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Are federations the future of general practice?

Federations will provide a career structure for GPs and allow them to be distinguished by their roles and not their type of contract, says the RCGP's Dr Maureen Baker. But Dr Mary Hawking argues that federations do not address the profession's problems and would level down by reducing the autonomy of partners to that of salaried GPs

Federations will provide a career structure for GPs and allow them to be distinguished by their roles and not their type of contract, says the RCGP's Dr Maureen Baker. But Dr Mary Hawking argues that federations do not address the profession's problems and would level down by reducing the autonomy of partners to that of salaried GPs

There has been a sharp rise in recent years in the number of GPs taking on salaried jobs rather than entering a partnership.

For many, this provides welcome flexibility. The challenge for our profession is to ensure that young graduates have the opportunity to reach their full potential, whichever role they choose.

There is no difference in the quality of care given by either role. Partnerships are valuable because they encourage tenure, continuity of care and innovation, while salaried positions can provide flexibility.

We need to develop innovative models of care that allow GPs to pursue the career options that suit them. This is why the RCGP is promoting a federated model of general practice with GPs working together in associations, to build on the strength of traditional general practice. Practices would retain their independence but benefit from a shared management structure looking after functions like HR.

The extent to which the practices in federations work together would be up to the GPs involved to decide - different models will work for different areas. There will be financial arrangements to suit various preferences. Most are likely to have a formal legal structure, a management board and a public engagement strategy. This would enable GPs to maintain a high degree of autonomy and enable those with special interests to develop and share their skills, allowing GPs to concentrate on different priorities.

Federations can offer economies of scale that may lead to increased efficiency gains to reinvest in patient care. But perhaps their most important feature would be their ability to distinguish GPs by their roles rather than their contractual arrangement or level of importance. Those roles could overlap as much as any practice wants, focusing on three broad categories:

  • l traditional GPs providing traditional, quality general practice
  • l GPs with other interests such as local leadership, academia or commissioning
  • l primary care directors responsible for management and organisation.

With a federated model there is no reason why salaried GPs should be excluded from management positions. Many of the younger generation are desperate to make a contribution, but feel they can't because of their contractual position. They have to be given this opportunity to develop their leadership and management skills, for both their benefit and their patients'.

The federated model offers the chance for partners and salaried GPs to come together to offer improved services to their patients. We see professional leadership, flexibility, innovation and collaboration as the pillars of this model - qualities GPs and practices have in abundance.

The Croydon GP Federation is a good example. Led by RCGP fellow Dr Agnelo Fernandes and formed last year, it is made up of 16 local practices covering 140,000 patients. Recently it won a Health Service Journal award for its diagnostics-in-the-community project, providing ultrasound, echocardiography and direct-access MRI.

The other key advantage would be federations' ability to compete with private firms which entice GPs with the prospect of retaining control of their practice, while receiving financial, back-office and IT support from the corporate partner.

All this explains why the college sees federations as a key policy focus. We are developing a toolkit to help support GPs and practice teams to develop federations and make the model work.

This model will allow GPs to take their destinies into their own hands. Not only will it create opportunities for the next generation of GPs, it also goes a long way towards safeguarding general practice for future generations.

Dr Maureen Baker is honorary secretary of the RCGP and a GP in Lincoln

The discussion paper by the RCGP and BMA, Changing Partnerships, is about the plight of salaried doctors and the increasing levels of dissatisfaction they apparently feel. But it gives a historical account of GP contractual changes that does not always match my recollections and the federations it recommends would seem to place all GPs - including partners - in managed jobs, with the favoured few in total control.

These primary care directors will, according to the document, 'take responsibility for organisational concerns, including clinical and corporate governance, risk, finances, strategy, and workforce and disciplinary matters'. But it is the responsibility for these areas that is the difference between being a real partner and being a salaried GP - or a partner reduced to the equivalent of being salaried: the ability to be involved in managing the workplace and organisation, and to accept the financial and personal risks involved.

Another quote: 'The relationship and power balance between the federated and constituent practices is the difference between a partnership and a managed organisation.' Quite. If you are part of a managed organisation, what is the point of being a partner? All the financial investment and risks - and no control!

Why am I out of sympathy with this report and its only proposed solution?

I don't see that what it identifies as the problems - career development for non-principals, competition for partnership vacancies, changes in the NHS environment - are necessarily right. Neither do I think its proposed solution would be sustainable or address the problems identified.

I'm a partner with a lot of investment in my practice. We have always run on partners, not salaried GPs: it suits our ethos and business model much better.

I am not clear about this demand for partnerships: we advertised for partners in 2004 and 2006. The number of inquiries was under 10 both times so we had to appoint via other channels. Where were you discontented salaried GPs when we needed you as partners? Or did you prefer not to take on the management responsibilities, financial risks and lack of defined and limited hours and employment benefits? Can't say I blame you if so!

The GP business model and the detail of service delivery requirements have indeed changed since 1990 and even more so since 2004. But there have been changes about every three years - or when a new health secretary arrives - ever since I came into practice. I wouldn't want a return to the pre-GMS John Wayne contract and its unlimited workload. It may be a delusion, but I don't agree that autonomy has been abolished: certainly not to the extent proposed in the RCGP federated model.

Experience of being in a collaborative locality and now PBC consortium does not convince me that the GPs likely to become primary care directors would represent my practice's interests. After all, PEC members who are GPs are forbidden to represent the interests of local practices, and they may have got into bad habits. Wouldn't these same GPs be likely to be selected for any position of power within a federation?

This paper risks pushing a one-size-fits-all model - especially if it is developed at

a suitably high, strategic level - and lacks examination of the few existing, and varied, models developed to address specific local circumstances. Is there some resemblance to the approach used in reviewing the future of the NHS? Appoint a tertiary surgeon with no experience of the NHS outside a single tertiary hospital, develop a blueprint to reorganise London and then widen it to impose the same solution on the whole of England?

Is Scotland still accepting refugees?

Dr Mary Hawking is a GP in Dunstable, Bedfordshire

Yes No Are federations the future of general practice?

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