Five focus areas for creating PCN harmony

The last three years have brought dramatic challenge and demands on primary care. These arrived at a time of system revision for the sector, where practices were joining up into PCNs and innovating access models at pace.  Changes that had to happen without the capacity or development resources that were likely needed, addressing the ‘urgent, rather than the important’ in the words of a GP partner.

Increasingly, our business psychology service receives calls for support from PCNs who have experienced problems through their efforts to collaborate. Some are healthy functioning practices, but now clashing at the point of coming together as PCNs. Others were already struggling alone, now facing the challenge of forging a multi-member vision. 

The three main concerns are:

• the challenge of fractured PCN boards who struggle to agree decisions and avoid, or are stuck in conflict
• emerging competitive responses to culture differences, where practices and their staff can compare their work cultures to that of other practices 
• PCN managers struggling to deliver an equitable service into practices with significantly different processes and levels of engagement

For many, this results in a lack of engagement with the PCN from  practice partners and their staff despite the fact that PCNs work for, and are essentially owned by these same people.

The causes of these issues are really too vast to summarise in a short article as they encompass the complex business model of primary care, the developmental history of primary care teams, the top-down directive to collaborate and the required pace of change in the context of extreme challenge. Needless to say, there is often an organisational development need for PCNs, recognising that poor engagement is most often signalling a need to address culture. 

A helpful framework

As psychologists, we bring many models to our work with practices.  A simple organisational design approach can empower a partnership and a PCN to find the cultural issues that need work. In this article, I will introduce Patrick Lencioni’s ‘Five dysfunctions of a team’ model as an accessible reference point for leaders, where common team dysfunctions are reframed as needs for optimal team function. We frame PCNs as an opportunity to get into a team around an innovation challenge, borrowing terms from Amy Edmondson’s work on Psychological Safety.

Spotting and developing areas of focus

Using Lencioni’s model, PCN leaders can question their system needs and consider solutions:

Focus 1: Absence of trust
Collaborative partners within PCNs may not trust that others have the interests of collective success above their own personal interests or that other practices don’t have the same challenges and so lack insight.

Be human: Recognise that the pace of formation and the top-down directive took away opportunities to bond as a new team while also perhaps failing to activate recognition of a shared vision. Newly formed boards need to spend time together in spaces that are designed to create trust and relationships. A shared space where the agenda is to understand these new collaborating partners, their values, the model they come from, why it was created and to invite shared learning and joined up approaches. 
Regular activities include check-ins, appreciative enquiries, sharing success, supporting each other to discuss difficult topics and valuing repair if difficulties arise.

Focus 2: Fear of conflict
PCN managers and CDs are tasked to integrate the expectations and experiences of practices with the evolving PCN. This is made complex by the power imbalances and culture differences between the PCN staff and practice leaders.  Seeking to preserve a sense of harmony, even if artificial, can lead the team towards avoiding conflict.  The ability to communicate openly about failures, challenges, differences is the core of psychological safety, when it is absent the ability to innovate, join up and rapidly develop towards success are hampered.

Create debate safely: While building trust, here are three approaches that can support communication;

1. Seek practice feedback to understand how the PCN is being received and communicate the PCN response to that 
2. Communicate the PCN experience of practices to partners and seek creative solutions to issues
3. Recognise and communicate that the role is new and many challenges invite innovation, where obvious solutions do not yet exist.  Clearly define CD roles with their reporting boards, both in terms of written and psychological contracts – the unwritten expectations and rewards of both parties.

Focus 3: Lack of commitment
Delivering a PCN across the mixed cultures and values of different practices makes joined up buy-in challenging. Without buy-in, PCN strategy can feel like interference rather than support. Practice and PCN staff can feel disengaged, as neither connect on a shared vision.

A shared vision: At the level of each practice, teams need to articulate a shared vision and appetite for engaging with their PCN. This could explore how they might identify as members of the PCN and how that links to their personal values and drivers and organisational identities considering business strategies and shared goals. Practice PCN representatives or the PCN CD can stimulate this conversation in meetings or via surveys.
Communicate PCN activities and strategies back, in the language of each practice’s goals. Join up PCN efforts and outcomes to the drivers of each practice, in reporting and activities that invite contributions. Demonstrate the innovative culture of PCNs by articulating what will be tried differently in response to data, reassuring teams of the direction of travel.

Focus 4: Absence of accountability
Avoiding personal discomfort can mean that we avoid addressing real, concrete problems that occur.

Add in skills: It can be challenging for PCNs to challenge practice, GP and board system delivery issues. If a practice fails to follow a protocol or a senior staff member under delivers on a project they led – it does not serve the PCN to ignore it. This is where good management skills are imperative for PCN CDs and meeting chairs. Meetings that are formally led, with agendas, minuted discussions, clear actions and deadlines create the opportunity to review and query any deviations from what is expected. PCN CDs in particular will benefit from leadership programmes, where communication, governance and systems management skills are developed. Developing management systems across the PCN depersonalises accountability, making it a process rather than an interpersonal issue.

Focus 5: Inattention to the right results
Focusing on the wrong results which here would included personal or specific practice returns over the collective definition of success of the PCN will lead to problems.

Define and review success: Success for a PCN requires the previous four needs to be met. There is a risk that tangible benefits and returns become the success or fail criteria in respect of the PCN team’s performance and PCNs are subsequently blamed for pain points. PCNs are young, their performance is ultimately related to patient care and practice sustainability, but the challenge of delivery in such a complex setting could mean that success would best be measured by how well practices engage and collaborate. Evaluation is often the enemy of innovation, so be careful not to chase the wrong reward.

Summary

Lencioni’s model for teams is a helpful lens for approaching the development of PCNs as teams that support connected practices. The same approach is helpful for practice partnerships, where any of these five dysfunctions are recognised as a need. When partnerships become dysfunctional within practices, it is challenging to create a healthy relationship with a PCN – as trust, communication, vision, accountability and goals need to be agreed at home before a PCN can be expected to realise and express these further. This is a call to practices to develop their in-house culture, if any of these are missing.

This article acts as a brief introduction of culture and PCN, through an easy to reference model. It is not a complete answer, or an authority on what works in every space – rather an invitation to be playful with ideas, suggestions and perhaps the concept that a model may exist that your PCN can try, to take you towards an engaging and rewarding culture. 

Dr Craig Newman is an award-winning clinical psychologist and team coach who specialises in developing NHS teams and leaders, particularly in primary care. He authored the book ‘Leading Primary Care: Resilience, Team Culture and Innovation’.  He is CEO of both a team development service Aim your team and an NHS burnout prevention not-for-profit Project 5.