Does your Primary Care Network really represent its practices?

This series is inspired by Ian Dunt's How Westminster Works... and Why It Doesn't. Dunt takes Westminster apart piece by piece and asks what each part is actually for.

This series does the same for primary care networks, and asks what it means for neighbourhood working.

The series so far:

1. Part one looked at what a primary care network is. It is a contract, not an organisation.

   
   

2. Part two looked at who leads a primary care network. Its leaders carry a lot of responsibility but little formal authority.

   
   

3. Part three looked at where the money sits. The practice holding the account sees the full picture first, and withholding information breeds distrust.

Check out the series here: https://www.thcprimarycare.co.uk/blog/categories/how-primary-care-networks-work

This blog focuses on representation, and it applies to anyone in a leadership role in the network or practice who is asked to represent them in some form.

That might be a board member, a practice manager lead, or a clinical lead for a particular area.

I have worked with over 300 primary care networks, and I hear "it's all about relationships" a lot. I think representation underpins that sentiment.

Relationships are strong when people in the network feel the leadership and management team represents their best interests.

Speaking for people in a room they are not in

The question of what a representative is for is an old one. In 1774 Edmund Burke told the voters of Bristol that he owed them his judgment, not just their instructions.

Political scientists now describe that as the difference between a trustee, who uses their own judgement, and a delegate, who carries instructions.

Anyone leading a primary care network is asked to be both.

Who the network speaks for

A primary care network should represent the sum of its parts. That means its patients, the staff it employs, each practice's needs, its role in the wider system, and now its place in the neighbourhood, working alongside trusts and councils.

To represent the network, the leader needs a clear, shared understanding of the network's issues and priorities. Without that, they are guessing what the practices think. Practices will not all want the same thing, so the leader also has to hear the smaller and quieter practices, not just the loudest.

What it feels like to be represented

Feeling represented means you are listened to, and your view is respected. You feel your leaders will fight for you, support you and back you.

Being represented means trusting someone else to speak for you. You hear about decisions second-hand. Sometimes you hear about them after they have been made.

But it has to be reciprocal. The Clinical Director and the other leads in the network need to feel that as well.

They were chosen because they are respected and have the experience. They are trusted to make the right decision, and that decision has been developed in consultation with the practices.

A practice feels represented when two things happen. Its view is carried into the room, and it hears back what happened. Miss either one and the PCN starts to feel like something done to practices rather than something working for them.

Reporting back matters most when the answer is no. If the network could not get what a practice asked for, tell them why and what the trade-off was. A practice can accept a decision it disagrees with if it understands it.

What it feels like to represent

Network leads are usually chosen for their standing and experience. Then they are asked to speak for every practice at once, including on questions those practices have not discussed yet.

The hardest part is the mandate. Can I agree to this today, or do I need to go back to the practices first? If you go back every time, the meeting stalls and partners lose patience with you. If you agree in the room, you risk going back to practices that say they never signed up to it.

So you sit between speed and permission.

Not every decision can be made by committee. That is where trust in the leadership comes in.

The goal is to seek consensus and alignment, which is always difficult in a group. In my experience, there are often one or two practices in a network that feel they are not being represented. They feel their voice isn't heard and their practice's needs aren't considered.

That is where negotiation, conflict resolution and facilitation come in. The leader must ensure those practices are heard, even when the decision doesn't go their way.

Two more things help. Practices need to see you across the network, not only at the board. When was the last time the Clinical Director spent time with a member practice outside a board meeting?

You also need to be clear about what you can and cannot change. Do not promise practices something you cannot deliver.

In a conversation with Ruth Griffiths of Hill Dickinson, she described the two hats a leader can wear on a PCN board. One is the voice of their own practice. The other is a director, with legal duties to the company.

When a decision benefits the network but costs their own practice, they have to choose which hat to wear. The other practices are watching to see which one they pick.

The hats multiply when a leader holds a portfolio of roles. Alongside being a Clinical Director, the same person might be a director of the GP federation, chair of the Health and Wellbeing Board, and a medical director in a community trust. Each role has its own interests and its own people to answer to.

So when that person speaks in a room, practices need to know which organisation they represent. If it is not clear, it is hard for a practice to feel represented, even when the leader is trying to do their best for everyone.

I have written separately about how PCN governance works across its different levels, and why the three-tier model separates practice representatives from company directors. → Neighbourhood governance and the three-tier model: what PCN leaders need to know

Do I trust you? Do you value me?

Let's start with trust.

When I facilitate, I often ask people what trust looks and feels like. I always get a variety of responses.

The notion of trust is related to our biases and past experiences. Sometimes those things have nothing to do with the issue in front of us.

Credibility. Communication. Doing what you say you are going to do. Discretion. Transparency. In tangible things like the sound of your voice, your perceived social standing in the hierarchy, your clothing choices.

This happens at the individual level, but it compounds in groups and affects culture.

Alongside, the question of " Do I trust you? " is the question: do you value me?

Each professional group wants to be seen, and needs to feel seen and heard, and at points every group feel overlooked, from the GPs to the reception staff.

To minimise this, leaders need to invest time in creating structures to share, consult, inform, respond, and facilitate multiple points of view.

It's hard. But this is your role as a leader.

So when somebody says "it's all about relationships", part of what they mean is this. Do I feel represented by you? And do I know which hat you are wearing when you speak for me?

Support

Facilitation

If your network would benefit from a neutral voice for those tricky discussions, we also provide in-person facilitation.

Members Club 1-2-1

If you need some further advice on how to set this up, please book your 1-2-1 here: https://calendly.com/thcprimarycare/members-1-2-1-w-tara

Interim Management

We're a great fit if you are struggling to recruit and need someone who can hit the ground running until you're ready to hire your permanent PCN Manager.

Contact admin@thcprimarycare.co.uk to discuss the support you may need.

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