GP Federations

A GP Federation is a primary care collaboration; an umbrella organisation that groups clusters of GP surgeries and other similar primary care practices to work together within a regional health economy. There are alternative terms used other than federation – some have been dubbed networks, whilst other names include collaborations, joint ventures, or alliances – but they all serve the same purpose.

That purpose is cooperation; to allow these health and care providers to share staff and medical resources more freely, thus delivering better care for their local population, but also to utilise the new stature to ensure better value contracts for the area and to take advantage of economies of scale to help offset costs at a time when the NHS – and arguably the world – is struggling financially.

The concept was first revealed by the Royal College of General Practitioners (RCGP) back in 2007, but it was only with the consensus of the next NHS five-year plan that real interest manifested. From there, the RCGP developed an online guide for the setup and management of what it called a ‘primary care’ federation (aka a GP Federation) – in conjunction with other trusted industry organisations including the Nuffield Trust, the King’s Fund, and Hempsons solicitors for legal support.

Preparation takes time, and the first GP Federations launched in the UK in 2014, with the Down Federation in Northern Ireland and North West Leicestershire GP Federation credited as two of the forerunners of this new collaborative approach.

Above these Federations sits the National Association of GP Federations; an organisation containing 50+ Federations from across England specifically (due to devolution) to establish best practice and engage with other national bodies and political interests or institutions.

GP Federations deliver many benefits to care quality, care delivery, work efficiency, and staffing levels, with collaboration enabling resource and data sharing, as well as greater balance of staffing and greater leveraging of funds.

The RCGP stated the aims of these federations back in May 2010:

• To strengthen the capacity of practices to develop new services out of hospital.
• To form an entity that can tender for services offered by a future GP commissioning consortium.
• To make efficiency savings utilising economies of scale. For example, in back-office functions or the procurement of practice services.
• To improve local service integration across practices and other providers.
• To enhance the capacity of practices to compete with external private sector companies.
• To strengthen clinical governance and improve the quality and safety of services.
• To develop training and education capacity.

These responses came from surveys of health and social care professionals, so this is based on real experience and the difficulties or hindrances they experienced. Thanks to the subsequent collective approach, GP Federations have been able to orchestrate more integration – led by new multi-disciplinary teams – and have used their success to argue for more from the NHS and the UK government.

Stronger contracting power, the economies of scale, and patient care quality improving are all welcome benefits of these Federations but perhaps ignored is the fact that the umbrella approach allows GPs more freedom: freedom to be flexible with their work patterns, but more importantly, the freedom to specialise. Whether that’s based on local needs or personal preferences would be a case-by-case basis, but an aspect of healthcare that has suffered in recent years with the sharp increase in patient demand has been the ability to further enhance skillsets.

The NHS needs people with uncommon knowledge and expertise. Not just for those few but crucial cases where their insights hold the answers, but also for the purpose of giving these doctors the capacity for professional development. It’s hard to feel satisfied - if not burnt out -, in such a taxing role, but to do that without any longer-term development or career plan is likely to result in staff leaving for other positions – some which might not even be in the NHS or even in the UK.

All organisations face challenges in their operations, but for a GP Federation – unifying so many different organisations – this can be a bit more exaggerated.

Financial: Individual practices and services are seeing their budgets squeezed. This can (in cases) impact cash flow and cause delays in payments. When also accounting for increased patient demand, this makes it difficult to free up spare funds for modernisation or new projects across the region.

Operational: The health and social care landscape is a continual evolution, with Neighbourhood Care the latest ambition and Primary Care Networks (PCNs) the last major push to alter care delivery. Change in the pursuit of better is welcome, but digital transformation takes time and effort and there are standards to meet. Doing this at one practice will take time. Ensuring consistency and cohesion across multiple providers within a PCN takes more time, as some services may be easier to transition or change, and doing that across an entire region is even more complex.

Structural: Where previously there were concerns about PCNs taking attention away from GP federations, now it is Neighbourhood Care that is looked upon with uncertainty. Clarity is important, but whilst implementation is figured out, elements like leadership are unknowns – a big problem for GP Federations who may need to adapt their strategies.

Workforce: GPs are dealing with the biggest workload in NHS history, and while plenty of trainees are still qualifying, the funding isn’t there to create new roles. This has an impact on staff performance, care quality, and staff retention, and if GPs aren’t sticking around – and they are seen as the centre point of most local care delivery – then it can be discouraging for fellow professionals in other departments to work locally. A GP Federation can’t do more in the bigger picture if the base elements – the GP surgeries – aren’t able to perform as intended. You need good foundations.

To those who aren’t in the health and social care sector, it’s easy to conflate GP Federations with Primary Care Networks.

A GP Federation is a large, independent organisation that acts as an umbrella for local care services such as GP surgeries and Primary Care Networks. This is typically regional level and can be anywhere from 100,000 people to 600,000 people accounted for. They are designed to leverage economies of scale and that purchasing power, to get the best deal for their members, but they also support administration, training and development, and best practice.

PCNs are much more local collaborations of GP surgeries and other social care services, and typically cover 30,000 to 50,000 people – small towns and satellite villages or medium sized towns alone, in effect. They are the ground level coordination effort for a range of services; a multi-disciplinary approach to treating people in their local area.

Their collaboration is an ideal way to have local impact with regional or national weight. The GP Federation can fight the bigger battles and engage in the political aspects, whilst Primary Care Networks can focus on person-centred care and better-quality healthcare.

The next step for GP Federations is figuring out how they will work to support the delivery of Neighbourhood Care, as mandated by the government and the NHS. Structurally speaking, there wouldn’t be too much need for change – PCNs are still the local level delivery of services and resources, and GP Federations are the broader overhead, so if anything, it’s PCNs that may be under threat, but that’s not to say there aren’t issues or won’t be further challenges.

Health and social care law experts Hempsons have their own take on PCNs, GP Federations, and their roles within neighbourhood care. To paraphrase, they believe that GP Federations are already doing a lot of the leadership work that neighbourhood care is uncertain about, and that they have the opportunity to take ownership of it and keep GP surgeries at the heart of neighbourhood care – rather than see that leadership and direction pass over to NHS Trusts or others.

The NHS Confederation had this to say about delivering neighbourhood health services: “Primary care-at-scale – through GP federations, collaboratives or alliances – will be key to delivering system support for neighbourhood care and in many areas can be the neighbourhood health provider. This includes bringing together general practice, community pharmacy, dentistry and optometry to operate in a coordinated way across place. They can host shared services, provide analytical support, employ staff and support quality improvement in providers. They offer the organisational maturity to interface with key partners in the system, aligning the voice of primary care with wider system transformation.”

Given that Hempsons were involved back in 2007 with the initial proposal of GP federations, it’s no great surprise that they are backing their continued existence and oversight, but they raise a valid point: the main concern about neighbourhood care at present isn’t the concept of localised care, or preventative action, or greater patient engagement. It’s the fear that it’s a leader-less project and ends up falling at the first hurdle. Nobody wants to commit wholeheartedly to a project, only to waste time, money and enthusiasm on something that was always destined to fail.

GP Federations could quickly dispel these fears and help to build momentum behind the switch away from acute settings to local person-centred care. Neighbourhood care is a brilliant concept, and the NHS needs to change one way or another, else it will collapse, so we wait and see if these Federations are ready to step up to the challenge and steer the NHS into a bright, sustainable future.