The quest continues for perfection at scale

4 December 2018
The search for the best form of collaboration for general practice – and the wider system – goes on. That was one of the big messages from a recent PCC event in Manchester.
 
Ruth Griffiths from law firm Hill Dickinson said that although some 85% of collaborations involve practices working with counterparts within the same CCG boundaries, the number spanning two or more CCGs is rising.
 
There is other evidence that collaboration remains in a state of flux. Two-thirds of collaborations involve populations of more than 50,000 patients – the notional upper limit for the ideal size of GP collaborations promoted by NHS England and others.
 
Griffiths said: “We are talking about lots of different tiers in the system – from one practice working with a neighbour down the road to an integrated care system. CCGs are continuing to fund the development of collaboration, including by bringing in external expertise, but then most stop the funding. Don’t be afraid to ask if funding is available to support collaboration.”
 
Collaboration, she suggested, can appeal to general practice as a way of meeting
 
several challenges including:
 
• Falling income
• The threat from alternative providers
• Rising demand and workforce problems
• The requirement for extended access
• Succession problems
• Estates issues.
 
Practice leaders need to understand the purpose of collaboration and both the clinical and business case for change.
 
“The advantage (of practice-led approaches) is that collaboration will be primary care led and owned and primary care is best placed to understand the clinical case for change. Practices need to ask what they want to achieve for member practices as well as at the ICS (integrated care system) level. If the new organisation has the patient list for the whole CCG then it will be the sole potential prime provider.”
 
While CCGs had supported the rise of federations (including through providing seed funding), they now prefer to award contracts to alliances or prime provider type groupings, Griffiths said.
 
Meanwhile federation has become a “toxic word” in general practice because most have failed to deliver what they promised their GP members, Griffiths said.“A lot of federations have forgotten they are there to serve their members and are used as a reserve model for practices in distress. The membership can start to become disengaged because the federation is not delivering income and is instead asking for more capital. Federations need to change by responding to what is happening in the system.”
 
She set out her firm’s experiences working with federations in Leeds that formed a new city-wide organisation. The large federation also has a very different approach to governance to the early federations – something speakers at the event agreed is key to success.
 
“The federations in Leeds realised they were not going to be taken seriously unless they saw themselves at a commercial organisation at that city-wide scale. They have an executive board, none of whom are GPs and who have no competing interests. A locality-based partnership council acts as the non-executive board.
 
It sets the annual business plan and then holds the executives to account for implementing it. If the executive team want to do something on top of the business plan they seek permission from the partnership council.”
 
GPs providing such oversight should be given training in the role of non-executive directors, she said.
 
GP partner and primary care consultant Mike Smith escalated the onslaught against federations in their current guise, agreeing they had lost their way.
 
“Federations are not working: their purpose was not clear and GPs don’t like top-down leadership and management.
 
They are often too big to notice the nuances of small communities. Many of them spent too long doing nothing – partly because CCGs never really believed in them and the contracts they were chasing were too big for organisations that were too immature.
 
“The practices don’t trust the federation board just like they don’t trust their CCG, which is also a membership organisation, or even the local medical committee sometimes. What makes us think they would trust a limited company? CCGs and practices should start building collaboration from the neighbourhood level instead.”
 
Federations, he suggested, could be commissioning support unit-type organisations for general practice, with practices seeking support from them as needed.
 
He also questioned the use of the term mergers in the context of general practice and the need to label well-established joint working practices.
 
“It’s never a merger, there’s always a dominant practice. We are not a partnership, we are a business.
 
“Since 2015 there has been lots of talk about neighbourhoods and primary care homes which is fine but I don’t need a badge. This is how practices used to work – we were sharing district nurses, health visitors and ECG machines 25 years ago. Practices don’t need permission to employ a cardiac nurse that they will share.”
 
Successful relationships, Smith suggested, would be based on strong relationships not arbitrary business cases.
 
“GPs pick their friends: one of the advantages of being a GP is that you don’t have to work with someone if you don’t like them. In terms of size and relationships it has got to be about what feels right and what you are trying to achieve.”
 
Urging commissioners to seek partnerships between practices that are philosophically aligned rather than on the basis of geographical proximity, he said they should be “clinical enablers rather than clinical commissioners”.
 
“GPs are worried about workload, workforce, estates and a £30,000 fall in their income over five years. They have been promised that the cavalry is coming for years but they never arrive and there is sort of a learned helplessness among GPs. Commissioners should not be tied to a minimum or maximum patient list size.
 
If someone does not come to the table, don’t wait for them.”
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