Primary care: from cottage industry to multi-million-pound enterprise

Primary care was a cottage industry for decades. For most of its existence, in fact. That’s not to reduce the scale or complexity of what was delivered and achieved. But practices were owned and led by a small group of small business owners – or GP partners as we know them. 

Practices were local, teams were small, and there was a sense of ‘in-house’ organisational and cultural design. By ‘in-house’, I mean personality-led by partners, limited in scale to the patient population and often to the actual practice building. 

There has been much change since then and increasing pressure on services. Practices have been digitised in many ways, with more to come. Patient choice drives change, and the political agenda is to create more capacity in the context of significant staff retention, wellbeing and capacity challenges. This is against the backdrop of unprecedented NHS waiting list times and challenges across all levels of care. 

And there are changes in the staff in modern primary care. Once, a practice manager would rise through the ranks with experience as their credential. Now, managers are sourced from industry – crucial expertise includes HR, innovation, finance, business development, project management, and change management. 

What do I hear most from these managers? “I’m not heard by the partners.” And that’s a problem when it comes to scaling up in primary care.

The scale-up perspective

Since the introduction of Primary Care Networks (PCNs) in 2019, there have been rapid system revisions. There has been a continued push for what can arguably be seen as organisational scale-up. And it’s happening at breakneck speed.

In a short time, we have gone from single practices to PCNs. And, with the emergence of Integrated Care Systems, we’re now moving towards neighbourhood integration, collaborations and community hubs. 

The rate of change is astronomical when you consider how private sector organisations scale up. Their procedure is to look at processes that are effective, well-resourced, and franchise-able (this being key).  Then they scale them by x5 or x10 to ensure they don’t break as they grow. 

Contrast that with scale-up in primary care. Practices were tasked to merge their processes at pace, connect as a network and find continuity of process at rocket speed. 

As a result, PCN networks are resource-rich but process-poor. Their processes were created on the fly because there could be no plug-in-and-go model for PCN delivery. The complex nature of multiple practices joining the PCN made that an impossibility.

So, the scale-up is a process of evolution. PCNs hoped processes would emerge as the x5 or x10 approach is implemented. It is risky and has been painful for more than a few networks.  It’s unsurprising because primary care’s long history means embedded cultures are shaken by rapid change and scale-up.

Three approaches for PCN scaling

So, what can help?

I recommend three approaches for PCNs that want to scale up successfully. I’ve adapted methods taken from start-up change management to take into account where I’ve seen PCNs succeed – and get stuck.

1. Adapting PCN culture for scale-up successAdapting PCN culture for scale-up success

Adaptation is critical in scale-ups. It is so important that it can often make or break success.  There are several ways PCNs can boost their adaptability.

• Adopting a growth mindset is crucial. Scale-up calls for change at all levels, and resistance to change is the greatest threat to success. Recognise that what got you here may not get you there. When organisations experience stumbling blocks to scaling, it’s often because they have failed to learn new approaches to delivery – no matter the sector. The change is coming; learn to embrace it.

• A collaborative culture is a must. A culture of collaboration enables strong relationships among team members, resource sharing, and working together to achieve common goals. This type of culture is vital for adapting to the larger environment and coordinating with other healthcare organisations. As you progress, ensure you frame collaboration as going beyond the PCN to include other stakeholders.

• An emphasis on continuous learning and adaptability will help. It can help PCNs remain agile and responsive to the changing healthcare landscape and evolving patient needs. This means embracing and expecting failure. It also means empowering the PCN team to lead on this, avoiding micromanagement or risk aversion.

2. Creating a culture that supports scale-up success

Culture drives staff behaviour when they are unsure what to do – which means there is no requirement to manage all tasks when things are going well. Scale-ups bring unexpected challenges, and culture is the safety net. 

• Develop a shared vision. Establish a clear and shared vision for the PCN’s future to ensure alignment among staff and stakeholders, promoting a collective sense of purpose. Recognise that focus on a core mission is at risk when scale-up is underway. This needs regular attention.

• Build psychological safety. Foster an environment where staff feel comfortable sharing ideas, concerns, and feedback, encouraging open communication and innovation. Delegate power when it makes good business sense to do so. This is the true foundation of the adaptation approach listed above.

