Federations

Wansworth PCT Health Overview and Scrutiny Committee

Posted on December 23, 2009. Filed under: Federations, Polyclinics, Reports/papers |

Wandsworth PCT | accessed 23 December 2009 [pdf]

Par. 2. Primary care, polyclinics and polysystems. A major focus for the work of Wandsworth Primary Care Trust over the past two years has been the development of plans for primary care. In line with the NHS strategy document Healthcare for London, these plans have concentrated on the development of polyclinics, each serving a population of around 50,000. The approach favoured by Wandsworth PCT has been the development of ‘federated polyclinics’ with an identifiable ‘hub’ but retaining individual GP practices and other primary care services in a variety of locations across the area served. The development of plans has hitherto been structured around three localities: Battersea and North Wandsworth, Putney and Roehampton, and South Wandsworth.

On 30th September 2009 the Board of Wandsworth PCT received a report drawing together the plans for these localities and setting out an overall plan for the development of primary care across Wandsworth. Two factors underpinned this report to the PCT Board: (a) criticism in the ‘gateway’ review of plans for Battersea and North Wandsworth at the lack of a co-ordinated Borough strategy and the need to ensure that investment was fairly distributed across the Borough; and (b) the much tighter than expected financial position of the NHS, with correspondingly more cautious assumptions about the availability of funding for capital developments. This has been reflected in the change of terminology within NHS London, the word ‘polyclinics’ being replaced by ‘polysystems’, emphasising the working together of professionals within a locality without the assumption that this requires investment in a new building.

The report proposes the establishment of five polysystems in Wandsworth: Battersea; Putney and Roehampton; Central Wandsworth; Balham; and Tooting and Furzedown. Primary care services within each of these areas will work together to provide a coherent service pattern and to enable a shift of provision from secondary to primary care. Within each area, from March 2010, there will be a service offering extended hours access to urgent GP-led care. However, the most significant thrust of the report is a retreat from previous proposals for significant new capital investment in polyclinic ‘hubs’. The abandonment of plans for the Putney Hospital site SW15 (Thamesfield), signalled in June 2009, is confirmed, and of the four developments in Battersea and North Wandsworth on which the PCT consulted – Grant Road, SW11 (Latchmere); Doddington, SW11 (Queenstown); Bolingbroke, SW11 (Northcote) and Bridge Lane, SW11 (St. Mary’s Park) – there is only a commitment to proceeding with the smallest, Bridge Lane, within the foreseeable future. The report confirms the intention to establish GP services at Queen Mary’s Hospital SW15 (West Putney) from October 2009, and to follow this with the full development of a polyclinic hub at Queen Mary’s in 2010.

This reduced commitment to capital investment reflects the drastic change in the financial prospects for the NHS. It is justified by an audit of existing primary care premises, which suggests that there is scope for much better use to be made of the existing estate. Nevertheless, it is unclear whether the proposed shift of services from secondary to primary care will be seen by patients as an improvement in quality or access if the primary care settings are scattered around localities as space permits, rather than concentrated in a purpose-built polyclinic hub at the centre of the locality served. The abandonment of the majority of investment plans for Battersea and North Wandsworth is likely to be resented by the community in this area, which had been led to consider the new investment as a recompense for the closure of the much-loved Bolingbroke Hospital.

This matter is being reported to the Council at the request of the Chairman of the Overview and Scrutiny Committee and the Opposition Speaker.

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LMCs draw up federation blueprint to protect against ‘APMS-hungry PCTs’

Posted on November 26, 2009. Filed under: Federations, News stories | Tags: |

Pulse | By Lilian Anekwe | 26 November 2009

Londonwide LMCs are working on new plans to help practices group together into federations to avoid small practices being ‘picked off’ by their PCTs.

Small practices in London are increasingly being forced either to close or to aggregate into groups of practices, according to Londonwide LMCs chief executive Dr Michelle Drage, and need to explore GP federations or risk being targeted for closure by trusts.

‘We are trying to advise practices that want to federate and offer a package of advice on how to do that, and promoting the fact that these can be done.

‘What practices don’t have at the moment is a description of what federations should look like, in legal and financial terms.’

‘We’re trying to offer practices a range of options that will help them move out of the target zone of being a small practice in the spotlight of the PCT for inappropriate reasons and toward something more appropriate.’

Dr Drage said Londonwide LMCs were also exploring ways of offering salaried and sessional GPs more career opportunities, and cited the Hurley Clinic – whose partners include RCGP vice chair Dr Clare Gerada – as an example of a practice offering an ‘intermediate partnership’ that allows GPs to take a step up the career ladder.

GPs at the Hurley Clinic, in Kennington, south east London, can join the group as a stakeholder – helping to run the practice and keeping a share of the profits – while aspiring to become a full partner within the group itself.

‘The current model of partnership is not providing them with the autonomy that they seek and one of the things we are supportive of is providing career progression for salaried and sessional GPs who are looking for them,’ said Dr Drage.

‘We are looking at how we can create career development opportunities without the millstone round doctors’ necks of having to have equity and so on.’

‘It’s overt, how practices are still being picked off because it does not fit the model. It will be important for small practices that when they come up for retirement they invest in the future rather than allowing themselves to be picked off by APMS-hungry PCTs.’

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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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MEETING ON ‘SUPER’ HEALTH CENTRE PLAN

Posted on July 28, 2009. Filed under: Federations, GP-led health centres, News stories |

Southwark News | 27 July 2009

By Anthony Phillips (news@southwarknews.org)

The results of consultation on whether to create four ‘super’ health care centres in the borough are set to be revealed in a public meeting tonight.

