The Importance of Training for New GP Partners

There is a big difference between being a GP and being a GP partner.  All of the training to become a GP is designed to ensure you have the clinical skills needed to deliver great patient care.  The training is not designed, however, to provide you with the skills you need to be an effective GP partner.

A partner in a GP practice has overall responsibility for the running of the business of the practice.  The staff who work in the practice rely on the partners to run the business effectively.  If things go wrong, the buck stops with the partners.  It is a big responsibility.

At the same time, it is a huge opportunity.  Uniquely within NHS, GPs as clinicians have the opportunity as partners to run their own businesses in the way they choose to.  They can employ the staff they want, design their own way of doing things, and have their own rules about how things should work.  This freedom is highly unusual (ask any hospital consultant!), and means that GP partners are independent.  They have no line manager, and no one telling them what they have to do and how they have to do it.

Of course, life is never that simple!  Practices have contracts, and partners are responsible for ensuring the practice fulfils the contract it undertakes.  There may not be any line manager, but there are contract managers, CQC inspectors and others who will step in if the practice is not fulfilling its duties.

But the opportunity to choose how things are done, and to shape the culture of the GP practice, are what have drawn many to GP partnership.  I spoke to Dr Liz Phillips about why, after many years as a salaried GP, she chose to become a partner.  You can hear her story here, but for her it was all about the ability to make a difference.  She is loving her new life as a GP partner!

I have worked with a number of colleagues to provide training sessions on partnership for GPs.  It is interesting to me that the reflections are often not that the model of GP partnership needs changing, but as one salaried GP put it, “I left (the session we ran) feeling GPs need to be conversant with politics, finance, and management, so that we make informed decisions about our roles and the services we run for patients.” (you can read her full reflection here).

She is right.  Practices won’t run themselves, and responsibility cannot simply be delegated to a practice manager.  Partners need to be actively engaged in the business of the practice.  And for this GPs need specific tools and skills.

I wrote recently on the content of a training programme for new or potential GP partners that myself and some colleagues are putting together.  I am delighted to say that this week we are formally launching that programme.  For more information about the programme and how to secure your place, simply click here.

There is no doubt that the role of a GP partner is challenging, but it also presents a huge opportunity to make a real difference to people’s lives (both patients and staff).  As with any role, it requires specific skills and understanding, and our aim in this programme is to give new GP partners the tools they need to be successful in the role.

All Your PCN CD Mastermind Programme Questions Answered!

Dr Rachel Morris and myself are setting up a new “Mastermind” programme exclusively for PCN Clinical Directors.  Here is everything you need to know about the programme (and more!).

What is a Mastermind Group?

A Mastermind group is a group of peers that meet to give each other support and advice.  The beauty of a Mastermind group is that it combines brainstorming, education, peer accountability and support in a group setting to sharpen your leadership and personal skills. A Mastermind group helps you and the other Mastermind group members achieve success. Members challenge each other to set strong goals, and more importantly, to accomplish them.

Mastermind group facilitators start and run groups. They help the group to dive deeply into discussions, and work with members to create success — as each member defines it. Facilitators are the secret to thriving mastermind groups, and I am really excited to be working alongside Dr Rachel Morris to facilitate our new Mastermind Group for PCN CDs.

Through a Mastermind group process, first you create a goal, then design a plan to achieve it. The group helps you with creative ideas and wise decisions-making. Then, as you begin to implement your plan, you bring both success stories and problems to the group. Success stories are applauded, and problems are solved through peer brainstorming and collective, creative thinking.

The group requires commitment, confidentiality, willingness to both give and receive advice and ideas, and support each other with total honesty, respect and compassion. Mastermind group members act as catalysts for growth, devil’s advocates and supportive colleagues. This is the essence and value of mastermind groups.

Why is it only for PCN Clinical Directors?

Being a PCN Clinical Director is one of the most challenging roles there is in general practice right now.  And there is precious little support available.  Those most able to provide support to PCN Clinical Directors are other PCN Clinical Directors, because they are the only ones experiencing the same challenges.  By providing a safe space for a small number of PCN Clinical Directors to come together and support each other we are creating a unique opportunity for those who participate to support each other and thrive in their roles as PCN CDs.

Who are the Facilitators?

The group will be facilitated by Dr Rachel Morris and myself.  We will support the group by facilitating the meetings, providing input, expertise and challenge tailored to the individual needs of each of the participant, and making sure everyone gets what they need out of the group.

Why is it called a Mastermind Programme?

The reason it is a Mastermind Programme is because as well as the mastermind group meetings, those on the programme will be part of an exclusive WhatsApp group for participants (for ongoing support and challenge between meetings!), and will have access to Dr Rachel Morris’s fantastic Resilient Team Academy – with all the resources that includes!  You can find more details about the Resilient Team Academy by clicking here.

When does it start and how often will it meet?

The group will meet every 6 weeks on a Thursday lunchtime from 1pm to 3pm.  All the dates are on the website and can be found here.

How much does it cost and how do I join?

The cost is £1995 plus VAT for a year’s membership of the Mastermind Group.  Applications are via a short application form, which you can find here.  There are a maximum of 12 places available for the group so get your form in quickly, and no later than 31st July 2021.

