General practice has come a long way since the
foundation of the NHS in 1948. In those days, GPs generally
worked alone, or with an assistant, supported by one or two
receptionists. No practice nurses back then, and certainly no
practice managers!
Over the last 60 years, general practice has developed
into modern small businesses that deliver around a million
consultations every working day in the NHS and almost 90%
of all NHS contacts. But times continue to change, and GPs
General practice has come a long way since the
foundation of the NHS in 1948. In those days, GPs generally
worked alone, or with an assistant, supported by one or two
receptionists. No practice nurses back then, and certainly no
practice managers!
Over the last 60 years, general practice has developed
into modern small businesses that deliver around a million
consultations every working day in the NHS and almost 90%
of all NHS contacts. But times continue to change, and GPs
and practices need to cope with the demands of a highly
consumerist society, increasingly used to 24/7 services from
a number of sectors, with an ageing population and
increasing numbers of people living with one or more
long-term conditions.
Against this background, the Royal College of GPs
(RCGP) set out its vision for how general practice could
continue to evolve in its Roadmap for the Future, published in
2007.1 In the Roadmap, the college described the concept
of ‘federated practices’ whereby existing general practices
would work together in a formal way, based on individual
practices continuing as the basic unit of care. The college
believed that newer ways of working could build on the
strengths of existing general practice, while pooling expertise
and resources to develop new services and streamline costs.
Over the last few years, this concept has gradually gained
favour with practices, and a number of federations have
been established that operate in a variety of different ways,
according to the needs of communities and the challenges
that practices faced in their particular areas.
More recently of course, the coalition government
has published its health white paper Equity and Excellence:
Liberating the NHS.2 The white paper makes no mention of
federations; however, one of its major commitments is the
establishment of GP commissioning consortia.
Consortia and federations
Further details on GP consortia are awaited, but at present it is understood that all practices in England will be required to be part of a consortium. Consortia will be statutory bodies with responsibilities for commissioning services (other than those provided under General Medical Services) for the patient population within constituent practices. The range of
consortium powers and responsibilities will be set out in the
Health Bill, introduced to Parliament in the autumn, but it
is believed that commissioning and providing responsibilities
will be separated such that the commissioning consortium
itself will not provide any services.
So now we have two ways that practices can group and
work together. Consortia will be responsible for commissioning,
while practices can come together as provider federations.
From the perspective of an individual practice, it will be part
of a consortium by statute, but can also voluntarily be part of
a federation – the consortium and federation (and indeed
the practice) will be different legal entities.
Commissioning consortia
The white paper is clear that, from now on, power in the NHS
needs to move away from the Department of Health and NHS
managers to “frontline clinicians and patients”. Responsibility,
and budgets, for commissioning services will be vested in
local consortia of GP practices and they will commission the
great majority of NHS services for their patients.
At present, there are no clear requirements for size of
consortia, but they will have to be large enough to be able
to manage financial risk and allow for accurate allocations.
It is commonly suggested that consortia are likely to be
responsible for 150,000–500,000 patients and they will be
expected to use their resources to obtain “the best and most
cost-effective outcomes for patients”. All practices will be
required, by statute, to belong to a consortium and practices
may be assigned to a consortium if some practices have been
left out of local arrangements.
Another consequence of the white paper is that primary
care trusts (PCTs) are to be abolished from 2013, with
their functions being spilt between the GP commissioning
consortia and Health and Wellbeing Boards within local
authorities. This implies that other existing PCT functions
will devolve to consortia, although the full range of these will
not be clear until the publication of the Health Bill.
Provider federations
Although federations as such are not mentioned in the white
paper, the case for practices coming together to develop
services, share expertise and streamline costs remains strong.
Regardless of their responsibilities as part of a consortium,
practices will still be providers of general medical services and
may also wish to bid, in competition with other providers,
to supply extended primary care services or be part of
integrated care organisations.
Membership of a federation will be voluntary and their
activities will be determined by local needs and priorities. The
RCGP Federations Toolkit has case studies from a number of
existing federations and describes a large number of activities
that they currently undertake (see below).
It might well be the case that federations are generally
smaller and that several federations relate to one consortium.
It is unlikely, although not impossible, that a consortium
and a federation will comprise exactly the same constituent
practices. It is also likely that some federations will comprise
of groups of practices from more that one consortium,
particularly within cities, or where practices are from
adjoining consortia. Where there are several federations, or
where federation practices and consortia practices are not
exactly the same, that will help to fend off possible allegations
of conflicts of interest, although robust governance
arrangements will always be necessary and active monitoring
should always be in place to detect and manage potential
conflicts.
Federations supporting consortia
As it becomes clearer what the functions of consortia will be,
it might become apparent that there will be ways in which
federations can assist consortia with their statutory functions.
It is clear that commissioning responsibilities will have to
stay with consortia, but there are other possible roles for
consortia, some of which might be able to be delegated
to federations.
For example, aspects of clinical governance, appraisal and
performance management might well work better within
smaller structures, although the Accountable Officer function
will be with the consortium. On the other hand, it might also
be helpful if some functions are divided between federations
– it could be the case that GP appraisers within one
federation conduct appraisals on GPs of other federations
within the same consortium. Training and educational
support activities could also be delegated to federations,
and some federations may take the lead on training in
some activities, eg, treatment of substance misuse, or child
protection, on behalf of the consortium. Although many
details of the workings of consortia have yet to emerge, it is
probably fair to assume that consortia will be ‘lean’ structures
and will probably look to maximise efficiency and minimise
costs through delegation to federations where appropriate.
From the perspective of practices, GPs will need to plan
how they most effectively organise their input to both their
consortium and their federation, and will also need to avoid
any perception of conflicts of interest.
Another way in which federations can work to support
consortia is by acting as a channel to feed patient and public
involvement into consortium activity and decision-making.
Successful federations are likely to have established strong
and meaningful input from patients of constituent practices.
Where this is the case, it would make sense for a consortium
to draw upon, and support, these activities, rather than set up
separate, and possibly competing, structures for patient input.
Conclusion
Both consortia and federations are new structures within
primary care. They will exist for different purposes and
will have different responsibilities. Practices in England
will be members of a consortium and may be members of
a federation. Practices will need to consider how best to
work within both structures to minimise effort and avoid
duplication and ultimately to achieve the best results for
patients and practices.
References
1. Lakhani M, Baker M, Field S. The future direction of general
practice – a roadmap. London: RCGP; 2007.
2. Department of Health. Equity and Excellence: Liberating the
NHS. London: HMSO; 2010.RCGP Federation Toolkit
The RCGP has published its Primary Care Federations Toolkit,
developed jointly by The King’s Fund, The Nuffield Trust and
Hempsons. It is designed to be a compendium of practical
advice for existing and fledgling federations. The Toolkit is
available to download on the RCGP website at www.rcgp.org.uk
and contains the following sections:
• Introduction and context
• Coming together – where do we begin?
• Deciding on a federation’s legal structure
• Governance
• Involving patients and the public
• Engaging the wider primary care workforce
• Improving quality and safety
• Training and education
• Developing and redesigning services
• Tackling public health issues
• Sharing back office functions
• Working with an external partner
