You will not get better; What next for GP Federations?

  |   Thought Leadership

July 2014


It was 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 invited by the CCG to try and push the GPs into seeing the benefits of working collaboratively at scale, having managed to pull something off in North London over the last few years.


“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 made an announcement.


“If you decide to form a Federation, the CCG will fund you 50 pence per patient as transformation money”, she said.


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?” said an old ‘difficult’ GP at the back of the room.


“You just have to demonstrate the will to work collaboratively under one umbrella”, replied the CCG.


The background volume of the table discussions goes up a notch. A flip chart falls over in all the excitement. It’s like the end of ‘Grease’ when Danny and Sandy take off over an elated dancing crowd.


They’ve even named the Federation.


December 2014


I’m invited back to the board meeting of the new GP Federation. Let’s call it Apollo Healthcare (or something similar from the ‘The Apprentice’)


The previous PEC chair that nobody thought they would see again has been appointed the Chairman of the GP Federation, although nobody is quite sure how.


I look around the table. 8 people, all GPs. There is a practice manager at the side of the room 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 is a GP but has taken it upon himself to be the branding expert of the organisation.


12 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.


Next up? We discuss their mission statement.


“High Quality healthcare for all people through collaboration”




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 long look at the accounts and yet another ‘difficult conversation’ about what to do next. They haven’t got a strategy (well not a meaningful one), they haven’t got a plan. They have spent all the cash. Time to make this organisation ‘dormant’.


So, what now for GP Federations


Are GP Federations yesterday’s news? Do they still have a role?


I believe that a large majority of GP ‘Federations’ across the country have formed for the wrong reasons, and 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.


“We need to get some 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 Accountable Care Organisations / 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.


The amount of times I 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 also conflated quite a bit), 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, QOF etc. on the practices behalf? Is the Local Medical Committee happy about this arrangement?


The truth be told, when Federations turn up at STP meetings, ACO meetings, CCG meetings or any public fora, I doubt in any case they do represent the practices in the way that other stakeholders would like.


Engage with your own practices. Get a mandate. Downsize if you have to (Better to work with 8 willing practices than 34 hostages)


  1. Have you put any of your Core, LCS, DES, QOF or private income into the Federation to run?


Whilst these 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 (and I don’t mean the less sexy stuff like shared ‘back office’ etc.)


However, this ultimately comes down to trust, and it is staggering the number of GP practices that don’t even trust their Federation to do this for them.


There has to be a plan though. It can’t be done on a handshake.


  1. Have you done any internal work on Clinical Governance, Clinical Quality and Safety amongst your Federation of practices?


This is such an easy win. A standardised approach to governance amongst the Federation of practices 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 would be more of breeze.


  1. How are you engaging your local community and your patients?


This doesn’t mean creating a patient participation group. This 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.


Then speak to your local community trust, mental health trust and even your local acute. Perhaps they can help lend some expertise? General Practice may have very bright doctors with good ideas for improving community healthcare but not so much in large scale operational design and delivery. Ask. They can only refuse.


  1. What exactly are you trying to achieve by Federating a group of GPs?


I take you back to the mission statement mentioned above by the Federation I visited.

Nobody can argue with vanilla statements about ‘best care for all’, ‘celebrating the role of primary care’, ‘Protecting General Practice’ and various other combinations.


(It reminds me of a Restaurant I saw in Bradford one year with the sign in the window, “YOU WILL NOT GET BETTER”).


Be honest. You aren’t on the Apprentice.


Go back to why Federations were originally introduced. Personally I believe there has to be something about sustainability in a Fed’s ‘raison d’etre’. We know where we are struggling in General Practice, so why not reflect this in your Federations organisational aims?


  • 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 Estates in General Practice


Believe me; 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 and a little bit of direction a purpose.


Otherwise all you will have left next year is an absolutely smashing logo.