Management Adviser, Trainer
As well as being a management consultant and facilitator in general practice, Patricia is also a Fellow of the Chartered Institute of Personnel and Development, and was a practice manager/partner for 11 years. Patricia runs a workshop for practice managers called "The Trouble with Partners", which explores the issues discussed in this article
Take one very bright young person with dreams of making a difference. Send him to medical school where the going is tough. Then allocate him to a hospital to be terrorised and humiliated by consultants. Then train him to become a primary care practitioner with the emphasis on making autonomous decisions and working independently.
The result? A GP, of course. But, when you think about it, also perhaps someone who has been moulded outside the concept of teamwork.
Things might be changing though. Training for GPs now recognises the need to develop self-reliance while not ignoring reliance on others. The recommendations from the Shipman disaster have identified the risks of isolation and the importance of working in teams.
The latest crop of GPs seem more onboard with teamwork, but the partnerships they join are full of a motley selection of colleagues, some of whom have perfected the art of having their way and have no intention of changing.
It's not all gloom and doom of course. But I am sure many practice managers will agree that one of the biggest challenges they face is working with the partnership team and what, if anything, the practice manager can do to help it function better. Here are a few of the problems that can occur.
Our "young GP" may find himself in a partnership where you have to do time before being allowed to have an opinion (we are talking years, not months), and woe is he who challenges a predetermined course of action or decision, usually made by a clique of long-timers.
The young GP may feel this is unfair but is hampered by lack of experience. He will be overwhelmed by examples of how this or that has been tried in the past but didn't work then so won't work now. He will soon learn that it is easier to put his head down, see the patients and go along with the "groupthink".
Then there is the "tyrant partner" – in the worse-case scenario a senior partner – who strops around with temper tantrums if he doesn't get his own way. If "supernanny" had her way, she would have him sit on the stairs until he learned to behave more reasonably. But instead, his partners have learned that giving in to his demands is more palatable than the potential bullying that comes from defiance.
Then there is the "know-it-all partner", who makes it his business to stick his nose into everyone else's business and read copiously on selected areas of interest, in order to baffle fellow partners with his superior knowledge.
This type of partner can be very persuasive to a less experienced group, and even be instrumental in swaying decisions to do things that no right-minded person would consider – or, on the other hand, persuading others not to do things that most people would consider perfectly sensible.
We then come to the "selfish partner", whose primary objective is to protect his own interests at all costs, often at the expense of his fellow partners. This might relate to workload, where the selfish partner manages to get away with doing less because no one has successfully challenged his strategies for fear that he will simply take sick leave.
Next is the "financially driven partner". OK, everyone needs money to live and there is nothing wrong with being efficient – but this partner displays bizarrely obsessive behaviour, including vetoing normal expenditure, demanding the cheapest biscuits, and sulking at the suggestion of staff pay rises (while relishing his own vastly increased income).
Sometimes, this partner will get ridiculously involved with actually doing the wages or keeping the practice chequebook under his own lock and key.
We must not forget the "female partner", part-time and bringing up a family, who is subject to the most blatant sex discrimination and patronising behaviour by male colleagues who have never quite forgiven her for having taken – shock, horror – two maternity leaves.
Then there are worrying examples of partners with dodgy clinical practices, blatant gaps of knowledge, wrong prescribing, etc, and the ones who attract more complaints than anyone else, often because of their appalling manner and lack of social skills.
Not to mention the partner who may or may not be having an affair with one of the nurses or, more worryingly, with one of the patients. There are also the ones in a fragile emotional state, who are suspected of drinking rather too much, or perhaps worse …
"Ha!" I hear you say. "What about GP appraisals? Don't they pick these things up and get them sorted out?" Well, do they? Take a look at the GP appraisal scheme and ask yourself if it might be possible for a rampant, bombastic, alcoholic miser to come through smelling of roses. I think the answer is "yes".
Leadership and group functioning
Of course, these are the extreme behaviours, but often it is not that things are dreadful, just that they are not great. There may be petty disagreements, areas of friction that don't go away, different motivations or values, different commitments to the practice, different personalities who do not understand one another, difficulty in decision making, and so on.
