The Infinite Game of General Practice

Everyone knows how a Finite Game works. Like a football or tennis match, you know the players, how to score and how long it will last. The game finishes, a winner is announced, and the players go on to new games.

An Infinite Game(*) is different. Players come and go, and your objective is to stay in the game and keep it going as long as you can. The game goes on and it is the players who drop out. You don’t win an infinite game any more than you win a marriage or win at being a family.

But so much of what happens in the NHS is finite minded and short term. Sacrificing experienced teams to balance budgets. Cutting long term funding to then “invest” in one-year projects which look good in year-end reports only to be scrapped when the “improvements” don’t last.

General Practice was always set up as an Infinite Game. Doctors joined a practice, looked after their patients, and then dropped out to be replaced by new doctors to carry on the work. However, the 2004 contact brought in a finite mindset where hitting targets became the name of the game.

And my generation of GPs and I took on these targets, chasing QOF points and prescribing incentives and admission avoidance schemes. We turned out to be better at this than anyone predicted and there was much fun and income to be had.

But the dark side of chasing targets is prioritising what is paid for and building businesses where partner income is paramount. This encourages a few partners to profit from the work of salaried GPs and when the squeeze inevitably comes, older partners maximise their pensions and leave.

Target based General Practice has also taught future GPs to look at practices with the same finite mindset. How much do you earn? What is the workload? What is the area like? Could you be left last (wo)man standing? Thinking about your exit strategy is not a great way to start your career.

For most GP surgeries their core purpose is along the lines of: “We are here to help people in our community live longer, enjoy better mental and physical health and be more fulfilled by reducing the impact of illness and disease on their lives.” This is not a finite goal they will ever achieve but acts as a compass to judge choices against whether they move the practice in the right direction.

Young GPs could do well to ask prospective practices what is important to them and what they are doing to get closer to their ideals next year. How teams treat each other and how they build trust and encourage development in the whole team is a stronger predictor of whether a practice will thrive than what cars the partners drive.

The problem of putting a worthy purpose first is that it makes you worry that you are putting yourself and your needs second. This is real and your purpose will get in the way if your only aim is to earn as much as you can. But improving long term health in our communities requires us to look after ourselves and our teams. We need to sustain ourselves and enjoy our work if we and those who follow are going to be there, continuing to make a difference, in 30 years’ time. So, keeping our focus on our core purpose also requires us to achieve a good work life, reasonable hours, and a comfortable income so that others will want to take over from us and keep the work going .

General Practice has always been an Infinite Game. Our only choice is whether we accept this, align our actions with our core purpose, and build the long-term strength and capability of our teams. Or not.

(*) Simon Sinek is far better than me at explaining the Infinite Game and I thoroughly recommend his book and this YouTube video:

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