Safety in numbers: the rise of the GP federation

Posted on November 17, 2009. Filed under: Arm's length providers, Federations, News stories, Providers, Social enterprise | Tags: , |

Pulse | By Nigel Praities | 17 November 2009

It’s two years since the RCGP proposed its ‘roadmap’ for general practice, which envisaged practices working together as federations, pooling skills and resources to broaden the range of services on offer in primary care.

Many at the time thought it would go the same way as the Middle East roadmap for peace. Yet increasing evidence is emerging that GPs are experiencing a major shift in the way they work, some more voluntarily than others.

Nigel Praities investigates the growing move towards new models of working and asks if federations are now the only way forward.

Where does the idea of primary care federations come from?

The RCGP’s ‘roadmap’ was largely designed to steal a march on the market-based approach being spearheaded by Lord Darzi and his NHS Review.

The concept was one of primary care federations giving patients better access to services with change being championed locally by GPs, rather than through ‘one-size fits all’ plans from central Government.

Initially federations were seen as nothing more than glorified practice-based commissioning hubs, but a 2008 paper from the RCGP was crucial in putting more flesh on the bones of the federation concept.

Federations, the paper said, could give practices ‘economies of scale’ they could not achieve otherwise, by sharing back-office functions and directly employing managers and nurses to provide new services.

It gave a list of characteristics a federation should have, including a formal legal structure, an executive management team and a written public constitution.

What evidence is there that federations are beginning to evolve?

There are no official numbers on primary care federations in the UK but, anecdotally at least, it seems more practices than ever are working collaboratively.

Pulse has uncovered evidence of practices linking up in all areas of the country – from the centre of post-industrial Sheffield to the rural heart of Worcestershire.

Trailblazing schemes in Croydon and South London have been followed by other partnerships, with some practices forming limited companies or provider arms.

The schemes involve nearly 300 practices in a wide range of different models, from collaborations with private companies to organic growth from successful PBC hubs.

In Sheffield is a group of 90 GPs working in an area with high deprivation and social need that is heading towards a federated model.

It directly employs specialist nurses to run diabetes and ENT clinics in the community and is working on several schemes to bring other services closer to home, such as midwives to provide obstetrics clinics in GP surgeries.

All the 28 practices in the consortium sign an agreement and work with centrally employed practice managers. They have also formed a provider company this year, Central Care Sheffield Ltd, to take on their projects and save administrative costs.

Paul Wike, Primary Care Lead Manager at the consortium, says: ‘It is safety in numbers, they have another 26 practices standing should-to-shoulder.’

What different models have emerged?

As in Sheffield, many of the practice groupings have grown organically out of PBC clusters or consortiums.

GPs in Brent have recently set up a federation council that contains representatives from the five PBC local clusters. It sits on an executive council with the PCT and looks at how services can be commissioned all over Brent

Dr Ethie Kong, a GP in Brent and member of the federation council, says it gives GPs a powerful voice in how primary care services are commissioned for areas such as improving health inequalities and care for long-term conditions.

‘Some of the needs are common and some specific to the locality. We work within our clusters, and across clusters, and Brent-wide we liaise with the PCT.

‘This means we have local autonomy as well as borough-wide co-operation,’ she explains.

Services are currently provided by the PBC clusters themselves under a not-for-profit social enterprise model, but this may change in the future.

Other areas are working closely with private companies to form provider companies. A network of 22 practices in Worcestershire have formed a ‘GPCo’ through a 50:50 partnership with the company Assura.

Assura provides money to set up the company and shares the profits with the GPs. A statement from Assura says it enables GPs to ‘exploit the economies of scale that a national organisation brings’ by reducing the costs of service design, bid management and service implementation.

‘Due to the fact Assura operates nationally, all of its members are able to benefit from its bulk purchasing power of equipment and utilities, as well as understanding how other localities provide services more efficiently,’ the company says.

PCTs are also seeing the benefit of making practices work together. NHS Tower Hamlets has recently dangled a massive £12million carrot in front of their practices to fund the development of new care pathways and ‘networks’ of GP practices.

As Pulse revealed last week, the PCT – in one of the poorest parts of the country – brought in the external consultants McKinsey to assess their primary care services.

