There is so much we don't know in medicine that could make a difference,
and often we focus on the big things, and the little things get forgotten. To
highlight some smaller but important issues, we've put together a series of
pearls that the Red Whale found at the bottom of the ocean of knowledge!
Staff: leading, managing, developing
“And now I will show you the most excellent way… love” – Saint Paul
“More love, less paperwork” – slogan on Jamie’s favourite coffee mug
The building blocks
Very few teams are designed.
There is always a dance between need and availability, between ideal and what you can get.
But all teams can perform better; all teams can improve and become better at their tasks, more enjoyable to be part
of.
We are starting with the basics here, not to patronise but because they are very easy to forget as we shift our focus to the ‘difficult
stuff’. As the 80s business cliché said, “The soft stuff is the hard stuff”.
Talk to them!
A surprising feature of many practice teams is that team members rarely talk. So talk to your team. By this I don’t mean “Ring Mrs
Smith and tell her I’m on my way”. That’s tasking not talking. Every once in a while, just chat. But more than that:
Have one-to-ones with those you manage.
You don’t have to do this with everyone in the team, but it should be a regular and frequent priority for anyone
you are line managing, e.g. salaried GPs.
This should happen across all teams in the practice between managers and their direct reports – if your manager
isn’t offering this opportunity – ask!
It doesn’t have to be a massive time commitment – protect space for both of you to meet for 20 minutes once a
month, say.
Use this time to hear (not just listen to) what your team members have to say; seek to understand what motivates
them, what is concerning or worrying them, what pressures they are under, and how work fits into their world.
You don’t need to do this all at the first meeting!
This time allows you to say what needs to be said – about the direction of the practice, the recruitment issues or
to address any ‘rumbles’ of unhappiness head on, before they become an issue.
It also helps you to ‘connect’ – more of this in the next point. Your direct report will want to do the same – to ask
what’s happening about the merger, the CCG service being commissioned and the recruitment for the new
partner.
People work for people
Not contracts. Not organisations. People work for other people. So if your team are working ‘just to pay the bills’ that may mean that
to them, you are not a person.
They may well be working for the people at home, or even for themselves. This might help explain why they seem allergic to ‘going
the extra mile’ or taking initiative to help your patients!
Become a person to them!
If you get to know your team and allow them to know you they may start to perform better.
You don’t necessarily have to become bosom buddies, just having normal social interactions and interacting with
them as a person, not a boss, can make all the difference.
There is more at stake in making it to ‘tea break’ than sustaining workable caffeine levels.
Much military research has focused on understanding why soldiers fight – and what has broken down when they become unwilling
to. The answer seems to reside at ‘squad level’ – a small community of people working together dependently are powerfully
motivating to one another (Rielly (2000) Military Review 80:61).
The same is true of our practice teams – we work for one another. Break or erode this social contract at peril. Reinforcing it will likely
pay dividends. This is true whether or not your team are ‘your’ staff – or whether you are a salaried GP.
Be clear about what you expect
Disappointed with your team? Irritated by a particular staff member?
Ask yourself whether you are able to clearly articulate what you want to be different.
If you can’t, work at it until you can.
Then ask whether it’s a reasonable request – if it is – make it!
It’s important to be clear with team members what you are looking for. So long as your request is in the job description, ask for
what you need.
Use your structures
Having said talk to your people, chat with them, ask for what you need… there is an exception:
If you know that what you are asking for is a ‘re-tasking’ then use your structures, e.g. if you want to ask a member of reception
staff to start to do something that was not already part of their job (perhaps scanning your mail and coding it), then the most
appropriate line manager should introduce the concept.
If you don’t do this, staff get confused, your practice manager may get the hump, and your partners will be unimpressed that
the whole team are irritated!
Significant changes to a staff member’s job should be agreed with the management team ahead of time, and should be
communicated by that team member’s line manager to avoid setting up parallel or, worse, conflicting lines of accountability.
So, for example, use the practice manager, even if both of you have the conversation with the team member.
Play fair
It’s good to be compassionate, good to make contact with your team – but don’t have favourites, and don’t excuse something in one
team member which you would sanction in another. Like a family, nothing causes division and rancour faster than favouritism. This
applies to day-to-day interactions, but also to bigger things – like how much discretionary leave is allowed.
If you‘d do it for one, you must do it for all!
Appraisal and objective setting
All staff should have an annual appraisal, and in many practices this will be linked to setting objectives.
Objective setting became a foundational part of managing staff in the management literature around the 1950s, and was popularised
by Peter Drucker in his seminal 1955 text ‘The Practice of Management’ . He termed it ‘management by objectives’. The intent was
to link the strategic direction of the company with the performance measures of every employee, with objectives cascading down
through the business from CEO all the way to the most junior staff.
