Local General Practice Inc

I am going to write over the next few weeks a series of articles outlining the actions that general practice can take in a local area to be effective within the new integrated care system (ICS) environment.  This is the first of these articles, and is about putting a single board or leadership group in place for local general practice.

I have written previously on the potentially huge impact the loss of CCGs and the introduction of ICSs could have on general practice.  With general practice losing its system voice as a commissioner, it has to create one as a provider.  All signs from the Fuller report indicate that more of general practice funding will be channelled via ICSs (as opposed to the national contract) in future, so as a minimum local general practice needs to be organised to at least be able to negotiate effectively.

The first action that general practice needs to take is to put a single leadership board for local general practice in place.  As a minimum this needs to include the PCN Clinical Directors and the LMC Chair.  The system recognises PCNs, and the LMC has a statutory role to play.  If there is a local federation they also need to be included on it.

If general practice is not united it will be weak in the new system.  Different facets of the service will be played off against each other, as the system asks different people the same question until it gets the response it is seeking.  Equally, influence at system meetings is nullified when different parts of general practice argue against each other.  Strength comes from unity, and a single general practice board is the first step towards this.

There are a couple of important considerations to make about setting up such a board.  The first is one of scale.  Should this general practice board be at the level of the ICS, or of the local area (which more likely relates to the “place” area within the ICS)?  Whilst influence at an ICS level is important, the more natural grouping and ability for short term cohesion within general practice is at the local level.  One LMC, less than 10 PCNs and one federation feels both more manageable and more likely to be able to focus on common issues than one operating at an ICS scale.

Rather than having one large ICS group it would be much better for there to be several local place-based groups, and for the leaders of these to work together to influence at ICS level.

The second consideration is one of ownership.  There has been a tendency for local systems to try and set up these primary care leadership groups.  Groups set up in this way rarely work for a number of reasons.  First, the scale is often set at an ICS rather than local level, so there is little in common binding the members.  Second, the agenda is generally set by the system, and so becomes about an ability for the system to interact with general practice rather than general practice being able to influence the system.  Third, they quickly become just another meeting that busy PCN CDs and general practice leaders have to go to rather than being a place where important decisions are made, and so attendance and then influence of these meetings becomes poor.

Instead these groups need to be owned and created by general practice.  General practice needs to set the agenda.  There can be some space allocated for others to come to talk to general practice, but this is secondary to general practice working together to influence the system.  It needs to be where local general practice works out where and how it will influence the place-based board, where it sorts out general practice issues (like extended access) together, and where it shares information about local system issues.  If the system is running the meeting for general practice, this is not what the meeting will achieve.

This raises the interesting question of who will chair the meeting.  I know of a series of different places across the country who are already running these local leadership groups, and the role of the chair varies significantly.  In one it is a PCN CD, in another it is the LMC Chair, and in another it is the senior manager from the local federation.  What all these people have in common, however, is that they are trusted and respected by the rest of the GP leadership team.  It is not about getting the right role as chair, it is about getting the right person, and each local area will need to work out who that is for themselves.

Putting a local general practice leadership group in place is important but it is only the first step.  If general practice is going to survive and thrive in the new system it will then need to develop this group so that it is effective and has real influence in the system.  In the coming weeks I will outline the steps such a board needs to take to build its impact.

5 Steps to Improve Joint Working in General Practice

Effective joint working is the key to successful general practice.  It may be joint working between the partners in a practice, joint working between the practices in a PCN, or joint working between the PCNs in an area.  Joint working is difficult, and where it is not effective individuals, practices and general practice as a whole all suffer.

The most important metric for joint working is trust.  How much do I trust my partners/the other practices/the other PCNs?  Where my trust is low I assume the intentions of others are poor, I avoid interaction where I can, and I am unwilling to be helpful because I do not believe there would be any reciprocation.  Life in a low trust environment is generally tense, unpleasant and often draining.

I spend much of my time supporting joint working within general practice.  Here are 5 steps that I have found to be extremely helpful in shifting from a low to higher trust environment:

  1. Stop communicating primarily by email. One clear indicator of poor relationships is where the majority of the communication takes place by email.  The problem with email is that it is one way and open to misinterpretation.  You are not there to correct any misunderstandings when the email is being read.

 

  1. Communicate by talking at least once a week. It is far better to have a short conversation of 20-30 minutes once a week than to have a (poorly attended) monthly meeting interspersed by heavy amounts of email communication.  Simply shifting the mode of communication from email to conversation in this way can have a huge impact.  It shows respect (people feel more valued when they are told things in person rather than by email), and allows questions and concerns to be answered and dealt with straight away, as well as preventing misunderstandings from festering.