More Questions?

If you have any further questions, please do not hesitate to contact me.  Email me at ben@ockham.healthcare

What do Integrated Care Systems Mean for General Practice?

Following the publication of the White Paper in February, new guidance has just been published by NHS England outlining the “Design Framework” for the new integrated care systems that are to replace CCGs and bring providers and commissioners together.  What can we learn from the new guidance about what the new integrated care systems will look like, and what does it all mean for general practice?

At the top of an integrated care system(ICS) there will be two bodies: an ICS Partnership and an ICS NHS Body.  The ICS Partnership is essentially the body to bring health and social care (under the remit of the local authorities) together, and has responsibility to develop an “integrated care strategy”.  There is no explicit mention of the need for GPs or PCNs on these bodies.

The second body is the ICS NHS Body.  This will be a statutory NHS organisation which will receive and distribute NHS funding, and will take on all CCG functions and duties, including the commissioning of primary care.  It is explicitly required to “support the expansion of primary care and integrated teams in the community” (p16).

Because the changes are intended to end the commissioner/provider split in the NHS, the ICS NHS Board is described as being a “unitary” Board: it will have a Chair and at leas two other non-executive directors; an executive team of at least a CEO, Finance Director, Medical director and Nurse Director; and will also have at least 3 “partner members” – one from the NHS Trusts/Foundation Trusts, one from the local authorities, and one from general practice.  The partner members, “will be full members of the unitary board, bringing knowledge and a perspective from these sectors, but not acting as delegates of these sectors”(p20).

What does that mean?  Well, it means there will be a GP on the NHS ICS Board, but it is up to the NHS ICS Board to appoint them, and they don’t have to represent the profession.  This in turn means it is highly unlikely there will be any form of election process.  It is up the NHS ICS Board to come up with and agree how it wants to appoint the partner members.

Beyond the ICS NHS Body, there are two other important pieces of the new system architecture.  One is called “place-based partnerships”, and the other “provider collaboratives”.

In my view place-based partnerships are the most important part of the new integrated care systems for general practice.  Each local system has been asked to define its place based partnership arrangements.  A place should have “configuration and catchment areas reflecting meaningful communities and geographies that local people recognise” (p24), but it is up to local areas to define exactly what that means.

Not only that, but it is also up to local systems to agree the membership and form of governance that place-based partnerships should adopt.  “As a minimum these partnerships should involve primary care leadership, local authorities, including Directors of Public health, providers of acute, community and mental health services, and representatives of people who access care and support” (p24).

Here is where it gets interesting.  The NHS ICS Body remains accountable for any resource deployed at place level, but there are different options outlined as to how this accountability could be discharged through place based arrangements.  These range from it being a consultative forum, that informs decisions made by the ICS NHS Body (ie has no power), to it being a committee of the NHS ICS Body with delegated authority to take decisions about the use of ICS NHS Body Resources.  It can even be delegated authority by both the local authority and the ICS NHS Body as a joint committee to make local decisions and allocate resources.

This is key.  Primary care’s influence and ability to shape the delivery and provision of services is realistically going to happen at a place level not at the wider ICS level, and that ability will be determined by how the ICS designs these place based partnerships in the next few months.

There is an interesting note in the guidance on the role of Primary Care Networks (PCNs) in the place based partnerships, “PCNs in a place will want to consider how they could work together to drive improvement through peer support, lead on one another’s behalf on place based service transformation programmes and represent primary care in the place based partnership.” (p27).  Regular readers of this blog will be no stranger to my view that primary care and PCN influence in the new system is predicated on their ability to work effectively together and present a unified voice.  The good news is that the guidance explicitly states, “This work is in addition to their core functions and will need to be resourced by the place-based partnerships”(p27).

The second important new piece of the architecture is provider collaboratives.  From April 2022 NHS trusts are expected to be part of one or more provider collaboratives.  There is a strong expectation in the new system that providers will work together (as opposed to in competition with each other).  They could be paid (by the NHS ICS Body) separately, or via a lead provider arrangement.  There will be far less competition and tendering in future, as it is to be a “tool to use where appropriate, rather than the default expectation” (p30).

The transition to the new system will happen quickly.  The NHS ICS Body Chair and CEO are expected to be in place by the end of September, along with the draft ICS operating model for 22/23.  NHS staff below board level (ie CCG staff) have been given an employment commitment to continuity of terms and conditions, but this does not apply to those in senior/board level roles.

The most important part of all of this for general practice is how the place-based arrangements will work locally.  It is vital that GPs and PCN CDs get involved in these discussions, and do not leave it just to those who are currently involved in the CCG, as they are the ones who will have to make the new system work.  At this stage there is a lot of local flexibility, and there is an opportunity to ensure systems are put in place that support locally-led bottom-up change, but it is an opportunity that won’t last long.

Do the Additional Roles Belong to the Practices or the PCN?

One of my favourite questions for guests in the current series we are running in the General Practice podcast on the additional roles in general practice is where do they belong?  Do those in the roles feel like they belong to a specific practice, or to the PCN as a whole?

