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Inside every GP: Working at scale in primary care – a PM’s view of the process

by in Opinion

The picture of general practice in the UK is a mixed one, depending on so many varying factors.

If your practice is, for example, a large rural dispensing one, in an affluent area, fully staffed with a strong partnership, large list size and a sizeable building that doesn’t have a lot of outstanding finance left on it, you might be forgiven for thinking, “Thanks, but we are OK, there’s no need to panic”. The GP community has a wholly deserved reputation (most would agree) of an ostrich like resistance to change and unless core interests are blatantly under threat, it takes a lot to get many GPs to look outside of their surgery walls.

If, on the other hand, you work in a depressed area, be it rural or urban, are constantly understaffed and cannot recruit, don’t get home until 10pm every night, have major worries about who will succeed you and take over your large building investment, and have no headspace whatsoever to innovate, then you are probably wishing fervently for some kind of cavalry galloping to the rescue from over the horizon.

Whilst some of the threats that we in primary care feared greatly have not come to pass, including incursions by the private sector (it’s not profitable enough), wholesale privatisation of LESs and DESs, some others, such as geometric workload increases combined with arithmetic funding increases, recruitment issues and rocketing media fuelled public expectation are getting inexorably and crushingly worse whilst the spectre of an unforgiving and remorseless CQC inspection is enough to have most of us wishing we were somewhere else.

And in some areas, according to Pulse magazine’s “Postcard from the Edge” it is clear that the domino effect really is taking place and primary care is in real danger. Plymouth, parts of Northern Ireland and Wales, Essex and Cumbria, not to mention East Kilbride, are all facing big problems. Around one third of a million patients in the past five years have had to look for a new surgery due to closures.

Assuming you are not in one of the unfortunate areas listed above, it is likely that your surgery continues to provide a good service in the face of all the challenges. However, it’s more than likely you’re wondering how much longer it can continue to do so. You’re probably one of the 81% of practices that are now members of some kind of collaboration (of whom only about one in ten feels that their sustainability has improved as a result) and wondering if you can make it all work.

Collaboration comes in many forms

Collaboration, of course, means many different things: networks and clustering (formal or informal), federations, practice mergers, large salaried practice models (Hurley Group), so called ‘vertical integration’ i.e. your local hospital takes you over-see Wolverhampton and, finally, ‘super partnerships’ such as Lakeside, Vitality, Our Health, Modality and Suffolk Primary Care.

A crude generalisation is that all of the above are trying to preserve the uniqueness of British General Practice and the personalised, caring human service that we all try to offer whilst at the same time protecting it from predation and threats. That’s quite a balancing act to achieve.

Any PM who has, over the years, pinched themselves to stay awake through endless lengthy, boring and ultimately futile meetings, whilst a room full of GPs takes hours to come to the conclusion there is nothing to tempt them to stray from the path of the status quo (other than agreeing a different format for the minutes), might have noticed a sea change in collective GP attitudes. This has been forced upon them, perhaps by the unmistakeable reality of the multitude looming threats to Primary Care.

A story of success

While change may have been forced upon practices, the current precarious situation in primary care means that the various changes need to work. That’s why I would like to share a few of the factors that I feel have mitigated for success in our own particular locality, which is a mixture of rural and urban general practice in England.

The number one factor on the list, that has driven change above all else, is a facilitating organisation, which has the power and resources to make things happen and drive change. One that is light on its feet, able to change course quickly and unerringly on the money when it comes to making the right choices in supporting General Practice.

Our local federation, formed in 2013, has grown from niche player to entirely self-funded provider organisation and has membership of the vast majority of practices in our locality. Along the way it has supported and facilitated practices in the hard discussions needed to make things happen. Two groups of practice managers have undergone specialist training in change management, underpinned by some really effective communication and active listening techniques

An identical ethos and culture of communication has also taken root in the GP population. A genuine spirit of cooperation and willingness to give and take in the interests of the greater good has been discernible. The difference? Meetings where radical, best interest decisions are able to be taken in an atmosphere of co-operation and change, aided and abetted by the thoughtful and insightful facilitation of https://www.judyoliverandco.com/ (worthy of recommendation).

This eventually resulted in the genesis of a single partnership organisation covering over 100k patients where huge progress has been made on joint issues such as a common approach to the management of Long Term Conditions (LTC), one single IG Toolkit application for all involved practices, one insurance policy for all (locums, buildings), shared payroll and accounting provision and a common approach to filing of results, notes summarisation and workflow management.