 

  1. Communicate in person. Whilst there has been a huge time and convenience benefit to meeting and talking online, it is very difficult to develop and improve relationships in a virtual space.  It is too easy for individuals to simply disengage from the conversation (how often are we in meetings where the majority of people have their cameras off and are on mute?), rather than have their concerns noted and dealt with.  Online it is difficult to spend enough time understanding and valuing each other as people, as without shared coffee breaks or pre-meeting chat we focus only on the business.

I worked recently with a PCN that shift from monthly virtual meetings and email as the primary communication route, to weekly half hour virtual meetings and a monthly face to face meeting with far less reliance on emails.  The impact on relationships across the PCN was transformational.  Trust that had become low was restored.  There was a shared confidence in a new sense of transparency, and a new willingness to take actions together as a group of practices.

  1. Show vulnerability. The counterintuitive thing about building trust is that you build more trust by sharing your weaknesses than your strengths, and asking for help builds more trust than offering to help.  If I ask you for help I show that I respect you, that I believe you have strengths that I do not have and that I trust you enough to show you my weakness.  Conversely if I offer to help you I reinforce your belief that I think I am better than you, that I have no sense of my own weaknesses, and even that I may have a secret agenda to take you over – however well-intentioned the offer may be.
  2. Admit when you are wrong. We all make mistakes.  Sometimes we are convinced that a course of action is the right one to take, but with hindsight we can see the error of our ways.  But it makes a huge difference to other people if we are prepared to put our hands up and say we are sorry when we have made a mistake.

I worked with one federation who had a difficult relationship with some of the PCNs in its area.  But this all suddenly changed when in one meeting the federation acknowledged that it had made mistakes in the past, said sorry for the impact of those mistakes, and asked what it could do to put them right.  Almost immediately the relationships were changed and moved to a much more positive place.

While it is generally true that trust can be hard to gain and is easy to lose, my experience has been that by starting with a good intent and taking the right actions in line with these 5 steps trust can be rebuilt surprisingly quickly.

How Much Autonomy are GP Practices Prepared to Give Up?

Much of the strength of general practice comes from its autonomy.  While the rest of the NHS totters under the weight of being part of one of the largest centralised systems in the world, GP practices are free to operate as they choose to deliver the contracts they have agreed.  While this autonomy carries its risks (the practice is the business, not simply a part of the business), it also creates huge freedom for practices to operate exactly as they want.

The pressures on practices mean that the sustainability of these independent, autonomous businesses is coming increasingly under threat.  Growth in funding does not keep pace with the growth in workload, and the staff required (especially GPs) in many areas simply cannot be found.

Here comes the challenge. In order to improve sustainability, practices have to find new ways of working.  These nearly always involve working with other practices.  These could be things such as creating a shared visiting team, building a staff bank, establishing a document management service, putting in place a prescribing hub, or any number of other things.  All of them will make a difference to practices, but all of them involve working with other practices.

If working together can make a difference to practice sustainability, particularly now when individual practice sustainability is under such pressure, why is that so few practices undertake these shared activities?

It is because working with other practices requires a ceding of some autonomy.  If five practices are working together to create a document management hub, they all have to agree to a single way of working for actioning and coding the incoming documents.  It doesn’t work if there are five different ways of doing things.  In order to gain the benefits of the shared hub, each practice has to give up its individual autonomy on how it does things and agree to the single collective way of doing things.

Instinctively GP partners and GP practices resist any attempt to curtail their autonomy.  It is in the DNA of GP practices to be extremely protective of their own autonomy.  This is why joint working is hard, however rational and straightforward it might seem on paper.

There are two critical components to enabling collaborative working in general practice.  The first is a shared belief that continuing on our own is unsustainable and that joint working will make a difference.  The second is that practices trust those whom they are ceding autonomy to, most commonly the other practices that they are working with.  If we do not trust them, and in particular those leading whatever the change is, we are unlikely to go ahead no matter how clear the potential benefits.

As an aside, this is why PCNs are difficult.  The starting point of PCNs was not a shared understanding that joint action is required, but rather a contractual requirement.  The initial level of trust between the practices thrown together in a PCN was usually low, unless there had been some history of effective joint working previously.  So PCNs started with a set of practices who were supposed to work together, but all of whom were hugely protective of their own individual practice autonomy.

As the sustainability crisis worsens, the need for joint working gets greater.  The challenge for GP practices is whether they are prepared to cede some autonomy now to enable this joint working to take place and be effective.  The risk is that refusing to give up some autonomy now will lead to a complete loss of autonomy in future when the practice reaches a crisis point from which it is not able to recover.

What Should General Practice Do With PCNs?

There is a danger starting with a title like this that it will provoke many into further calls for general practice simply to abandon PCNs and have nothing more to do with them.  This was the call at the national LMC conference, and as I understand it has become BMA policy.  But as I have previously written, such a move has the ‘cutting off your nose to spite your face’ feel to it, and a more nuanced approach is required.  So what could this be?

