Collaborative General Practice

About Collaborative General Practice

Clinical and non-clinical professionals in primary care are increasingly working together in new, different and innovative ways. Pharmacists, physiotherapists, social prescribers and paramedics are just some of the roles where much more integrated working will be seen over the next few years.

Collaborative General Practice provides an opportunity to support this newer way of working within General Practice, primary care and across the wider health, social care and voluntary sector teams working to improve patient care. 

Supporting primary care teams to build relationships, understand the challenges and successes and share learning will be crucial as we move to a more community-based model of care. Using a person-centred approach to make sure care is holistic whilst also being supported by population health data will be central to improving outcomes for patients and carers.

Collaborative General Practice aims to support GPs and other professionals navigate through the development of how we work together across practices, communities and levels of care including primary, secondary and tertiary care. Making sure that the need for evaluation and creating standards (e.g. definitions, core competencies, qualitative experiences) is understood and appreciated. 

Collaborative General Practice, whether as Primary Care Networks, Clusters, Federations, Super-Partnerships, Quality Clusters or other collaborative organisations, offers an opportunity for connection, inclusivity, inspiration and creativity in the development of a connected approach to improving the lives and journeys of patients, colleagues and communities. 

Progressing in a rapidly changing UK landscape

Throughout the country a more collaborative approach to ways of working across primary care is being introduced quickly and place-based teams are being asked to be respond and make significant changes over a short period of time. Collaboration within multidisciplinary teams and across different organisations can feel challenging and it is helpful to have a framework for delivering high-quality primary care. 

Ten key building blocks of high-quality primary care

Collaborative General Practice aims to support the development of a coordinated and joined up approach to care for patients by focusing on the ten key building blocks of high-quality primary care:

  1. Leadership and vision (goals and objectives)
  2. Data infrastructure and utilisation
  3. Matching resources to the population need and continual review process
  4. Team based care model 
  5. Person centred care
  6. Population health management
  7. Continuity of care
  8. Flexibility of care provision
  9. Network of comprehensive care 
  10. Creating the future of care

Collaborative working is based upon groups of people working together in a network. The strength of this network relies on the connections and relationships across individuals and teams and this forms the foundations of collaborative working. These foundations need to be supported by strong to enable a sustainable healthcare system that meets people’s needs.

N - Need

  • What is it that we need?
  • How can you be creative in your thinking?
  • How can you use local resources supported by digital technology?
  • How can you make a tangible and measurable difference?
  • What local and available data will you use to inform and drive your projects?
  • Do you need business intelligence or data analysis support?
  • How will you measure and demonstrate improvement ?
  • How will you measure network health outcomes and not just outputs?
  • What quality improvement tools would be helpful ?
  • What are you going to do together that is just too difficult to do by yourself?

More information: 

Public Health England, Population data

E - Enjoyment

  • Have fun – bring enjoyment, enthusiasm and energy to the table .
  • Does everyone feel included and motivated?
  • Don’t set yourself up to fail - do something that’s actually possible.
  • Be pragmatic.
  • Celebrate successes.
  • Reflect on the reasons something might not have worked

Watch: Leadership Lessons from Dancing Guy

T - Talent Management

  • Talent Management embraces leadership.
  • Anyone can be a leader you just need to want to make a change.
  • Harness talent in your networks – think of the whole team and empower leadership by all.
  • Play to people’s strengths.
  • Create an environment where everyone can thrive.
  • Have the courage to reflect on successes and challenge.
  • Work on the culture of sharing.

W - Why

  • Start with “Why?”
  • What are the reasons for coming together to work collaboratively?
  • What is your shared purpose and vision?
  • Spend time developing this shared purpose and vision before you do anything else.
  • Develop a collective why to generate a collective momentum.
  • Seek dissent.
  • Highlight what you are not trying to do from the start.

More information: 

Watch: Simon Sinek, Know your WHY 

Read: Becky Malby, The purpose matters


O - Organisational Development

  • Form will follow function.
  • Consider what you are doing and why first and then organise your teams around this.
  • Then what organisational form do you need?
  • Who is going to host your network – is their trust and accountability built in?
  • What does clinical leadership in your network look like?
  • How might credibility, knowledge and trust play a part in effective leadership?
  • How might you select and elect leaders?
  • What legalities and governance do you need to navigate?
  • What is the role of at scale providers, for example, federations in supporting this work?
  • Develop a network maturity matrix.

R - Relationships

  • Do not underestimate the importance of relationships.
  • Spend time getting to know the WHOLE team.
  • Eat together.
  • Consider using team huddles.
  • Build trust.
  • Take time to listen.
  • Be genuinely curious in order to build meaningful relationships.
  • Transformation is all about relations.

Watch: Kings Fund, Collaboration and compassionate leadership 


K - Knowledge

  • Empower yourself with knowledge.
  • Find facts and not myths.
  • Ask questions and seek out answers for yourself first-hand

Collaborative General Practice Across the Four Nations

Collaborative General Practice in England

Primary care networks (PCNs) form a key building block of the NHS long-term plan. From 1 July 2019, all patients in England will be covered by a primary care network (PCN) – the most significant reform to general practice in England in a generation.  Bringing general practices together to work at scale has been a policy priority for some years for a range of reasons, including improving the ability of practices to recruit and retain staff; to manage financial and estates pressures; to provide a wider range of services to patients and to more easily integrate with the wider health and care system. PCNs should help to integrate primary care with secondary and community services and bridge a gap between general practice and emerging Integrated Care Systems.

