One of the areas that initially feels quite straightforward but turns out to be relatively complex is representation.  How general practice is represented in system meetings and system discussions, and how this is done effectively, is an area that insufficient thought is given to, and as a result is an area in which general practice is currently faring badly in most areas.

It seems easy.  A GP representative is needed for a meeting and someone needs to go.  In the end someone volunteers/is volunteered and job done, general practice is being represented.

But who is this GP representing?  Themselves? Their practice? Their PCN? The whole of local general practice?  If they agree something in the meeting does that mean that the whole of local general practice also agrees to it.  Probably not.  So that means they are not representing local general practice.  Instead they are most likely giving a view.  Which means that general practice is not actually being represented at the meeting.

The complexity comes because as a disperse group of practices, PCNs and general practice organisations we are generally not clear that anyone can represent us if we are not there ourselves.  Indeed sometimes we feel the need to attend simply because a colleague is attending and we either don’t agree with their views or are concerned that they will use their attendance to exploit the best opportunities for themselves or their practice/PCN.  Even if we agree someone can represent us we rarely agree what it is they can or cannot sign up to, or what outcome we want them to achieve.

The starting point for this process is establishing a single leadership group for local general practice (which I have written about here).  I have also written about establishing priorities for general practice, which will help any representative understand what they may want to achieve.  But the leadership group need to be clear how representation will work in practice.

The first question is who will do the representation.  The choice tends to be between whether one or two key individuals carry out most of the representation on behalf of general practice (like the Chief Executive or Medical Director of the acute trust would), or whether it is shared out amongst multiple colleagues so that the burden of meeting attendance is distributed and more manageable.

My preference is for the former option.  The reality is that much of the system decision making happens not at the meetings themselves, but as a result of the relationships between those at the meetings.  If a small number of individuals are cultivating these relationships on behalf of general practice the influence is likely to be much greater than if a different GP is attending each meeting.  It also means there will be a consistency to the views given by general practice, and different GP representatives cannot be played off against each other, unaware of what their colleagues have said in other meetings.

Available time is the enemy.  In some places a senior manager (such as a federation Chief Executive) is used to carry out this representation as they have the time and skills to be effective in this role.  Where a dispersed model is used then there needs to be one or two leads with overall responsibility for representation who can both brief and receive feedback from the representatives so that all of the system information and dynamics are held in one place.

The second question is what process will be put in place for representation.  The first instinct here tends to be to create a very prescribed framework where what people can or cannot agree is explicit, with clear guidelines on what must be brought back to the wider group for sign off.  The problem is that it emasculates the representative in the meeting as they are not able to agree what others in the meeting can.  The real world is also unpredictable, and so what actually happens rarely matches any predetermined framework.

The process has to be built on trust.  The group has to trust their representative that they will have the skills and experience to agree/not agree to the right things and to bring the right things back for wider discussion.  What is helpful to put in place is a regular review process so that the wider leadership group can feedback to the representative(s) what is working or what is not (e.g. where they may have overstepped the line and agreed something they should not have, or where the feedback could have been more detailed) so that representation develops and becomes more effective over time.

There are two areas where GP representatives generally fall down.  The first is communication back as to what is due to be discussed in a meeting, what has happened in the meetings and what has been agreed (most often due to lack of time).  A process for ensuring this communication takes place needs to be agreed and put in place.  If not, the lack of communication leads to an erosion of trust, and the whole representation process can collapse.

The second area is that of action.  In many of these meetings actions are required as a result of whatever has been agreed.  GP representatives often do not ensure these actions are carried out (again generally because of a lack of time), which in turn means general practice can lose its influence and any gains achieved during the meeting.  Key here is putting some management or administration support alongside the representative(s) to ensure that any actions are carried out.

Getting representation right is not easy.  An early challenge for GP leadership groups is working through how this will happen, and then refining this process over time so that it builds and strengthens the influence general practice is having on the system.