus course ‘How to work together across practices and networks: 6 mistakes leaders in healthcare make and how to avoid them’. This very special offer for Ockham Healthcare ends on the 2nd May – click here for more information.

What did the GP Forward View Achieve?

It might not seem like that long since the GP Forward View (GPFV) was published, but at the end of the March we come to the end of the 5 year GPFV period.  Just as a reminder, the headline of the GPFV was an investment of £2.4bn over those 5 years to demonstrate that the challenges in general practice had been heard and understood, and to provide real financial and practical support to the service.  What did the GPFV achieve, and where has it left general practice now?

There are a number of reflections to make about the GPFV:

5 years is too long a time frame.  In 2019, 3 years into the GPFV, the GPFV was effectively superseded by the new 5 year GP contract and the introduction of Primary Care Networks (PCNs).  When announcing funding uplifts a longer timescale works better because the money sounds more, but the reality is things change too much over that time period for it to remain a firm plan.  No one has really spoken about the GPFV for the last 2 years since the new contract was introduced.

It was really about access. While not immediately obvious, what became clear from the GPFV over time was that the real intention of the document was to deliver the government’s agenda of improved access to primary care.  The only significant recurrent additional funding in the GPFV, on top of the contract awards, was the £500m funding, or £6 per head of population, for additional access.  What then happened was the introduction of access stretched the already-thin workforce even further, diverted portfolio and part-time GPs away from core practice, as well as moved funding thought to be for core general practice into alternative providers – the £6 per head never went direct to practices.

In the new contract the primary policy objective is the introduction of primary care networks.  As with access in the GPFV, the real new money follows the policy objective, not the demands of the service.

There was never £2.4bn additional funding.  The GPFV struggled right from the outset with transparency over the funding.  It was very difficult to track and find the money.  Some of us persisted in trying to track it down, and it turned out the extra £2.4bn never really was £2.4bn.  It was less than £1bn.  Headline announcements of large sums of money over 5 year periods are largely an accumulation of inflationary rises to the global sum.  And in the case of the GPFV these were backdated to before the document was even published.

Money in the GPFV came via NHS England to CCGs, sometimes to federations, and eventually to practices.  Multiple pots all had their own application processes.  The money proved difficult to access and was beset by bureaucracy.

In the GPFV the headline figure was £2.4bn over five years, and in the new contract it is £2.8bn over five years. £1.8bn of the £2.8bn comes via the new networks, the rest is primarily in the uplifts to the global sum.  This year the uplift was 2.1%, less than the figures around 3% we were seeing during the GPFV.  But at least this time there is more transparency and the money is embedded in the contract.

5,000 extra GPs was always a myth.  One of the government’s promises when it published the GPFV was to provide an extra 5,000 GPs.  This became a particular source of embarrassment for the government, as not only did it fail to provide the extra GPs but the total number of GPs actually fell.  In 2019 there were 6.2% fewer full time equivalent GPs than in 2015[1].  At that point the old trick of changing the way the numbers are counted was introduced (see here[2]) to try and prevent further embarrassing comparisons.

With the 2019 contract the move was to additional roles to support GPs via the Additional Role Reimbursement Scheme.  How successful this is in supporting practices with the core workload remains to be seen.

It started the journey of delivering care in new ways.  The GPFV promised to support practices to introduce new ways of delivering care, and the Releasing Time for Care programme and the work of people like Robert Varnum on the 10 high impact actions were amongst the most helpful parts of the document.  However, there is no getting away from the fact that it was Covid-19 not the GPFV that has ultimately led to a step change in the way that care is delivered.

 

But for all its faults, the GPFV did represent a clear change in government policy towards general practice.  Previously, ever since the introduction of the revised GP contract in 2004 which the government felt it had paid too much for, there had been disinvestment in the service over many years.  This had left general practice in a parlous state, and it was only the introduction of the GPFV that really marked the end of this period of austerity.

However, for many this came too late, and the GPFV struggled to stop the exodus of GPs either into retirement or reducing their hours.  As a result the plan was never able to address the core workload and recruitment issues the service faced.

Five years on general practice is starting to feel different, but that is primarily down to the new contract and Covid-19.  The next few years are critical for general practice, particularly in terms of whether it can access the PCN funding to support the delivery of core services and build a sustainable staffing model, and whether it can embed the more helpful changes made during the pandemic. At least with a clear contract now in place the service has a more secure platform than the GPFV ever was to build on.

[1] https://www.bmj.com/content/bmj/369/bmj.m1437.full.pdf

[2] https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services

Who is looking after General Practice?

This pandemic has not been just one big challenge, but rather a whole series of different challenges over an extended period of time.  As we move into yet another phase, and the next set of challenges, where does the energy come from to keep going?