In medium to large enterprises meta-analysis has shown it to be associated with productivity gains of between 6 and 56% (Journal
of Applied Psychology 1991;76:322).
Is this relevant in primary care?
Possibly not – in most practices it may be somewhat irrelevant:
We tend not to have clearly articulated annual strategic aims; those that we do have are usually related to processes that are
already in place – “Let’s maximise QOF income this year”.
We are smaller and potentially more agile than many of the companies studied.
Our commercial environment is very different.
However, objective setting does not have to imply the full rigour of ‘management by objectives’, and could be used more
supportively, for example, by allowing staff to set their own objectives based on the challenges they see in the coming year. In
addition, it can be a useful moment to discuss training for the future – please see the section on this below).
The dark side of ‘management by objectives’
This approach has other flaws. Perhaps most importantly it perpetuates what some management writers have termed the ‘illusion of
control’.
Their criticism of this sort of management is that it is used by managers to help them deal with their own anxieties and with the ever
growing uncertainty of the environment in which we have to function. The problem is that none of us know in April and May what the
rest of the year will be like – so how can we possibly set performance objectives for our staff (especially if these objectives are tied to
incentive structures)?
Ralph Stacey would go as far as to say “Strategic planning activities are fantasies whose function might largely be to form social
defences against anxiety”. If this is true, what point objective setting? And how are we to proceed if all is uncertain and our welltrodden paths are simply there to defend us all against anxiety?
Changing the world one conversation at a time
Another management researcher who draws insights from complexity theory, Patricia Shaw, has proposed that the thing that really
changes organisations is conversation. She talks about the ‘transformative activity of conversing’:
“Organising is conversational process, and organisational change is shifts in the patterning of conversation” (Shaw, 2002)
This view sees conversation not as ‘just chatting’, but as the real stuff of change. It’s how we change the organisations we work in,
and change the futures we are moving toward – by having a new and different conversation.
This way of seeing ourselves and what we are working on also takes seriously the insight that we are part of every pattern we
experience.
“I am a part of all that I have met;
Yet all experience is an arch where thro'
Gleams that untravell'd world whose margin fades
For ever and for ever when I move.”
Alfred, Lord Tennyson; Ulysses
Thinking in this paradigm, appraisal and one-to-ones become important as conversations where we take careful time to intentionally
talk and listen. This conversation rather than being formulaic and routine – a once yearly pointless ritual – can open the door to
genuine change.
Rethink what appraisal is!
To paraphrase Peter Block again, what we think of as the work we do in these conversations needs to change. Try moving away
from problem solving and aiming to create ‘outputs’ and ‘action plans’.
What if instead we were to understand the point of staff appraisal as being to:
Strengthen our relationship and connectedness with one another.
Learn something of value about how we work together.
Explore together what gifts we each have and how we want to bring them to bear in the practice.
This may seem like a giant leap or a step too far, but it’s worth exploring what happens when you do experiment with this way of
understanding your role in the team.
Let me share my experience.
Leading a team as a clinician executive in my CCG, I had around 20 direct reports, both clinical and
managers. I started to move our one-to-ones and appraisal reviews toward this approach. We had some
really significant conversations, and started to ‘gel’ as a team.
I’d say previously rather than working well together, we had got on together, but not worked together
very much. This was part of making that change.
Initially my internal focus when we were talking was on ‘connecting’ with the team members. For me (as
a certified motor-mouth) this was about listening not talking. However, it was also about exploring the
team’s responses to the work they were doing both intellectually and emotionally. Exploring where they
felt they needed support or development, and also hearing from them what the next steps should be
rather than telling. I found this really hard!
We started to value one another as people rather than as functions; as we did this, we started to see our
work in a better context. The silos between different parts of the team started to erode, and the
connections between the work each member was doing started to make sense to them. It seemed to me
that the better connected to one another we were as a team, the better we connected the work, and the
more integrated our approach to it.
Try it – in small ways initially. Try focusing on connecting as people, remembering that people work for
people.
You truly can change your practice one conversation at a time!
Leading your team into an uncertain future
There is no doubt that Primary Care is an uncertain place currently. As you think about your team you can probably identify some
shifts that are needed right now, to position the practice to survive the year ahead.
Here are some points to consider and reflect upon:
Talk to your team about these issues in one-to-ones and larger team meetings.
Do you have the right people?
Enough of them?
Doing the right things?
Do they feel they are doing the right things?
Do they see ways that they could do things differently?
Do these opportunities match up with what you’re thinking as a practice leadership team?
The result of having conversations with your team like this may well be new roles and training needs.
E.g. If you really need a new GP but know you can’t get one, you might be able to cover some of that work by using the staff you
have better, and growing some supporting roles below them.
Train for the future
Training and development conversations should cover these issues:
What do your team want to do next?
Are they happy to carry on as they are?
Are you happy for them to?
