The recent move towards a ‘market’ environment in the NHS has had the intention of introducing freedom for commissioners, but has also placed potential barriers in the path of traditional GP providers. Practices can no longer expect a healthy income simply from retaining their patients and fulfilling their basic contract. There is now a range of commissioners, including local authorities, and a willingness on the part of the NHS to promote competition.
Marketisation has also driven segmentation of primary care into accountable itemised enhanced services, split from the block contract of GMS/PMS, and this trend is likely to continue as more work is pushed out of the hospital sector and picked up by community based contracts.
GPs are therefore looking to develop the skills and structure required to compete more successfully in the new NHS, and this is increasingly in the form of new provider organisations led by general practice.
This five-step article explains how to make an existing provider organisation more resilient, or how to build up your new organisation to be more competitive.
1 Identify local needs
A problem, which appears obvious to some, may not be as apparent to their colleagues, and in developing as a stronger provider it is clear that size is important. Few practices will be able to compete for future contracts alone, and it is therefore essential to identify and work with colleagues across as wide an area as possible.
To identify the problem just ask your CCG which enhanced services or other community based contracts are likely to come up for procurement in the next two years.
Also, enquire of the Local Area Team (part of NHS England) how they propose to manage contract terminations and the award of new primary care contracts.
If the answer to either of these queries cannot be handled by your practice on its own, you have identified the problem.
It is then possible to talk to GP colleagues, practice managers and others in your area in order to estimate support for a joint effort to address the survival and development of your businesses. Do not expect every GP and practice manager to be fully engaged, but every practice must have one person who is willing to communicate with the new project and to keep their practice colleagues informed.
If there is little or no local interest, then the only real opportunity for new business is an alliance either with a GP company or partnership outside your immediate district, or with a commercial provider. The latter is to be approached with caution as previous examples have sometimes resulted in the eventual removal of the local GPs and a ‘takeover’ by the commercial company. A GP-led company can be constructed such that this cannot happen.
2 Explore ways to set up a provider company
There are numerous examples of practices coming together in large partnerships, provider companies and ‘federations’ in order to combine expertise and resources, protect their local health infrastructure, and compete for new contracts.
Information on how to develop as a provider, and the options available, is accessible through your LMC, the GPC, and the RCGP, as well as from a number of commercial companies working in this field.
There are also accountancy and legal organisations willing to help, often at surprisingly acceptable rates.
This step is crucial in assessing what will work for you and the process needs to be shared with every practice that is likely to be involved. Beware of spending a huge amount of time discussing the possibilities, as it is better to get agreement across your district on the best provider organisation for your needs, and then start work on the details.
Possible solutions include:
- A new provider company owned and controlled by practices
- A large GP partnership that can negotiate for CCG level contracts
- A partnership with a commercial company that will bring in external expertise.
The solution must create a legal entity with which others, especially the NHS, can do business. The difficulty with the word ‘federation’ is that it is not in itself a recognisable legal term.
3 Gather support and appoint a project team
At this stage it is crucial that you obtain commitment from practices on your chosen way forward. It is almost certain you will need to hold at least one general meeting open to all GPs, practice managers and nurses in every practice which has expressed an interest in belonging to your new organisation. You will probably also want the LMC to be present.
It will be necessary to present the case for coming together within a new organisation, and the reasons for choosing the option you propose. A blank canvas is not appropriate for a large meeting and you must cover any potential risks to practices arising from your intended model. If you don’t mention risks you can guarantee the audience will do so.
A small project team must be willing to do the preparatory work and then present results to colleagues. The meeting may endorse the team or propose additions or alterations and you must be willing to change when necessary.
The meeting must secure the commitment of all practices through the payment of a signup fee, and possibly also a commitment to donate clinical and management time towards the project.
4 Appoint leads and seek legal/financial advice
There are a number of issues that require work from the project team:
- Basic organisation structure and legal framework
- Communication with CCGs and others in order to gain support and gather market intelligence
- Financial planning
- Human resources, particularly if you propose a change to current practice structures by moving to a large partnership
- Engagement with member practices and GPs, who tend to take a back seat but can block any progress
- Technical issues such as CQC and IGsoc (information governance).
This is the nuts and bolts stage that requires a dedicated team and usually significant external expertise. The new provider organisation is - at this stage - a reality!
5 Gain new members, and contact the local CCG and LMC
There is very little good news in the NHS at present. The recent hurried re-organisation has left all parts of primary care, commissioners and providers in a confused and uncertain state. A new and vibrant provider organisation will attract practices as new joiners, CCGs eager to do business with local providers, and other provider organisations planning bigger ventures as joint projects.
It should also have support from the LMC, even where the LMC has had little involvement in the initial stages. Patient representatives may also be involved at this stage, for example as non-executive directors in the organisation.
The key to maintaining momentum is good leadership, constant communication and explanation with practices, and the ambition to aim high. The chaos in the NHS offers a clear opportunity to anyone with the will and drive to both protect their business, and to expand in ways favourable to practices and patients.
Dr Brian Balmer is north and south Essex LMC chief executive and a GP in Chelmsford.