• Invest in training and professional development. Provide opportunities for staff to develop new skills and competencies and support their adaptation to new roles and responsibilities during the scale-up process. This brings the additional benefits of staff engagement and retention. Nobody in your network should be outside this strategy – investing in people is the bedrock of scale-up success.

3. Operational changes for scaling up work in primary care

To scale up effectively, PCNs must adapt their operations and adopt new ways of working in a larger environment.  

• Streamline processes. Identify and eliminate inefficiencies in existing processes, ensuring smooth operations during the scale-up. Process mapping will become your best friend – skill up leaders to utilise this approach.

• Implement technology. Utilise technology to automate routine tasks, manage patient records, and facilitate communication across the organisation, improving efficiency and service quality. While it’s true that innovation burnout can put teams off, this approach is not externally mandated. Instead, it should be framed as a future win so everyone can get excited about where technology can reduce the admin and logistics load.

• Integrate with other healthcare organisations. Create a strategy for collaboration and PCN board expansion. Invite potential future collaborators as stakeholders to give input on your scale-up ideas as you change.

• Data-driven decision-making. Use data to inform decision-making, identify growth opportunities, monitor progress, and evaluate the impact of services, enabling continuous improvement. Unfortunately, data is often poor in primary care, so understand how to improve this or find a way to get straight to meaningful data. Invest in staff skills to make this business intelligence available often.

• Resource management. Allocate and manage resources, including workforce, finances, and infrastructure, effectively to ensure the sustained delivery of high-quality care during the scale-up. Sounds obvious. But for some PCNS, this becomes a sticking point between practices. Consider allocating a business development lead and consider change management support.  Scale-up should be seen as a business and people strategy as much as a service delivery strategy.

A call to partners to embrace delegation.

The role of GP partner is a tricky one. Their primary function in their organisations is that of owner and leader. This is both a strength and a potential barrier to scale-up success. 

Leadership is primarily about driving change in response to environmental shifts and their impact on an organisation. But when the leader is also the person who delivers the primary function of that organisation, it is a barrier to change. That’s because the focus can be on how the function will be affected rather than how the organisation can evolve to meet external opportunities and threats. 

I see it often in primary care teams, mostly through the words of named “managers” or “directors”, who talk about having no power and being vetoed by the partnership board on strategy decisions. 

The context is more complex, of course. Portfolio careers for GPs are increasingly seen as the way to increase resilience and the engagement and sustainability of the profession. So more and more GPs are embracing new leadership roles beyond clinical practice, which makes sense since they are a talented cohort. 

My call to GP partners is to learn how to spot business talent and then delegate to it with trust. This does not mean you sacrifice the ability to steer as a board – board room training may help you do this. Instead, it is recognising that the successful delivery of a multi-million-pound scaled-up enterprise is a light year beyond the cottage industry of only 5 to 10 years ago. Corporate organisations employ CEOs at scale-up. They hand the jobs of operations, growth, change and financial success to talented, proven leaders. 

If these roles call to you as a GP, invest in being adequately trained, coached, mentored and networked. Enterprise leadership is not a specialty; it’s a career. Recognise that a good leader can drive your organisational success beyond your current perspective when given the power to innovate. And be aware that they won’t stand for being repeatedly undermined and disempowered. 

Learning to let go, delivering on what you do best and meeting the rest via recruitment and delegation is the foundation of scale-up success. And those scale-ups who fail or suffer endless pain? They usually have leaders who still try to be involved in every part of the cottage industry, blocking innovation at scale because of their limited capacity and skill gaps.

Challenge or opportunity?

The future is unclear. We don’t know yet what new changes will emerge as a national strategy nor which will be reinforced. In one sense, it doesn’t matter.

The challenge, or opportunity, for leaders in primary care is to understand their role regardless of what comes next. We know for sure that the days of single practices are gone.  The days of siloed PCNs may soon be gone too.

What has arrived is a call for agile, connected and collaborative organisational design. PCNs are already scale-ups. And many of the PCNs I’ve met experience pain around that change. Psychologically, they have struggled to scale up. 

The invitation here is to reflect as a leadership team on what resonates in the article above – and identify blind spots you may wish to explore further.

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.