Introduction

In 1998 I completed an MBA. For my dissertation I undertook a triangulated study to identify the barriers to public participation in General Practice. I found culture, leadership and structure of General Practice to be contributory factors.  These terms were alien to NHS management language at the time. In the emergent purchaser provider split of the time, with the introduction of commissioning and competition into the NHS, there was a reliance on quantitative and empirical evidence, with little room for qualitative evidence. As a result, my dissertation sat on a shelf until I became a Practice Manager.

Finding my personal motivation and beliefs constantly conflicted in a toxic command and control environment, I found it increasingly challenging to function as a middle manager in commissioning. At the time, I thought academic leaning was my route to influence in the NHS. Heading towards a PHD I was head hunted to apply for a practice manager job. Taking it became the best decision of my career. More on that later………………

Fast forward to November 2019 when I was fortunate to attend a Kings Fund conference on “The Challenge of Culture Change in the NHS”.  Promoting a move away from the command and control culture, this event explored the type of culture (in alignment with the Interim NHS People Plan) that would make the NHS a better place to work in. The emergent words on the day included “collaborative and compassionate culture and leadership”. This brought music to my ears. Emotionally exhausted from hearing some very brave individual accounts of collaborative and compassionate leadership, I left the conference with renewed hope and personal ambition!! I had waited two decades for this.

Having dusted off my MBA dissertation and reflected on my findings, it becomes clear to me that the structure, culture and leadership style in individual practices not only prevented meaningful engagement with patients and the public, but may also be a contributing factor to the challenges we face in embedding PCNs and new models of care.

Leadership and Culture

Many GP practices aspire to a command and control leadership style and culture, aligned to a vertical organisational structure. This leadership style is authoritative in nature and decision making is top-down. Privilege and power are vested in the Senior Partner (the heroic leader) with limited opportunities for broader involvement and engagement. This leadership style facilitates a weak organisational culture, one in which core values are not defined or communicated. The absence of shared values results in individualistic compliant behaviour, with a greater need for policies, procedures and bureaucracy.  Employees are compliant with low morale. Staff are disengaged and disempowered.

A weak culture is associated with:

• Incompatible vision, mission, goals, and a lack of understanding about the future direction of the organisation, which may lead to failure;
• Lack of leadership, poor direction from senior managers, competition and poor role models, and;
• Lack of quality of service provision, poor running of the organisation, and priorities externally perceived as being incorrect.

A strong positive culture is evident in practices where members within the organisation have deeply embedded shared values and beliefs. In this culture committed employees understand what is required of them and are empowered to act in accordance with the core values. Bureaucracy is reduced and there is high staff morale, engagement, and productivity. Internally, this positive culture provides the “glue” that binds the organisation together. Many practices with this culture and collaborative, compassionate leadership style are forging the way forward towards successful new models of care and scaled up General Practice.

The Practice Manager Continued….

Working at Oxford Terrace Medical Group taught me that command and control is not the only model available to general practice. There was no Senior Partner.  Leadership roles were distributed across the partnership.  Individual partners worked with the practice manager on management issues, taking an active role in running their business. At first there was limited involvement of patients and the broader Primary Health Care Team.

Equipped with my MBA and the necessary operational management skills, my first job was to co-ordinate a merger with a failing practice. It became very clear to me early in the process, that operational management skills alone, were not adequate for the culture change required to lead large scale transformational change. With three clear strategic priorities: improving access; transforming the workforce, and premises development, I embarked on a quality improvement programme. This provided structure for the merger project, through three modules:

• Fundaments of quality improvement;
• Human dimensions of change, and;
• Facilitation Skills and developing a compelling narrative.

A focus on human dimensions of change and quality rather than finance, transformed engagement of patients and employees during, and after the merger, enabling us to achieve the first two priorities quickly. We developed new roles (Frailty Nurse, Older Peoples Specialist Nurse, Care Navigator and Occupational Therapy in GP) to meet population need, this helped us to manage the access issues. Tied up in the merry-go-round of the ETTF process, premises development eludes me to this day.

What I learned was that a distributed leadership model focused on engagement and collaboration could not only succeed but also make a real difference within the general practice environment.

Quality Assurance and Quality Improvement

CQC further perpetuates the command and control leadership style and culture through target driven “quality assurance”, stifling opportunities for collaboration and the value of quality improvement. The Well Led KLOE, focused on transactional process is a clear indication of this.

There is a recognition now that the Well Led KLOE is limited, and there are plans to split the transactional (quality assurance) from the transformational (quality improvement) elements. A strong organisational culture requiring less bureaucracy, is better placed to facilitate quality improvement and collaborative, compassionate leadership with strong organisational culture.

Putting quality at the heart of the organisation, embedded though continuous improvement, involving all levels of the organisation working together to produce better services and care, through transformational processes and action. Quality improvement relies on the use of methods and tools to continuously improve quality of care and outcomes for patients. There is no place for command and control leadership in this environment.

PCN Leadership and Culture

Faced with changing demographics, people living longer with long-term conditions, with increasingly complex health needs alongside a shortage of GPs and nursing staff, the unprecedented pressures in primary care are well rehearsed. To date, workforce in general practice has remained simple with GPs, Practices Nurses, Health Care Assistants, Administrative staff and recent introduction of pharmacists in some practices. As new roles emerge, a different leadership style, culture and structure will become essential to enable safe embedding and sustainability of the new roles.

It is disappointing then, that the traditional leadership style and culture has been lifted and shifted from General Practice into Primary Care Networks in the guise of the Clinical Director role (The heroic leader).  Lip service is paid to management and non-clinical leadership, with only one paragraph in the PCN DES relating to administration support for CDs. The ensuing effects are already being felt by individuals and across the system.

Contracting of PCNs perpetuates financial incentives to passive engagement. This culture, with a focus on process, individual targets and transactional approaches to organisational and team development minimises the full potential of PCNs.  It limits the opportunities of active participation of individual practices. This will result in increasing performance management and bureaucracy for practices to maximise PCN income.

The rhetoric is around collaboration and integration, but actions are individualistic. The structure around practices is changing, but there are no incentives in the contract to influence and facilitate the necessary culture and leadership changes for collaboration and integration. The continuation of the existing culture, leadership style and levels of engagement across PCN practices will present significant risk to the introduction of new roles working across practices. Patient and staff safety will, therefore, be compromised.

To grow and flourish, PCNs will require a different leadership style and culture. A collaborative and compassionate leadership style, embedded in a strong positive, supportive and facilitative organisational culture. For PCNs to succeed we need Clinical Directors functioning as inspirational leaders, supported by a collaborative infrastructure with complementary skills.

Conclusion

My conclusions in 1998 were that the structure, culture and leadership style of general practice were barriers to patient and public involvement. My reflection now is that these are also contributing factors to some of the challenges we face in general practice, potentially including the move away from partnerships.

In his last address to the North East RCGP faculty: GP Reimagined conference in 2018: the late Sir Donald Irving (RIP) invited us to be brave, be accountable and be responsible in order to maximise the benefits and opportunities offered by new models of care. I believe, this is exactly what we must do to transform not only the structure of general practice, but also the leadership style and culture. It will take a brave leader to challenge the engrained culture that has endured decades of change in General Practice but maybe the time is nigh!