The vision for the NHS set out in the Long Term Plan is predicated on a new model of general practice where traditional ‘corner shop’ clinics are grouped into large-scale, geographically coherent primary care networks (PCNs).
The plan expects big things from PCNs, such as seven-day access, delivering multi-professional care for patients with complex problems, as well as providing a rapid response to acute illness. Some front runners, such as the Rushcliffe GP practices in Nottingham, are already demonstrating what can be achieved. But, as with the herding of GPs into clinical commissioning groups, the rate of progress towards the anticipated end state will vary.
Our 2017 survey showed that over 80% of GP respondents were already participating in large-scale organisations, and in October 2018 over 200 groups covering nine million patients were actively engaged in the NAPC primary care home programme. The NHS plan can therefore be seen as a nudge to remaining standalone practices to fall into line, pushing general practice to evolve into the central element of a multi-professional, community-based health system.
Lessons from what we already know
To this end, there are lessons available from established large-scale GP organisations that can inform the plan’s implementation. For the last year, the Nuffield Trust has been commissioned by Modality (a GP super-partnership founded in Birmingham and now spreading around the country) to act as a ‘critical friend’, observing groups of GP practices as they merge together to become Modality ‘divisions’.
Drawing on these observations, as well as interviews with clinical and non-clinical staff in one division and a literature review, the following factors will need attention if large-scale general practice is to fulfil expectations.
First is engagement. Each Modality division consists of practices that have come together voluntarily. Reviewing international evidence on voluntary versus compulsory networking, Pettigrew and others conclude that there are pros and cons to both approaches.
With voluntary mergers, research suggests 15-30% of practices will never sign up and it can be hard to introduce consistent change into these groups. Compulsory membership is associated with greater clarity of purpose and guidance on development, but members may be disengaged or even resistant to change.
PCN membership will become mandatory, and the challenge will be to ensure that practices that previously resisted working at scale become engaged. Not everyone in the Modality site I visited was receptive to change, but there were plenty of staff who saw joining Modality as an opportunity to sustain and develop local GP services. In line with Kurt Lewin’s theory of change, merging seemed to ‘unfreeze’ day-to-day routines and enable them to redesign many aspects of their work.
The narrative that brought members together was multi-faceted, but included using larger scale to enable the development of innovative services and jointly address workforce shortages, as well as sharper stimuli like survival and longer-term sustainability.
One ‘must do’ for primary care leaders implementing the plan will be to create a compelling narrative to persuade reluctant GPs of the potential benefits of working at scale. Rapid and effective communication about early successes will be important.
Second is the impact of the workload of transformation on staff who are already running to stand still.
Interviewees described the challenges of supporting change while getting on with the day job. They included having less time to support staff through day-to-day operational challenges, long working days, personal fatigue, and coping with colleagues who abreact in the face of change. But there were opportunities too, such as being large enough to invest in technology, and diverting work away from GPs through paramedic home visits shared across practices.
A substantial dose of transitional support is needed, and NHS England is designing a support programme for emerging large-scale GP organisations. It knows this can’t be a burdensome top-down offer (remember the bureaucracy for developing and ‘authorising’ CCGs?), but neither can a thousand flowers bloom only for some to wilt and die. A new approach to transformation support is needed.
Third is the human impact of transformation on almost family-like practice teams.
A recent Nuffield report described how the relationships between members of the GP workforce – from receptionists to doctors – play a central role in ensuring that patients are steered to the right service for their needs. This detailed knowledge of colleagues, local services and how they work together plays a critical role in the delivery of high-quality, patient-centred and organisationally efficient care.
Networks may require new working practices and might disrupt long-standing relationships. Some staff were excited about new opportunities for collaboration, but others described a period of reduced productivity after the network formed. Some struggled to cope with change and others took time to settle into new roles that they now enjoyed.
Such experiences may be inevitable in a transformation programme, but this could have disastrous consequences if forcing practices to work together drives clinicians to leave. With patients across the country already at risk of losing their GP practice, there is no slack with which to soak up the departure of more doctors.
Need to tread carefully
These observations may not be surprising, but they should act as a reminder of the possible impact of the enforced formation of PCNs. Nobel Prize winning writer Mikhail Sholokhov described the minutiae of the enforced collectivisation of Russian farmers in Virgin soil upturned. Reluctant to see their individual animals merged into a group, the farmers painted the tails of their goats in distinctive colours so they could recognise them in the crowd.
Human nature comes into play in these situations and we need to ensure that the expectations we create, and the support we provide, enable a better form of general practice in the future, without burning out a fragile workforce.
Rosen R (2019) “Primary care networks: work needed to fulfil expectations”, Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/primary-care-networks-work-needed-to-fulfil-expectations