In this latest blog, management consultant Scott McKenzie examines the consequences of rushing into change in general practice and pushing through the process without undue care. 

I read with interest an interview with Professor Helen Stokes-Lampard, Chair of RCGP Council, where she was reflecting on her second year in the role.

The full interview can be found here and is well worth a read.

Scott Mckenzie

Independent Management Consultant

From my own work I am finding it far more common these days to be asked to support practices explore the future and whether merger, federation, hub of 30k to 50k patients or something else may be the right route for them.

I therefore fully appreciated the views in the interview and agree entirely that if you end up being rushed it is likely to cause both “problems” and risks leaving “deep scars in the new organisation”. It is for that reason I advocate that Practices consider any change of this magnitude when there is no panic, no need to rush and when you can take the time to engage everyone affected in the change.

Instead what often happens is the practices come together and agree there is no panic, so they will leave it for now and review to 6 to 9 months. Alternatively, they produce a long list of reason for why staying the way they are now is not the right route, but when then asked for their red lines (things that are non-negotiable in terms of progress) often site being able to continue to work exactly as they are now as their first red line. Left unaddressed that will be a block to progress and in addressing it you are going to have to be prepared to negotiate and compromise.

It is often at this point I highlight that you cannot be half pregnant (meaning you cannot be pregnant when it suits and not pregnant when it suits). People have to come with a mindset that they are prepared to negotiate and compromise to get an outcome that everyone believes is fair and workable. To be clear nobody is going to 100% what they want. Without a willingness to negotiate (give and take) we end up with negotiation breaking down.  What often happens then is 6 months later we have a problem and the decisions are rushed to address a problem that would have been avoided if we had taken time.

This is where having a great facilitator with a track record in delivering new models or General Practice that work (demonstrated by outcomes, projects and contracts) is key. What you don’t need is people who can talk the theory but cannot back that with evidence of new models that work and with clients you can speak with openly about their work.

I also want to highlight that you can avoid losing members of the practice team by being open with people right from the start. This need not be a warts-and-all approach, but rather an opportunity to engage people before decisions have been made.

You definitely need to be having “honest conversations about what lies ahead”, the likely impact and the likely outcomes. Reassure people this will be change for the better, not change for the sake of it. You are looking to collaborate to create a future model for everyone and a work environment that people will enjoy.  That way you avoid people leaping to the conclusion that the change is going to be so bad for them that they want to leave before you have even started.

What I find is that people in general believe the worst possible outcome for them is going to be the outcome achieved, when that is in fact highly unlikely. If the leaders work openly with their teams and keep them updated in general about progress being made you address a lot of the fears people have and prevent an exodus.

There are many ways to gently handle this and avoid problems, however, it will require that you look ahead for 12, 18 or maybe 24 months and highlight that with that kind of timescale you will not be rushing decisions. Highlight you will engage everyone affected by the change at the appropriate juncture and that you will keep them updated on progress. This is why when you have no pressure to change it is the right time to look at what change may mean for you. Nothing worse than having pressure to make decision for making bad decisions.

Don’t make any false promises e.g. we guarantee there will be no redundancies. You can highlight this is your goal but that it may not be possible; however, at the same time, you can guarantee it will not be a last-minute conversation.  You should also highlight that everyone will be involved in the conversation about what work practices will look like going forward. That way people own the problem and the creation of the solution, leading to ownership. With ownership you get implementation and the outcomes you want.  Without ownership you are likely to get resistance to what is viewed as top down change and, of course, this leads to people leaving.

In to this mix we now have the advances in technology, which are undoubtedly going to impact.  I make no judgement on the rights and wrongs of the various solutions being offered to the NHS and General Practice. Suffice to say, if I was a GP I would be owning the problem and the creation of the solution for the practice I work in long before anything is imposed.

My last thought on the interview. If General Practice had the £14.5bn a year, equivalent to 11% of the NHS budget that it used to have, while I have no doubt it would solve some of the problems, it wouldn’t solve all of them. Money will not have the GPs feeling less “demoralised” or less “under pressure”. To do that means taking a step back and looking at how best to utilise the income practices have. That means making tough decisions on what work to do (I advocate only work that is properly commissioned and properly funded) and what work to stop doing (I advocate work that isn’t properly commissioned or is either underfunded or not funded at all). In doing that exercise, General Practice is likely to lift a lot of the burden it has. If the service is “good for the patient”, it should be properly commissioned and funded.

I have areas I work now where we are “putting the joy” back into General Practice. One practice in particular when I arrived had 3 GPs and all were waiting/wanting to retire in 2018/19. What we now have is 3 GPs all staying on for 2 to 3 years more, and possibly longer. Yes, it was painful at times, but if you speak to those GPs they will tell you the pain was worth the gain and so would the team of people who work with them.