Time for Reflection

I am tired.  It has been difficult over the last few months not only having to keep up with the pace of change, but also having to constantly adapt and get used to new ways of working.  It is not only our professional lives, but our personal lives as well.  Everything we do has been completely changed.  It has been exhausting.

I know I am not alone.  Everyone working in general practice has had their world turned upside down.  All we want is some respite.

The talk nationally is of recovery and restoration.  Sounds like exactly what we need.  But of course it is not about us.  It is about restoring the services that are not being offered, and creating that dreadful term “a new normal”.

It is into this context that we hear about how this is a new future for general practice, how we must build on the changes and go further, faster.

But we are tired.

It may be the start of a new future for general practice.  Or it may be that many GPs are just waiting for the opportunity to close the much-touted new digital front door.  The draw of the comfort of ways of working that we know and trust may well take many back to how things were, not forwards to the newly glimpsed but (for some) highly uncomfortable ways of working we are now experiencing.

Recovery and restoration in general practice needs to start with practices and practice staff.  It needs to be about creating time for teams to reflect on the changes they have made over the last few months, to share the things that been difficult and to ask for help where it is needed.  We need the opportunity to talk to others about what they have done, how they have coped with the changes, and what the impact has been for them.  We want to learn from what they did differently and understand what this teaches us about our own experiences as well as theirs.  We need the comfort of knowing we are not the only ones who have found this difficult, and the reassurance that what we are doing now is ok.

We need time to consider whether any of the changes have been positive, and if they have which ones we want to keep.  We need the opportunity to think this through for ourselves, rather than be told it by other people.  We need to do this at our own pace.

At this point in our covid journey, I don’t think there is anything more important than creating time and space for reflection and review.  We have to recognise that we and those around us are tired, that change is difficult and this feels like it has been going on for a long time.  We need to create the opportunity for ourselves and our teams to be able to move forward.  It may feel counter intuitive, but the way to do this is by creating the time and space for our teams to look backwards, so that we can decide for ourselves where we go from here.

Are PCNs Making General Practice More or Less Resilient?

Resilience is a popular term at present, as we all cope with the challenges of covid in our own way.  While our individual levels of resilience may vary, it is not just our personality that will determine our overall level of resilience.

For GPs and those working in GP practices, the robustness of the GP practice itself will be a huge contributor to our personal resilience.  If our practice is well run, has strong leadership in place, and has good relationships across the practice, we can use the practice a resource to help us with the challenges we face.  When we are confident in the strength of the practice as a unit, we can draw on that to help us when things like covid come along.

Conversely, if the practice has divided leadership, poor systems and processes in place, and weak relationships between the staff, then the practice is likely to be a source of worry and concern for us.  The practice itself becomes yet another contributing factor to the stress and anxiety we feel, and so is likely to make us less resilient.

And so the strength of the practice unit is critical to the overall resilience of general practice.  So what impact do PCNs have on the resilience of GP practices.  Do they help, or do they make it worse?

For some practices, the PCN is a real source of concern.  We have seen this articulated in some of the resistance to the PCN DES.  PCNs are designed so that the performance of the individual practice becomes linked to the performance of the other practices in the PCN.  The inability of your practice to control the performance of the other practices in the network, alongside a lack of confidence in their ability to deliver, means the PCN will serve primarily to reduce our confidence in our own practice’s ability to deliver.  Putting performance outside of our individual control is a source of stress and detracts from our overall resilience.

The desire to maintain the independent contractor model in the context of PCNs is about enabling a practice to keep control of everything within its contract, and not allow concerns about other practices to make the job of running your own practice even more difficult.

For others, however, particularly as a result of the recent challenges of tackling covid, the PCN has become a source of real strength.  While I as an individual practice may not have been able to cope with covid on my own, by working with the other practices in my PCN I found support, joint working, and a collective strength that enabled the challenges we faced to be overcome.

By working with other practices I trust I can become more confident in the delivery of targets because I can access the support and help I need when things are difficult or I don’t know what to do.  The PCN becomes a vehicle for sharing of ideas, information and resources that means I feel more confident about my practice, and so more resilient overall.

So are PCNs making general practice more or less resilient?  It varies.  Some practices feel that the PCN makes their practice less resilient, while others are starting to feel that their resilience is very much improved by being part of the PCN.  The most interesting thing about this is that practices control the PCN.  PCNs can support the resilience of general practice, but ultimately it is up to the practices in the PCN to decide to work on building the trust and relationships required to enable this, or whether to resist the PCN, treat it as a threat, and suffer the impact on overall resilience that will result.

The Opportunity of the Additional Role Reimbursement Scheme

By far the largest amount of funding in the PCN DES is for the Additional Role Reimbursement Scheme (ARRS).  But is general practice making the most of the opportunity that such an investment represents?

