There is something difficult, elusive even, about the concept of governance. It should be straightforward. According to the universal fount of all knowledge (Google) the definition of governance is, “the action or manner of governing a state, organisation etc.” Yet somehow in the NHS, governance has drifted into becoming a stick managers wield over clinicians to drive compliance.

Am I overstating it? I am not sure. The first time I really saw evidence of this was when CCGs were first formed. Keen, eager and green, groups of GPs worked together determined to use NHS money to make a difference to local populations. But then these fledgling organisations were subjected to an “authorisation” process, where the focus was on governance and the ability of CCGs to operate as stewards of public money.

Whatever your views on the rights and wrongs of the authorisation process, the result of it was that it sucked the life and spirit out of nearly all of the CCGs. The model constitution, non-executives, multiple committees (etc. etc.) all contrived to create organisations too unwieldy to make any real change happen, to diminish trust between the organisation and its member practices, and to sap any sense of organisational pride or identity.

Last week we published our four step guide for practices working at scale. The real point of this was to encourage practices wanting to work at scale to think about why they wanted to work together and what they wanted to do before getting bogged down in questions of governance.

Don’t get me wrong, governance is important. But it is not more important than having a clear purpose for the at-scale general practice organisation, or more important than working out the guiding principles that will determine how the organisation will operate (its values). It is not more important than building trust between the new at-scale entity and the member practices, or more important than achieving the goals the organisation has set itself. Focussing on these things makes good governance an enabler, rather than governance existing for governance’s sake.

In the days when CCGs were being established, the key cry from practices was that it “did not become like the PCT”. Now the concern from practices about the development of new at-scale general practice entities is that they “don’t become like the CCG”. Yet the pressure “to have good governance” is often forcing some of these newly-emerging organisations down the same route. This is the tyranny of governance.

But things can be different this time. The cycle can be broken. At-scale general practice organisations are not statutory bodies in the same way that CCGs are. They do not have to hold population-based budgets (which will take them down the CCG route), and it is perfectly feasible for them to partner with other organisations (with the required governance) to enable that to happen. They can be whatever the member practices want them to be.

This means there is no ‘right’ model of governance for them. There is no checklist they have to adhere to.   Appropriate governance will depend on exactly what it is they are trying to achieve and do.

New at-scale GP organisations have choices. First they must determine why they exist, then decide what they want to do and the way they want to do it, and finally choose what governance they need to enable them to do the things they want to do in the way they want to do them. Governance in its place is an amazing enabler, but out of place can create a fast track to failure.

Many practices are considering the benefits of working at greater scale. But, from our experience at Ockham, we see so many approaching it from the wrong direction; by considering what form this expansion will take before even reaching agreement on why they are seeking to get bigger. So we have put together a simple and helpful guide on the steps practices should take to help them successfully navigate this journey.

When I was about 5 years old my brother and I became supporters of Liverpool Football Club. No-one told us we had to. Our parents were not football fans. We did not have to sit in a class to learn about Liverpool Football Club, or pass an exam before we could watch them play. No-one forced us to learn the names of all the players, or their shirt numbers, or the endless statistics from the previous decade. We learnt about the club because we were passionate about it which created our energy and enthusiasm to find out as much as we could, whenever we could, and to pester our father constantly to take us to matches.

Whilst not a football fan, my mother was a catholic. So when we were the same age every Sunday she used to make me and my brothers go to church. We never asked to go, and we went because we had to. We didn’t pay attention, got out of going whenever we could, and spent our time when we were there daydreaming about Anfield and whether Liverpool would win when they next played, as well as generally causing trouble. Eventually, we made life so miserable for my mother that she stopped making us go.

Now I am older, things are not much different. I spend my time doing the things I am passionate about and enjoy doing. There are some things I have to do (chores, shopping etc.), but, as my wife will no doubt attest, I do them as quickly as I can (or try and get out of them!) so that I can focus my efforts on the things that matter to me.

My brother is the same. In fact, we all are. We all want to spend time doing the things we want to do and care about, and avoid doing things we are doing because we have to. GPs are no different. Most GPs want to spend their time in the practice, focussing on making a difference to patients and the things that matter, not doing the things they feel they have to do (but hate) like preparing for a CQC inspection, or attending yet another CCG meeting.

For GPs, where does operating at scale fit in to the spectrum, where “doing it because we have to” is at one end, and “doing it because we are passionate about it and the difference it can make” is at the other?

Looking around the country, it varies.