They recommended a 40% increase in funding for primary care and that this should be used to develop networks – with hubs for each care package – and would eventually include specialists, local voluntary organisations and the borough.

Are there any dangers for GPs?

One risk is that the schemes will cause GPs to surrender the protection of their nationally negotiated contracts.

In Tower Hamlets, the additional investment in primary care is dependent on all practices switching to APMS. That could be a bad decision in the long-term, as their contracts could be rewritten at the whim of the PCT or handed to private providers.

The involvement of private companies could also open up GPs to criticism they are profiteering rather than seeking to improve the care of patients.

Dr Michael Dixon, chair of the NHS Alliance, says the way GPs develop their federations will be crucial to whether they survive or not.

‘There are some really big questions here that general practice has to ask itself – are we in it to make a short-term profit or for the long term to make services more responsive to local patients?

‘I think a social enterprise is the best model, because it is really important the extension of services is seen as something done for local people, rather than tabloid headlines saying we are “fleecing” local people again.’

There is also a danger federations will bite off more than they can chew. They are able to take on more risk than an individual practice, as it can be spread more thinly, but this could backfire.

A PBC federation of 32 practices in Bexley made £4m worth of savings after being given real budgets for prescribing last year, but they also took on responsibility for 54% of any overspend, which could have cost them tens or hundreds of thousands.

What does the future hold?

If Tory plans are anything to go by, GPs could see themselves with much greater responsibility for commissioning and real budgets written into their contracts from next year.

This could push those not currently in a federation into thinking about how they can work closer together and become more business-like in the way they organise commissioning.

The NHS Alliance is due to launch a paper this month on developing ‘local care organisations’, extending the federation model to secondary care and other partners.

This model – similar to the networks planned by Tower Hamlets – could see the traditional barriers between different aspects of healthcare being blurred, ideally with GPs driving the changes.

This is the best case scenario, but whatever happens GPs working on their own is likely to be a thing of the past. The formation of federations may be the only way to ensure GP practices remain the basic unit of care for patients, albeit with risks.

As Dr Dixon warns: ‘Whichever party is in power next year, there will be a much bigger drive to emancipate these organisations. Whatever happens there will be change, and GPs should be developing these systems in readiness.’

RCGP chair Professor Steve Field is in no doubt federations are the future.

‘This is the way forward,’ he says. ‘The most important thing is strong GP leadership and that patients are at the centre of it.’

Increasing numbers of practices appear to be heeding that call.

How GP Federations are progressing across the country

1. Bexley: PBC federation of 32 practices that was responsible for making a £1.4 million saving in prescribing cost last year and is now looking at working with consultants to develop new pathways of care

2. Brent: Initially a PBC cluster of 67 practices, it has now progressed to have a GP Federation Council and is involved in all mainstream commissioning and planning

3. Worcestershire: 22 practices working in a ‘limited liability partnership’ with the private company Assura to develop PBC opportunities

4. Lincolnshire: Cluster of 14 practices that is registered as a ‘limited provider company’ and has worked to ensure their local hospital survives by having primary care-led acute medical beds, a GP-led A&E department and holding additional diagnostics in the community

5. Croydon: Led by RCGP fellow Dr Agnelo Fernandes, it is made up of 16 local practices covering 140,000 patients. Recently it won an award for its diagnostics-in-the-community project, providing ultrasound, echocardiography and direct-access MRI

6. Surrey: Epsom Downs Integrated Care Services is a collaborative venture involving a federation of 20 practices in Surrey. It has established nearly 30 new community clinics, enabling over half of out-patient consultations to take place closer to home

7. Sheffield – Consortium of 28 practices that has been working on schemes to improve prescribing and community services for chronic pain and COPD. Has just set up their own provider company – Central Care Sheffield Ltd

8. South London – RCGP vice-chair Dr Clare Gerada’s group of five GP practices across Southwark and Lambeth has set up new musculoskeletal clinic and gynaecological services and was mentioned as a good practice example in the Darzi review

9. Tower Hamlets – Revolutionary plans for primary care ‘networks’ with a hub for each long-term condition, with GPs working with specialists and community/social care services and local voluntary groups

10. Kingston – The Kingston Co-operative Initiative is a not-for-profit limited company overseeing PBC on behalf of 27 practices. Runs an education and support service and a GP-led referral management scheme. Also developing a service provider arm.

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