13
dec
0
Here and there

What got general practice here won’t get general practice there

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There’s a tricky issue at the heart of the general practice crisis. Ostensibly, those working in general practice need to do things differently. It’s tricky because if I accept I need to do something differently, it means I am taking responsibility for the difficulties I am facing, even though the situation is not my fault.

To try and pick a way through this, I am going to lean heavily on a book by Marshall Goldsmith, “What got you here won’t get you there: How successful people become even more successful” (2008). I found this a really helpful book when I was a newly appointed CCG accountable officer. Previously, as a middle manager and running a small organisation, I had always been successful by being very task focussed, by making things happen, and by delivering results. What soon became clear was that this style of managing was not effective when I was the leader of a larger organisation.

It turns out what I needed to do was spend less time trying to force things to happen, and more time communicating what the organisation was about and where it was going, and listening and talking with those who worked in and with the organisation. I needed to be visible, and trust the managers working in the organisation to make things happen, whilst I focussed on making sure the direction and priorities were clear and understood by all.

It might sound obvious, but it was a very difficult personal transition. As Marshall Goldsmith explains, it was difficult because of my personal beliefs. He describes it like this, “One of the greatest mistakes of successful people is the assumption, “I behave this way, and I achieve results. Therefore, I must be achieving results because I behave this way.”

It was hard to change the way I behaved because it had always worked for me in the past. But the world around me had changed, and to be successful I needed to do things differently. The difficult bit was really believing that it was me that needed to change, rather than falling into victim mode and blaming the people and organisations around me. Marshall Goldsmith puts it like this,

“Many people enjoy living in the past, especially if going back there lets them blame someone else for anything that’s gone wrong in their lives. That’s when clinging to the past becomes an interpersonal problem… When we make excuses, we are blaming someone or something beyond our control as the reason for our failure. Anyone but ourselves.” 

I remember the point at which I realised it was me that needed to change. We had been a really successful practice based commissioning group, but had struggled in the transition to becoming a CCG. It was easy to dwell on the successes of the past, and blame the challenges we were facing on others. But ultimately that wasn’t going to help. For me it was facing the feedback from our CCG authorisation process (remember that?) – it was as if that was the event I needed, to get me to understand I had to do things differently to change the situation. Back to Marshall Goldsmith,

“There’s nothing wrong with understanding. Understanding the past is perfectly admissible if your issue is accepting the past. But if your issue is changing the future, understanding will not take you there. My experience tells me that the only effective approach is looking people in the eye and saying, “If you want to change, do this.”

Focussing on my own past successes, and how events had conspired against us, was not helping me. In fact, it was holding me back. Which brings me to general practice. Practices are in a difficult position. It is not their fault. But they are the ones in the difficult position. Getting out of this position requires different behaviours to those that were successful in the past.

This is the kind of thing that is easy to say (or blog about!), but hard to act upon. It only becomes possible when an individual really believes things need to change, because without that conviction people take half-hearted steps (or none), or do the same as they have always done, which won’t lead anywhere productive. I don’t know what the equivalent of my ‘authorisation-moment’ will be for individual GP partners, or practice managers, or federation leaders, but the truth of it is that for their situation to change, they are the ones who will need to change. Not to satisfy others, but for themselves.

The environment general practice now finds itself in requires collaboration (with other practices, NHS organisations, the voluntary sector, social care), a willingness to explore new ways of working, and an openness to letting others do what for many years has been the sole domain of GPs. The changes themselves are not that difficult, but personally getting to the point where you are prepared to make them, and adopting the new behaviours that are needed, is.

If we could apply Marshall Goldsmith’s work to general practice directly, perhaps it would read: “What got general practice here won’t get general practice there: How successful practices become even more successful”. Or “What got GP federations here won’t get GP federations there: How successful federations become even more successful”.

The world has changed for general practice, and, like it or not, it is GPs and those working in general practice that will need to change if general practice is to thrive into the future.

6
dec
0
Accountable Care Clinical Commissioning Part 2

Becoming a butterfly…Part Two

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General Practice and the Transition from Clinical Commissioning to Accountable Care –2

Last time (here) I explored the negative impact that dual running the existing commissioning system and the future accountable care system was having both on general practice, and on the success of the new accountable care models themselves. We want GPs to focus on engaging with accountable care, to ensure general practice and the registered list is central to it. But the commissioning system hasn’t stopped, and we still want GPs leading and actively participating in the commissioning system.

By creating an artificial split between general practice as providers through federations and general practice as commissioners through CCG localities we are making it difficult for core general practice to be involved in the new models (How are practices represented? Do federations have a mandate to speak for practices? etc.), wasting valuable general practice time, and unnecessarily limiting the GP leadership capacity available to the new system.

If the heart of the transition is moving where the energy for redesign sits, how might we shift it from the GPs sitting in their commissioning role, to the GPs sitting in their provider role (rather than simply asking two different groups of GPs to do both)?

Could we transfer the responsibility for redesigning services from CCGs to groups of providers now? In practical terms, could we cope now without GPs carrying out their commissioning role, and ask them to take on the redesign role as providers, working with local partners? Could we transfer the resource we spend on our CCG locality structures to the GP federations (and what is the real return on the investment of that money anyway?), against a set of outcomes and outputs that we want in return? Wouldn’t that, in fact, be modelling the future?

Immediately I can feel the unease growing around the dreaded conflicts of interest. How can we give GPs the responsibility to design something they will potentially benefit from as providers? It has been the bane of CCGs in recent years, and this could feel like a step backwards.

