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When is a federation not a consortium?

For a while the terms were used pretty much interchangeably, but the college now insists GPs must join up in two very different types of structure, says Pulse editor Richard Hoey

Back in May, Pulse ran a front-page story about the RCGP's warning that GPs would have to begin joining federations right away or face ‘forced restructure'.

The warning had been made at a round-table debate held the evening David Cameron was confirmed as Prime Minister, and his coalition government quickly introduced just the forced restructure the college had apparently been warning about.

There was widespread assumption back then that the RCGP's proposal that practices should voluntarily group into federations would be swallowed up by the compulsory requirement in the white paper to join a commissioning consortium.

It was pretty inevitable that the two concepts would quickly become conflated, given that many early federations were born from practice-based commissioning groups. A Pulse survey carried out over the summer found two-thirds of GPs who considered themselves to be in a federation belonged to an organisation that was focused on commissioning.

But actually, the college was never convinced that commissioning was really what federations were about, and as early as July its chair Professor Steve Field was suggesting to me that GPs might join up with a federation focusing on provision of services at the same time as a commissioning consortium.

Federations, went the argument, ought to be focusing on making the business of providing general practice more efficient, by sharing back-office functions, and more effective, by collaborating to offer a wider range of specialist services and more standardised chronic disease management.

I must admit I was slightly sceptical at the time, not about the federation concept itself, but about whether GPs could be persuaded to link themselves up into two separate types of collaborative organisation at the same time.

It's still a massive challenge, and the headache of joining a consortium is bound to put off a chunk of GPs who might otherwise have been persuaded of the merits of federating. But federations do have a chance now, because of the increasing awareness among GPs of what a big problem conflict of interest could be.

The idea is that federations could provide a forum for the kind of relatively small-scale remodelling of care that tends to enthuse many GPs much more than large-scale commissioning. It's federations that could deliver out-of-hospital services, or GPSI clinics, or community-based diagnostics.

In other words, federations could well be doing much of the stuff that was called commissioning under PBC, but was really just extended provision.

But the idea is that having more than one federation compete against each other for the right to host these kinds of service will get round the tricky issue of GPs commissioning stuff from themselves.

Dr Maureen Baker, the RCGP's federation's lead, says there's likely to be two or maybe more federations within each GP commissioning area, pitching them against each other to try to offer services to the consortium.

That's the theory, and the RCGP's long-awaited toolkit, developed with the King's Fund and Nuffield Trust, does a decent job of setting it out.

Whether it will be so simple in practice – when consortia and federations will often actually have the same member practices – is less clear.

And there's a major challenge to be overcome before general practice can even reach that point. GPs were fairly tentative in moving towards a federated future even before the white paper came along and made everything an awful lot more complicated.

The RCGP has a big communication job on its hands. Federations and consortia are actually quite different organisations. The college just needs to explain how.

Richard Hoey, Pulse editor