Phns and GPs… engaging with strategic intent!

This article in a nutshell

The Commonwealth Government has placed GPs as the cornerstone of a reinvigorated primary care system and has mandated them as the central clinician stakeholder group for Primary Health Networks (PHNs). It is undeniably crucial therefore that PHNs engage effectively with GPs across their regions. This is easier said than done given the diversity which characterises the profession and the geographic vastness of the rural and remote PHN regions. This is complicated further by historic criticisms of the PHN’s progenitor organisations, the Medicare Locals, for their perceived failure to engage with GPs.

This article seeks to provide points of reflection which PHNs might use to appraise the current status of their engagement and relationship with their GP community and stimulate thinking about how this might be improved.

Engagement is predicated on a relationship, with the quality of the relationship predicated on the value that the parties attach to it. For PHNs to maintain an effective engagement it is important to establish and market the ongoing value proposition to GPs- and the value proposition needs to be commensurate with what we are actually asking them to do.

In short, for GPs to engage in the PHN’s initiatives they need to know what’s in it for them and PHN’s need to be offering something in return that is of sufficient value to warrant their participation.

Read on for the full article

Why do PHNs need to engage well with GPs?

Some of the reasons are obvious but others perhaps less so. The most obvious reasons include:

The Commonwealth, as the PHNs’ principal funder, requires it
GPs are highly respected by the public and as such carry enormous influence with the funder
General Practices are highly distributed and therefore constitute an extremely wide footprint from which to leverage change nationally

Less obvious reasons:

GP’s know stuff- they talk with the public and other clinicians every day of their working lives
GPs are a smart lot- PHNs need to harness their intellect in dealing with the very significant challenge of modernising the primary care system

Why it is important to engage with strategic intent

The PHN’s strategic intent is the starting point for its stakeholder engagement strategy. Your strategic intent will dictate the nature and scope of your engagement strategy. Reflecting on my experiences with PHNs I have observed three ‘types’ of strategic intent. I won’t call them levels as this would denote a preferred hierarchy – all are valid.

Type 1- The PHN as a force for transformative health system change- whereby engaged GPs and practices are offered a ‘challenge’ to partner with the PHN in system reform.

Type 2- The PHN as a system ‘gap-filler’ and diffuser of established innovation- whereby engaged GPs are offered an ‘opportunity’ to participate in a project with the PHN. Securing equity of health outcomes for under-served groups is a particular concern.

Type 3- The PHN as a consolidator and incremental improver of the current system – whereby engaged GPs are offered ‘familiar services’ by the PHN e.g. CPD, CQI, etc.

These types are not mutually exclusive with elements of each coexisting within the same PHN. However I feel that one type would be prevailing and would serve to characterise a PHN’s strategic intent to its funder and its external stakeholders.

The PHNs strategic intent will determine:

Who to engage i.e. whom from your market research is likely to have an interest in a given PHN initiative
What to engage them in e.g. a joint project to transform the health system (Type 1) or …. participation in a professional development activity routinely offered in past years by an external provider such as Vaccine Administration (Type 3)
What will be expected of the engaged party, i.e. are you offering them a challenge (Type 1) or offering to provide a familiar service (Type 3)?
What kind of value proposition needs to accompany the engagement to make it adequately attractive for the GPs or practice to participate e.g. a Type 1 engagement will need to have very strong inducements whereas as a Type 3 engagement may require very little inducement or ‘selling’
Where there are likely to be overlapping interests between the PHN and the engaged party that can be leveraged i.e, the win- win scenario

There is more to be said about the importance of strategic intent in crafting an engagement strategy and this might be the subject of another article. Suffice to say it is crucial that the PHN is clear about its strategic intentions to avoid confusing staff and external stakeholders. With the PHN achieving clarity on its strategic intentions the elements of the engagement strategy are more likely to “fall into place”.

