General practice, primary care networks (PCNs) and Local Medical Committees (LMCs) all want to ensure strong, resilient, sustainable general practice with good, high functioning and high performing primary care networks.
The LMC assumes something akin to a ‘pastoral’ role with all practices. If there is a problem at practice level, the LMC will often step in and act on their behalf, playing the pivotal role of a critical friend to practices and networks alike.
When communication breaks down, or where it was not effectively established in the first place, it can cause enormous problems within an integrated care system, as a client of ours discovered recently.
SCW facilitated a workshop for a Local Medical Committee working with the clinical directors for all the networks across the integrated care system. There were more than 20 PCN leaders in attendance. Our approach was to capitalise on the real desire to ensure the clinical directors and the LMC have a good, strong relationship with the ability to work together for the benefit of the practices, the primary care networks, the system and the LMC itself.
But in this case, the LMC found themselves to be in conflict with the primary care networks. Why? Communication. Or, rather, miscommunication. The LMC believed all parties had been working toward a common goal but the reality, as they discovered, was that they were sometimes in opposing corners.
To whom does a system listen when they are looking for a coherent voice for general practice.
This level of disconnect can cause enormous problems within an integrated care system; to whom does a system listen when they are looking for a coherent voice for general practice. Is it the LMC, is it the networks, the local GP federation, or individual practices?
How a perceived ‘conflict of interest’ can stand in the way of a united voice
A phrase that gets used a lot is ‘conflict of interest’. Rather than being an enabler of change, frequently a perceived conflict of interest can be the catalyst that brings everything to a crashing halt.
In our example, the LMC ended up being excluded from conversations at system and place level because of the potential of a conflict of interest, with all communication then defaulting to the networks. The unintended impact of this being that the LMC was left out of the conversation, leaving a very confused picture of General Practice across the system.
Working with both parties we facilitated discussions to enable a common understanding of how everyone can operate together, ensuring the LMC and clinical directors sit alongside each other and influence what's happening at network, place and system level.
Not waving - drowning
This also required clarity on the role of the clinical director. Funded time to undertake the duties of a clinical director barely covers the time required to lead the PCN through the changes in the ways General Practice needs to work to meet the requirements of the DES.
Layering on additional activities, as integrated care systems see ‘give it to the networks’ as the solution to many of their challenges, risks the systems losing sight of what PCNs were created to do in the first place with clinical directors drowning in work.
To ensure progress, we supported the participants to develop an approach that would enable a strong, coherent voice for general practice within the integrated care system at system level, at place level and at network level.
In her report, Dr Fuller reminds us that the biggest challenge facing systems is the creation of conditions by which local change can happen. She singles out PCN leadership and representation at every level within the system as being crucial to the success of integrated primary care.
In our real-life example, this was achieved through facilitated and robust discussions on themes such as the identification of;
- common goals and interests between the LMC and clinical directors.
- approaches to general practice representation at all levels – from the integrated board, the place boards and at network level, ensuring communication upwards, downwards, and out to primary care through the networks
Key to the success of the outputs of this session was to ensure that primary care would have the right people sitting in the right meetings with the right hats on.
System success depends upon having the right primary care representatives in the right meetings with the right hats on.
This was a powerful session that resulted in the creation of a clinical director/LMC forum which will meet to discuss the ‘ask’ from systems and place.
The intention of this approach is to create a trusting and dynamic environment through which practices and networks will be represented, at every level, coherently and robustly. Minimising the risk of future conflict will ensure that Primary Care are well placed to have a consistent voice in the system. Crucially, this pivotal component of an integrated care system will be able to play an active and considered role in system development.