At first there was the arrival of the pandemic itself, changing the operating model and moving to remote working, and putting systems and processes in place for managing patients presenting with Covid symptoms.  Then we had to work out how to do this alongside the normal work of general practice.  Then we had to introduce a vaccination programme, which has been all consuming and itself a series of different challenges (different vaccine types, care homes, housebound, practice dispersal etc etc).

One year in, we are once again moving into a new phase and a new set of challenges.  Some of the core services (such as QOF) that were put on hold are restarting.  The vaccination programme continues.  The work of PCNs accelerates, as the ARRS nearly doubles in size and the move towards integrated care means PCNs have to start to play an important role in influencing the system as whole.

But are we ready for more challenge?  How do we find the energy and personal resources to cope with and manage more change, more disruption, and yet more new ways of working?

We have not been good in the NHS at looking after the people who work in the service, or indeed at looking after ourselves.  We have known for a number of years that most GPs are looking to reduce the number of hours they work, and a large percentage of those who can are planning to retire in the next five years.  It is not just GPs; many practice managers and other members of the practice team are also looking to leave.  The recent pay offer for NHS staff and the freeze on the lifetime pension allowance is not going to help.

The continual wave after wave of challenges the pandemic is creating has made this situation more critical than ever.  If we do not take time now to look after ourselves, and look after the people we work with, it wont be long before the exodus of people out of general practice reaches unprecedented levels.

We have to prioritise our staff and ourselves.  The good news is that there are actions that we can take.  In this week’s podcast I talked to resilience expert and GP Dr Rachel Morris.  She outlined a range of tools, techniques and approaches that can all help with personal and team resilience.

It seems to me that the starting point is deciding that looking after ourselves and our teams is the priority.  We cannot rely on or even expect other people, or the wider NHS, to do that for us.  Most people working in general practice have spent a lot of time doing whatever has been needed to meet the different Covid challenges.  Going forward the only way general practice is going to be in a position to serve its local populations is by ensuring it takes time now to invest in itself and the people who work there.

ARRS Roles: Planning for Year 3

We are about to embark on year 3 of the Additional Role Reimbursement Scheme (ARRS), through which the PCN DES funds additional roles for individual PCNs.  How can we take the learning from the first two years and build it in to our planning for next year?

The first year of the ARRS was relatively quiet, as PCNs were only allowed to employ a pharmacist and a social prescribing link worker.  Last year the scheme took off, in part because the list of different roles was expanded to 10, and in part because 100% (as opposed to 70%) of the salary costs were reimbursed through the scheme.

The investment into roles through the scheme continues to increase significantly into year 3, with the total investment reaching £746M nationally.  Many PCNs will be in a place where they can afford 10 or even more staff with the funding available. This number will continue to rise for the next two years.  What this means is PCNs have to move from considering the ARRS staff on an individual basis to thinking about all of the roles collectively as a team.

I have written previously about the challenge of introducing the new roles.  This challenge just gets greater as the number of roles increases.  We are now at a tipping point where the overall approach needs to change.

Any business that employs 10 or 20 staff would put a business plan in place.  Having a plan is what is now required for PCNs.  The plan needs to contain (as a minimum) the following 4 elements:

  1. Team Objectives

PCNs need to clarify exactly what the objectives for the ARRS team are.  How will the PCN know at the end of the year whether the new team has been a success?  How will the team itself know?  How will the practices know?  Agreeing objectives for the team will help everyone, and help move the PCN away from a mentality that it is recruiting these roles simply because the funding is available.

  1. Team Structure

The retention challenge for these roles is something I have already written about, despite the recruitment only really taking place in earnest over the last 9 months.  It is clear the individuals in these roles need to feel part of a team.  At the same time, practices cannot simply absorb the extra work of looking after these roles, and asking them to do it means in many cases it simply does not happen.

My sense is most PCNs will need to create an overall ARRS team.  Very large PCNs can probably create more than one team, such as a pharmacist team and a social prescribing team, but the majority of PCNs will need one team so that the individual Health and Wellbeing Coach (for example) does not end up being isolated.

The team will need a leader.  It needs to be someone’s job to be responsible for the overall ARRS team.  This does not mean line managing every member of the team, but it does mean responsibility for ensuring the team is functioning effectively, delivering on its objectives, has effective communication across it, and that any issues that arise are dealt with.  This could be the Clinical Director or PCN manager, but someone needs to take on this role.

The team needs to have a structure.  Moving beyond 5 or 6 members of the team means that there needs to be levels within it, e.g. one of the pharmacists managing the other pharmacists, a senior link worker managing the other link workers etc.  Planning the structure, thinking about individual advancement, making the team more self-sufficient are key aspects of this part of the process.  No structure means as more staff are recruited, the burden simply becomes greater on a relatively small number of individuals.