But isn’t is true that within an accountable care model of providers working together within a fixed envelope of money, some of those providers sat round the table will end up providing more, and some will end providing less? The prevailing wisdom suggests the likely shift is from secondary care into primary care (a shift the purchaser/provider system singularly failed to enact). The logic of the new system is that, for the new system to be successful, exactly what we fear from a conflict of interest perspective (general practice designing services that shift resources into primary care) is what is needed for the new system to succeed.

If we place the redesign resource for a system into a provider partnership that the GP practices are part (maybe a major part) of, then all we are doing is modelling the future. We have to unlock the creativity of front line clinicians working together to improve the lives of the populations they serve. We can’t do that if we bind them in bureaucracy.

Attempts to develop a contractual approach to overcome the potential conflicts issue (the dreaded ACO contract) has already proven unwieldy and time consuming, focussing energy on form and governance structures and away from the key challenge of making change. In our transition plans from the old system to the new we need to find a way of shifting the energy for redesign as early as possible to make it central to the new way of working.

We are wasting valuable GP resource in dual running a system we are winding down alongside the new system we are trying to put in place. We need to accelerate the shift from the old to the new. The longer we wait, the harder it will be to engage general practice in the new model, and the more disenchanted they will be with the old model as it is dismantled around them. If we don’t do this now, then when?

29
nov
0
Accountable Care Clinical Commissioning Part 1

Becoming a butterfly…Part One

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General Practice and the Transition from Clinical Commissioning to Accountable Care – 1

The NHS is faced with something of a conundrum at present. We have the system of commissioners and providers as laid out in the legislation and statutory architecture, and the system of providers working together as laid out in the Five Year Forward View and STPs. The two are fundamentally different. The conundrum is how to manage the transition from one to another, without any legislation or mandated transition plan.

General practice sits at the very heart of this transition. The new models of care are based on the registered lists of GP practices, yet all the while it remains mandatory for these practices to be part of a CCG. We want GPs to (eventually, at a time yet undetermined) stop doing “commissioning”, and (immediately) to start doing “accountable care”. Unsurprisingly, the early lessons are that general practice needs to be involved in accountable care from the outset.

The transition has of course already started. STP leaders and teams are growing in number and power, and we are starting to see reductions in the number of CCGs and also in the number of CCG Accountable Officers, as CCGs increasingly share management teams. The overall system leaders are no longer exclusively commissioners, and they are grappling with how to make the transition from the existing system to the new one a reality.

At the heart of this transition is the shift of where what I would call the “energy for redesign” comes from. In a commissioner/provider split, the commissioner designs the pathways and ways of working and contracts each provider to deliver their part. Within an accountable care model, the providers work together to redesign the pathways and the interfaces between organisations and clinicians. For me, it is this shift of the energy for redesign from commissioners to providers that is critical to the success of the new system.

If we go back to why we wanted GPs involved in commissioning in the first place, it was because of their unique perspective on the wider healthcare system and how it impacted on their patients, and their ability to use this to drive change for their registered list. Is it any different with accountable care? I don’t think so. We are simply trying to harness the same insights, knowledge and experience within a different system. In truth, we are doing it because the commissioning system has not worked as the driver for the change that the NHS needs.

How, then, do we make this transfer of the energy for redesign from commissioners to providers a reality? How do we empower GPs to start to make the changes we wanted them to make in commissioning, but not through contracts but by building relationships with other providers?

Most places are encouraging the development of federations, or other at-scale general practice vehicles. These are then seen as the GP “providers”, and the sub-structures of commissioning groups, often called localities, are seen as the GP “commissioners”. We then try and talk accountable care and the future with the federations, and commissioning and business-as-usual with the localities. But this has three fundamental problems. First, we are halving the already limited GP capacity available by splitting it between the two. Second, engaging GP federations rather than practices and practice representatives in emerging models of accountable care (unintentionally) limits the general practice input to those activities the federation undertakes and often excludes core general practice. And third, the GPs who have built experience of working in partnership through their CCG work are left in the commissioning camp when they are desperately needed in the accountable care camp.

Dual running general practice as both commissioners and providers suits the system because of the complexity of the current situation, but we are not serving an already overstretched general practice well, and we are diluting the potential impact of the new system right from its very inception. Next time I will explore whether within the transition we can empower general practice to make a fuller shift to the new system earlier, without resorting to the bureaucracy and upheaval of the proposed ACO contract.

 

22
nov
0
Joining A Federation

Seven good (and seven bad) reasons to join a federation

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Joining federations is currently de rigueur in general practice. But is it right for everybody? For federation leaders, is it important that practices join for the right reason, or is it more important that as many practices as possible join? And for a system trying to push for general practice at-scale, does the underlying motivation of practices to work together matter, or should we be pursuing the goal of scale regardless?

As someone who has led a federation in the past, and now works with practices and federations up and down the country, my view is there are good and bad reasons for practices to join a federation. When federations form with practices joining for “good” reasons, federations can fly quickly. Initiatives can get off the ground rapidly, a powerful voice for general practice can be formed, and partners can find the group easy to do business with.

Conversely, when practices have joined a federation for the “bad” reasons, progress can be painfully slow. The group can be beset by internal arguments and in-fighting from the start. Gaining practice agreement for any, even minor, initiative can be extremely challenging and the leaders are often disconnected from their members; unable to speak with any real authority for them.

Here are my seven “good” and “bad” reasons to join a federation:

15
nov
0
Get Involved

How to get GPs involved in accountable care?

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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 1st 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.

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