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Strong and successful partnerships in general practice don't happen by accident.

Like most things in life they need to be worked on. Dr John Couch explains how.

A good and successful practice is an exhilarating place to be. But such a practice won't happen all by itself. It is a sad fact that partnership disagreements are still a fairly frequent occurrence. And though partnership dissolutions are less common, most of us will know of at least one that has taken place in our patch during the last five years. When they do occur it is an incredibly disruptive process, certainly akin to divorce. Maintaining harmony between partners is therefore vital for success and like all good recipes there are some essential ingredients.

Choosing carefully

The process should start when taking on a new partner. Assuming that you have some choice (sadly not always the case!) it is not necessarily the best-qualified candidate who should be offered the post. A partnership is a team. To use a football analogy, you would not employ a star striker if you actually needed a reliable goalkeeper.

This means you need to look carefully at your present mix of skills and personalities. Skill gaps do need to be plugged but it is more important that your new partner, after meeting basic practical criteria, must fit in or enhance the cohesion of your group.

The traditional interview process leaves a fairly wide margin of error and relies too much on plain good luck. More practices now include personality profile testing, such as Meyers-Briggs, as a way of increasing the chance of success.

To determine which personality type your group requires you will need to test all the existing partners first, an interesting experience! But I am still waiting for the first advert stating: 'New partner wanted. Must be type ESTJ.'

This aside, the basics of selecting are still important. Read CVs thoroughly, interview carefully and make sure you follow up references by phone as well as by letter.

A practice agreement is essential

Any practice without an up-to-date practice agreement is asking for trouble. It is surprising that many practices still do not bother with this essential document. The agreement must be clear, comprehensive, fair, and should be signed by all of the current partners. The BMA will provide invaluable help and advice and the agreement must be drawn up by a solicitor with specialist experience.

The roles and responsibilities of each partner should be clearly shown. There must be a clause detailing arrangements for partnership earnings vs. individual earnings, sharing ratios and time input during a normal working week.

Decision-making should be covered and should include voting rights, the size of a quorum, and which decisions require only a majority vote and action if there is a tied vote. It is not now considered best practice for a senior partner to have a casting vote.

Sadly an expulsion clause is also required. Although rarely used, it protects the partnership in the event of serious partner misconduct.

There should also be a 'bottom line' clause covering the action to be taken in the event of unresolved dispute. Normally involvement of an outside agency such as the BMA is required, with binding agreement on their decision.

Meetings

Regular business meetings are an important ingredient to ensure success and avoid problems. Informal meetings should not be underestimated. Coffee-time chats can often be a good place for floating ideas as well as building working relationships. However, due to sporadic attendance, these cannot be relied on for formal decisions.

Many practices have formal weekly business meetings. These deal with week-to-week management and business issues. Barring holidays and sickness, attendance is expected.

The meetings work best with a fixed agenda, minutes and an appointed chairperson. Honesty and inclusiveness are important in order to achieve consensus opinion and decisions.

Clinical meetings are also important and all of the above points apply.

An awayday, once or twice a year, can provide a useful opportunity for in-depth and strategic discussions. It is an interesting phenomenon that meeting outside the practice building can have a positive effect on objectivity. The structure of such meetings can be set in advance. Or the meeting can be 'free-flow'. A good facilitator is important, and if none of the existing team members fits the bill it is worth investing in an outside individual.

Resolve disagreements quickly

Ignore disputes at your peril. All partners must be alert to signs of escalating disagreement. While healthy debate and alternate views can enrich a partnership, there is a fine line between this and destructive differences.

It is usually not too difficult to spot the signs, whether it be raised voices or significant silences. When the signs appear, partners should be encouraged to air problems in a non-threatening and conciliatory atmosphere as soon as possible.

This may take the form of a one-to-one chat or an item on the weekly agenda. It is important to sympathise but not to take sides. Lateral thinking often provides a solution. For more significant issues the practice agreement may need dusting off.

Property ownership

In the last few years some younger GPs have been put off joining a practice by the need to invest in the practice premises. In order to improve recruitment, more practices are now making property ownership optional. Although this has had the desired effect, new tensions can be created.

When some partners own the premises and some do not there can be situations where opposing views appear. Repairs and decoration are a good example. Non-owners may not agree to a particular expense which an owner feels is important.

It is therefore imperative to have a separate written agreement spelling out the responsibilities of the property owners and those of the whole partnership. This should make clear who pays for outside and inside replacements, repairs and decoration.

Finally

Finally, of course, there is patience and tolerance, something we practise clinically without thinking but which we often find more difficult with our partners. Human nature can be very frustrating at times but a deep breath is often more sensible than a sharp response.

John Couch is a GP in Ashford, Middlesex

The human ingredients

There are some vital human factors that are found in most successful partnerships. Inclusiveness is one, and means the ability to ensure that

all members have an equal say and are listened to respectfully.

Flexibility is another. This means not just adapting to outside situations

but also being able to adapt your own views if the group feels another approach is required. This is not the same as always giving way but does requires us to think about the needs of the group as well as our own.

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