We need to turn the approach to solving the workforce crisis in general practice on its head

If I had an hour to solve a problem I would spend 55 minutes thinking about the problem and 5 minutes thinking about solutions” Albert Einstein

Why is all the effort being put into general practice workforce not working?  Two and half years after the publication of the GP Forward View GP numbers continue to fall, workload continues to rise, dissatisfaction continues to grow.  We are told the money is being invested.  So what is going wrong?

The NHS England workforce plan is pretty simple: increase the number of GP training places; attract overseas doctors; provide financial incentives for GPs in hard to recruit areas; recruit an additional 1500 clinical pharmacists; co-locate an additional 3000 mental health therapists; introduce 1000 physician associates to general practice.  All the individual elements of this plan are reportedly on track, so why is it not working?

In short, it is because we have jumped to solutions without spending enough time understanding the problem or thinking about the change process required to make solutions successful.

Do practices want clinical pharmacists, mental health therapists and physician associates?  Some do and some don’t.  Practices are independent businesses; creating roles that practices don’t want isn’t going to help.  Each practice ultimately has to choose to pay for any new roles.  The problem isn’t insufficient physician associates.

It is too big a jump to move from a case study of a practice, or group of practices, who have developed a solution to their specific workforce challenge, to then assuming this solution will work for all practices.  Making it national policy, and performance managing each area on delivering it is a change management approach that won’t work with GP practices.

Each area is different.  Each practice is different.  The workforce problem manifests differently in each area and each practice.  Where the problem is different, the solutions needed, and how they are implemented, will be different.  For a solution to work, it needs to be owned by the practice not imposed from above, yet this is where we currently are.

What, then, is the alternative?  Each area should work out how they want their specific challenges to be addressed.  Practices need to work out what they want to do about their problems, and own their own solutions.  They need to set the agenda.  The majority of practices are now in some form of primary care network.  This is an ideal grouping for practices to work together to identify the changes they want to make, such as employ paramedics to undertake a joint visiting service, build GP-led clinical teams for populations of c5000, create a multidisciplinary team to manage the on the day demand etc etc.  Each area should identify the solutions that will work for them.  This should then drive the workforce plan, not the NHS England targets.

Each local area currently has to justify how it is complying with the national workforce plan.  This approach is never going to work.  The whole approach needs turning on its head.  Local groups of practices should be shaping the agenda.  The available funding should be focussed on helping practices to work out the solutions that will work for them, and on helping them implement them.  Regional workforce organisations should be accountable to these group of practices, not to national organisations.

If we are going to start making inroads into the workforce crisis in general practice, we have to accept the current approach isn’t working, and start doing things differently.

Never mind the models, it’s the mind-set

Back in the dark mists of time, I used to work in the national emergency care team. Our job was essentially about applying service improvement to improve the delivery of emergency care. As part of the role myself and others would visit many different A&E departments and hospitals. What struck me most about these visits were the different mind-sets of those we visited.

They generally fell into two camps. There were those who were very warm and welcoming. They wanted to show us every part of their system and explain how it worked. They were eager for our feedback, and were keen to understand how they could make it better.

Then there were those who were not welcoming, who would make us wait, and restrict access to the areas they wanted us to see or to a certain amount of time because of how busy they were (i.e. had more important things to do). They were defensive to any reflections made about their practice, dismissed innovations developed elsewhere, and were not open to doing things differently.

We were not there to judge these departments, only to help. But it was clear from the outset which ones were actually open to any help and which ones were closed to it.

This phenomenon of having an “open” or “closed” mind-set is not limited to emergency departments. It is also prevalent in general practice. There are practices who are keen to learn from others, eager to try new things, and who want to find out where they can improve. Then there are practices who will tell you they have already tried everything that is out there, that it “didn’t work” for them, and that it is the system that needs to change, not them.

Possibly the leading international thinker on this subject it Carol Dweck. She talks about an open mind-set as a growth mind-set, and a closed one as fixed. She says,

A fixed mind-set doesn’t easily allow you to change course. You believe that someone either has ‘it’ or they don’t: it’s a very binary frame of mind. You don’t believe in growth, you believe in right and wrong and any suggestion of change or adaptation is considered a criticism. You don’t know how to adopt grey thinking. Challenges or obstacles tend to make you angry and defensive.”

The tricky part of all of this is that most people and practices will say they are open to new ideas, and that they have a growth mind-set. But saying it doesn’t make it so. Some people and some places maybe were open to new ideas once, but no longer are. Years of relative success breeds a confidence in what you do and how you do it. It creates a mind-set that challenges and difficulties are driven by external forces and that making changes to meet them and learning from others is disrespectful to how they do things and unnecessary.

This is the difficult place that general practice finds itself in. Some practices are open to new ideas and to making changes, and are developing rapidly. But others are not. Their mind-set remains closed. This is where the real challenge for general practice lies. Primary care networks, operating at scale, technology, the introduction of new roles, creating John Lewis style ownership models (etc.) will only help practices if they have an open mind-set, if they want to learn from others, and if they want to make changes.

Creating a new future for general practice is not really about creating a new partnership model. At its heart it is about developing a new mind-set.

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.

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