At a geographically local level there has been a mushrooming of collaborative activities between practices that could not have been dreamed of under Practice Based Commissioning. These include:

  • Shared on the day triaging of patients between multiple practices
  • shared paramedic home visiting services
  • shared primary care mental health triage
  • shared first call physiotherapy
  • shared practice pharmacy initiatives

The above are all examples of concrete achievements that would have been unthinkable even a few short years ago.

Evolution of PM roles and responsibilities

As a PM I haven’t had to try and think up clever proposals to capture some of that £x’s per patient funding being dangled as a carrot by our CCG or NHS England to pump prime change. That’s simply because, in our single partnership, we now have a track record of success in making these kinds of bids and our expertise is growing at every stage. Of course, if I want to be involved I can be, and we have within our single partnership the kind of groups and committees that have time to devote to this type of thinking. The key to this is a sense that PMs will have to move from the “Jack of All Trades, Master of None” role towards a more specialised skills-based approach centred upon the needs of a wider organisation and having the opportunity to do things that they feel good at and enjoy.

We also have a realistic business plan, and some clearly agreed strategic objectives all formulated with varying degrees of adherence to the ‘Gold Standard’ of planning for change that we discovered in our facilitated organisational development meetings. Not perfect, still flawed, sometimes exasperating and overcomplicated, but better than before and the direction of travel is clear.

Is this working and will it continue to do so? For me personally and some of my colleagues I have reached the point where locality PM meetings have now been replaced by PM meetings aligned to our single partnership organisation. PM meetings always left me feeling overwhelmed as I always came away with a plethora of sometimes futile things to do and deadlines generated by other individuals and organisations. But the sense of change in the air is here to stay and things are improving because the list of demands and the pace of change is slightly more organised and thought out.

After many years as a PM there is a glimmer of hope for me that, as part of a larger cohesive single entity, we are now more in a position to face down threats from a position of relative strength.

Oh and the title? It’s my first axiom of general practice: “Inside every GP there is a grown-up person struggling to get out”.

By @virverax (Forum Legend!)


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6 Responses to “Inside every GP: Working at scale in primary care – a PM’s view of the process”
  1. Avatar
    Paul Tayler Says:

    Very interesting Virverax and in the main encouraging!

    What’s the source for your statement (which does ring true) that “Only about one in ten feels that their sustainability has improved as a result” of collaboration?

    I have direct experience of trying to support collaboration in other parts of the NHS (mainly commissioning in previous roles). I would say that “The Centre” systematically underestimates both the effort and elapsed time required for successful collaboration. Sounds as if you have been on it now for 5+ years – is that right?


    • Avatar
      Virverax Says:

      I’m pretty sure it was a Pulse article called “Postcards from the Edge” but I may be wrong if I can find my research notes I will update as I actually wrote this a few months ago. Thanks for the comment!


  2. Avatar
    Sue Says:

    With coffee in hand I am reading through the Long Term Plan and GP contract documents. It got me thinking about how we will look at PCN’s – we already network to some extent. Your article is very timely.

    The concerns are around budgets/how our income might be affected if/when DES monies are included in the PCN remit, who will be brave enough/knowledgeable enough to manage this. As I am coming to the end of my career – are there opportunities to use the skills I have in a different way?…. Exciting times and of course change is scary. Something needs to shift though – I hope we can all grasp the horns and manage the charging bull..


    • Avatar
      Virverax Says:

      Thanks Sue. I feel the willingness to change has never been greater so now is a good time. Be careful not to say “yes” too much as it’s still the PMs who end up stressed with all the additional work. PMs need to ensure they are clear on terms of engagement with all of this.


  3. Avatar
    Christine PM Says:

    Thanks – great post. I am feeling positive and energised by the new GP Contract. Positive that it covers a 5 year period, this will aid planning and investment. By working together, the value and effectiveness of our (as tax payers) money will have a greater opportunity to be optimised. Will be interesting to see how CCGs respond to and work with PCNs. PCNs must, in my opinion, be allowed to “do things differently” without immense unnecessary bureaucracy.


  4. Avatar
    Virverax Says:

    Thanks Christine. As above and the new contract is reasonably encouraging so now is a good time.


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