Collaborative General Practice in Northern Ireland

In Northern Ireland, GP Federations have been established as not-for-profit Community Interest Companies Limited by Guarantee since June 2016. The creation of the Federation model was created and initially funded by GPs themselves and there are 17 Federations covering the entire region, with all practices aligned with a Federation. Northern Ireland is the only part of the United Kingdom that has a unified model of Federations governed by a unified Members Agreement covering the entire population . 

Through this structure, practices are working collaboratively in numerous ways including recruitment for multidisciplinary team posts, practice-based learning days and other direct support. Following the allocation of funding in 2018, Federations play a key role in the development and rollout of a new model of multidisciplinary team working, embedded in general practice. Working with the local Health & Social Care Trust in the area, the Down and Derry GP Federations are currently prototyping a new model which sees the direct employment of mental health workers, physiotherapists and social workers through Federations, with posts based in GP practices in the area. This model is now being further rolled out in West Belfast and two additional Federation areas, yet to be confirmed. 

Additional links 

  • GP Federations: Northern Ireland Medical and Dental Training Agency - NIMDTA
    To provide the best possible healthcare for the people we serve, it is essential that GP Federations attract and retain staff who are appropriately qualified, professional in the service they deliver, happy and productive in their work and committed to lifelong learning and developing in their role.
  • GP Federation Support Unit
    There are 17 federations encompassing the whole of the Northern Ireland region. Each of the 17 federations will cover about 100,000 patients with, on average, 20 practices. The federations are all Community Interest Companies in the Not for Profit Sector. Northern Ireland is the only part of the UK which has a unified model of Federations governed by a unified Members Agreement covering its entire population.

Collaborative General Practice in Scotland

After the publication of Improving Together: A National Framework for Quality and GP Clusters in Scotland, in 2017, general practice in Scotland has been encouraged to work collaboratively. Practices are now working collaboratively through Quality Clusters to deliver improved care. RCGP Scotland, along with Scottish Government, Healthcare Improvement Scotland and the Scottish General Practitioners Committee has developed guidance for clusters. Alongside the practice collaboration the new GP Contract in Scotland will expand the multi-disciplinary team with the aim of improving the quality of care provision.

In Scotland we support the development of these organisations through our Local Advocates network. In mid-2019, national guidance on GP Clusters in Scotland, developed jointly by RCGP Scotland, the Scottish General Practitioners Committee of the BMA (SGPC), Scottish Government, Scottish Primary Care Clinical Leads and Healthcare Improvement Scotland, was published.

Collaborative General Practice in Wales

After the publication of Setting the Direction: Primary & Community Services Strategic Development Programme in 2010, general practice has been encouraged to work collaboratively. Practices are now working collaboratively through Primary Care Clusters to deliver improved care. Alongside the practice collaboration the clinical team is expanding with multi-professional teams collaborating to improve the quality of care provision.

In Wales we support the development of these organisations through our Advocates network. RCGP Wales is currently working with the Royal Pharmaceutical Society to produce a best practice guide for multi-disciplinary team working and is an active partner in the work of the Bevan Commission to identify best practice in future delivery of prudent healthcare.

Additional Resources

Online learning network

The RCGP Collaborative General Practice Online Learning Network provides information and support around general practice working at scale. We have developed an Online Learning Network to facilitate the sharing and signposting of useful resources, case studies and enable users to network with colleagues across the country.

Through this network and in combination with regional events we are connecting with, and learning from, collaborative organisations about how and why they are forming and what makes them successful, bringing together GPs and helping to navigate potential problems and pitfalls.

We hope that you will find on here useful resources and case studies as well as opportunities to share learning from your experiences and make useful links with other organisations and networks. Whether you have been working collaboratively for a while or just want to find out more, this OLN can support you in your journey and connect you to colleagues across the country who are working in innovative ways.

Join the online learning network

Resources for collaborative general practice

Case Studies

  • Leeds Case Study

    After identifying people with frailty as a priority area, Leeds CCG set about improving population outcomes and reducing health inequalities.

  • Thanet CIC Case Study

  • An Acute Rapid Team (ART) service was established to enhance the level of integration of a range of services caring for elderly in the local community.

Podcast 1: Collaborative General Practice: The Quadruple Aim

RCGP Vice Chair for Membership, Professor Mike Holmes, talks to RCGP Clinical Support Fellow for Collaborative General Practice, Dr Alka Patel, about motivations in general practice and Don Berwick’s Triple Aim, which includes improving the experience of care for patients, improving healthcare outcomes and reducing costs. They also support the need for a fourth aim, the Quadruple Aim, which focuses on improving the experience of delivery of care.

Podcast 2: Collaborative General Practice: The impact of scale

RCGP Vice Chair for Membership Professor, Mike Holmes talks to RCGP Clinical Support Fellow for Collaborative General Practice, Dr Alka Patel about his journey of working at scale and what at scale general practice has been able to deliver. Professor Holmes also shares how he envisages Primary Care Networks can build on this work.

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