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NHS working at Scale: As a federation shareholder what message does your behaviour send?

I recently tweeted a question: “why is it that Member Practices within a GP Federation believe it is acceptable, as shareolders, to fire missiles at their Board?”

The reason for my question is that I see it happening time and time again. Practices sign up to become Members of the Federation and often don’t understand what is required of them, or what they have signed up to.  It’s not uncommon to find GPs and Practice Managers admitting they “didn’t read the company documentation” and therefore didn’t realise emailing concerns, company information, business cases etc, outside of the company is not acceptable and would cause a problem.

While it is incumbent on the Board of Directors to own and drive engagement, as they have a legal duty to act in the best interest of their company, it is also incumbent on Member Practices, as shareholders, not to do anything to undermine the company or the Board. Consequently, before doing or saying anything that involves your perception of the company, please think about how your actions are going to be construed by others within the health economy. While your Board are out selling the new company as having fully engaged Memebrs ready to engage in new ways or working and service delivery, will your intervention support that, undermine that, or possibly completely destroy that pitch?

The first hurdle is all too often where the Board can run into difficulties before they have even got going. The danger lies in assuming that just because Practices have signed up they are engaged. As a result Board and Member Practices misundertand that the whole process is a journey from where they are now to where they want to be. The goal is to deliver the company vision, this is the reason why you formed and it should be at the forefront of everyone’s mind, and often it isn’t. This requires selling everyone involved a vision of why the new outcomes will be better for them, the company, the CCG, local hospitals, the population and patients.

Stephen R Covey in his book – 7 Habits of Highly Effective People - says it simply; “Begin with the End in Mind”. To that I would add that if you don’t clearly know where it is you are tring to go, how will you ever know whether or not you get there?

The key to any major change, and that is what forming a federation is, is that the new ways of working require all those involved to work daily to change behaviours, most importantly the deeply embedded behaviours learned over many years. You will be required to take lots of small steps to achieve your outcome. Seldom, if ever, does it happen that you deliver major change in one leap. You need to keep progressing towards your ultimate goal, and that requires everyone involved being engaged in the positive aspect of whatever you are trying to achieve – small progressive steps count just the same as one giant leap, as long as you remain heading in the right direction.

Without that culture in your organisation you will quickly find you spend more time dealing with the “issues” than you do in making progress. A federation director recently dsecibed it to me as like keeping frogs in a wheelbarrow, where she spends most of her time catching the one loose frog and getting it back in the wheelbarrow, and just as she does that another one hops out.

Keep in mind that it’s your current behaviours that are giving you the outcomes you are achieveing, therefore if you want a different outcome you need to apply new behavious to drive those outcomes – this again should be why you federated. You could of course argue that you are entirely happy with your current outcomes and see no point in changing, in which case, why did you join a federation?

Put simply, to be succesful in implememting change you have to embed new work practices and mindsets in your organisation – leading to a new culture.

Whether implementing change for yourself, or for an organisation, you need a strong strategy; one that will change the culture and deliver the ouctomes you desire. Your strategy also has to be strong enough not to buckle under the challenges and obstacles put in your way by people who will not want to change under any circumstances. I also argue that if your disruptive forces become so disruptive that the compnay cannot progress you will need to use the compnay rule book and act to remedy the situation.  Ultimately in extreme cases that could mean exclusion, eg where behaviours have cost the company a contract.

A definition of engagement is “an arrangement to do something or go somewhere at a fixed time” for me the key point is the statement “to do something”.

That something could be many things; however, as a starting point for a new GP federation, for me the focus should be on how Board and Practices collaborate (collaborate meaning “work jointly on an activity or project”). This could be a collaboration with the CCG or indeed another provider to develop services, which makes the appropriate shift from in hospital to out of hospital care. It could be in delivering simple projects (of which there are many that ANY federation can engage with) that reduce overheads and expenses and/or possibly increase income. This is a very basic way to test engagement. Put simply if Practices cannot engage when there is a simple win for them, how or why will they engage with anything?  

Given the current financial position within the NHS, and the significant challenges we now face in the next 4 years, the newly emerging GP federations offer significant opportunity for General Practice to operate at scale and start to create new ways of working that build resilience and stability in to General Practice. However, that opportunity can only be realised where Member Practices are genuinely engaged, willing to take a small risk and the leap of faith that working in collaboration with each other and across providers is going to be to their advantage. This means developing one company, with one vision that everyone involved then works to deliver.

Without that my sense remains that you will suffer one of the following two pains and miss a fantastic opportunity for General Practice to create the General Practice of the future.

“We must all suffer from one of two pains: the pain of discipline or the pain of regret. The difference is discipline weighs ounces while regret weighs tons.” Jim Rohn, Motivational Coach.

Scott Mckenzie

Scott Mckenzie

NHS Management Consultant

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