If given the go ahead, the new centres could radically change the way GPs operate in the borough, with longer opening hours and increased services, as smaller surgeries compete to survive.

The ‘News’ exclusively revealed in January this year that Southwark PCT, [now NHS Southwark],  had put together a 28 page draft proposal, called Transforming Southwark’s NHS, for the centres.

The Health and  Social Care (HSC)  centres, which would be based in Canada Water/Surrey Quays, Peckham, Elephant and Castle and Dulwich, offer out-of-hospital services from 8am-8pm, seven days a week, to both registered and un-registered patients.

The HSCs would house new GP surgeries, intended as additional practices to ones already operating. There would be a minor injuries clinic, a walk-in service, consultant led clinics and a variety of testing facilities. Some of the centres would provide X-ray machines, while all would handle blood tests, ECGs (heart activity monitoring), 
spirometry (which indicates lung disease), ultrasound and MRI and breast screening.

There will be additional maternity clinics offering specialist provision in both ante and post natal care, with plans to include a midwifery group to support teenage mothers and women with mental health problems.

When the ‘News’ revealed the existence of the proposals, fears were raised that the new centres would threaten existing GP surgeries. But Jane Fryer, NHS Southwark’s medical director, told the ‘News’ in January:  “It’s not about closing down practices at all.”

But Dr Fryer, also the Chair of Southwark’s Health Partnership Board, admitted that the smaller practices might go under unless they modernised and competed with the new super health centre model.

Dr Fryer added: “We think that the very small practices will not be sustainable in the future. We will be working with them in a new federated way.” NHS Southwark Chief Executive Susanna White added at the time: “The market forces will mean that the surgeries will have to come up with ways of keeping patients – opening hours, providing services, etc.”

NHS Southwark will be feeding back the results of the consultation at a public meeting at  Millwall Football Club’s ground The Den, Zampa Road, from 12pm to 4pm, today, Thursday, July 23.

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Federations in action: The St Helens experience

Posted on April 17, 2009. Filed under: Federations, News stories, Providers |

RCGP News | February 2009

Four general practices in St Helens are showing how the federated model can work to improve GP training. Aspect Health Ltd is made up of four training practices who decided to pool their resources last summer following the RCGP’s publication of Primary Care Federations: Putting Patients First and amid the backdrop of Lord Darzi’s review of the NHS. 

An innovative teaching programme covering key areas of the nMRCGP curriculum has allowed trainers from the practices to hold monthly tutorials with subjects covering their particular area of interest. Tutorials are co-ordinated through the federation teaching website and have been well received by GP trainees. 

According to Dr Greg Irving, one of the federation trainees, working together has been a great success. 

“It has gone down very well – trainees get to see different practices and work with a wider range of people. It gives us wider exposure and access to tutors with different specialties and distinct experiences. 

“The St Helens experience is an example of how working more closely to share local knowledge and expertise can build on the strengths of each individual practice.” 

At the same time, each practice has retained its autonomy, independence and unique identity by continuing to use existing buildings. 

Working together means the four practices are well placed to bid for PCT contracts. The federation has been successful in its bid for two Darzi equitable access schemes in the area, with the training of GPs seen as a key strength. 

Federation also means better access and different ways of accessing the service (some booked, some walk-in appointments) with extended hours being more practicable. Economies of scale also mean that one practice manager can now do payroll for all four practices. It has been a busy six months for Aspect Health: 

● A limited company has been formed, along with a Board, an executive team and a website. Accountants and solicitors were consulted to help set up the business model 

● Exploratory meetings have been held with the Chief Executive of the local Acute Trust, the Director of Social Services, the Carers Centre, local third sector organisations and the local Chamber of Commerce, as well as our host PCT 

● The federation is working with the local Rotary Club to run a two-day event promoting health awareness in the town centre Aspect Health has already been approached by a number of other groups looking to follow a similar teaching model, and in the future will aim to use their federated model to deliver revalidation.

http://www.aspecthealth.net

PRESS RELEASE   (Added 5/3/09)

‘Aspect Health win contract to provide new GP services in St Helens.’ 

Aspect Health win contract to provide new GP services in St Helens NHS Halton and St Helens has awarded a new contract that will see extra GP provision within St Helens. Sherdley Medical Centre, which will be based within St Helens Hospital, will provide residents of Thatto Heath, Marshalls Cross and the surrounding area with a new GP surgery providing 60.5 hours of medical care. The new practice will become operational from 1st September 2009.

Commenting on the awarding of the contract, NHS Halton and St Helens Interim Chief Executive, Ian Williamson, said “We have awarded the contract to Aspect Health. Following an open and fair procurement process, 8 potential providers were shortlisted from the independent sector, existing GP partnerships and social enterprise. Their proposals were rigorously evaluated by a panel against clear criteria for quality, and value for money.

In addition to the contract to provide a new GP Practice within St Helens Hospital, Aspect Health (a group of 4 St Helens Teaching Practices) has been awarded the contract to provide a ‘virtual’ practice called Eldercare. Eldercare will provide a home visiting service for the frail, vulnerable and elderly, predominantly to residential and nursing homes. Services will commence from 1st April 2009 and will be the first of its kind in the North West.

These developments are part of the Government’s drive to improve the public’s access to primary care services, ensuring communities have access to high quality primary health care services in easy to reach locations.

Ian Williamson, Simon Hargreaves, Jim Wilson
Pictured from left to right: Ian Williamson, Interim Chief Executive – NHS Halton and St Helens; 
Dr Simon Hargreaves, CEO – Aspect Health Ltd; Jim Wilson, Chair – NHS Halton and St Helens

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