What is the right structure for your primary health network?

The right structure for your PHN is of course the one that supports staff to best deliver on your overarching commissioning strategy.  As the saying goes- ‘if you don’t know where you are going any road will take you there’. Knowing where you want to take your PHN is fundamental to discerning the best structure for your organisation. However, no-one is saying that setting your overarching commissioning strategy is going to be easy as it will require trade-offs and compromise.  Not everyone is going to be happy all the time. Check out this post for some thoughts on how to go about setting or reviewing your overarching strategy. It is called ‘overarching’ because it needs to encapsulate all the PHN’s initiatives and reconcile all its disparate roles, competitive tensions, and other pressures.

Your overarching commissioning strategy will need to have considered:

• The real extent of your influence that comes with the size of your total fundholding in each program area
• The status of your relationships with your strategic partners esp. LHDs
• The influence you carry with your provider markets esp. clinicians
• The unique challenges associated with your catchment
• The healthcare needs of the discrete populations and groups you serve
• Your internal capacity
• The enabling culture and associated values

Having agreed the strategy with funders, and socialised the strategy internally with managers and staff, and externally with strategic partners, the Board and Executive can consider the following considerations. They will help inform choices as to structure and associated staffing arrangements.

As you work through these you will see the clear connection between your strategy, your structure, the needs of your communities, the prevailing internal culture, and the necessary staffing requirements.

Gaps v. Leaps – A PHN that sees itself primarily as a gap-filler for a given time-delimited strategic cycle will organise very differently from one that wishes to position itself to challenge the mainstream regional health system to make the ‘leaps’ to being more inclusive and better integrated. With gap-filling, the PHN seeks to prioritise a select and discrete group who are underserved by mainstream arrangements and supports them through stop-gap measures that can continue while the program is funded.   So, when the funding stops the gap re-opens and this may be considered both unavoidable and acceptable.

Alternatively, those PHNs prioritising self-sustaining ‘leaps’ in system wide performance across their entire catchment will need to staff and organise differently. Choices here will affect the time horizons and the importance that needs to be attached to leveraging strategic relationships. Also, the mindset and skillset of staff will need to be entirely different.  Living in the real world, this isn’t going to be an ‘either-or” decision.  Some initiatives will be gap-fillers, and others will work over the longer term to leverage system-wide change.  However, the PHN needs to be explicit in its choices and have a good rationale for its actions.

Places v. Programs –People, including your staff, live in physical places not the artificial construct that is the health service program.  This means that staff will naturally look to prioritise the needs of known locals even if they have cross-regional responsibilities for any specific program. In its most disruptive form regional offices will actively compete against each other and this makes it impossible for program staff to sustain a focus beyond their immediate locality.  Executive and management leadership is vital but in my unhappy experience sometimes they are the worst culprits for driving partisan agendas.  As ‘blood is thicker than water’, people live in places not programs!  Local communities will pressure PHN staff to look after locals first and foremost, and those with cross-regional roles need to be supported to resist partisan interests.

Specialism v. Generalism -With commissioning relatively new to Australia there are very few who see themselves as generalist commissioners.  This means that we tend to recruit mid-career clinicians with an inclination to improve health system performance.  In my experience the PHN staff usually comprise people with a background in allied health, nursing, mental health, indigenous health, health administration, and corporate specialties such as accounting, contract management, law, media, and communications, etc.   The pool that we are therefore drawing from will naturally wish to capitalise on their specialised professional expertise, networks, and passions; to do those things that are personally and professionally important to them.  The challenge of course is that working in primary health, and with a lens on the social determinants, we need staff who are prepared to serve as generalists meeting the diverse and changing needs of the communities we serve, focussing on their needs and less so on our own professional agendas.  The global trend to health specialism rewards professions over patients, at the very time that we see populations ageing, living longer under the burden of complex multiple chronic illnesses.  This sees PHNs with a very real challenge of recruiting staff who will want to stretch and work outside of their professional ‘comfort zone’ to serve as part of a team of generalist commissioners. Yes, their rich specialist expertise will continue to be highly relevant but more in terms of serving as a Subject Matter Expert (SME) helping other team members to broaden their understanding and becoming collectively more capable.  Accordingly, structure and staffing arrangements needs to prioritise ways to meet the generalised needs of communities, while seeding teams with the right mix of SMEs to build overall capacity.  Regardless, everyone from the Board, through the Executive team, managers, and operational teams, need to believe themselves to be commissioners and share a rock-solid understanding of what this will require of them. The ongoing challenge of building a common conception of commissioning cannot be understated, with training and development an ongoing priority.

