General practice in Northern Ireland is suffering from overwhelming demand, persistent underfunding and understaffing, and an increasing shift of work from hospitals. GPs wanted to co-ordinate practices to push back against unfunded dumping of work, so practices in Northern Ireland decided to form not-for-profit provider companies, based on a plan formulated by the Northern Ireland GPC.
LMCs agreed to use a single organisational model similar to a not-for profit community interest company. GPs will form 20 federations in Northern Ireland, each covering populations of about 100,000 patients and comprised of an average of 20 practices.
In addition to the advocacy, ‘push-back’ role GPs plan to use federations as providers of care in the community along a ‘GMS plus’ model. They will cover areas of care that practices currently struggle to provide.
Underfunding of general practice is endemic throughout the UK due to the atavistic institutional prejudice of health service managers and we need to develop an alternate platform for funding and investment. Not-for-profit federations can provide services over and above the GMS contract, such as:
- enhanced care for the frail elderly and nursing homes
- extended hours
- GPSI clinics eg dermatology and minor surgery
- innovative care pathways
- diagnostics services
- mental health services
- medicines management programmes
- public health and social development projects
- collaborative working with hospital-based specialists.
Funding for these services will be protected from GP ‘profit’ (since the federations are not-for-profit). GP practices will be protected from the tsunami of work-dumping, as the federation will provide these services in parallel to GMS services, allowing practices to focus on their core activities.
So parallel funding into federations allows the federations to mature into provider organisations for collaborative working, but with clear distinctions between these ‘GMS plus’ services and core GMS services.
GPC Northern Ireland wants to ensure that GP practices retain their autonomy and unique local identity. We see no role in Northern Irish practice for the King’s Fund model of ‘mega partnerships’, which would undermine the effectiveness and efficiency of GMS practice.
Federations could also control of budgets for areas such as prescribing, community nursing, OOH and outpatient services. It is self-evident that GP federations run by local GPs should have control of these budgets if they’re to be used in the most effective way. The federation would be working with local commissioning groups, our version of CCGs, so there is no apparent conflict of interest in this arrangement.
Federations are not only an effective method of GP advocacy and resourcing services over and above core GMS, but they also help reduce the pressure on the profession. Recruitment and retention in general practice is at crisis point throughout the UK. It is difficult to keep older GPs engaged, and even more difficult to retain younger GPs who require flexible working.
If we can stabilise the delivery of GMS services by introducing a ‘GMS plus’ contract to cover workload dump, and provide a sustainable work environment in federations, we can ease the pressure on the profession. Offering more opportunities for portfolio working, for example, helps older GPs stay on in practice longer and allows younger GPs to stay engaged during that period of time in their careers when they need family-friendly hours.
Federations also provide a forum for education and continuing professional development and most importantly act as a hothouse for the nurturing of future leaders of the profession.
The NHS must recognise federations as part of its own system, for financial purposes such as tendering and superannuation. However, it is vital that GP federations remain under autonomous GP control. Federations only work if they are organic grassroots organisations, run and controlled by local GP members, empowering and enabling GPs to create a sustainable model for working and delivering patient care.
Voltaire said, ‘it is dangerous to be right in matters where established men are wrong’, but GPs need to impose their will if they are to maintain the traditional model of UK general practice, with patient-centred care at its heart.
For GPs, in Northern Ireland, forming federations is the best way to achieve this.
Dr Tom Black is the chair of GPC Northern Ireland and a GP in Derry.