The environment in which primary care operates has changed dramatically since the last general election. Practice contracts are now managed by NHS England and GP involvement with commissioning has passed from commissioning groups to CCGs. Powerful private sector competitors have entered the market, the BMA appears to be less influential than in the past, and the policy agenda is being driven firmly by the Department of Health.
To signify the increased emphasis on competition, it has been confirmed that LES contracts are to be offered for tender. Local boroughs and councils who now administer a wider range of LESs have been instructed not to treat GP practices as preferred providers.
Significant infrastructure is needed to bid successfully for these contracts in a more competitive NHS.
In addition, across the country, the population continues to age and in urban centres has become more ethnically diverse and disadvantaged. Patient expectations are rising inexorably and workload is becoming more complex. At the same time, recruiting GPs and retaining older ones is becoming more difficult.
Flat practice income, rising costs and clinical workloads have set partner drawings on a downward trend, reinforcing recruitment difficulties, encouraging thoughts of early retirement for the 22% of GPs over the age of 55 and placing additional pressures on practices. We decided to explore the possibilities open to us to strengthen both our ability to compete and to work together in the face of these problems.
There were four pre-existing GP groups in the region, formed in GP commissioning days and against this backdrop, we launched an extensive review and consultation process exploring responses open to practices.
Taking no action was widely rejected and the idea of large scale merger gained no traction, with practices valuing their own independence and individuality.
The conclusion was to federate as a single new organisation across the patch. The benefits of federating are that the significant challenges facing primary care can be addressed together rather than by individual practices on their own. GPs own an organisation with the management and infrastructure required to successfully bid for contracts (such as LESs) in the new competitive NHS environment.
One large group brings economies of scale when funding expensive senior management, board costs and tendering procedures.
In addition, federation is in line with RCGP policy and retains the independence and individuality valued so highly by local practices.
What we did
On the April 1, 38 GP practices covering 360,000 patients in Ipswich & East Suffolk came together to form the Suffolk GP Federation. Practices in the area remain exclusively independent partnerships in the traditional model.
The federation will be a not-for-profit community interest company open to all practices and governed by a members’ agreement. When votes are required, each practice has one vote. To preserve local flavours and identities, the four pre-existing localities continue as groups of GPs who meet regularly. They feed ideas into the board, and debate board proposals. Management is by an elected board of six GPs, two practice managers, a co-opted member and the chief executive.
Our federation was able to save time and expense by utilising the pre-existing management team, service contracts, IT infrastructure, registrations and insurances of a pre-existing GP groups – Partners in Practice Suffolk.
Practices invested a nominal one-off 30p per patient as a joining fee and agreed to meet the obligations of membership, such as acting in the spirit of working together, participating in decision making, sharing non-commercially sensitive data and playing a fair part in the delivery of services.
The main income for the federation will be from expanding the range of contracts and services it offers.
Almost all local practices have now joined – avoiding the scenario of a number of forward thinking practices deciding to expand alone. The consultation process demonstrated that local GPs felt this could be divisive.
We aim to support, strengthen and develop the existing independent contractor model of primary care in Suffolk in order to enhance patient care. As a provider group, we also aim to win contracts to offer high quality patient care in clinical fields close to primary or community care.
In its first year, the federation will focus on achieving financial and organisational stability as well as developing channels of communication with member practices and fostering a sense of ownership and involvement.
In addition, the board want to start addressing some of the issues identified by practices – such as recruitment and retention of medical staff, setting up a locum chambers, looking at operating costs, sharing best practice in long term condition management, addressing unscheduled primary care workloads and putting together a clinical research offering.
We believe that by coming together in this way, practices can preserve their individuality but at the same time overcome the weaknesses inherent in the cottage industry model of traditional primary care. Sharing best practice and innovation will enable the group to improve clinical efficiency, vitally important if we are to overcome the challenges currently facing primary care.
In a competitive environment, the federation can be one way of bringing into play all the strengths, commitment, passion and quality evident in everyday local general practice.
Dr Tim Reed is the chair of the Suffolk Federation and a GP in Woodbridge, Suffolk.
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