What next for GP federations? Going beyond the logo

10 May 2018
July 2014 – A CCG event for all the member practices about general practice working at scale. All the attendees could claim backfill for the afternoon, so attendance was high.
I had been asked by the CCG to try and push the GPs into seeing the benefits of working collaboratively at scale, having had experience of setting up a successful federation in north London.
 
“We need them to form a federation,” said the director of primary care. “We need them to come out of their practices and work together. Can you light the touch paper and show them some of the benefits?”
 
A simple enough brief. So, I did my talk. Cracked a few jokes. Did a Q&A session afterwards and stayed for the workshop.
 
There was a real buzz in the room which reached fever pitch when the director of primary care announced that the federation would be funded to the tune of 50p per patient from transformation money.
 
If any of the cynics in the room had needed convincing, that was the tipping point.
 
“What do we have to do to get the money?” someone asked.
 
“You just have to demonstrate the will to work collaboratively under one umbrella,” replied the CCG.
 
The background volume of table discussions went up a notch. They came up with a name for the federation.
 
December 2014 – I’m invited back to the board meeting of the new GP federation. The previous PEC chair has been appointed chair of the GP federation, although nobody is quite sure how.
I look around the table. Eight people. All GPs. There is a practice manager taking minutes, but there is no agenda. In fact, there is nothing to review apart from a rather eager looking GP with a PowerPoint presentation. He has taken it upon himself to be the branding expert of the organisation.
Twelve different logo designs are put up for the board to vote on. Tell us your first, second and third favourite and we will weigh the scores. They settle on a snake wrapped around a stick.
They then discuss their mission statement.
 
“High quality healthcare for all people through collaboration.”
Snappy.
 
December 2015 – “Thanks for coming Mike”, the new chair said. “We are in a bit of pickle here. We haven’t secured any contracts. The CCG won’t talk to us anymore. They won’t give us any contracts.”
 
A long chat. A look at the accounts and yet another difficult conversation about what to do next. Time to make this organisation dormant.
 
So, what now for GP federations?
I believe that many perhaps most GP federations have formed for the wrong reasons. When I speak to the boards, a lot of them view the federation as a contracting vehicle or a provider company rather than a federation of general practices. Winning contracts appears to be the main focus of some GP board meetings.
 
Surely, we have missed the point. If we try and become a new private provider, compete with the big boys, we don’t stand a chance. Commissioners won’t be sentimental for long, just because we are GPs. The advent of integrated care systems will test this further.
 
We need to play to our strengths.So, if you are a commissioner, a GP federation or anyone interested in general practice at scale, then please consider this list of questions to ask at your board meeting, quality meetings, patient meetings or on the train home.
1. Does your GP federation represent all practices within it?
Be careful with the answer here. I often hear people say, “Our federation represents all 34 practices in our CCG.”
But does it? Are you just reflecting the shareholding structure or membership (terms that are often conflated), or do you have a mandate to make decisions on behalf of the practices you claim to represent?
 
Are you able to negotiate locally commissioned services or QOF on the practices’ behalf? Is the local medical committee happy about this arrangement?
 
When federations turn up at STP meetings, CCG meetings or any public forum, I doubt that they represent the practices in the way that other stakeholders would like.
Engagement with your own practices: do you have any? Get a mandate. Downsize if you have to.
 
2. Have you put any of your core, LCS, DES, QOF or private income into the federation to run?
While federations are searching for new business and contracts, there is plenty of opportunity right under their nose if practices were creative in how they deliver their core contract.
 
This ultimately comes down to trust, and it is staggering the number of GP practices that don’t even trust their federation
3. Have you done any work on clinical governance, clinical quality and safety among your federation of practices?
This is such an easy win. A standardised approach to governance is a simple task and one well within the expertise and resources of primary care. CQC inspection would be so much easier, less time would be spent on writing 34 needle stick injury policies – even how we check the fridge temperatures could be standardised.
 
4. How are you engaging your local community and your patients?
This doesn’t mean creating a patient participation group. It means really empowering local businesses, groups, religious groups and volunteers to lead change supported by you. Not the other way around.
 
Speak to the pharmacists, the dentists, the optometrists who also have primary care contracts. Hear their ideas of how they are making their businesses more resilient. Look for areas of duplication. Don’t treat them like competition.
5. What exactly are you trying to achieve by federating?
I take you back to the mission statement mentioned above by the federation I visited. Nobody can argue with vanilla statements about providing the best care for all, celebrating the role of primary care, and protecting general practice but what do these statements amount to?
 
Be honest. You aren’t on The Apprentice. Go back to why federations were originally introduced. There has to be something about sustainability in a federation’s raison d’etre. We know where we are struggling in general practice, so why not reflect this in your federation’s organisational aims?
How about thesefor a start?
• To help address the issues of workload in general practice
• To help address the issues of workforce in general practice
• To help address the issues of premises in general practice
 
If we don’t address these issues soon, then federations definitely won’t be able to provide “better care for all”.
 
So, calling all surviving GP federations out there and their hosting CCGs and neighbouring acute trusts: you have a very limited amount of time to give your federation a spring clean, a clearer sense of direction and a real purpose.
 
Otherwise all you will have left next year is an absolutely smashing logo.
 
Contact PCC for information about how we support GP collaborations, including board development and help with business planning and strategy.
Mike Smith is a GP in St Albans, a federation expert and a partner in MBI Community.

 

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