To put the funding into context, a PCN with a weighted list size of 50,000 will receive £356,600 under the ARRS.  This size of PCN will have funding for more than 7 roles this year.  This will rise to £618,600 next year, £850,900 the year after, and reach £1.17M in 2023/24 (network contract DES guidance p20). The £7.13 per weighted patient PCNs receive for the ARRS for this year compares to a combined total of £5.61 for all of the other funding in this year’s specification put together (excluding the care home premium, which is not going to significantly alter the figures).

The funding is not, however, given as a lump sum.  It is paid a month in arrears based on the actual expenditure made by the PCN.  A PCN must, “complete and return to the commissioner a workforce plan, using the agreed national workforce planning template, providing details of its recruitment plans for 2020/21 by 31 August 2020 and indicative intentions through to 2023/24 by 31 October 2020” (6.5.1 Network contract DES Specification, p36).

We are currently at the end of May.  Assuming a PCN has not yet employed any additional staff (although I know some have, many have not), our 50K weighted population PCN now has funding for 9.3 additional roles.  If the PCN waits until the end of August (the deadline for submitting its plan), it will have funding for 11.6 additional roles.  The longer we go into the year, the harder it is going to be to spend the money.  Once we are over a third of the way in next year’s funding is unlikely to cover the incurred recurrent expenditure even if we do manage to spend it all.

Any money allocated to a PCN that can’t be spent will be offered to “other PCNs within the commissioner’s boundary”.  So a smart PCN will not only be well into planning how to use its ARRS funds, it will also be looking at its neighbouring PCNs and working out whether they going to be able to use all their funding and preparing accordingly.

This year, impacted already by covid as it has been, does present general practice with something of an opportunity when it comes to ARRS.  In effect there is 12 months funding available for 6 months of work, because the requirements of the specifications only start on October 1st.  The argument has been that the roles should be supporting core general practice, not simply carrying out additional work mandated by the PCN DES.  Well it may or may not be by design, but that opportunity is certainly there now for this year for PCNs.

The question, then, is how should PCNs respond?  With such a wide array of roles (10 in total) available, what roles should PCNs be prioritising?

Let’s take the work to meet the requirements of the specifications as a given, and focus on what to do with the roles beyond that.  The specifications are not going to require all of the ARRS funding, and certainly will not this year.  Once the specification requirements are met, it seems there are two ways to think about how to use the new roles.

The first is to focus on the roles that will free up the most GP time.  The biggest challenge in general practice for a long time now has been GP workload, and so it would be logical to use this funding on the roles that most directly reduce GP workload.  This would lead to a focus on first contact physiotherapists, physician associates, pharmacists and (next year) paramedics, as roles that can directly have this impact.

The second is to focus on the roles that can change the shape of demand into GP practices.  Instead of reacting to the incessant rise in demand on practices, this may be an opportunity to do something about it.  A team made up of some combination of social prescribers, health and wellbeing coaches, occupational therapists, dietitians, podiatrists and care coordinators may be able to start with the currently shielded and housebound patients, and prepare a PCN for the anticipatory care and personalised care specifications that are on their way in future years.  By proactively meeting the needs of those patients who are the biggest drivers of demand on PCN practices, the constantly rising demand may be slowed.

These two approaches are not mutually exclusive.  It may be that some combination to the two is what is needed locally.  And of course there may be others.  What is important for PCNs is to be clear on what they are trying to achieve with the new roles, before they start deciding which specific roles they want to employ.

It is rare that general practice finds itself with an opportunity like this, backed up with such significant resources.  I very much hope we make the most of it.

The impact of virtual working

The working day has transformed for many people (including me!) in recent weeks, and one of the key changes has been the shift to Zoom (or Teams, or Hangouts, or Skype) video calls for meetings.  Zoom has been a vital part of managing during the pandemic, enabling rapid communication and decision making without the need for in-person meetings or travel.

But how is the shift to Zoom affecting relationships?  While some are reporting that the increased communication means relationships have never been better, others are finding that relationships are beginning to suffer.

There are a number of reasons for this.  Firstly, it turn out that Zoom fatigue is “a thing”.  This HBR article explains that the focus required in video calls, the ability to get distracted by other things, plus the need to be paying attention the whole time, all contribute to this growing phenomenon of Zoom fatigue.  This BBC article (I told you it was a thing) also suggests the need for greater focus means people cannot relax into conversations.

I am not sure it is just about getting used to the technology.  I think the ease with which we can hold the meetings actually leads to more meetings than we had before.  This is quite some feat, given the NHS’s penchant for back to back meetings.

At the same time, there can be something impersonal about Zoom meetings.  This humorous video (which I am sure you have already seen) reduces attendees into certain types.  It does seem to me that it is a difficult platform on which to actively build personal relationships.  Alongside the rapid growth in group video meetings we seem to be having less one on one meetings.  It is so easy to add people into a call that meetings are rarely with less than 4 people, and regularly with many more.  The cost of this is potentially individual, personal relationships.