How to engage well with GPs

To engage well with General Practitioners, and their practices, PHNs need to:

Know the strategic intention for the engagement i.e. have an explicit understanding of what the PHN is looking to achieve (we need to get better at this)
Ensure a unifying narrative is delivered by the PHN’s staff- no mixed messages!
Tailor the value proposition so that it is attractive enough for GPs to engage- find out what they want, aim to deliver it and make sure that it carries enough value!
Pursue reciprocity– if you are giving GPs what they want they will be more inclined to give the PHN what it needs out of the engagement, although there can be no guarantees
Consider the nature of the message a health alert about a disease outbreak is very different to an invitation to attend an event to learn about how they might become a pilot for the Health Care Home reforms
Consider the nature of the different ‘audiences’-
- GPs are diverse and pluralistic in their views and interests (different value propositions are needed for different groups)
- General Practice operators’ views and interest are not the same as those of the GPs that work for them
- GPs practising in different geographic settings have different outlooks- metro, regional, rural and remote may have highly polarised worldviews (think back to the RACGP- ACRRM split for evidence of this)
- Practices can be ‘categorised’ into groups with common characteristics and this can be used to tailor the engagement strategy for known ‘market segments’
Ensure that the appropriate modalities for communication are employed; informed by the nature of the message, the plurality of the GP profession and practices (i.e..the audiences), and the strategic intent of the engagement
Be mindful of timing- people are not always ready to listen to a message until it is abundantly relevant to them!
Be concise– GPs are extremely time-poor so messages need to be broken down into readily ‘digestible chunks’
Know what your value proposition is and sell it – despite their diversity all GPs share an interest in improving the outcomes for their patients and as such PHNs are advised to stress the benefits to patients in the ‘sales pitch’.
Know how to get past the Practice Manager – practices task the Practice Manager to “gatekeep’ access to the busy GPs so it is important to know how to deal with this and it will be different for each practice

Perhaps more important than any of these is for the PHN to know why it exists, what it is meant to do and how it is going about it. Medicare Locals were de-funded because they could not establish a clear vision and purpose. PHNs are well placed to avoid this mistake- provided they are alert to it.

More on the nature of the General Practice profession

Having worked intimately with doctors and GPs over the past 20 years I offer a few insights:

GPs are the doctors who have chosen to work outside of the hospital sector. I sense that many GPs have had difficult experiences during their hospital training including bullying and other forms of harassment by senior hospital staff. This makes for a resentful and combative relationship with their hospital counterparts complicating the PHNs’ efforts to encourage the integration of patient care.
GP training over previous decades prepared GPs for “autonomous” clinical practice. This is at odds with the emergent needs of an Australian population living longer under the burden of complex chronic illness. Interdisciplinary team-based practice is what’s needed for these patients. As a result many GPs feel out-of-step with the PHNs strategic imperative of “hard-wiring” patient integration across the primary and acute sectors, to better serve the community’s needs
General practice can be professionally isolating – other than occasional professional development events GPs may have relatively few opportunities to meet with colleagues beyond their own practice.
GPs seem frustrated and alienated by the work practices required of them. In my view, fee-for-service medicine, predicated on high patient throughput, has a “stupefying” effect on many GPs. We need to remember that GPs are among the most intelligent people in our community, and day-to-day general practice with its expectation of fast medicine with referral to hospital specialists as the standard resort for disease-difficult patients, does not permit GPs to apply their intellect and develop their clinical acumen. I recall many UK- trained GPs lamenting that they felt that the Australian system had a deskilling effect. In the UK, GPs are expected to actively treat patients with complex care needs rather than refer them on to the hospital ‘experts’!
Like Australian society more broadly, the GP profession is subject to inter-generational tensions. Many of my GP friends have expressed their frustration with younger colleagues who are intent on having a career that accommodates their family responsibilities and lifestyle preferences- not the other way round. I have witnessed serious conflicts with younger GPs choosing to practice part-time and declining after-hours work. Older GPs are characteristically of the view that the profession is a “vocation” not a job, but younger GPs may disagree. I won’t go into gender differences as this warrants an article in itself.
Many GPs report ‘change fatigue’. The ‘false starts’ that typify primary care reform in Australia makes the job of the PHNs more difficult that it needed to be. The Commonwealth’s predilection to “hit the reset button” has been unhelpful!
Interdisciplinary care arrangements exposes a GP’s clinical practice to others and not everyone is comfortable with this, Some GPs fear negative scrutiny from their peers and other healthcare professionals. I suspect this has a lot to do with how doctors have been trained in previous generations and how they were treated during their formative years working in the hospitals,

What about the preconceptions of PHN staff about GPs?

Our views about any profession are naturally shaped by our experiences with those in the profession. It is highly advisable to check in with your staff to see what they think of the profession as these views will reflect in their interactions with GPs and Practice Managers. This is an important consideration when recruiting staff to GP- facing positions.

Effective engagement requires an understanding of the different types of practices in Australia

Without wishing to over-simplify or stereotype I feel that practices generally fall into five categories – although in reality each practice functions as their own unique working accommodation of the following competing sets of drivers.