Many PCNs have already experienced turnover in the additional roles, despite the scheme only having just completed two years (and for the first year only pharmacists and social prescribing link workers could be recruited).  One of the most common reasons cited by those leaving is that they did not feel like they belonged anywhere.

It is a difficult conundrum.  The PCN is a collection of practices, and is not really an entity of itself.  It does not exist in a specific place, and is defined as much by a series of meetings and actions as by any physical reality.  So when an individual is appointed to work for the PCN it is not surprising that they can lack this sense of belonging to something.

This issue is then exacerbated because these roles in many places are very new.  Most practices are not used to working directly with social prescribing link workers or health and wellbeing coaches or physician associates (etc).  Making something new work involves change, and change inevitably leads to resistance.  So those taking up post in one of these new roles is working for the less-than-tangible PCN, and at the same time encountering push back from the individual practices within the PCN.

Those taking on these roles need somewhere safe they can retreat to, somewhere they can feel supported, somewhere they can regroup and work out a plan to win over those who have not yet understood the value they can add.  They need to feel like they belong somewhere.

What is really interesting about the responses that I have had to the question from those in roles that are clearly working extremely well is that they are not consistent about where they feel they belong.  Some respond quite emphatically that they feel like they belong to their host practice.  They feel part of the practice team, welcome in the practice, supported by the practice, but at the same time enjoy working with patients from across all the practices in the PCN.

Conversely others feel part of a PCN team.  This is particularly true where there are a number of roles working together, for example social prescribing link workers, care coordinators and health and wellbeing coaches.  They feel like they belong to the PCN team, and that this is where they get the support they need.  The team often has a number of key individuals (clinical supervisors, line managers etc) from across the practices, who enable this team to feel an integral and valued part of the PCN.

Where it doesn’t work, and where more commonly we see turnover in the additional roles, is when those in the role does not feel like they belong to either a practice or a PCN team.  Problems occur when roles are isolated, and left to try and work with each PCN practice without really being a part of any of those practices and without any peer support to speak of.

As long as the new roles feel like they belong to either one of the practices or the PCN then which is not really important.  What is important is they feel like they belong somewhere.

How to Make the Additional Roles a Success

We have a strange irony in general practice right now whereby the biggest investment into the service, the Additional Role Reimbursement Scheme (ARRS), is in many places adding to the challenges practices are facing rather than helping.

What is happening is that the burden of recruitment, line management, and clinical supervision, along with the time needed in each practice to make these roles effective, is outweighing the value the new roles are bringing.  This is then exacerbated by rapid turnover in these roles, and the need to constantly start over and over again.

I have written previously on the need for PCNs to plan for the new roles, and also on the challenges associated with introducing them.  But how can PCNs and practices turn this huge investment (£746M this year) to their advantage?

In recent weeks I have been talking to areas that have found ways of making the new roles a success.  What is becoming abundantly clear is these areas have understood that the introduction of the new roles is a change process and have treated it as such, rather than simply recruiting to the roles and expecting the benefits to automatically follow.

What does this mean in practice?

The leading thinker on change at present is Professor John Kotter.  In this Harvard Business Review Article, in addition to outlining the 8 steps of a robust change process, he states 8 reasons why change processes fail.

Read the article for yourself, but my take on the first three of these reasons, as applied to the introduction of the new roles, is as follows:

Error 1: Not Linking the Roles to the Need for Change

Practices are at breaking point right now.  The workload pressures on top of trying to operate in the environment of the ongoing pandemic are making life extremely challenging for many.  What many PCNs are doing is introducing the new roles without being explicit as to how they directly link to this challenge.  Without this link in place practices feel they are making the situation worse not better.

Error 2: Not Creating a Cross-Practice Team to Lead the Changes

The way many PCNs work is that the leadership of the introduction of the new roles is left to the PCN Clinical Director (CD).  They have a PCN meeting to gain sign up as to which roles from the list to recruit, but overseeing the recruitment process and introduction of the roles is left to the CD, who then in turn has to assign line management and clinical supervision roles out across the network.

The problem is that it is simply not possible for someone to successfully introduce a new role into a practice if they are not part of that practice.  A team is needed with a range of individuals, taken from across each of the practices, that is multi-professional (including practice managers, reception managers, nurses etc as well as GPs), to work together to lead the changes to make the new roles a success.

Error 3: Not being Clear what Difference the New Roles will Make

Kotter calls this lacking a vision.  The places where the new roles are working well have a plan in place as to how the new roles are going to make a difference.  They have created multi-professional visit teams to take the burden of visits off practices, or created multi-professional non-clinical teams that can manage the social and non-clinical work that comes into practices, or built prevention teams with a clear plan to tackle pre-diabetes (etc etc).  This is in stark contrast to PCNs who have simply identified the roles they most like the sound of and recruited to them because the money is available, but have not taken the time to create a clear plan as to how these new roles will make a difference.

These are not the only mistakes being made.  All of the errors Kotter outlines can easily be applied to the introduction of the new roles.  The key message, however, is to think of the introduction of the new roles not as a task to be completed, but as a change process that if done well can add huge value, but if done badly will probably make things worse.

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