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Tuesday 23 July 2019
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General practice at scale: ‘Collaborative working is the way forward’

The latest three letter acronym (TLA) seems to be PCN: primary care network.

Martin Bell, business manager at the Sacriston Surgery in County Durham, on how to successfully move forward with primary care at scale
 
The latest three letter acronym (TLA) seems to be PCN: primary care network. Also known as PCH: primary care home or, locally where I work in County Durham, TAPs: teams around patients. So many TLAs, but what impact will all of this have on us practice managers?
 
There are around 7,300 practices in England, according to data from NHS England. That’s 7,300 autonomous businesses, all doing the same thing. Where I’m based there are seven practices serving a patient population of approximately 56,000 patients, within a five mile radius.
 
That’s seven practice managers, seven sets of non-clinical admin staff answering seven different telephone systems (funded by costly leasing agreements) and seven sets of ‘to come in’ letters sent out to patients using seven different franking machines (another lease to pay for, and that’s before you even factor in the postage).
 
It’s also seven sets of nurses all doing chronic obstructive pulmonary disease (COPD), diabetes, long-acting reversible contraceptives (LARC), and other clinics.
 
There must be more efficient and effective ways to do what we need to do – provide a top class service to our patients – incorporating greater synergy and a focus on economies of scale. The great and the good at the and NHS England and the Department of Health and Social Care certainly seem to think so and, being up front and honest about it, I’m inclined to agree with them.
 
Presently, the main show in town seems to be ‘primary care at scale’, with PCN appearing to be the latest TLA for this strategy. But let’s just ‘gan canny’ (take it easy and carefully) as they say around these parts and make sure we understand what we’re getting ourselves into.
 
Collaborative working is the way forward, of that I am sure. But what’s the logical conclusion of that view? Should the seven practices in the area where I’m based become one?
 
Population-based health advocates assert that a combined list size of at least 30,000-50,000 is a good number for PCNs – allowing them to work collaboratively in an effective way and to make a difference. The proponents might be right, but that’s one heck of a business.
 
The core of our business is people. We manage people who help other people. Sounds simple, but co-ordinating as many as 100 - 150 members of staff across multiple sites in the way necessary to gain the efficiencies needed to make primary care at scale work would require quite a bit of planning, as well as firm execution. Are practices ready for this? Are we practice managers ready for this? And would staff cope with the upheaval?
 
Collaborative working will require us to think and behave differently to what we’re used to. Running a business with 20+ staff and around 10,000 patients is challenging enough, but it will demand a different mind-set to facilitate working across multiple practices, with a bigger pool of staff and more patients to keep happy.
 
What will be the biggest challenges? I think there are two key ones. Firstly, the GP partners. They are the business owners and while they may not always be natural managers (it’s not what they went to medical school for), they are astute people, mindful of the need to run a tight ship – and it’s their livelihood and future income at stake.
 
I believe that GP partners can sense the need for change, but how enthusiastic are they about changing their business model? They need to be walked through what can be a challenging and complex journey in such a way and at such a pace that it does not destabilise their business ownership.
 
The second major challenge will be the staff. Nursing teams and non-clinical employees, such as admin staff, are the heart of the business. They are professional and competent people focused on the patients’ best interests and they know what’s going on in the community. They are rightly precious, in the positive sense of the word, about the patients and what they can do for them.
 
So if we are to ask them to look at what they do, to critically appraise the way they have worked for years, seek more efficient and effective ways to do the job and embrace new tasks and technologies, we practice managers need to ensure we’re nurturing and supporting them through that process.
 
It might, in one way, be easier to sit tight on any change and wait until this current NHS storm blows over. But when I hear colleagues who have been practice managers for more than 20 years say that they’ve never known such challenging times within general practice and have never experienced organisational upheaval on such a scale, it makes a relative newbie who have ‘only’ been in the job for 10 years, sit up and think – will this storm actually blow over?
 
As managers we need to lead others towards primary care at scale, and do so wisely. We need to stay connected to one another and to developments at local and regional level (good relationships with the right people in your CCG, NHS England locally and the local foundation trust are paramount) and seek development and support for ourselves wherever we can.
 
Martin Bell is business manager at the Sacriston Surgery in County Durham