The NHS has long supported the idea of GPs working together and in the 1968 contract, which essentially put the specialty on the map, group practice was encouraged. Today’s familiar GP partnership model has both advantages and disadvantages but in theory it does enable GPs to have clinical freedom, and to be independent contractors who cannot be accused of being in thrall to government initiatives or vested interests e.g. drug companies. To some, this remains the essential bedrock of what we do, although the landscape is changing. Many partnerships now include the practice manager or other key members of the team, and further changes are afoot with the advent of STPs and PCNs.
If a partnership is like a marriage, consider this section of the Safe House to be the nearest you will get to Relate! Harry Yoxall, the Somerset guru of the ups and downs of GP Partnerships, believes that all partnerships wax and wane in their “functionality” but he also has found that once a certain point of dysfunctionality is reached nothing can save a partnership.
Some early reflection may be no bad thing, as the state of partnership health can clearly make or break good patient care, not to mention professional satisfaction over many years. You might want to begin by exploring the health of your partnership by following this link How healthy is your partnership? or considering the different relating styles of Dr Chalk and Dr Cheese
The potential for difficulties in a partnership often results from:
More and more, partnerships are developing a ‘vision statement’ to give a flavour of the joint aims of their practice. This often takes the form of a snazzy, snappy statement posted somewhere on the practice website. It is important to have this; to give the partners, management team and wider staff some guiding principles of how they wish to work. However, it is even more important to have the exploratory, supportive and understanding conversation of each other’s values in order to create said statement. This conversation should start with the partners and then be taken to the wider staff group and even the patients.
In healthcare, our values are often assumed or implied; it is easy to think that we are all in it for the same reasons. However, some GPs may put practice income at the top of their priorities, while others may put serving the diverse needs of their community. Both of these are perfectly valid, but for them to co-exist happily in day-to-day practice needs clarity and understanding on all sides. The development of a shared purpose for your partnership is key. Truly understanding and appreciating each other’s values is a cornerstone for building a successful partnership. The happiest practices have addressed this issue. If you have not, the best way is to hold an away day led by an experienced independent facilitator.
GPs have different approaches to their work, ways of dealing with patients, and priorities in terms of what patients need. One of the fallacies of attempting to manage in detail the work of primary medical care is the notion that “one size fits all.” The spectrum of patient needs and expectations is as wide as humanity itself. For this reason, it is well known that patients will often seek out a GP whose style is congruent with their needs. Arguably, a sophisticated country should support this level of medical care, and good Doctors have traditionally been patient-centred. Thus it is important for practices to be aware of the differing contributions of their doctors, and to support the best use of these in delivering holistic care for their populations. If you’d like to consider your own style, have a look at Dr. Chalk and Dr. Cheese
The above paragraph deals with differing GP approaches to consultation, but this is not the only form of communication evident within a practice. Where we are struggling with our interactions, it can be helpful to consider ourselves first. Sometimes when we feel challenged by another it is because they are completely opposite to us, because they remind us of someone we have historically struggled with, because they remind us of a characteristic within us that we are less keen on, or because we are conflicted in some way. So, if you find someone difficult or irritating, start by asking yourself what’s going on for you?
The next step is to ask yourself what’s going on for them? The reality is that, in the vast majority of cases, people behave in a way that they think will deliver them a positive outcome. The trouble is that this can be misperceived by others, depending on their own filters, and land negatively. Try and imagine what the positive intention of the other person might be.
Remember that everyone is different and that’s OK. We are not all motivated by the same things, we don’t all behave in the same ways, we all have our own personality traits and preferences. Successful partnership demands that we take some time becoming aware of what’s going on for ourselves, understanding this and how it differs from our partners, gaining an acceptance of those differences, and appreciating the benefits that brings to the partnership as a whole, making us ultimately more cohesive and more effective.
Nothing beats evidence followed by facilitated discussion. Perception is not truth, data is key in establishing the facts of the matter. If the facts confirm the perception and your partnership is not set up for supportive conversation, an independent mediator or facilitator would be strongly recommended. Exploring the wider truth of the matter (what is going on for all involved? What stresses are they each under? Are there compromises to be made?) is part of the process – this is difficult to do if you are part of the fabric of the problem, no matter how expert a facilitator you are.
Curiosity can work in your favour here. Asking open questions and listening carefully to the answers can help ascertain why certain habits have stuck and what purpose they continue to serve following a change in circumstance. Remaining non-judgemental is important; remember Steven Covey’s 5th Habit (of the ‘7 Habits of Highly Effective People’): seek first to understand, then to be understood. Once you have a true understanding you can begin to explore the pros and cons (or helps and hinders) of the habit to the individual, the partnership, the practice and the patients. Your success in this will depend on your existing relationship with the partner in question and your skills as a coach. You might that signposting your colleague to an independent practitioner preserves your working relationship.