Now v. Future -Rounding back to our discussion on the PHN’s legitimate roles as gap-filler or system enabler, the PHN’s leadership needs to be clear as to the time horizons it is working to.  Funders and strategic partners need to be on board as well. Structure and staffing decisions need to be considerate of this. Again, people naturally think in terms of their local community so they will prefer things that deliver improvements now, less so abstract things that may or may not benefit future and therefore unknown groups.

Equality v. Equity -Thinking back to my time in the GP Divisions and Medicare Locals I recall the strong mantra from both staff and stakeholders that everyone needed to be offered the same opportunities as this is what fair treatment looked like.  While on face value this looks reasonable it doesn’t consider the pre-existing situation that sees certain individuals and groups with highly disadvantaged circumstances from the outset.  PHNs need to prefer those providers and strategic partners that will commit to doing the heavy-lifting with those groups that are hard-to-treat or otherwise marginalised through mainstream arrangements. Structure and staffing need to reflect the PHN’s intentions, and this may mean pre-positioning resources in a way that will deliver equity in health outcomes over equal distribution of finite resources.   Some parts of the organisation may need to be preferentially resourced over others to deliver better equity for disadvantaged communities.

Some members of staff, especially those who worked in the time of the GP Divisions may have problems with this approach and we may need to remind them we are here for patients first and foremost, and we should reasonably prefer providers who will look past their narrow professional interests to share the health equity challenge with the PHN.

Face-to-face v. Digital -The COVID pandemic has seen a rapid escalation in the adoption of digitally delivered services.  While this has been a pragmatic and necessary response, we are yet to see whether it will constitute a paradigm shift that will naturalise remotely delivered health services.  Personally, I prefer face to face interactions but have concluded that a pivot to digitally enabled delivery is essential to achieve equity in health outcomes, especially in highly dispersed and underserved rural and remote communities. Similarly, PHN staff will need to feel comfortable in establishing and maintaining effective relationships remotely.  It isn’t good enough to just associate with providers in near proximity that you can easily visit.  Structure, supporting infrastructure and staff delineations need to ensure that a PHN can deliver effectively to its entire footprint while demonstrating a capability to engage meaningfully sometimes across vast geographic areas.  In this sense technological considerations should have a bearing on the PHN’s structure.

The ‘head-office’ effect -Collocating corporate support functions with the Executive team is sensible, however it can distort and subvert other intended aspects of the organisation’s structure.  Staff based in the PHN’s head-office will have enhanced access to executives and corporate services and unless carefully managed this will result in a deprioritisation of initiatives in other regional offices.  This is exacerbated when corporate managers don’t have a rounded understanding of the overarching commissioning strategy, seeing their role as injecting excellence in their special but narrow corporate discipline. While excellence is to be lauded it needs to be tempered with the pragmatism mandated by the Board and Executives to get things done on time.  We need to avoid the situation that sees you as the best managed PHN never to deliver anything!

Choosing a location for the head-office is always fraught in the geographically larger PHNs as it invokes inter-regional competition.  Decisions of this kind will get a great deal of scrutiny and as such a sound rationale and supporting narrative is necessary. 

Factors for selecting a location for a head office might include choosing one that:

• Is geographically central to all parts of the PHN’s catchment
• Has convenient access to all sub-regions e.g., road, air routes, etc.
• Has ready access to major strategic partners e.g., Local Hospital District Offices
• Has ready access to highly specialised expertise esp.  through universities
• Has a local population with the necessary depth in the labour market to fill key positions

In my experience the location of a head office without a supporting narrative will see other centres feeling alienated and resentful. This can be hugely problematic when trying to establish trust and build strategic alliances.  Regional centres can be fiercely competitive and have long memories.

Key insights for this post

• People are more important than structures. People make structures work- not the other way round.
• Structure, culture, and staffing are inextricably linked. Good structures help good staff with the right values to do great work.
• Every structure carries inherent trade-offs. All structures reflect a working accommodation of different concerns and interests.
• Structures can help enable people to deliver, but they are not necessarily the main determinant. It just makes it a whole lot easier if the structure is designed purposefully to support people to do what is being asked of them. Hence the importance of linking structure to your commissioning strategy.
• People can subvert structures, therefore what’s most important is recruiting people who are naturally committed to delivering the overarching commissioning strategy, and will prioritise team-based working and equitable delivery across your entire footprint.
• One should never underestimate the difficulty of making it clear what in fact you are asking staff to do.  Most position descriptions don’t reflect what staff do on a day-to-day basis.
• Structures need to be set in ‘plasticine not concrete’. The experience of the COVID pandemic illustrates the need for us to be able to flex and adapt in the moment.  This is core to the value proposition of the PHN.

How are you going to ‘slice and dice’ your limited resources to make the most impact for your communities?