Conflict in General Practice - Part 2

As promised in my earlier article where I laid open the types of conflicts I see in practices and primary care networks (PCNs) and how they can quickly escalate into quite profound consequences, I will focus this next instalment on preventing and managing conflict.

By far the most important preventative measure is good governance; and this is when about half of the GP partners in the room (if I say this at GP event) silently groan. Some find it boring, unnecessary, perhaps even too expensive, but it really does reduce the likelihood of a dispute and is money well spent.

Partnership agreements, staff handbooks, employment contracts, network agreements; not only must they exist, but they need to be up to date, reflect the current ways of working, and cover potential future issues. They also need to be valid, that is, signed by all partners; something that is often overlooked.

When in place, there is simply less to argue about, and there is also a framework that can be used to resolve an issue. I would say that three quarters of the partnership disputes I get involved in as a mediator are with a partnership at will (i.e., they don’t have a valid partnership agreement).

Decision-making is another area that might not get the attention it deserves, to the detriment of all. Decisions need to be made per an agreed process, minuted, and minutes then approved. When this is done well, it can save your bacon – everyone agrees that something happened, and this thing that happened was per an agreed way of doing things. Without it, it can be argued whether the thing even happened; there’s no proof. If it’s not documented well, it didn’t happen.

Even more basic than documenting decisions made, is the act of meeting regularly to make decisions. Crazy as it may sound, in some practices and PCNs, meetings do not occur; businesses are run with a ‘keep going’ approach, or with just one person making the decisions.

Clearly there is a risk here of feeding megalomania, and fraud, but meeting regularly – for whatever reason, or indeed no reason – is so, so important for these working relationships. Things are less likely to get misunderstood, misheard, and miscommunicated if done together rather than via email trails.

The more we meet, even for coffee, the more we get the opportunity to develop trust, find out about what makes each other tick and build those foundations of a well-functioning team. Communicating with each other will be familiar, so difficult conversations are less likely to land badly, and we will have far more opportunities to bring up issues early before they really start to fester. Furthermore, it is so much more difficult to start or escalate a conflict with someone whom you must sit with in the coffee room every morning.

And that reminds me… food. I am a big foodie and therefore biased, but food does bring people together, keep them together for longer, and give them something to bond over. I am sure my settlement rate is higher when everyone comes into a mediation with home cooked bits and bobs to share.

So, let’s say a conflict has happened; it hasn’t been prevented, despite your best efforts. What can you do?

Well firstly, don’t panic; this is not a failure. It happens all the time, and as I said in my earlier article, good things come out of demanding situations, and a team with no disagreement won’t be making much in the way of progress.

Get in there as soon as possible; spot the soft signs that I talked about already – rumours, people isolating themselves, sickness etc. The earlier you look for help the better, because the people in the conflict are less likely to be entrenched in their positions and to have invested lots of time, worry, and even money in their own side of the argument. The conflict will therefore be easier to resolve because the parties will be more able and willing to compromise.

The first part of acting once you’ve spotted a conflict, and often the hardest part, is getting your colleagues to acknowledge that there is an issue. If this is a long term, unspeakable conflict then how can you challenge the mindset? Stick to facts about how it makes you (and others if appropriate) feel. How you feel can never be challenged because only you know how you feel. Is it uncomfortable? is it making you dread certain meetings? Is everyone talking about it around the water cooler? If so, say ‘I feel uncomfortable’, ‘I think we need to confront this’, ‘I’ve heard people talking about this over coffee’…

Are there any other observations that you could then make to compliment this? Have there been opportunities that the organisation has missed because of the conflict? Have there been resignations, retirements, or perhaps patient incidents?

The next step is time-consuming, or timesaving, depending on how open you are to the concept of an unresolved conflict costing vast amounts of energy, stress, money and time. Have an exploratory conversation with those involved – your agenda should consist only of wanting to listen and find out what’s going on for that person. Let them talk. And talk. And talk.

That might be as far as you get; a private ‘chat’ between two colleagues, but you will have done a lot. It will have been healing. That person may have never spoken about the issues before, and the act of just getting it off their chest and being listened to can be enough to move people on and get them focused on a solution.

So, good governance, lots of hanging out, and plenty of listening. Easy right? But what happens when it goes sour? When people have ‘lawyered up’ and the predominant emotions are fear, ‘proving’, ‘winning’, and ‘making someone pay’? How can we work with this mindset?

Look out for the next, and final, instalment on how to handle this, and the role that a mediator plays.