A key part of making neighbourhoods work is building relationships with the local provider organisations.  But in many places general practice has struggled to be able to develop any sort of meaningful relationship with the local acute trust.  How can this change now?

In a past life I worked in acute trusts, and at one point was a Director on the Board of a hospital Trust.  This was before I had worked much with general practice.  Looking back, a number of things stand out about how the hospital perceived general practice.

The most noticeable was that there was no understanding within the Trust as to how general practice worked.  Very few people within an acute trust, particularly on the management side, have any sort of experience of working in a general practice environment.  The language of general practice (DES, LES, GMS, PMS, QOF, PCNs etc etc) is daunting and off-putting, and makes the service feel impenetrably complicated.

General practice is also perceived as very difficult to do business with.  When working in an acute trust it feels very hard to identify individuals who can make agreements on behalf of general practice.  Those particularly long in the tooth will remember GP fundholding and how hospitals had to agree contracts with each fundholder individually, and that sense of not being able to pin general practice collectively down to an agreement still remains.

At the same time, general practice can feel that hospitals themselves are distant, focussed only on themselves, and uninterested in general practice and the community.  There is a hostile undercurrent of frustration from GPs with the perceived shifting of (unfunded) work onto their laps.  Any primary to secondary care initiative feels designed to create yet more work for practices (shared care, advice and guidance, referral management etc etc), and so even the incentive for a stronger relationship is not always obvious.

But now the advent of neighbourhoods and the prospect of multi neighbourhood provider contracts has created an urgency for developing this relationship that has maybe been missing in recent years.  But moving forward is not straightforward, so where should we begin?

The best place to start is to identify the person or people within the hospital who are the easiest to do business with.  I remember on my executive team there was a range of individuals, and some were definitely harder to do business with than others.  Not all had the same attitude towards general practice.  Generalisms about the ‘acute trust attitude’ towards general practice are not helpful because different individuals will have different attitudes. The trick is to find those most open to working with general practice, and let them be the ones who work to persuade their less amenable colleagues.

But how do you find them?  Asking senior ICB colleagues is a good place to start.  They will be able to recommend the best people to contact.  You don’t want anyone too junior (because their influence within the acute trust will be too limited). This is the perennial problem with identified “general practice liaison leads” – you can invest time with them, but it can often lead to no tangible changes because they have insufficient clout within their own organisation.

The ideal place to get to is a small group of management and clinical leads from both sides (4-6 people) who can oversee any joint working, and where each side has enough influence to troubleshoot any issues that arise.  Of course this also requires general practice to have established its own way of working collectively so that it can participate effectively in this kind of arrangement.  Otherwise the general practice leaders can end up feeling very exposed!

A priority for this group is to establish a rationale for joint working that both can sign up to.  There will inevitably be a fear from some GPs that the acute trust may want to take over general practice, and so this needs to be explicitly taken off the table.  Recently from the GP side this work has been around reducing the pushing of unnecessary workload from secondary to primary care, and from the acute side about improving the appropriateness of referrals.  With the advent of neighbourhoods this can be expanded to how joint working can enable neighbourhoods to be effective, and of course joint preparations for the multi neighbourhood provider contract when it arrives.

Ultimately, the relationship between general practice and the acute trust will come down to personal, individual relationships.  The mistake that is often made is trying to use big set piece meetings with multiple attendees to develop the relationship.  These are fine, but can only work if they sit on top of some individual relationships. Getting these in place is the most important place to start.