Business driven practices – patient services are commodified and the main intention is to maximise profit and return on investment

Patient needs driven practices – the GPs working at this practice see their profession as a vocation and will often subordinate their own interests in the service of their patients

GP ‘Quality of Working Life’ practices – GPs at these practices are concerned to maintain a good work-life balance so that they can pursue personal life interests and goals. They work to live – not live to work.

General Practice as an intellectual discipline – GPs at these practices are highly engaged with the practice of medicine as an intellectual discipline. They may pursue academic appointments and characteristically have a commitment to teaching. They are also more likely to be active within their profession. I note that GPs from these practices often seek to develop areas of special clinical expertise e.g. Diabetes, Asthma, Mental Health, etc,

Boutique General Practices – GPs at these practices choose not to offer longitudinal whole person care but rather maintain a focus on a specific aspect such as Skin Care or Nutritional Medicine, Cosmetic services, etc.

Admittedly these are loose constructs and require formal study to be fully validated. However I feel that they have heuristic value and serve as a useful way of categorising practices for the purpose of tailoring an engagement strategy. I hope to elaborate on this in a future article but suffice to say, for the purpose of this article, smart PHNs will tailor the engagement strategy for each type of practice.

Engaging with Aboriginal Medical Services is perhaps best dealt with in a separate article.

The importance of having good personal relationships between PHN staff and GPs ….. and the perils of over-relying on this!

Those who have worked with GPs and Practice Managers know that good personal relationships are at the heart of effective engagement. This is undeniable but it’s not the whole story. An over-reliance on this creates a material risk for the PHN because:

It creates a key dependency for the PHN- when the staff member leaves the relationship ends!
It creates a strategic tension within the PHN’s staff as those prioritising being “‘friends’ with a practice will be conflicted when they need to challenge the practice with the need for reform
It creates a dynamic that sees the PHN’s practice support team preferentially support “friendly” practices and avoid “difficult” practices
When a personal relationship sours it has significant consequences for the PHN’s relationship with the entire practice not just the individuals who are in conflict.

In my view PHNs need to be “fierce friends” with the GPs and Practice Managers. PHNs need to be abundantly supportive, but also seek maturity in the relationship that allows the PHN to present challenging information and advice when it is required.

I have witnessed great Practice Support staff balk when asked to engage with practices over the need for reform. They balk because they fear upsetting the relationships or do not have a sufficient grasp on the reform message and fear being embarrassed if unable to respond to questioning. As wonderful as our Practice Support staff are a PHN cannot allow individuals to dictate the engagement with its most important stakeholder group. A manager once told me that it was my job to “just hang out” with the practices but I felt that this was disingenuous and wasted everyone’s time. PHNs are there to make a difference or what’s the point?

In the days of the GP Divisions life was a bit simpler. Then the job of the Practice Support Team was to present the members with a ‘smorgasbord’ of opportunities that practices would select at their discretion. No pressure was applied and the worst thing that a Practice Support person could do would be to upset or pressure a GP. In the era of the PHN the dynamic is totally different as Practice Support staff are often presenting a challenge to practices – to collaborate with the PHN and others in systemic reform (i.e Type 1 Strategic Intent).

Please don’t get me wrong though- nothing can replace the insights of those actually visiting practices as this allows the data collected in other ways to be qualified and contextualised. It’s just so important that the PHN does not over-rely on it.

PHNs should not underestimate the importance of developing a practice support team able and willing to deliver on the organisation’s strategic intent- whether it be Type 1, 2 or 3 (see above).

The importance of having the real ‘intel’ on your GP community

Some industries invest huge resources, time and energy in understanding its market. It is curious that some PHNs appear comfortable with guessing at the interests, concerns, preferences and intentions of its GPs and practices. As one colleague said to me- ” I know my practices and my practices know me”! and as such my colleague was entirely comfortable in discerning things like their professional development needs or their interest in engaging with the PHN’s initiatives. The reality of this is that a person (over time) may develop a deep appreciation of the needs of those that they engage with routinely but this cannot replace the need for systematic standardised data collection purposefully crafted to support the PHN’s strategic intent and shaped by a considered appreciation of the constraints and behavioural drivers of their GPs and practices. This is particularly true when one consider the diverse social demographies of people living in capital cities, regional centres, rural towns, mining camps, and remote indigenous communities.

PHNs can’t allow GP engagement to become a ‘dark art’ mediated by the initiated few. It needs to be systematic, transparent and open.

