It is one of the perennial challenges of NHS management – how do we engage the GPs? I remember when I was an NHS management trainee, in the days when GP fundholding was imminent but had not yet arrived. There was a look of fear in the hospital contract manager’s eyes, as he grappled with the prospect of engaging GPs, with no real clue of how to do it. Some STP meetings feel similar. We want GPs to be central to the whole process, but (ahem) as we look around the table, there are none to be seen.

It works the other way. GPs have previously been duped into participating in a whole raft of system initiatives, largely against their better judgement. Generally, if it works for them (e.g. fundholding) it gets taken away, or if it gives them any real power (e.g. CCGs) the power gets taken away, or if it has the promise of power (e.g. practice based commissioning) it turns out to be an illusion and built on sand.

Which leaves GPs facing the prospect of accountable care systems with an understandable lack of relish. Promises and reality have been so different over the years that scepticism seems like a reasonable starting point.

So how do you get GPs engaged? Professor Kotter, Harvard professor and one of the leading current thinkers on change, is clear the first (and most important) step is to create a sense of urgency. What he talks about is creating a clear reason, a rationale, for getting involved in the change, and why action is needed now. If you haven’t read his “penguin” book, Our Iceberg is Melting, I would highly recommend it.

There are potentially three ways to create a sense of urgency for GPs related to accountable care. The first is the current crisis engulfing GPs. Accountable care, and partnerships with other organisations, represent a potential way out for GP partners who no longer want to continue with the daily struggle of trying to keep up with ever increasing demand without the staff or resources to realistically cope. Certainly this has been one of the drivers in some of the vanguard areas.

In my closeted management world, a distinction is drawn between “towards goals” and “away-from goals”. Towards goals are ones like winning a medal at the Olympics, where individuals have a very clear picture of what they are trying to achieve and they use this picture to motivate everything they do in pursuit of that goal. Away-from goals are ones like wanting to change job because you hate your boss, where individuals don’t necessarily want the job they are going to, they just don’t want to remain in the situation they are currently in. You know where I am going with this. Towards goals work well, away-from goals do not (you end up in a different job that you hate equally), and using the crisis in general practice to motivate GPs to engage in accountable care is an away-from goal.

The second way is to draw out how the NHS world is changing, and how involvement in accountable care is the only real way for GPs to shape the environment they will operate in in the future. The voice of GPs through CCGs is getting lost as commissioners merge and align with STP areas. Despite assurances about where the core GP contract sits, the reality is accountable care includes all of what general practice does (not just the extra services the local federation provides), and the changes will include to a greater or lesser extent some aspects of how GPs are reimbursed.

This is a tough sell, largely because the default GP strategy of head down and wait for the wind to blow over has by-and-large worked for the last 70 years. Why will it be any different this time? Worse, there is no legislation to fall back on. At least with CCGs you could point to the Health and Social Care Act and the 1^st April 2013 for CCGs taking on real responsibility. No such luck this time. But on the plus side, the threat of acute hospitals controlling primary care expenditure will corral many GPs into action.

The third way is to attempt what I describe as the Martin Luther King approach (“I have a dream…” etc.). In the true spirit of “towards goals”, we could start with an inspiring vision of what accountable care can do for our communities. What if we asked our local community what they really wanted from their health system, and what if we could work with our local partners to make their vision a reality. What if consultants, GPs, social workers and the voluntary sector could really work together to change the experience of diabetes or asthma or frailty (or all of them) in our area. Starting with the difference individuals wanted to make when they chose to become a GP and tapping into that may ultimately be both the hardest and most productive route to follow.

In the end, the contracts manager did what these days we often fail to do: he went out to all the practices, listened to what they had to say, built a relationship with them, and the hospital survived fundholding. There are no shortcuts for this. If we want to engage GPs in accountable care, whatever arguments or approach we want to take, we have to get out to the practices and talk to GPs about it.

The Nuffield Trust have published a new report[1] on how collaboration between GP practices has developed over the last 2 years. It is based on a survey of 565 GPs and practice based staff, and 51 CCG chairs and accountable officers. It makes for fascinating reading. But what can we learn from it?

The first point is the findings have been skewed slightly by the availability of funding for extended access to general practice, including recurrent funding from this year onwards. As a result, over half of collaborations made improving access one of their priorities, and it was also the highest ranked potential benefit. The access funding has not been available to individual practices, and even if it was few were keen to take it up. Consequently, it has ended up almost as a system lever to provoke more joint working between practices. The concern is that its success in that regard may lead to similar types of “incentives” in the future.

But that aside there is much to consider. I have two hypotheses about federations. The first is that the current crisis in general practice is driving collaboration between practices to support delivery at practice level. In the past, federations were primarily about transferring services to the community, but I would suggest this has changed to a focus on practice-sustainability over recent years.

Does this hypothesis stack up in light of these survey results? It would seem so. 67% of respondents identified improving the financial and organisational stability of practices as a potential benefit of collaboration, higher than the 53% who identified the transfer of services into the community.

But interestingly only 46% of respondents reported their collaboration had identified improving the financial and organisational stability of practices as a priority in 2016/17 (the exact same percentage who identified transferring services into the community).

Why might this be? If GPs and practices are joining federations to improve the stability of their own practice, why is there this discrepancy in the number of federations who then prioritise it? Other survey responses provide clues. Smaller collaborations, covering less than 100,000 population, were much more likely (47%) to have it as a priority than larger collaborations of 100,000 population plus (37%). And collaborations formed more than two years ago were more able to fully or partially achieve the aim of improving practice sustainability.

It is because the ability to improve practice sustainability requires trust. It requires practices to trust the federation enough to allow them to take control of parts of the business that have historically always been within their control, right through from ordering supplies to employing staff and managing their visits. Smaller groups of practices, and practices that have been working together for a longer period, are more likely to trust each other (because they know each other), and as a result encourage and enable the federation to take steps that might benefit them, even if it means ceding bits of control.

If federations really are going to make a difference to member practices then this journey of building trust is one they and their practices will need to go on together.

My second hypothesis is that federations are needed to ensure GP practices as providers have a voice in the emerging new models of care. Well at present, it would seem, GPs don’t agree, with less than 9% of respondents identifying it as a potential benefit of a collaboration, and an even lower percentage reporting it as one of their collaboration’s 2016/2017 priorities.

At the same time over half of GPs responded that general practice had been not at all influential in shaping their local Sustainability and Transformation Plan (STP).

Maybe GPs don’t see it as the federation’s role to represent them in discussions about new models of care. But if it is not the role of the federation, whose role is it? The GPs in the CCG have to go to great lengths not to be seen to be favouring practices over other providers in their role as local commissioners, so it can’t be them. LMCs are the only other option, and other providers do not see LMCs as a fellow-provider they can collaborate with in an accountable care set up. Like it or not, it has to be the federation.

In summary we have learned that clear financial drivers like the access funding can successfully drive collaborative working across practices. Practices want collaborative working to help them with the challenges they are facing, but the reality of making that happen is proving difficult. It relies on trust, which is a hard won and easily lost currency. And finally the need for practice leadership within the accountable care arena by federations is one that has not yet been fully recognised.

[1] Kumpunen, S. Curry, N. Farnworth, M. Rosen, R. (2017) “Collaboration in general practice: Surveys of GP practice and clinical commissioning groups” Nuffield Trust, Royal College of General Practitioners survey www.nuffieldtrust.org.uk/research/collaboration-in-general-practice-surveys-of-gp-practice-and-clinical-commissioning-groups