  1. Team Support

The key retention question for the PCN is how will this team be supported?  The provision of support is critical to getting the most out of them.  There are plenty of examples up and down the country of either ARRS staff such as Physician Associates carrying out low level work because no clinical support is being provided, or of staff such as social prescribing link workers working to other agendas because what support there is is provided outside of the PCN.

Increasingly there are opportunities (e.g. for pharmacists here or physician associates here) to ensure ARRS staff receive the training they need.  We are beginning to understand better how work needs to be organised to ensure ARRS staff can be effective (e.g. for FCPs here).  The PCN plan needs to be explicit about exactly how the ARRS staff will be supported.

  1. Team Finances

As the team expands the financial model of matching the monthly cost of the ARRS staff against the reclaimable allowance is no longer sufficient.  This is an important element of the financial plan, but cannot be it in its entirety.

The ARRS team are a (funded) investment in the wider work of the PCN.  There are wider costs beyond those which can be reclaimed, e.g. clinical supervision, line management, estates costs, training costs.  PCNs also need to be mindful of potential VAT costs as they are likely to exceed the £85,000 VAT threshold, and of the need for a fund to cover potential employment liabilities.  Equally, income can come from other sources such as CCG/HEE/ICS funding pots, PCN core and development funds (etc), as well as benefits in kind provided to practices (e.g. support for vaccination services, a home visiting service, support with the delivery of enhanced services etc).  There are also future opportunities on the horizon, such as support with the delivery of extended access.

The funding model is not perfect, but for the ARRS team to be effective a financial plan for the team as a whole needs to be put in place.  This is more important this year than it was last year, and its importance will continue to increase year on year as the total amount of ARRS funding received (and associated costs) grows.

 

The plan does not need to be long or complicated.  But spending some time and energy now in putting a plan together will put the PCN in a much stronger position for making the most of the opportunity of these new roles in the year ahead.

Does Integration Really Mean Centralisation?

I wrote last week about the new White Paper published by the government, and what it means for general practice.  My sense at the end of the White Paper is that I am less clear now than I was before as to what exactly is meant by “integration”.  Does it mean removing the barriers between organisations to enable joined up care, or does it in fact mean a further centralisation of control?

I understand the logic of integration, and why it is perceived to be a ‘good thing’.  Years of an internal market have created divisions and rivalries within the health service, and led to behaviours focussed on the needs of individual organisations rather than necessarily what is best for the patient.  It makes sense, then, to take steps to remove these artificial barriers created by the system, and for the organisation of care to be centred on what is best for patients.

There is, however, a difference between removing the barriers that have prevented health and social care professionals from working across organisational boundaries and centralising control into single organisations.

The new statutory NHS Integrated Care System (ICS) bodies will be given more formal power, “In order for ICSs to progress further, legislative change is now required to give ICSs stronger and more streamlined decision-making authority” (White Paper 5.4).  Further “each ICS NHS body… will be directly accountable for NHS spend and performance within the system” (6.18 f).  The NHS is well known for its mindset that accountability cannot be exercised without control.  Indeed, the system’s experience of the regional tiers of NHS England points very much to the fact that centralised control is something NHS England is extremely comfortable with.

All organisations within the NHS will not be merged into these new ICS bodies.  How, then, could control be exercised by the new system?  Well there are “several further changes to reinforce or enable integration” (the actual words used, 5.13 of the White Paper), one of which is a new “duty to collaborate” (3.11) imposed on all organisations across the system.  It does not take a huge stretch of imagination to envision a situation where any organisation not complying with the central diktats of the new ICS are taken to task for failing to comply with the new duty to collaborate.

The White Paper does talk about “the primacy of place” (6.5), and by place it means local areas within an ICS, but it only goes on to say that place is important, and not how this primacy should be effected.  Instead the government is not, “making any legislative provision about arrangements at place level – though we will be expecting NHSE to work with ICS NHS bodies on different models for place-based arrangements” (6.14).

Worrying, then, that a centralist-minded ICS would be able to set up its own arrangements for how arrangements in local “place” areas will work, with as many control mechanisms as it likes.  The argument is that by not legislating the arrangements that work best in any local area can be made, but that does leave it wide open to local interpretation/abuse.

We are therefore left with a situation, embedded by a new legislative framework, that seems designed to bring about integration not through relationships but through a system of centralised control.  How it works in practice will be dictated by the way NHS England behaves with the new ICS’s, and how the local leaders then operate within their own area.

Now I am generally a glass half-full individual, and of course there will be local leaders who focus on empowering and enabling local teams.  But I suspect this will be the exception rather than the rule, and so all of this leaves me feeling less than optimistic about the future.

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