The challenge is that all of the additional funding and resources for general practice over the course of the current 5 year deal comes via PCNs, and general practice simply cannot afford to do without this.  Any move away from PCNs will not result in the funding being transferred into the core contract, but in a loss of control of these resources to other organisations eager to take them on.

We know that the Fuller Report has laid out a direction of travel for PCNs to evolve into Integrated Neighbourhood Teams.  This means the focus of PCNs moving away from GP practices and towards multi-agency working across local neighbourhoods.

What will happen to the funding of PCNs after the existing 5 year deal for general practice expires in 2024?  The funding for them will potentially grow (neighbourhood multi-agency working is becoming more not less important to the system), and will most likely continue to consume any additional funding for general practice.  It is also highly likely to come via the local Integrated Care System rather than via the national contract.

So the additional money for general practice is, and will continue to be, tied up in PCNs, but the control of PCNs may start to shift away from practices.

I have written previously of the need for local general practice within each area to start to work together to create a collective voice and influence for general practice as a provider.  My question now is to consider what role PCNs should play in this collective action?

Should the voice of general practice in an area be channelled through the PCNs and the PCN Clinical Directors?  After all, it is the PCNs that the system wants to talk to.

Right now PCNs and PCN Clinical Directors should form part of any collective general practice voice, particularly as the Clinical Directors all come from general practice at present.  But in future the Clinical Directors of the Integrated Neighbourhood Teams may not come from general practice.  Some may come from the community trust, the acute trust, or the council.

Meanwhile general practice needs to create its own provider voice in the system, particularly as its commissioning voice is being lost.  But it needs to build this as the voice of the GP practices at its heart.  It needs to do this in a way that means it can both harness the resources for general practice that come via PCNs, but also when general practice in future has to negotiate its role within the Integrated Neighbourhood Teams it can do so because there is a clear enough separation between what is local general practice and what are the activities of these new multi-agency teams.

This means the local general practice leadership voice cannot be solely that of the PCN Clinical Directors.  The LMC and any local GP provider must also be involved, and there must be a way of ensuring that there is route for voicing the needs of practices, and negotiating on their behalf, that is separate from the needs of PCNs.

While this nuance is difficult, I think ultimately it will largely come down to leadership.  If local GP leaders can work together for the good of the practices and their populations, regardless of the role that they are in, then they can create a strong leadership voice that they can iterate with the changing environment.

Making the Transition from Commissioner to Provider

The impact of the formal establishment of Integrated Care Systems and the abolition of CCGs may not have been felt straight away, but there is no escaping the huge consequences this has for general practice.  The question is whether general practice can shift from influencing as a commissioner to influencing as a provider quickly enough to prevent any real damage being done during the transition period.

For the last 30 years, ever since the introduction of the internal market, the influence of general practice has grown through the commissioning route.  It started slowly at first, with the initial forays of GP fundholding, but then steadily grew until Clinical Commissioning Groups were established built around a membership of GP practices.

While the influence of general practice grew through the commissioning route, its influence as a provider steadily receded.  A strong provider voice for general practice has not been needed because GP leaders were already at the system table via the CCG.  Indeed, GP provider representation was actively discouraged because of concerns around conflict to interest.  At best we had GP federations and GP provider organisations purporting to be the voice of general practice provision, but in reality they represented additional provision undertaken by these organisations above and beyond core general practice.

This has been of little concern to the profession because the main representation of general practice takes place nationally via the negotiation of the national contract.  It is this contract that has been pivotal to the sustainability of the service, much more important than any additional local income.

But now this is a problem for two reasons.  First, the representation of general practice at a national level is finding it difficult to secure an effective deal for the profession.  This is encapsulated by the self-defeating policy to promote the withdrawal of practices from the PCN DES, despite all the agreed additional resource for general practice over the last 5 years coming via this route.  This creates a huge risk for general practice, because it relies on a premise that this funding will be reinvested into the core contract instead, when a much more likely outcome is simply that practices will lose control of the PCN resources.

Second, all the signs are that much more practice income will come via the local route rather than via the national contract in future.  This was signalled strongly in the Fuller Report, and backed up by a letter from all 42 ICS Chief Executives.  If this is the case, how organised is local general practice to negotiate as a provider with its local system.  Are LMCs up to the job?  Is the infrastructure of LMCs sufficient for the size of what may be required? While some clearly are, there is a huge variation amongst LMCs across the country.  The system is going to want more ‘integration’ by general practice in return for more resources, so how are PCNs going to play into these discussions?  Will PCNs and LMCs be joined up, or will they be played off against each other?

For the first time in over 30 years local general practice needs to establish its voice and influence as a provider in the local system.  The support that has historically been in place from commissioners will quickly recede in the new system.  Much of the responsibility that has sat with national leaders and the national contract will become the responsibility of local leaders.  It will be up to general practice in each local area to support itself.  LMCs, PCNs, federations and practices will need to work together to ensure local general practice is unified.

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