One of the best things about my job is I have the opportunity to speak to some of the leading practitioners and thinkers in general practice.  This week was no exception as I was lucky enough to interview Dr Robin Miller, the Deputy Director at the Health Services Management Centre at the University of Birmingham.  Robin has published two really important papers on transformation in general practice recently (you can access both of them for free 10.5334/ijic.3044/">here and 10.1108/JICA-03-2018-0023#_i7">here), and we discussed them for a forthcoming episode of the podcast.

The conversation really challenged some of my thinking.  We all understand the idea of a primary care network being about practices working together around populations of 30-50,000.  Where I had got to previously was that there are almost two options around this.  The focus could be on those practices working together to support core general practice.  The crisis in general practice is, and remains, real, and these networks form an opportunity for practices to find a way through this by introducing new roles, developing shared systems for managing demand, creating back office efficiencies, and introducing new technology.  Granta Medical practice is a fantastic example of using this population size to deliver these benefits.

The second option has more of a focus on the local community formed by the 30-50,000 population, and on making changes to impact health outcomes.  It includes a much stronger focus on prevention, on the wider determinants of health, and on integrating services across health and social care to better meet the needs of the local population.  This approach is beautifully illustrated by Dr Steph Coughlin and her colleagues in City and Hackney.

The first option is more internally-focussed on the practices themselves, working together to support their long term viability.  The second is more externally-focussed on the local communities, and developing the role of general practice to support them.

Back to my conversation with Robin Miller.  He has published a number of lessons about primary care transformation, from research into national and international primary care transformation initiatives.  Two lessons particularly stood out for me.  The first is that “transformation” of general practice requires more than an incremental approach.  It requires a more fundamental redesign based on its purpose and contribution to society.  In the transformation programmes Robin looked at the GP leads had to change how they viewed their role in local health and care systems.  The practices had to move beyond their individual histories and interests and put the interest of people and communities at the centre of their work.

The second lesson is that when practices move beyond their traditional practice boundaries it changes the role of GPs.  The role changes from one defined by the trusted relationship between the GP and the patient to one defined by the GP as contributor to the wider primary care team.  Moving outside a domain where GPs can dictate what happens (as the owners of the business) to one where GPs need to influence each other and other clinicians, individuals and organisations, also requires GPs to find new ways to communicate and interact.  It requires a more facilitative approach.

Back, then, to the role of primary care networks.  It seems there is a more fundamental question than I had previously realised sitting behind them.  Are they a vehicle, an enabler, for primary care transformation?  Or are they this year’s initiative, to be tolerated until the next one comes along?

If it’s the latter then, fine, use them as a way of enabling practices to gain some incremental sustainability benefits by working together.  But if it’s the former (and, given the parlous state of general practice, it does feel like a tremendous opportunity) then it is not the either/or choice I had originally envisaged.  It is a platform to widen the primary care team, shift the role of general practice within the local community, yes make practices sustainable but at the same time make a more fundamental impact on local health outcomes.

As with everything in life, it is not black or white.  In any area there will be GPs wanting the latter, those wanting the former, and a majority in the middle not really engaging with the question.  The leadership challenge is to set a direction locally and to galvanise practices behind it.  This may require an initial focus on incremental benefits to practices to lead them to the wider transformation possibilities.  The journey will inevitably be difficult (change always is), but maybe, just maybe, a primary care network is a vehicle for real transformation of general practice.