A Co-operative Future for General Practice?

imgresIf you take the work of Steve Peters (of “The Chimp Paradox” fame) seriously, which I do, then you can see Chimps at work everywhere in the NHS right now (and I’m not taking a cheap shot at Jeremy Hunt). For those of you, who have no idea what I’m talking about, then do read the book….but a brief precis is this: each of us are two people – we are both simultaneously an emotionally driven, primal chimp and a more rational human being. When faced with difficult circumstances, our chimps all too easily take over and our behaviour is driven by our emotions, because our human also feels insecure and we lose hold of our values (the computer part of our brains) which is able to alter our chimp behaviour.


I’m not making a judgmental criticism, I see it in myself. I see the raw emotion of how Iimgres feel about what is happening in General Practice, Community Nursing/Therapy and indeed the NHS at large and it becomes easy to function out of raw emotion, heading into ‘rant mode’ or a strong defensive posture with the rest of my pride. But I have found it brings division. It pits my practice against another or General Practice at scale against the Hospital Trust or the government or whoever. But it doesn’t actually solve anything. It stares the problem in the face and hollers at it or throws faeces at it, and other than being cathartic (which has it’s place for a while), it doesn’t engage with a creative or collaborative process about how we face the future. The facts are right in front of us, and there is some thought about how to make General Practice strong enough to survive, be that through giant mergers or the formation of federations. Here in Morecambe Bay, we are experimenting with both those options and also trying to work in Integrated Care Communities (incorporating all our community partners) according to geographical locations.


However, I’m not sure we are facing up to the realities we see creatively enough. Whether we like it or not, General Practice as we have known it is unsustainable. There simply aren’t enough doctors coming through training, there aren’t enough doctors choosing to be GPs and there certainly aren’t enough GP trainees wanting to become partners.The partnership model as we have known it, is over, and the sooner we face up to this, the more creative energy we will be able to harness to find solutions. The formation of federations or the advent of the ‘super-practice’ will go some way to stop the gap, but it is the structuring of them that deserves some attention. Integrated working with community teams, be that district nursing, mental health, community therapies or social services calls for a wider and deeper system change. But here is the very difficult thing for GPs to let go of: the idea of the autonomous self, being in charge.


Co-Op-PrinciplesIf we are going to find solutions to the needs of the people we serve and develop together (no matter what is being shaped from the centre) a future healthcare model that works, GPs may need to let go of our power, as we have known it and embrace a different way of being. I think a possible solution lies with the co-operative movement as this would allow a truly integrative model to develop that benefits all our workers, no matter what their role, giving us the cultural environment in which innovation, excellence, learning, creativity and compassion could really flourish. Due to the nature of co-operatives and the principles at their core, a powerful force could be released which provides alternative solutions for a more equitable society.


What would a co-operative model be like? Well, there are different options and different imagesstyles, from John Lewis to Mondragon, or the model adopted by Jos de Blok in the Netherlands. But the reason I like it so much, is that it takes power from the few and shares it with the many. It allows for a different style of leadership and a different mode of making decisions. Collaborative conversations and compassionate care of one another in providing care to the wider community becomes the order of the day with leadership that is both clinical and managerial but modeled on financial benefits for everybody and cooperation of wider teams of people.


imagesThere are draw backs and co-operatives are not perfect, but they are a solution that should be seriously considered as General Practice tries to navigate itself into the future. They can be complex to set up, but I would argue that complexity is worth it when it offers a solution that lasts longer than a more straight forward quick-fix that may not make it past a decade or two.  Are we brave enough to explore solutions that dis-empower us for the sake of a better future for everyone?

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Why Better Care Together?

imgresThere is an ancient proverb that says: without vision, people perish. I believe we in danger of watching the NHS perish in front of our eyes, not because we don’t know what to do or even how to do it. I believe we have been so focused on the what and how of healthcare, that we may have forgotten why we do what we do.


