The relationship was over.  After a bright beginning things had slowly deteriorated, and now it was time to call it a day.  The problem was we had a house, a car, joint bank account, the works.  We were faced with a choice – get the lawyers in to fight it out, or sit down and work it out ourselves.

Would we have been better sorting out a legal contract at the beginning, so that in the event of this situation arising we would have had a framework to sort it out?

This is the question some practices facing the prospect of entering a Primary Care Network are asking themselves.  Two thirds of the promised new money for general practice is coming via these networks, and that may just be the start.  CCGs and STPs are likely to put nearly all future local enhanced services through these nascent networks.  The fates of each practice within a network will be intertwined.

With this in mind, the temptation is to establish some form of legal contract between the practices.  Yes there is going to be a model network contract, but is it going to be enough?  Networks are going to need every practice to pull their weight.  Would it be better to get them to sign up to both their commitments and, more importantly, the consequences if they don’t meet them?  Won’t that provide better protection for everyone?

Back to the end of the relationship.  We sat down and had the difficult conversation, and agreed who would be having what.  It felt like a better way to sort things out than paying expensive lawyers and asking them to decide.  We would have had to have the conversation anyway, but this way we had it face-to-face rather than through our legal representatives.  I don’t think an upfront legal agreement would have done anything other than breed mistrust from the very beginning and increase the likelihood of legal fees down the line.

If a practice in a network doesn’t pull its weight, doesn’t fulfil its commitments, or doesn’t do what it is supposed to do, all of the practices will lose out.  Stronger legal agreements won’t prevent the need to have the difficult conversation.  Better to focus on the work needed to avoid this situation in the first place.

Three things feel more important than investing in lawyers for practices at this stage:

1. Build positive relationships. Develop enough trust between practices to be able to have the “difficult” conversation without getting the lawyers (or the CCG, or NHS England, or the LMC etc) in.  Time invested in relationships before these conversations are required will repay itself over and over if it means practices in a network can work through their own challenges and issues internally.
2. Appoint the right GP network leader. Brokering these conversations is likely to fall to the appointed GP lead of the network.  Building bridges between the practices may well be the key challenge of these new leadership roles, and be much more difficult than the external facing requirements.  Appointing someone trusted by all of the practices will be key to future success.
3. Get the size of the network right. Smaller may be better.  There has been an initial reluctance in certain quarters to move from pre-existing localities and groups of 70 or 100 or even 150 thousand populations into the new 30-50,000 limits.  There is a sense of safety in numbers in the larger groupings.  But the point of the new size is that it is small enough for everyone to know everyone.  At this size, building trust across everyone is more possible, and the leadership challenge less impossible.

One of the key strengths of general practice has been the family feel of the practices, and the close relationships between staff and with patients.  This is a strength practices should aim to build on as they move into networks, rather than abandoning personal relationships in favour of legal frameworks as a way of reducing risk.  Involving lawyers might feel like it is adding a layer of protection, but the reality is the success of the network will be based on the strength of the relationships, the quality of the leadership, and the ability to have the difficult conversations when they are needed.