Conflict in general practice: Why is it on the rise?
Conflict is all around us; it's a normal part of our interaction with other human beings, and many would argue that without constructive handling of conflict, individuals, teams and organisations cannot improve, innovate nor fulfil their true potential.
However, as a mediator of disputes in primary care, I'm coming across more and more destructive conflicts in practices and primary care networks (PCNs). Why might that be?
Well, in GP partnerships, the 'common' causes of disputes remain and will be here to stay as long as general practice is: sharing of clinical and non-clinical workload, retirement (whether that be forced or voluntary), personality / ethos clashes, premises issues, General Medical Council/NHS England level investigations, and Care Quality Commission (CQC) problems to name but a few.
And as long as GPs are human, there will also be fair numbers of conflicts about money, sex (sometimes with colleagues; occasionally with patients…), fraud and other crimes. It certainly makes for varied work.
But Covid has had a permanent impact now too. Some GPs have succumbed to long Covid which has resulted in them being removed from their partnership. Others were working at home for large parts of the pandemic because of their risk assessment which of course caused tensions in the workplace and difficulties with communicating. We're now in the 'new normal', but often find ourselves disagreeing on what that new normal should look like… how much remote consulting should we offer? Should all patients still be triaged first?
We all had time to ponder life a bit more during those days of home-schooling and zoom quizzes. Many have decided to change their work-life balance, take sabbaticals or even switch careers.
PCN conflicts are also on the rise; it's been four years now since the PCN directed enhanced service (DES) was introduced. Incentivising practices to work together - practices that deliberately hadn't already merged because of differences in the way they work - was always going to be difficult. Some will be hot on governance, some will make all decisions by consensus over tea and biscuits, some will let their practice manager (PM) make almost every decision, others will have a PM who is told what to do. Some will be watching the money, others will be interested in having the best relationship with patients and reputation that they possibly can. All will use the same additional roles recruitment scheme (ARRS) staff in a different way.
There's more and more funding coming into PCNs these days, so there's more to argue about - or more to be greedy about depending on how you view things. Covid brought much more money in to PCNs – the clinical director (CD) uplift, vaccination payments etc. Over the past eight years that I've been supporting GPs in conflict, I see disputes about money being much more commonplace in the highest earning practices and PCNs. More money, more problems…
Voting or decision making is another cause of conflict in PCNs. A lot of PCNs have, or had, quite a casual system for making decisions that wasn't necessarily in keeping with what their network agreement says. Some PCNs leave it all down to the CD to make decisions… until it's a decision they disagree with. There are often few people willing to take on the CD role, and it's the same people that may already be involved in the integrated care board, the local medical committee or the local federation, which then gives rise to conflicts of interest; another source of conflict.
What is the impact of all of these conflicts? Well, in the early stages people will start to avoid each other or the situation. Meetings will feel 'strange'; some people might not turn up, others may not contribute. There'll be sickness, closed doors and awkward coffee breaks. If this doesn't get dealt with, it starts to affect staff performance, patient care, profits, CQC rating, and sometimes the practice contract gets handed back or the PCN dissolves.
There are some simple steps that GP providers can take, however, to either prevent or de-escalate conflict. Beyond that there is the option of mediation, which gives people a confidential, legally safe space to attempt to resolve their issues on the same day with the outcome being a legally-binding agreement that ends the matter entirely. In the next blog, I will talk about this in more detail, but do get in contact if you'd like further information or to discuss a case.
Clare Sieber
Clare is a practising GP in West Sussex. She is a fully insured CEDR-accredited mediator and gained a distinction-level qualifying law degree whilst working as a GP. Clare is a PCC associate. To discuss how Clare can support you enquiries@pcc-cic.org.uk.