Even though the partners may not function well in a working team, they can get on well enough socially – which makes things rather more obscure as they might be misinterpreted as a "close knit team".
Then there is the thorny issue of leadership. All the research into group dynamics shows that teams need leadership, even if it is "soft touch", to facilitate team performance.
Today's partnerships often strive towards democracy, moving away from the previous model of the charismatic senior partner who made all the decisions. Today's partners want, at least on the face of it, to respect their colleagues and not upset anyone. Yet what seems to happen all too often is that this desire for democracy causes inertia in decision making and difficulty in dealing with differences of opinion or conflict when they arise.
Many GP partnerships nowadays have no clearly defined leader and this results in different (and sometimes inappropriate) team members assuming leadership in different situations. The risk is that the partner with the strongest opinion or the loudest voice becomes a leader by default, while others may fail to engage properly in the group's activities through personal frustrations or lack of commitment.
Partners' meetings often provide the litmus test to demonstrate how well the team works. With no defined facilitator in the team, conflicts between group members might be kept under wraps for fear of potential damage to personal relationships. Or they could surface explosively, fuelled by frustration. The lack of group facilitator often impedes decision-making. Discussions can go round in circles, resulting in a lack of commitment to any decisions eventually made, which are often undermined.
The lack of overt leader can also allow unhelpful behaviours in the team to persist, such as partners dominating discussions and others disengaging.
Amid all this, the practice manager is trying hard to run the practice and to keep the partners happy, as well as the staff and the patients! Quite a tall order when those at the top are in disarray.
Sometimes, the partners will adopt the manager as their "leader", which might work well for a while but runs some terrible risks to the manager. You can guarantee that the partners will be quite happy with someone else taking the lead while things are going well, but the minute a tricky issue affecting them personally arises, the manager can become a scapegoat and lose credibility – as well as self-confidence.
Many managers spend much of their time supporting their partners and trying to develop partnership teamworking. There is no quick fix or ready-made solution. Each partnership is different and each manager must develop their own relationship sensitively with their group of partners. This takes a great deal of skill, and managers can often come across problems here.
A common one is that the manager may lack respect from the partners – this can happen when the manager has risen up through the ranks and is still viewed by some of the partners as the receptionist of former years.
Another difficulty is that the manager may lack confidence or not know what to do – not surprising amid the types of problematic behaviours previously described! Alternatively, the manager may be confident but become quickly disillusioned through an inability to move things forward.
Individual partners may seek to influence the manager privately by offloading their moans, while avoiding direct confrontation with their fellow partners. This leaves the manager feeling "dumped upon" and exasperated.
It is often difficult for those within the team to see and appreciate what is going on. It is a bit like what happens when relationships between a couple go wrong. An outside consultant or facilitator can be very helpful in identifying the issues and guiding the team with useful suggestions. The advantage of an outsider is that they do not have any history or emotional baggage, and should therefore be able to be entirely objective in identifying the real issues.
Of course, the difficult challenge for most partnerships is to trust someone enough to open up the cupboard and give the skeletons a dusting down without destroying relationships within the team. For those who have sought outside help, though, this has often proved invaluable.
The engagement of a consultant or facilitator often comes from the suggestion of the practice manager or one of the partners who proposes the idea to the team. There must be some acceptance from the team that working relationships could be improved. It is sometimes helpful to suggest this in terms of a "practice health check", which sounds less threatening.
The team members – usually the partners and the manager – need to be comfortable confiding with the chosen consultant or facilitator. In fact, this can be quite a cathartic experience, particularly for those whose true feelings have not been voiced before.
The consultant or facilitator must be able to gain the credibility and trust of the team, while maintaining a neutral position but not being afraid to challenge behaviours or inertia when appropriate.
The objective must be to help the team develop its own solutions – this is important to ensure ownership and commitment. The facilitator or consultant must ensure a fine balance of being supportive to the team while avoiding any inappropriate dependency.