Do they know that you think they are going to need to change and why?
If not, start that conversation before telling the admin clerks that they are going to be responsible for coding the scanned
letters!
It’s worth trying to train for the future. The worst that happens is that you increase your team’s skills and then decide not to develop
in that direction. Whereas allowing or facilitating development that does not take account of the shifts that you see coming risks
letting the team get ‘out of shape’ to meet the challenges ahead. For example, saying:
“No, I see no need for you to do the nurse independent prescriber course; we won’t support it” to your senior nurse is a very different
proposition to saying “I’m not sure about the nurse prescriber course; Dr Joshi will retire in 6 months, she’s our diabetic lead, we are
going to struggle to replace her. Could we look for some advanced diabetes input that would help you grow into the role of lead
clinician for diabetes over the next couple of years?”
Are you sitting comfortably? Then I’ll begin…
Finally, don’t underestimate the power of language and story in managing your staff team. The story you tell yourselves about
yourselves has an uncanny habit of becoming reality.
This can be used to advantage.
Take every opportunity to tell ‘good’ stories about the team to the team. Again, this is a ‘start small’ and get used to it thing. But it’s
fun to gradually start telling your team the story of the work you are all doing together in the terms that you want used.
Putting this into practice
So, for example, if you were to want your people to view themselves as a quality motivated team, take
every opportunity to talk about when and how you work on making it better for patients. Praise high
quality ‘customer service’ when you see it at the front desk. Set the work of the audit clerks and QOF
team in the context of ‘high quality care for our patients’. Resist cutting corners so you model that
quality focus. Use every interaction you can and every situation that falls to hand to tell the story to your
team of who you think you are together, and of what the work you are doing together is. Talk about the
bigger thing you are building than just seeing the punters and earning the points.
When you meet the stories coming back at you – you’ll know it’s working! When a member of staff says “I knew you’d want to do
such-and-such because we always aim for quality” – then you know the ‘story of us’ is taking on a life of its own.
Some final thoughts
It goes almost without saying that leading your team in this way is something to do carefully and gently rather than all at once.
If you are thinking about changing your style and approach, please do so gradually – evolution rather than revolution!
I have found it a huge help to have others I can work with on this sort of change. In some cases that has been just one other person
in the team whom I trusted to help me to think about what was going on and how best to engage it (you know who you are!) and at
other times it has been by engaging the services of a professional team coach.
That’s not to say you can’t do it alone – it’s just harder, lonelier and less fun. But if that’s what it takes for you – go for it, and good
luck!
Staff: leading, managing, developing
Talk to your team and connect with them on a human level – people work for people.
Have regular one-to-one time with those you line manage directly.
Be clear about your expectations.
Experiment with changing your organisation one conversation at a time, rather than
having the same tired appraisal interactions with your staff.
Talk to your staff about what you see coming, and train and develop for that future.
Try spending 20 minutes a week in reception talking to your staff for the next month, and see
what changes – in you, and in them.
If you already do this, consider where the conversations you are having need to change. Make
those small shifts and notice what happens – again, in you and them, and the relationship
between you.
Reflect on the behaviour and conversation patterns at work that you are often part of. Are they
positive, do they help you all work well together? What small shifts could you make which
might move it all on?
Books
Block P (2008) Community: the Structure of Belonging. Berrett-Koehler Publishers. This is a
good read although it has a lot in it about community development and empowerment; much
can be used to help you develop a community at work.
Shaw P (2002) Changing Conversations in Organizations. Routledge. If the idea of changing
the world through conversation excited you this book may interest. It is very hard to read, and
rather academic, but has some great insights. Very much one for the enthusiast. You have
been warned!
Websites
This is already likely to be your PM’s ‘go-to’ support and resource. It’s got lots of downloadable
policies and advice, and includes a good section on HR advice for the formal stuff we have not
touched here. Ask your PM to show you it. It requires a paid subscription.
www.firstpracticemanagement.co.uk
This is for BMA members only; the BMA Employer Advisory Service website for GP practices
gives advice on employing recruiting disciplining appraising… all sorts of useful stuff. If you’re
a member, download the handbook and read cover to cover. Also has useful proformas and
example policies. They will give advice if you ring them (do so early if you’re running into
trouble!) and may assist with costs if you have involved them up front and followed their
advice. If you are a member, you’d be a fool not to use this service!
www.bma.org.uk/support-at-work/gp-practices/employer-advisory-service
We make every effort to ensure the information in these pages is accurate and correct at the date of
publication, but it is of necessity of a brief and general nature, and this should not replace your own good
clinical judgement, or be regarded as a substitute for taking professional advice in appropriate circumstances.
In particular check drug doses, side effects and interactions with the British National Formulary. Save insofar as
any such liability cannot be excluded at law, we do not accept any liability for loss of any type caused by
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