What would be best practice in the management of data collected as part of a GP engagement strategy?

To establish sufficient evidence to engage with Type 1 (i.e reforming) strategic intent, and deliver the PHN’s regular day-to-day operations, I think that it would be important to:

Develop and apply a data ontology– standardised data definitions, agreed naming conventions, uniform consenting arrangements and stable datasets so that information is collected in a way that provides meaning and is amenable to time-series analysis
Collect, collate and analyse data systematically – regular collection cycles designed to populate predetermined datasets made subject to reporting and robust analysis
Collect data in a way that is considerate of the respondents’ circumstances– i.e. time poor clinicians with variable interests in engaging with the PHN, and often subject to competing requests to provide information ( survey overload !!)
Design the data collection processes with a view to meeting the different data needs of the PHN
- Operational e.g. to update the CRM listings
- Management e.g. to identify those with an inherent interest in a portfolio’s activities, such as Aged Care, Mental Health, Health Care Homes, etc.
- Strategic e.g. workforce participation trends
Collect data in a way that facilitates its use in the intended ‘data products’ such as:
- An update file to refresh the PHN’s Customer Relationship Management (CRM) System
- An update file to refresh external ‘priority’ data repositories such as the National Health Service Directory (NHSD) or State Health Provider Directories
- An annual review of GP’s self-identified professional development needs
- A Regional Emergency and Disaster GP Response Register
- A Digital Readiness Status Report
- etc..
Design the data collection to inform the PHN’s initiatives– i.e. collect once and use for many portfolios. It is very important to avoid the situation that sees the PHN portfolio managers randomly using multiple survey monkeys in attempt to meet a felt information need – this drives GPs and Practice Managers to distraction!
Ensure that the data collection instruments have sufficient flexibility to engage with GPs and practices on topical and emergent issues e.g. a new disease outbreak, a crisis response or perhaps to get feedback on a looming reform or system change
Maintain the capacity for multi-modal engagement techniques such as:
- Focus Groups
- Semi-structured key informant interviews
- Surveys – printed, online or a combination
- Others such as online discussion forums for interest groups
Ensure compliance with the privacy legislation as amended from time to time (note that GPs and practices are often concerned to see that information they provide online is secured on Australian-based servers)

For those PHNs electing to function as ‘regional consolidators’, that is Type 3, then less sophisticated data management arrangements might suffice. The point here is that the level of sophistication needs to be much higher for those PHNs pursuing their Type 1 transformative remit.

Using the insights of Diffusion of Innovation Theory in crafting your GP engagement strategy

For those PHN’s fully embracing of their reform remit (and not all need to be) the insights afforded by the Diffusion of Innovations theory and the related Technology Adoption Lifecycle are very important. Both are sociological models which state that the propensity to adopt innovation are associated with the demographic and psychological characteristics of defined adopter groups.

The groups follow the regular bell distribution curve:

Innovators 2.5%
Early Adopters 13.5%
Early Majority 34%
Late Majority 34%
Laggards 16%

The Diffusions of Innovation Theory, posited by Everett Rogers in 1962, was based on a study of the adoption of new hybrid grain seeds by farmers in the American mid-west. Rodger identifies four main elements which influence the spread of a new idea: the innovation itself, the communication channels in use, time, and the prevailing social system. This process is said to rely heavily on human capital. The innovation must be widely adopted in order to self-sustain and within the rate of adoption, there is a point at which an innovation reaches critical mass, making the change irreversible.

Diffusion manifests itself differently in each adoption group and is highly subject to the type of adopters and innovation-decision process. The criterion for the adopter categorization is ‘innovativeness’, defined as the degree to which an individual adopts a new idea.

A quick scan of the international literature shows attention by academics to the application of the theory to healthcare practice as early as the 1970s. Since the 2000s these articles have tended to include a focus on the adoption of technology in clinical practice extending to information technologies such as electronic health records.

An article published in the BMC Family Practice 2013 – “A diffusion of a collaborative care model in primary care: a longitudinal qualitative study” by Vedel et al, confirmed that the adoption of innovation with new models of care is essentially a social phenomenon requiring a commitment by clinicians, a willingness to take risks with the role of opinion leaders key.

