Capacity and Capability
Capacity does not meet demand. How familiar does that sound? How long has that sounded familiar? This is an evolving and worsening problem. Here in Manchester we had a 12.8% population growth forecasts between 2010 – 2020 (source Office of National Statistics) but unmatched growth in primary care estates or staffing. Primary Care operated under a “make do and mend” approach. A few extra staff here, converting the odd staff toilet to a clinical room there. It was piecemeal, it was reactive. There was no system level strategy.
The background to the increase in demand has been a diminishing medical workforce. This workforce gap is likely to widen, with an expected exacerbation of the demand – capacity gap.
A New Hope
In 2019, Primary Care Networks came along – and offered a glimmer of hope. This hope manifested as the additional roles reimbursement scheme (ARRS). This is funding for staff to work in primary care coming from NHS E&I and routed through the Clinical Commissioning Groups (CCG). ARRS did what it said on the tin, it was ”alternate” roles – not funding for the traditional roles from traditional workforce pools. General Practitioners and Practice Nurses could not be funded through this scheme. Requiring some innovation and service re-design, significant underspend of these funds resulted. This situation improved, but there is a current forecast for underspend in Manchester.
A factor in this ongoing underspend is the uncertainty about how some of these named roles fit into practices. What exactly can a Nurse Associate do? What is the governance requirement for pharmacists? Does our indemnity insurance cover paramedics? In the face of these uncertainties, and with overwhelming workloads elsewhere, the work required to achieve ARRS just has not been happening everywhere.
From Hope to Success
So, what is a PCN to do? There is some initial work to be done to understand the potential of the new roles and how they may or may not add value at practice or network level. That is, indeed the first decision: whether to just give the ARRS funded staff resources to the practices or whether to establish network level services. There is no right answer here. Some PCNs barely function, some devolve the work to federations and some are making best speed. PCN boards must make their own decisions about the choice between resourcing practice or network level services, whether to recruit or outsource and most importantly how to govern and manage these new staff/services. These new staff/services present a new capability – a new way of addressing the demand driven capacity gap. This capability often goes to support PCN contract work (eg Extended Hours) and the benefit may be less tangible at practice level. The new staff are not the whole solution but accessing new parts of the wider health workforce will bring fresh bodies with fresh ideas. The resulting cognitive diversity is a direct benefit of generating these new capabilities.
An example of cognitive diversity are the new Mental Health practitioners. Co-employed with local mental health trusts, they are creating a new way of managing the primary care mental health workload. Some of these practitioners have already challenged existing practices and the very best of them are forging new capability at practice level that should, in turn alleviate burden from the other clinicians in the practice. In partnership with care coordinators and social prescribers, new service offerings are springing up – to meet local needs at “place”. These will evolve though PDSA cycles and as additional mental health staff come on stream in the coming two financial years, these service offerings have the potential to mature into really valuable assets for practices and patients alike.
One of the principles of ARRS is to reduce the demand burden at practice level. One of the unintended consequences of new staff with new capability is increased governance, education, administration, IT and estates pressures at the practices. This can so easily feel like robbing Peter to pay Paul – increasing rather than reducing the burden. There is a presumed medium-term benefit as these new staff members become increasingly independent, but the short term cost can be a barrier. This has almost certainly been another reason for ARRS underspend – it creates short term burden at a time when such burdens cannot be tolerated.
Leaders Please
Where is the solution? All solutions require change which in turn requires leadership, so all solutions need to be led – or suffer the indignity of not succeeding. Leadership is a key component in the delivery of change – rather than the management of business as usual. There are ways to minimise the initial burden on practices, digitisation has presented opportunities for alternate work plans to navigate the limitations of estates pressures and new services run at network level.
This is the time for the leadership that is responsible for the PCN (however it is structured) to step up, innovate and deliver. That is, of course, a lovely rallying cry. Where does the rubber hit the road, how to make things happen?
These changes are not simple to implement. Integrating new professions into a fledgling inter-professional team. Ensuring the development needs of these different professions’ cultures are met, establishment of new measurable outcomes and how/when to report and performance manage those outcomes. For many in primary care, these are new challenges, or at least solutions requiring novel nuance. Here are some pieces of advice that may or may not be useful in your situation. Our suspicion is that they will. Humans are humans, and there are some underpinning truths at play here.
Firstly, do what you can. It is not possible to do everything. Pick something achievable, deliver it and move onto the next task. You need to filter out the distractions – those urgent requests for information that are neither urgent nor important. Learn to say “no thank you”. Set your goal, stick to it.
Secondly make your big jobs into small jobs. Break them down. This is known as chunking. It has the side benefit of drastically shortening your PDSA cycle and will make your decision making more responsive. This is the “agility” that the management consultants are so enamoured with at the moment. Agility helps support a learning culture – changing direction in the face of new experiences. Keep your goals small, evolve, stay nimble. This is so much easier at the scale of place than system. Primary care is largely blessed with this smaller scale – it is time to take advantage of not being a massive institution.
Next, get help. Build your team, develop your relationships and influence the style of working (stay positive, learn not blame). Nothing meaningful in the health services can be achieved solo. Your team will almost certainly be a blend of formal teams, informal team building, stakeholder relationship management and the whole spectrum of human interactions. What leadership behaviour are you displaying at the moment and is it more or less likely for you and your team to achieve the goal?
Last, but by no means least, use that help! Delegate. To do so effectively you will need to display trust and trusting behaviours. When the inevitable hiccups occur, generate learning not blame. Unless you are in a very unusual position, whatever you are doing is not life threatening/saving. Keep some perspective. Listen to the team – and hear them. The litmus paper test for this is simple – how often are your decisions informed by feedback from the team? The more they are, the better the listening process is occurring. Your people’s wellbeing will always be more important than the goal, the value they will derive from being listened to will directly improve their wellbeing. Without staff wellbeing you will achieve nothing meaningful in the long term – your team will not be sustainable. How often have you already seen that failure play out?
Deliver and Sustain
Primary care is undergoing a significant workforce change. Set against the background of loss of general practitioner numbers, and further shuffling of the deckchairs of statutory institutional reorganisations there are plenty of reasons to do nothing. But that would not be leadership.
Set goals, lead, deliver, repeat.
To make this all sustainable, look after yourself and look after your whole team.
About the blogger
Drew Carroll is a Primary Care Network Clinical Director, Advanced Clinical Practitioner and Managing Director of a leadership consultancy. He has a background in healthcare, the British military and industry. Claiming to have learnt most leadership lessons “the hard way”, he works to have impact at system level and is passionate about looking after staff first.
