Formerly Director of an acute trust Ben was CEO of Nene CCG for 8 yrs. He is a founding director of Ockham Healthcare and programme director of the Practical Steps development programme@benxgowland
For GP federations and those planning to federate not only have the goal posts shifted, the pitch itself has moved, the rules of the game have been rewritten, the composition of the league, the style of play and the obsessions of the referees have all changed. And all of this in five short years. Think what the next five years might bring.
In this year’s BMA survey 43% of GP practices report that they are part of a federation. A few years ago federations were seen as the great hope for general practice, but if so many practices are now part of federations, why does general practice remain in such trouble? Were federations never the solution, or has something prevented them fulfilling their perceived potential?
Three things have changed since federations were first heralded as the future of general practice and have altered the fundamental role of federations, making the task of creating a successful one considerably more difficult.
First, the vast majority of federations were originally set up primarily to protect local general practice from the threat of new private sector entrants, such as Virgin, and to hopefully generate additional income for the member practices through the establishment of new services. Practices were not joining federations to change the way they operated, but rather saw them at best as a potential additional income stream.
Second, the problems of core general practice turned into a full blown crisis. Persistent underfunding, growth in demand and recruitment problems combined to turn a once secure profession into one that has left many practices teetering on the brink. For federations this has required a fundamental shift in focus. Federations are now needed not to provide a bit of additional income to practices, but to enable a sustainable model of general practice to be developed going forward.
Third, the release of the 5 Year Forward View signalled a shift away from a focus on competition to a new focus on integration. The introduction of two of the new models of care meant that general practice could either work together to lead the changes (in the multispecialty community provider or MCP model), or be swallowed up by others (in the Primary and Acute Care Services or PACS model). Federations suddenly took on a new significance for general practice as they strove to find their place in the new world.
Combined, these three factors mean that the challenge for a new federation today is completely different to the challenge a new federation faced five years ago. Federations must now be built around a different relationship between the member practices and the federation.
This different relationship requires member practices to trust the federation and be prepared to act differently as a result of what the federation asks. One of the key roles for the federation is to agree with its practices the shared level of ambition and enthusiasm for change, and then to identify the appropriate changes to drive forward as a result. These could range from introducing a support team to work across practices to reduce the cost of inspection and CQC visits, through to introducing 7 day working across multiple sites.
Federations are also now faced with the challenge of building effective partnerships across the health and social care system. This is not about attending lots of meetings, but about deciding how general practice can work with the community trust, the acute trust or any of the other local players, to drive joint working that is of benefit to patients and to providers. If the federation leaders are not arguing on behalf of practices around the system leadership table, who is?
So have federations failed? I don’t think so. Rather I think the world has shifted around them and they are running to catch up. The key question now for federations is whether it is possible for them to create the new, more productive relationship with member practices that is required? The growth in the so-called ‘super practice’ movement is primarily predicated on a belief that this type of relationship can only really be developed within a single, formal organisational structure. The challenge for federations is to demonstrate that this is not true, and that the looser collaboration of a federation can still deliver the results that the member practices need.
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