This scenario depends entirely on the circumstance, hence the possible solutions are myriad. If there are questions surrounding fitness to practice for a clinician, you are duty bound to report this to the appropriate authority (GMC, PAG). If you are concerned about stress, overwhelm or burnout in a colleague, a gentle, supportive nudge in the direction of the Safe House and an advocate would be appropriate. Coaching is also a valid option, but remember that we cannot change other people, we can only change ourselves. You cannot force someone to be something they are not, you cannot make them seek help if they do not wish to do so; you can only do your best and that’s OK. Alongside that, it is worth remembering that a colleague who is struggling is also doing their best, and they deserve our support rather than our judgement.
Most PMs fly solo and may enjoy all aspects of their sole responsibilities. Others may experience these responsibilities as isolating, and would value more peer support than is offered by the regular patch PM meetings you already attend.
Suggestions:
PMs might find that they are required to manage their bosses. This may prove to be challenging and the potential difficulties of carrying out this role could include:
Your job description may be clear and unequivocal about the boundaries of your authority but:
If the extent of your authority is unclear in your job description, then you may have discovered how things work in practice and yet this is covert rather than overt and needs constant negotiation.
Suggestion:
Uncertainty about aims and ethos may cause conflict and/or confusion about priorities, financial decisions, employment of staff and any number of other matters. It’s the kind of area that unfortunately often doesn’t come to light until certain decisions are taken and acted on and then feedback is far from positive.
Suggestion:
Sometimes PMs may be confided in about practice policy, finance, workload or other matters by two partners who are struggling with each other. The PM is sworn to respect confidentiality, but the partners’ needs are burdensome and conflict with the PM being able to do his or her own job effectively.
Suggestion:
Partners may easily lose sight of what is reasonable in terms of work expectation. The important and principal difference is that they are usually owners or part owners of the business whereas PMs are employees – an important fact which may be overlooked! If you are feeling overwhelmed and finding you are having to leave work undone or overworking to stay ahead, then you need to take action.
Suggestion:
The role of the Practice Manager varies considerably and continues to evolve. There may be potential to displace some traditional tasks to make way for new work:
Suggestion:
Not only is the Practice Manager (PM) in a unique ‘managing-the-managers’ role with the partners of the practice, but he or she is also often solely responsible for managing the practice staff. The PM usually has no immediate peer group to call on for support or aid in the many daily decisions that must be made, and the authority of the role will tend to be isolating. Stress from this role may come from many quarters:
Staff unhappy with various aspects of their employment
PMs know about management. They know that good communication is essential, that a sense of ownership via involvement in decision-making makes for harmonious working relationships and that perceived even-handedness limits discontent. When unhappiness arises regardless, swift action is essential to curtail its potential spread.
Suggestion:
The situation may be very delicate and require incremental steps so that trust is not lost. It may require a change in your own way of working or some other form of innovation that you had never considered. Staying open to possibilities is vital, and flexibility on your part means that staff know they will not only be heard but that their views will be respected, valued and may form part of new approaches to working.
One of the most important aspects of management is creating and maintaining a good, effective, harmonious working team. Despite time and energy devoted to creating positive working relationships, there may be individuals who are overtly or covertly unhappy with the status quo. When this is personal, action needs to be taken swiftly to curtail the spread of negativity and threat to team morale.
Suggestion:
The way to resolve personal conflict follows the same route as suggested above for staff who are generally unhappy with aspects of their employment. However, as this is personal rather than general, it is vital to be as honest as you are able about the part you may play in the difficulty. Responsibility for any relationship is shared equally, but where one person has authority over another, boundaries and clarity are essential.
You may also find the section on Emotional Intelligence in Professional Relationships useful.
You may be the PM in a practice where partners regularly meet the whole practice team. If so, there will be ample opportunity for staff to raise concerns. If not, then you may find yourself constantly fielding staff concerns with the partners and fielding partner concerns with the staff. Indeed, the partners may insist that a major part of your role is leaving them to get on with the job of treating the patients whilst you manage the non-medical staff. Whilst this may be reasonable in theory, it doesn’t generally make for good team morale in practice. Staff need to feel valued, respected and fairly treated, and if communication between them and the partners is always filtered via you, then they may well find it hard to believe in their own importance to the practice and you will be the main target for their discontent.
Suggestions:
Consider what opportunities for greater communication could be built into the working week:
Anything which diminishes an ‘us and them’ culture and works towards a positive team culture will pave the way for optimal communication and working relationships.
Self Help Gym
Staff Room
Consulting Rooms
Managers Office
Stress Reduction Centre
Burnout Recovery Suite