Some GPs are really passionate about operating at scale. They believe it is key to the sustained future of the profession, to ensuring GPs have a strong voice around the system table and to giving them the best chance of making a difference to the lives of their patients. They seemingly work 24 hours a day on making it happen, putting all their spare time into it, and do so with boundless energy.

But many GPs are doing it because they feel they have to. They feel the weight of system pressure pushing them in that direction, and go along with it because even if they recognise there is some logic to it, their heart is in small, independent general practice. Unsurprisingly, they rarely turn up to meetings, they contribute only what they have to, and are often negative and disruptive.

GPs working at scale because they want to, not because they have to, is what will create the energy to make something great happen. It is what already differentiates those really successful examples of working at scale from the rest. Getting the majority of your colleagues to agree to doing something they do not believe in is storing up problems for the future. Jumping into a federation or a network without even knowing why is a mistake, because you won’t invest of yourself in it.

Spend time on why. Spend as much time as it takes to generate energy for a movement, and only then move forward. That investment of time will repay itself multiple times in the future, because it won’t feel like (your equivalent of) going to church, but instead like going to Anfield!

Did you ever have a mullet? Regularly wear flares? Decide tattooing your eyebrows was a good idea? I suspect not (or not that you would admit to!). As we all know, things come in and out of fashion, and sometimes there is a real art to avoiding something popular in the moment that later we might come to regret.

A common question I get asked is whether the move to working at scale in general practice is just a trend. The profession has been burnt before (think PMS contracts, fundholding, even CCGs), and it is reasonable to consider whether operating at scale is just another in a list of initiatives that demand energy and time but leave little or no lasting benefit.

It could be a short term trend. It feels like there is pressure in the system on practices to operate at scale, and yet history suggests that changes practices have made because others want them to (like the move to PMS contracts) are often best ignored, because the fickle nature of health policy is such that there is likely to be an opposite policy (PMS reviews) a few years down the line.

When we look at joint working between practices we find the benefits are not always that great: purchasing gains can be limited; extra services can be time limited or put out to tender with little or no margin included; and the additional overheads of working at scale can quickly absorb any financial gains made leaving little or no benefit for the member practices.

Bigger practices can create bigger problems. Communication can be difficult (poor), practices become impersonal and it can feel like the soul of general practice has been removed. Individual disputes do not disappear, and where they are not tackled divorce can follow quickly on the heels of the marriage.

Working at scale itself has now been around for some time. Average practice size has grown steadily from 6250 in 2005 to 7860 in 2017, and according to the Nuffield Trust three quarters of GP practices are now in some form of collaboration with other practices. Could, then, we be heading in the wrong direction? Could working at scale be just a trend, something we will inevitably later regret?

The best way to determine whether something is likely to be a short term trend or something more permanent is to consider the causal factors affecting the change.

There are, as you are no doubt fully aware, some long term trends impacting general practice. Demand is rising. There are more patients, more GP visits per patient, more over 85s and more patients managing one or more long term conditions. This demand is highly likely to continue to rise. The supply of GPs to meet this demand is going down. In the time period from September 2015 to December 2017, the total number of GPs decreased by 720 full time equivalents, despite the national pledge to increase the number by 5000. Less and less GPs want to work full time, or to be partners.

Funding for general practice has fallen from 11% to under 8% of the NHS budget. The promised extra £2.4bn in the General Practice Forward View is hardly touching the sides. The recently announced 3.4% growth for the NHS means no windfall for general practice is coming any time soon. The national policy is towards integration, and providers working together. A 10 year plan for the NHS is expected this year, built on exactly these principles. 7,435 practices operating independently in this environment are unlikely to be able to articulate their need for resources as well as, for example, the 135 non-specialist acute trusts.

Ultimately, working at scale is a reasonable response to these long term trends impacting general practice. Simply deciding to work at scale will not in itself deliver benefits (for all the reasons outlined earlier), but using the opportunities that scale provides to find new ways of managing demand, to expand the workforce and incorporate new roles, to deliver efficiencies and respond to the opportunities that the new integration agenda presents is one of the few things practices can proactively do to meet the challenges they face.

Working at scale is a trend. But it is a trend that is a response to underlying changes affecting general practice. Sometimes working at scale becomes the change itself (which is where problems set in) rather than understanding that its function is to enable the continued challenges to be met. Because the demand, supply, financial and policy changes are all continuing to move in the same direction, my view is that working at scale won’t go the way of mullets and flares, but will continue long into the future.