Azeem Majeed: Are federations the way forward for general practices in England?

Azeem_majeedAs general practices in England come under increasing workload, funding, and contractual pressures, a new type of primary care organisation—the GP Federation—is becoming more common. The RCGP defines GP federations as practices “working together to share resources, expertise, and services.” In their simplest form, federations allow the general practices in one locality to share some administrative functions, and work together to bid collectively for NHS contracts.

However, as GP federations are not statutory organisations, they vary widely in both their structure and the activities they undertake. Some of the more advanced federations have established themselves as independent legal entities, and have already begun to compete for contracts against NHS hospital and community trusts.

The successful implementation of GP federations could help general practices meet the many challenges they currently face. Because federations are much larger than the typical practice, they can take on tasks that an average sized practice could not carry out by itself. This could include activities such as: locality-wide work to improve the safety, quality, and efficiency of primary care services; redesigning care pathways; and delivering more care in community settings.

Federations can also work together to provide extended access to primary care services in the evenings and weekends, and thereby reduce demands on other parts of the NHS, such as emergency departments. Some federations may also be keen to take back the budgets and responsibility for public health activities, which were transferred to local authorities by the coalition government.

To facilitate the establishment of GP federations, some clinical commissioning groups (CCGs) are considering imposing “minimum list size requirements” for contracts for local enhanced services. This would mean that practices that were not part of a federation would be ineligible to bid for such services, which would weaken their financial position and threaten their long term viability. The suggestion from NHS England that CCGs could have a role to play in commissioning local primary care services may also enhance the role of GP federations. However, mechanisms to address conflicts of interest, which would arise from GPs being both commissioners and providers of healthcare, need to be found.

How will GP federations develop in the future? Some of the more well established and ambitious federations have already begun to compete successfully for large NHS contracts. In the longer term, it is likely that some federations will become direct competitors to NHS hospital and community trusts, and even consider employing specialist and community staff. They could also bid for contracts to run general practices; thereby creating the potential for vertically integrated, healthcare provider organisations, which delivered primary care, along with community and specialist services.

Whether the increased local competition between healthcare providers—and the potentially higher transaction costs this could create—would benefit the NHS is currently unknown. In an optimistic scenario, GP federations could finally start to deliver a truly integrated healthcare service. This vision has long been an ambition of the NHS, but has proven difficult to do when there are a plethora of providers who sometimes have discordant objectives.

Conversely, GP federations could further fragment the provision of NHS services—leaving hospital and community trusts destabilised by taking away substantial proportions of their current work and income. Consequently, like all NHS innovations, GP federations need careful evaluation to assess not only the benefits they may bring, but also any unintended, adverse consequences that may arise through their introduction.

Azeem Majeed is a professor of primary care and head of the Department of Primary Care and Public Health at Imperial College London. He is also a GP principal at the practice of Dr Curran & Partners in Clapham, London. He can be followed on Twitter (@Azeem_Majeed).

Conflict of Interest: I am a GP principal at the practice of Dr Curran & Partners in Clapham, London.