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Have your cake and eat it

30 August 2013

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Managing to be both competitive and co-operative might sound difficult, but it is possible to have it both ways

Ask any management student to describe the key elements of a successful business and they will likely reply using words such as vision, strategies, competitive advantage and, most definitely, profit. Ask a GP the same question and you’ll get something around quality care for patients and full quality and outcomes framework (QOF) points. Practice managers are likely to concur with the GP view, but would also describe competitive ways in which they differentiate their practice’s services from others in the same neighbourhood – for example, as a yellow fever centre, providing counselling, complimentary therapies, GPs with special interests and so on. Not quite as clear-cut as the student’s response, huh?

So, is general practice in the business of pounds or patients? There is little point looking for clarification from the centre given that policies and initiatives swing from encouraging practices to be lean and competitive (how often have you seen practice performances being compared – and almost always poorly – to Tesco?) to fervently extolling the huge benefits of collaborative working. In fact, you would be excused for wondering if anyone knows the answer to this thorny question. It also begs a further question – how can we be market focused and do the warm, fuzzy, work-with-thy-neighbour stuff all at the same time?  

The marketplace

In an effort to answer the above, let’s firstly take a look at what we can (and should) compete on.

Starting with QOF, even though this now looks slightly different depending on which part of the country you happen to work in; this is very competitive with league tables pitting you publicly against neighbouring practices, GPs striving to achieve higher and higher threshold percentages and partners competing for best performance in their respective QOF disease areas. But the effort should justify the gain – after all there are a finite number of points, and while there may be professional pride at stake here, nobody gets paid for going above and beyond. Perhaps it would be better to use that energy for other practice goals?

Turning then to consider the rest of the general medical services (GMS) contract.  Fulfilling the essential services criteria, ie. caring for people who are ill, is our bread and butter – unfortunately there is not a lot of opportunity here for enterprise.   Similarly, the vast majority of practices will provide all of the additional services – perhaps with the exception of the out-of-hours service – but again there is little room here for a ‘Dragon’s Den’ type venture. However, there is definitely more scope for securing competitive advantage by carefully selecting the range of enhanced services the practice team makes available to its patients. While most practices will offer the same, or similar services, your practice could opt to provide one or two further services that no other local practice offers. This would mirror strategies used by the likes of Marks & Spencer and John Lewis – attracting patients by offering specialist, quality services that the competition does not provide.

Efficient, capable staff and effective systems will further enhance a practice’s reputation and by default give it a competitive edge over other local practices.

Things to consider

Are you aware of everyone’s skills and/or talents? Perhaps you have a yoga instructor or someone who can design websites in your midst. Use one-to-one discussions and appraisal interviews to discover and utilise these competencies to the benefit of both the individual and the practice.  Are you making best use of skill mix? Could someone be utilised differently, perhaps as a phlebotomist or as a health care assistant? Could the practice nurse undertake some of the GPs work? Are patients being seen by the most appropriate member of the team? Could this be reviewed in order to free up valuable GP and nurse practitioner time? Access and availability are valued highly by patients old and new alike.

Similarly, extended opening is extremely popular with patients – and is an excellent way of gaining new registrations. Unfortunately, it does increase staff costs, although this can be offset by utilising their time to maximise income, such as by phoning patients for recall appointments in the evening or updating QOF registers and enhanced services templates and completing new patient procedures all before the morning rush.  

Remember to ensure that everyone in the team is IT literate and is entering information in an agreed and consistent fashion for Read codes, finance codes, annual leave, etc. Are you using the latest applications, such as voice recognition software and text messaging? Do you have a practice Twitter or Facebook account?  Are these worth considering in an effort to attract younger (and for the most part, fitter) patients? 

Even the basics can give a cutting edge. What is the turnaround time for prescriptions? If it is 48 hours, is this competitive? What do other practices offer?  Check out other practices’ websites. Asda does comparisons against Sainsbury’s and Morrisons – why wouldn’t you do likewise? And not just prescriptions, think about travel clinics, appointment times/duration and so on. Don’t think for a minute other practices aren’t checking you out. Trust me, they are – you could safely bet your flu immunisation income on it.

Of course, the place with the greatest chance of being entrepreneurial is in the range of private services you offer – the only constraints here are your imagination, GMC restrictions and that 10% ceiling on private income earned on practice premises. Again, a little spying on your neighbours, this time on their private fee charges comes highly recommended – just before you start to work collaboratively with them.

Joint working

Partnership working, clustering, integration – if we had a pound for every time we have heard these the phrases used to describe working with other people and pooling resources we wouldn’t have to bother looking for new income streams! But joint working is not new to general practice. We already demonstrate successful collaborative working day in, day out. Take a look at our primary health care teams – a range of disciplines with various management structures and employers all working together with the same aim in mind – excellent patient care.  Most practices have identified buddy practices with workable contingency plans in place should disaster fall on either site. We have working relationships in place that allow practice managers to call one another to borrow stock, vaccine, and sometimes even staff. There are local peer meetings for GPs, practice nurses and practice managers – all intended to encourage the sharing of good ideas and best practice. Further examples can be seen in cluster arrangements where teams of nurses work from one base but provide services for several local practices’ populations. The most obvious example is, of course, the practice clustering and commissioning that my practice manager counterparts in England and Wales are living and breathing every day.   

However, there is still more to be gained from a collaborative approach. The range of services and professions engaging in joint working is becoming ever more diverse, allowing us to work with primary care in its broadest sense, including health inequalities, health promotion, colleagues in secondary care, social care and local authorities. Multi-disciplinary team meetings with a large membership of specialists sitting around the table enable opportunities to network, to break down barriers, to have meaningful discussion about patient care and pathways – and to learn, both from one another and about each other’s services. How else can we sort out shifting the balance of care, begin understand each other’s challenges, reduce duplication of work and identify areas in which we can help one another – and patients – unless we work together?  

Of course, creating, new partnerships and working relationships is not without its challenges but the advantages of collaboration – easier access to a vast range of services, to other professionals’ knowledge and expertise and the ability to provide a holistic service with undoubted benefits for patients – must be worth striving for. Add to this the managerial advantages to be had, such as economies of scale including shared expenses, reduced administration and plethora of people to help to support you with issues that arise, and it is hard to argue against joint working.  

Getting the balance right

Clearly, if your practice was, say, a branch of Costa and my practice was a Starbucks then the gloves would be off, and we would be fighting for every last skinny latte and blueberry muffin sale. But we are not coffee shops, we provide healthcare, and in order to do this well we need to be competitors, pitching against one another to attract patients, and generate income as well as collaborators – in it together working for the ultimate good of those patients.  Thankfully, practice managers are expert at working out strategies that allow the practice to achieve the objectives it sets for itself while best serving its patients, maximising income, pleasing its political masters and maintaining relations with the other local practices. You’ll have a hard job finding a management student who can tell you how to do that.