The world is moving quickly and the need to take a step back and consider how everything fits together is becoming more and more frequent.  For GP federations the move into Integrated Care Systems (ICSs) is creating one of these moments.

Historically GP federations have been set up in local areas often by a relatively small number of enthusiastic GPs.  They generally began with high expectations, and then over time relationships with member practices have waxed and waned, particularly as it has been challenging for federations to fulfil the delivery requirements needed to establish themselves as a provider and at the same time carry out the amount of communication necessary for practices to feel engaged and part of the organisation.

Then along came PCNs.  Up until that point it had been easy for federations to describe themselves as the ‘at-scale’ arm of general practice, as there were only individual practices and the federation.  But with PCNs came a mandated at-scale operation of general practice in every local area.  Now there are practices, PCNs and a federation, and it has made it more difficult for federations to articulate their role in the system.

The preference has generally been to describe themselves as the at-scale provider across any given area, as their remit tends to mirror old CCG areas and hence be larger than nearly all individual PCNs.  The mainstay of many federations has been the delivery of extended access, and recently federations and PCNs have been undertaking a round of relatively strained conversations to agree what the federation will do and what PCNs will do, now that responsibility for the service has shifted to PCNs.

But it is the emergence of ICSs that is bringing things to a head.  General practice needs to be able to operate as a collective entity within an ICS “place” area.  Within such an area there is often a number of PCNs, an LMC and (if one exists) a federation.  The question is whether, in such an environment, a federation can stand alone as a GP provider organisation, separate from core general practice?

This is problematic because the system wants to do business with general practice as a whole (not a limited company that can access GPs to deliver services).  Whereas in the past federations could point to their practice membership as a proxy for working across all practices, with PCNs in place this is no longer the case as they have a much clearer practice membership.  Federations were never really set up as a way of other organisations being able to do business with general practice, so now federations have a problem.

The most obvious way forward would seem to be to strengthen the federation/PCN relationship.  If federations can be the glue that holds PCNs together they would be perfectly placed to continue to provide at-scale services, provide support for PCNs and practices, and by including the LMC could start to be able to talk with authority in the system as local general practice.

But while some federations have been bolder in taking steps towards taking on the provision of support for PCNs as a new part of its core business, many have shied away from this (often because of emerging PCN/federation tensions, and because of the costs involved).  While PCNs are funded by the PCN DES, federations rely on funding from the delivery of services.  The need to breakeven/fund the federation infrastructure and even generate a return for shareholders has often created a tension in terms of what federations have been willing or able to do in terms of support for PCNs.

The irony is that federations are highly unlikely to be able to generate any kind of sustainable financial return if they maintain their separation from PCNs.  They will increasingly rely on the PCNs for the work (like extended access), and if federations are not the support provider for PCNs then whoever takes this on will end up being better placed to take on any at-scale work.

Without the protection of CCGs the ICSs are not going to tolerate small-scale provider organisations with no real remit.  If federations are not providing the scaled up support the new integrated neighbourhood teams are going to require, and don’t become the organisation that holds general practice together in an area, it is hard to see how they will survive beyond the next few years.