So, how might PHN use these insights to craft its GP and practice engagement strategy? My thoughts are:

Devise different but complimentary strategies for GPs and Practices– they are different stakeholder groups!
Develop ways in which they can be categorised into the adopter groups- innovators, early adopters, early majority, late majority and laggards. But be mindful that individuals can move between groups based on their experiences- positive and negative.
Customise the application of the engagement strategy for each adopter group- consider the intention of the engagement, the message form and content, mode of delivery, the time of delivery and the communication channels that will be used – formal, and informal.
Appreciate that adopter groups are not necessarily homogeneous– consider generational, gender and locational differences such as rurality
Anticipate the message distortion tactics that will be used by detractors so that they can be countered by the PHN where possible
Search out the clinician opinion leaders and enlist their support while co-opting dissenting opinion leaders to try to win them over!
Be mindful that a range of external ‘actors’ will be observing the way in which the PHN engages with its GPs and these may act to influence the outcomes e.g. peak bodies, professional associations, unions, politicians, state and local governments, community leaders, etc.
Leverage the power of existing social networks maintained by GPs and practices. In clinical practice these ‘social networks’ take the form of natural professional referral networks, and it is incumbent on PHNs to leverage these so that critical mass can be achieved earlier!

Differentiating between those innovations that are in the process of diffusing as opposed to those that are at a nascent stage

My curiosity has often been piqued by the application of the term innovation. At what point does one appropriately stop seeing something as innovative? This warrants investigation and poses questions for us to consider.

Is something truly innovative or just new to us?
Can we call something innovative if it is already established in other countries or other jurisdictions?
Should we differentiate between an innovation that has achieved critical mass (e.g. Health Pathways) as opposed to something that is yet to obtain this (e.g. My Health Record)?
Do we sometimes claim things to be innovative because we feel the need to be seen to be innovative?

In my estimation, true innovation entails risk and the chance of failure. PHNs owe it to themselves to know their ‘reform appetite’. Some PHNs will choose to be effective diffusers of established innovations and there is nothing wrong with this (Type 2). Others will place themselves at the “bleeding edge” of healthcare reform cutting through decades of reform inertia in Australia (Type 1). The choice needs to be active and explicit if the PHN wants to be clear about the role that it is assuming in the local healthcare delivery system.

Applying marketing principles used in other industries to the GP engagement challenge

Big Pharma has it all over us in this regard. Consider the ongoing investment that Pharmaceutical companies make to understanding the behaviour of GPs. No doubt there are marketing companies across the country that would be delighted to be engaged to help PHNs to be better able to “reach” GPs and Practice Managers.

I am not a marketing expert so I will go no further than to advocate for an exploration of professional marketing expertise in the development and implementation of a PHN’s GP engagement strategy.

How should we gauge the effectiveness of our engagement activities?

On reflection I think that this comes back to the strategic intent of the engagement. So let’s just recap the three types discussed at the beginning of this article:

Type 1- The PHN as a force for transformative health system change.

Type 2- The PHN as a system ‘gap-filler’ and ‘diffuser of established innovation’

Type 3- The PHN as a consolidator and incremental ‘improver of the current system’

This deserves a separate article but suffice to say that the relative importance of different metrics (input, process, output, outcomes) would vary for each type.

Type 1 given its transformative intentions would have a focus on outcome measures such as adoption rates of new models of care. Type 3, with its focus on maintaining the status quo would have more of a focus on activity counts, input and process metrics e,g, numbers attending CPD events ; numbers of practices participating in a CQI initiative, etc.

It is important to apply the full suite of metrics for each type of strategic intent while mindful that some metrics will be more informative and significant than others. Foundational of course is the need to periodically and systematically ask GPs and Practice Operators about their experiences when engaging with the PHN and its staff.

Please look out for a future in-depth article on measuring the effectiveness of GP engagement. It will be interesting to see whether the Commonwealth wishes to provide guidance as to what PHNs should be measuring to evidence effectiveness in GP engagement.

Conclusion

It is noteworthy that other western countries are acknowledging the need for healthcare system managers to get much better at GP engagement. Check out the GP Engagement Strategy developed in 2015 for the Shrewsbury and Telford NHS Hospital Trust. It stresses the need to:

Use market intelligence in a more strategic way
Secure the involvement of clinical leaders to ensure that the engagement strategy sees “clinicians talking to other clinicians”
Consider the use of “account management” practices similar to those used in other industries
Incorporate horizon- scanning practices so that GPs and practices can be better prepared for future change

A summation of this article would be:

Know your strategic intent
Know your market
Get your message straight
Get your value proposition right
Get clinical leaders involved
Seek reciprocity
Get change traction through engaging selectively

Please provide your comments to add to this important conversation