The NHS is an organism, made up of many living cells, called human beings, who have a vast range of complementary skills and interpersonal connectivity. These cells work imagetogether in tissues, joined to each other in complex systems to function as a body, a body which gives itself for the health and well-being of the nation. This body is not a robot, who’s performance can be processed like a machine for a predetermined output, but it has been treated as such, just another example of biopower, where people are used, rather than cherished. So now we have more of a Tin Man with no heart, than a living, breathing body.


But at the heart of the NHS is what we find in the heart of every human being, if we dig deep enough. The heart of the NHS, the very core of its being, it’s true raison d’être, it’s driving force is in fact, love. And the people, the cells who work in this loving imageorganism, also carry love in their hearts for other people. It is stamped through the DNA. It is the motivation. It is the reason people get out of bed in the morning, or work through their weekends and nights. It is why the wards are clean and the beds are made, why the bloods are taken, the investigations are done, the research is carried out, the people are washed and fed. It is why the hours of study and audit are diligently pursued, it is why the training is so robust, it is why the skills are acquired, it is why the time is given. It is why the NHS was founded in the first place, because all people, no matter how rich or poor, saintly or depraved, are worthy of love.


And yet we find that the human beings who join together to form this body are often struggling with severe stress, anxiety, depression and low morale. How can this be so? Is it possible that the structures we have put in place to try and support this body have instead become a hindrance? When my wife was born  she imageshad congenital talipes aka clubbed feet, due to a positional issue in her mum’s womb. When she was born, her feet were turned in and she had to wear painful calipers for 2 years until she was operated on by a very skillful orthopaedic surgeon. Now, in her mid thirties, she can run and dance because the calipers were taken off in childhood. As the NHS grew and developed, structures were put in place in its formative years to help the right sort of growth and strength to happen, but many of these are no longer useful and in fact are now a hindrance. We have become slaves to serving structures and ways of doing things that work against us as we try and stay true to our core motivation of love.


Part of what we are exploring through ‘Better Care Together’ hereiu-4 in Morecambe Bay is how to dismantle and reform these structures in order to allow this amazing body to function more naturally and freely. This organism is constrained within bizarre silos that make the what and the how of healthcare provision so complex that the why of what we are doing so easily gets forgotten amidst the complexities of service delivery. So, first and foremost, we must recover/rediscover/reconnect with/strengthen our vision, founded upon love and compassion for other people. Galvanized by this vision to provide continually improving, high quality, compassionate and loving healthcare to all in our community, we must tell the structures again and again, that we do not serve them, but they are only there to help us in our task. Right now, they need remodeling, and this is happening. We need less care in hospitals and more in the community, we need better integrated IT, different payment methods, new ways of working in General Practice (in larger more resilient practices, federations or co-operatives) and across the old boundaries, better pathways for patients and communities to be able to care for themselves and each other more effectively. But unless we have love, all these things are like a great symphony orchestra, playing a great new score but void of any connectivity with the audience. The form, as our chief commissioning officer, Hilary Fordham, rightly tells us, must follow the function, but I believe both the form and the function are motivated and under-girded by love and compassion.


So, why Better Care Together? Because the world has changed and the health needs of the population have changed and we simply can’t afford for things to remain as they are. But the deeper reason is so that we can provide continually improving, high quality, compassionate and loving healthcare to ALL in our community. This involves a mindset change. No more can we think of our own little patch. No more can we think ‘I’m just a GP of 1500 patients’, or ‘I’m just a nurse on the cardiology unit’ or I’m just a physio working in one particular area’ or ‘my practice only looks after 17,500 people’ (though of course this kind of personal care is still absolutely vital), but the paradigm shift in our thinking is towards being a member of a healthcare system that cares for the 350,000 people around the Bay. It’s about allow our hearts and our vision to grow bigger whilst giving brilliant care to individuals where we are located. That means learning to work differently, always motivated by the love and compassion we have for people.



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