The importance of ‘progressions’ in your PCN

Ben Gowland, director of Ockham Healthcare, and a former NHS CCG chief executive, believes that primary care networks need to start small in order to progress to success 

CREDIT: This is an edited version of an article that originally appeared on Ockham Healthcare

When I’m not working with general practice I spend much of my time playing tennis. One of the key principles in tennis when learning something new is the idea of ‘progressions’. This involves breaking down a complex task into a series of easier steps, working up to the final result. 

You start with something relatively simple and then, when you can do that task consistently, you move onto something slightly more difficult, and focus on that until you can do that well. 

For example, first, you hit a ball that is dropped next to you, then one that is fed to you from a coach’s basket, then one that is hit in a friendly, collaborative rally, and so on. You will continue to progress until, ultimately, you can hit your new and improved backhand on a regular basis. 

However, if you start off by watching Roger Federer’s backhand – and then immediately try and hit it like Federer at full speed in a match situation – you will inevitably fail, and revert to your old backhand. Instead, you have to work through the progressions so that you learn how the shot feels, what adjustments you have to make, and then make them habits that you can rely on in a match situation.

This idea of progressions applies equally to PCNs and joint working between practices; if a group of practices starts off by trying to run a shared urgent care service across core hours without ever having worked together before, it will most likely run into serious problems very quickly and the project will have to be shelved. The group of practices in the new PCN need to learn how to work together by using a series of progressions, taking steps of increasing difficulty and complexity, so that they can learn ways of working together that will enable them to do more and more together.

Some examples of what these progressions could be – with the assumption that were are discussing a PCN of four practices – include:

• If the four practices share a resource, such as a pharmacist: they work on this until they can do it in a way that means all four practices feel they are benefitting from the shared resource, no practice is feeling hard done by, and the pharmacist is happy.
• If the four practices work together on a shared project that creates additionality for the practices, such as a first contact physiotherapy service: the practices find a way of working together so that they can agree on the location and operation of the new service, how it is organised, how they can use it, and how they can benefit from it.
• If the four practices work together on a project where there is individual accountability for each practice, like a delivery against a key Investment and impact fund indicator: this is more difficult than the previous step because the practices have to work out how accountability and support will work across the practices, such as what happens if one practice is not able to fulfil its delivery requirements.
• If the four practices work together on a project that impacts how each practice operates, for example, a shared document management hub: here the individual autonomy of the practices has to be replaced with a standardised way of operating across all four, which creates yet another new layer of complexity and difficulty.
• If the four practices work together on a project that impacts how core clinical services are delivered in each practice, such as a shared in-hours urgent care hub: now the practices have to work out how they can work together on the delivery of clinical services that have always, historically, been the domain of individual practices.

As the four practices in the PCN work through the progressions they work out what clinical and managerial leadership they need for each type of new initiative, what communication across the practices is required, what the data and reporting requirements are and how these need to work, how support for individual practices within the group should best function and how to deal with differences of opinion without this derailing projects.

PCNs cannot expect to be effective at delivering core clinical services together if they have not worked through some progressions; just as we will revert to our old backhand because the new shot is too difficult, practices will simply try to find ways of continuing to work in their own old autonomous ways if the starting point is too difficult.

Where PCNs are struggling to work together the starting point needs to be something that they can do together, even if it feels small, and then build progressions from there.