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Federate or bust

In this new series, we check in with pathfinders around the country to see what makes them special and discuss the challenges ahead. This month we talk to Dr Stewart Findlay, of the County Durham and Darlington Federation.

Our pathfinder involves seven separate consortia – Durham Dales, Darlington, Easington, Sedgefield, Easington, Derwentside and Durham Chester le Street and Intrahealth – grouped as a federation covering 617,000 patients.

The various consortia basically formed 18 years ago back in the days of fundholding. The localities have stayed the same through the shift to Primary Care Groups and the formation of PCTs, so it's been perfectly natural for us to stay in the same groupings.

This history made deciding the size of the pathfinder quite straightforward. We want to keep our consortia relatively small because of the demographic and geographical diversity in the region.

One consortium covers the whole of the city of Darlington, whereas others cover much more rural, less populated areas. Each consortium has different commissioning priorities because of our different populations but will have the power of the larger grouping through the federation.

Waiting until 2013 when GP commissioning consortia officially take full control of budgets seemed a long time to wait to get started, so becoming a pathfinder now gives us the chance to start making real decisions straight away.

As soon as the consultation documents arrived last summer we started organising ourselves for the future. We had already thought it through and were ready to join together as a single entity.


With the federation arrangement, we are planning to share back-office functions between us, which will be much more efficient. In addition, each of the consortia in the federation was already taking the lead for a different area of work so that was another reason it made sense to stick together.

Another area we have been thinking ahead about is risk-pooling – just in case. We have already made an agreement between us to cover this.

Basically, the arrangement will work like a bank. We'll top-slice our budgets and have a risk-pool fund that can be called down

if needed. If one consortium overspends over the year, we'll effectively bail them out. They will then have until the end of the following financial year to repay the money. The scheme will ensure that none of the underspending consortia miss out on quality premiums because of the financial performance of their neighbours.

We think it allows us to have the best of both worlds. Although the underlying financial situation in our PCT – NHS County Durham and Darlington – is good at the moment, the arrangement gives us some security as regards the financial risk.


Officially, the pathfinder consists of seven projects, which will each focus on a number of QIPP priorities including the role of community hospitals in delivering intermediate care, the COPD respiratory pathway, children's commissioning, budget for planned care, purchase of nursing home beds and development of streamlined unplanned care. Six projects are geographical, the seventh is led by private GP company Intrahealth and looks at a range of issues across County Durham and Darlington.


The signs are that we're likely to succeed. There has been a very tangible change in the way the PCT seems to be working. We're quite well-resourced and we are already talking to the PCT about aligning more of their staff to the consortia. From next month, we'll be taking on delegated budgets in a number of key areas such as prescribing, planned care and continuing healthcare.

The key challenge for us has got to be trying to minimise the bureaucracy that has built up over the past few years so that we can move much more swiftly. This has been a very risk-averse period in the NHS with a large supporting bureaucracy that at times has made it difficult to make decisions.

All the rules and regulations emanating from the Department of Health have made things very, very difficult for commissioners. So if we don't make things simpler, this reform could fail – like practice-based commissioning largely failed.

This model will be nothing like the existing PCT. What's happening is that we're effectively turning the whole organisation upside down. Instead of one big statutory body – the PCT – controlling 90 practices, our aim is to form six or seven locally-focused statutory bodies. And it will be us running the back office functions, instead of the PCT. We've felt no need yet to buy in external support.

In three years time, and perhaps even sooner, I hope there will be many more services provided in our communities. That, and much closer working between us and our partners such as foundation trusts and local authorities. We'll have lean management where individual practices are able to influence decisions and that will lead to many more cost-effective services.

Dr Stewart Findlay is a GP in Bishop Auckland and chair of Durham Dales consortium

Dr Stewart Findlay: 'The seven consortia will have a risk-pool fund that can be called down if needed' Dr Stewart Findlay: 'The seven consortia will have a risk-pool fund that can be called down if needed' Pathfinder: County Durham and Darlington Federation

Wave: First
Practices: 90
Structure: Seven consortia ranging in size from 35,000 to 150,000. Federated model will allow risk-pooling and sharing of back-office functions. Each consortium takes the lead for a different area of work
Population: 617,885
PCT: NHS County Durham and Darlington
Hospital: County Durham and Darlington NHS Foundation Trust
Geography: Covers whole range – from City
of Durham to rural
Disease rates: High levels of health inequalities including high rates of heart disease and cancer. Smoking remains the cause of lower life expectancy and high disease rates. Obesity also poses a major public health challenge and risk to future health, wellbeing and life expectancy. Significant health inequalities between the area and the rest of England
Priorities: These include role of community hospitals, COPD pathway, childrens' commissioning, planned care budget, purchasing nursing home beds, streamlining unplanned care