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Dealing with the reluctant practice

Is a poorly performing practice blotting your PBC group’s copybook? Emma Wilkinson has 10 practical tips for engaging all practices

Is a poorly performing practice blotting your PBC group's copybook? Emma Wilkinson has 10 practical tips for engaging all practices

Your PBC cluster is set up and raring to go. You've redesigned a few services already and are pleased with the results. Or at least the results from most practices. But there is one that does not seem to be pulling its weight and is skewing the results for the rest of the team.

We asked some PBC experts what can be done to tackle the wayward players – and how to initiate the awkward conversations you might need to have.

1. Vet new members

First, make sure your consortium includes like-minded practices – it will not help in the long-run to force a reluctant practice into your PBC group. That also means every equity partner in a practice should agree for that practice to join the cluster – the whole practice is tied in, not just individual GPs.

PBC consultant Gerry McLean says: ‘Before reaching any formal membership agreement, check you all have the same goals and vision for what you want to achieve.'

2. Make it clear what's expected

Each consortium should have in place a membership agreement outlining accountability and responsibility.

PBC consultant Gerry McLean says: ‘Ensure from the outset everyone understands their entitlements, roles and responsibilities. And even though every practice remains independent in the group, they are working as a corporate body in respect of commissioning so there will be penalties as well as rewards. Also agree that the commissioning group will have agreed levels of access to each member practice.'

Another PBC consultant, Scott McKenzie, agrees: ‘Right up front there needs to be a process to help the cluster manage that situation. It means practices are not surprised when the call comes.'

3. Monitor progress and use your findings to prompt discussion

There should be a regular audit, usually in the form of monthly reports. If the agreement was done properly everyone will know what is being measured, why and how.

Dr Amit Bhargava, NHS Alliance PBC co-lead for South East Coast, says practices in his Crawley consortium get monthly budget and activity data. Every three months any practice that is overspent or underspent beyond an agreed percentage threshold will be expected to discuss this with the executive board.

‘We see how far they are away from the mean and practices are encouraged to look at areas where they might not be doing as well as others, maybe in ENT or dermatology. It's always about an open conversation – a very adult conversation.'

4. Start by being supportive

NAPC chair Dr Johnny Marshall says: ‘If I'm working within a cluster of practices that have signed up to PBC but are not engaging, I need to work with them to understand what the barriers are.'

According to Dr Luke Twelves, a GP in Huntingdonshire and PBC consultant for UnitedHealth: ‘It is a listening exercise. To set off, sit down with the practice, put the data to one side and ask them what sort of practice they want to be.'

He adds: ‘It's very much a supportive role, looking at what issues there are and how you can help. Sometimes, when you sit down with a practice, you get some very interesting answers about why they're not doing a certain pathway. Also, you will find that GPs will come in line just by being observed.'

5. Peer GPs, rather than managers, should deliver the pep talk

It should always be GPs talking to GPs. It becomes a conversation between two colleagues who understand each other's business rather than a telling off between a manager and a practice, says Dr Stewart Findlay, PBC chair, Durham Dales Cluster.

‘GPs are much more likely to listen and respond to their peers than their managers, so it's all about devolving responsibility to a cluster level. If a single practice is messing up the whole system for neighbouring practices, they are much more likely to toe the line if other GPs talk to them about it, than if some remote manager brings it up.

‘Things have moved on in the past 15 years. Under fundholding, practices were fiercely independent, working in isolation and very careful about managing their own budgets but a lot of us can see now that it's much better to work together. There's too many outside threats to our business to try to stand alone. If there's a difference between practices that can't be explained, the practice is far more likely to feel bad if their professional colleagues are trying to help them understand why.'

Dr Marshall adds: ‘If you have someone talking to that practice who is in the exact same position, and they have the same business, and they want to get to the same place, you're more likely to get the practice on board.'

6. Check your facts

There may be a good reason why a practice is appearing as an outlier in the data or not using a service you have set up. It could be anything from the particular demographics of that practice to a perceived or real barrier in using a particular pathway.

Investigating the reasons why could perhaps throw up suggestions for further service improvements. There may even be a need for specific education or training at a practice – something the PBC group can help provide.