What should we do?  This National Geographic article suggests when people start to experience Zoom fatigue then they should join meetings with the camera off.  This is because it is far less exhausting to not feel like you are in the spotlight every time you have a meeting.  But then the people with the cameras on assume you are not paying attention and more than likely doing something else.  Once again, it is relationships that can suffer.

And where there are disagreements individuals can often prepared to be much more forceful in their views when they are on a video call (but with the camera turned off) than they would have been face to face.

The basis of collaborative working is relationships and trust.  Communication is a key part of building trust.  But if the communication does not feel personal, is tiring, and even negative or aggressive, then relationships will suffer not improve.   Simply holding more Zoom meetings is not going to improve relationships per se.

I find myself in the camp that would say if you are going to be in a Zoom call then you need to commit to it and have the camera on.  More helpful, then, than the advice to join meetings with the camera off is the advice in this article which suggests 5 alternatives to zoom meetings we might want to try.  These include the “old-fashioned” phone call, holding shorter video conferences, and scheduling days without them.

Ultimately, what I think we need to do is prioritise relationships.  If we are finding that Zoom calls are enhancing relationships, building trust, and enabling collaborative working then great, carry on.  But where we find relationships are starting to suffer we need to take time to reflect on why, and identify what changes we need to make to rebuild those relationships.

Zoom has had a transformative effect on my life in recent weeks.  I am certainly not advocating abandoning something that has had such an impact.  I am, however, suggesting we review its effect on us and our work beyond simple convenience, to ensure it enhances what we do rather than detracts from it.

Holding the Gains

There is a lot of talk at present about improvements that have been made as a result of the crisis.  These changes include the move to remote working, connected teams, practices working together to create “hubs” for patients to be seen in, data sharing between practices and organisation, and systems working together to make decisions based on needs.  I am sure there are many others.

As a result, exercises are emerging (often management led) in identifying the changes we want to keep, and even considering how we can take these changes even further.

There is a presumption, it seems, that the changes made in response to the crisis, are somehow “locked in” for the post-covid future.  But the reality is of course that change is never that simple.  It would be unwise to underestimate the impact the level of recent change has had on individuals, and the discomfort it has caused.  A change made in response to a national crisis is very different from a change made in perpetuity.  Throw in a bit of conspiracy theory that there is some masterplan to move away from the core general practice model, and it is not hard to understand why holding the gains made so far will be a challenge, let alone building on them.

What do we know about sustaining improvements?  Nicola Bateman produced a guide on the sustainability of improvements made back in 2001.  The research was based on the sustainability of changes implemented rapidly in an improvement workshop, but there is a useful parallel here to changes made rapidly in general practice in a covid environment.

What she found was that there are 5 ways changes can go:

She divided the post programme period into two phases.  The first 3 months is primarily concerned with maintaining the new way of working and resolving the technical issues identified during the initial improvement period, and whether these are tackled and resolved.

The Class A and B classifications closed out the actions on the problem follow-up list and maintained the new way of working.  Class C maintained the new way of working but failed to close out tasks, and Class D activities closed out the tasks but did not maintain the new way of working.  Class E activities failed to do either.

There are lots of interesting lessons in this for us.  Beyond understanding that the only way is not up, it highlights that problems identified along the way to making these rapid improvements still need to be tackled and dealt with.  According to Bateman, they also need contribution and buy-in from the relevant teams, “making sure that the people who work in the area can contribute to the way in which their area is operated”.

A change implemented out of necessity, steamrollering any resistance along the way, will need engagement of teams to adapt that change to give it a chance of becoming permanent.

Bateman also advises, “ensuring that the team members and their managers remain focussed on the improvement activity”.  The idea that remote working (for example) is somehow “done” because it has been going for a few weeks misses the need to be continually addressing issues that arise and adapting it to meet the needs of the practice and its staff.  We are not yet at a point where any of the changes we have put in place so far could be considered permanent.

The second phase Bateman divided the post programme period into was from 3 months to 9 months after the initial changes were made.  This period is concerned with whether there is any ongoing improvement beyond the initial change period.  Class A is what happens when ongoing improvement is in place, as opposed to Class B where there is not.

Being able to make further improvements after these initial gains requires three things: consistency and buy-in; having a strategic direction; and (senior) support and focus.  So making the most of the opportunity that seemingly now exists will be no mean feat.  It will require a practice to adapt its medium term strategic direction, with full buy-in of the GPs and practice staff, and to develop a clear plan for moving forward.

There are five ways we can go from here.   If we are really serious about holding and even building on the gains made in recent weeks then we need to understand there is a lot of work to be done in keeping things as they currently are, let alone taking them beyond the current level.

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