The healthcare trade papers report that the RCGP and BMA (GPC) are pushing the GP Federation idea again, this time as a way to escape what they see as the problems with the commissioning reforms and the vulnerability of Clinical Commissioning Groups. We welcome that as something that GPs can unite around. Federations have considerable potential, but have been marketed poorly. “What are they for?” needs to be explained better.
Cats and frogs
It’s been said that getting GPs to cooperate is akin to herding cats – or as my Dutch friends would have it “keeping frogs in a wheelbarrow”. That aside, if GP Healthcare Federations were done well, they could create win-win situations for patients, public and clinicians (including the frogs amongst them).
Perhaps the way to get the frogs’ attention and persuade them is to consider the downside: if individual practices don’t take this opportunity seriously to work together with their communities, they may wake up to face an offer they can’t refuse coming from vertically integrating Foundation Trusts on their doorstep. Buying up primary care is a logical step for the consolidating acute sector to take. I think that would definitely be lose-lose for both GPs and patients: loss of freedom for the clinician; loss of choice for the customer.
Federations more than a group of practices
The alternative to today’s vulnerable GP micro-businesses is community based provider Federations which go beyond just collecting practices together. It is more than getting the covered wagons into a circle. Federations have the potential to take primary care into an enterprising future if they took a logical step to become Community Interest Companies (CICs). They could also be commissioned to provide integrated health and social care and in which patients, carers, communities and clinicians all had a real stake and a say in the governance of a new type of social business. This is something for GPs who don’t spend their waking hours sweating over the commissioning to think seriously about.
Some far-sighted GP Federations are already thinking along these lines. CCGs and Local Authorities may have this vision too.
Get the engagement right from the outset
I think that moving to the CIC governance form would be a great way to strengthen a Federation’s “commissionability” and competitive edge, especially if it wanted to diversify into doing business with the local Council about social care and create “thought leadership” with likely commissioners. But it should not be done lightly, as it has serious implications for engagement as a core CIC activity.
As a CIC, the Federation would be required annually to demonstrate to the external regulator through its governance structures and the CIC’s activities that it was engaging with stakeholders within the community it served and, further, that this makes a difference to how the Federation does business. The CIC definition of “stakeholder” includes not only patients registered with the practices but everyone living within the area served by the CIC in their capacities as both citizens and patients.
This mean it would need to find a range of different ways of engaging with stakeholders for different purposes at different times. Facebook, Twitter, virtual groups, electronic surveys etc all come in here.
Start with practice participation
This duty will not simply be about patients having a say in their own individual care, but also about local people who may not currently be patients having a real stake in the running of the organisation. That means seeing patients as customers, and as members and owners of the enterprise along with the GPs and their staff.
As a starting point, people registered as patients with the Federation’s practices can be regarded as a useful proxy for the wider population as a whole and the social capital and user-led intelligence harvested from them should be maximised. Any work which is done to improve the quality and effectiveness of engagement within constituent practices will make a considerable contribution to ensuring that the governance requirement to engage with local people is met and will provide a basis for future work in developing stakeholder input into the CIC.
How it is presented to the CIC Regulator each year also needs careful thought; she will be more hard-nosed about what evidence to accept than the NHS is. If all of the practices did the Patient Participation DES, as they should, it would be a lot easier of course.
Getting from here to there
The view of Clare Gerada, chair of the RCGP is pretty clear about how she sees the problem:
We need help, a sensible commissioning size and to concentrate on provider reform. What GPs do best is to get together as groups of practices, pull in the third sector and start sorting the big issues – end-of-life care, out-of-hours care.
Precisely. The logic that springs from that is simple. The best provider reform GPs could embrace is with their colleagues in primary care (not all doctors by an means), their customers (patients and carers) and their communities (the public) in a Healthcare Federation and set it up as a thriving social business. If they want a future that can withstand the tribulations of commissioning and fend off foraging Foundation Trusts, this looks like it.
The Moore Adamson Craig Partnership supports user and public participation, trains lay representatives and develops responsive health, care and education organisations. We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing. Feel free to contact us to discuss the opportunities.