Dr Findlay says: ‘The first thing you need to look at is what is different about that practice. There may well be a very simple explanation and it's much more likely that GPs are going to understand that than some of the PCT managers.'

Dr Bhargava agrees that neighbouring practices have strengths and weaknesses and there will be good reasons for some fluctuation. ‘We have built a 3% contingency into the budget for that. There will be things you can't control and patients don't always behave in the way you want them to. People could well have a good reason – it may be that one patient has been in hospital 20 times because they have cancer or another serious condition.'

7. Sell the vision

Every cluster should have a leader who drives the local agenda and vision for PBC. If practices fully understand what you are trying to do, you are more likely to get them on board.

‘There is a role in providing vision and peer support in terms of selling that vision,' Dr Twelves says. ‘The really important aspect is that it's about collaboration and driving the ambition of GPs. The vast majority of GPs, if it's made easy for them, will deliver good-quality care.'

It helps if the struggling practice is keen to change itself and Mr McKenzie has advice for GPs in such a situation: ‘If you see things going wrong in your practice, don't be afraid to ask for help. Find other practices that cope with it and get their help. Don't sit there in isolation.'

8. Address problems quickly

When potential problems arise, deal with them quickly. Do not just hope they will go away, rectify themselves or that someone else will deal with it. And do not pass the buck to the PCT.

Mr McKenzie usually advises a four-step process for dealing with problems so everyone knows where they stand. If those steps are implemented quickly in the event of an anomaly or potential problem, it sends a message that the cluster means business.

‘Step one is to sit down and have a chat with the practice; it should always be about encouragement and support. You might find there is a training and development issue or they are having problems but that with some collaboration these can be easily solved,' he says.

‘Step two would be along the lines of professional advice about this is what you need to do. Step three is a set of written objectives and if that doesn't work, step four would be being ejected from the consortium. Hopefully you wouldn't get beyond stage two because people can see you're taking the correct action at the correct time.'

Dr Bhargava says being poised to step in at the first sign of problems can have spin-off benefits for PBC. In Brighton, they have set up a system where the results of every practice are looked at monthly to quickly pick up potential issues.

‘They also look at whether there is lots of activity in an area that could be done in the community and that way they can very rapidly set up a service, for example in ENT or infertility. They put together business cases very quickly,' he says.

9. Lead by example

Show practices what can be done if you put your mind to it – prove that it works. Get used to sharing best practice and work collaboratively.

Dr Bhargava explains: ‘We already have an innovation lead who looks externally for best practice and different ways of doing things, but we are also planning on setting up an innovation group for sharing best practice internally and that's something every consortium should have. You need to be able to learn from each other.'

10. Get tough if you have to

A good agreement drawn up at the outset means it will be clear when a practice is not performing well enough. Follow the steps laid out about how you will deal with it and do not be afraid to use the powers you have when negotiation is not working.

Dr Bhargava says: ‘If you have that written agreement then it should be clear there are penalties. In our case, the first is that the practice has an action plan to get back on course with the budget. If they don't do that for themselves then a group of people from the PBC group will have a chat with them. If they still don't do it, they are out of the consortium.'

Mr McKenzie adds that while it is very unlikely a cluster will be forced to take things further than a general conversation followed up by support for a recalcitrant practice, the threat still needs to be there.

‘Personally, I have never had anyone go past stage two, we have always managed to negotiate and encourage. Kicking someone out is the last resort.'

Dr Findlay says: ‘In some ways if you're really going to take this to its limits, clusters are going to have to be given some authority to take over commissioning power from practices that are failing and messing up the budget. That's a kind of dangerous thing to say and it will frighten a lot of practices.

‘But you have to have some way of managing a practice that's not up to scratch – although I should point out that's going to be a very small number of practices.'

Emma Wilkinson is a freelance journalist

There are still some places available for our seminar in Birmingham on 9 July, PBC: Alive and Kicking. Go to

Ensure everyone understands from the outset their entitlements, roles and responsibilities Ensure everyone understands from the outset their entitlements, roles and responsibilities

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