This is the third in the series of blogs where Ben asks the questions that he believes will shape the future of general practice. This week he asks

What Role Will Federations Play?

As with any look into the future, dipping into the past is a good place to start. Federations have changed significantly over the last ten or even twenty years. Post fundholding, and during the practice based commissioning years, federations were set up primarily to deliver services historically provided in hospital, in the community in order to generate an additional income stream for GPs and practices.

Since then, two things have materially impacted on the role of federations. First is the crisis that has engulfed general practice. Where federations historically operated at arm’s length from practices, they now have an important role in supporting member practices through the current challenges. This is a critical difference. It means the activities federations undertake are much closer to the delivery of core general practice e.g. visiting services, delivery of extended access, employing pharmacists and other new roles for practices. They have to work hard to ensure the cost of the additional layer of administration is offset by the value they bring to their members.

Second is the rise and fall of CCGs. At their inception they gave a powerful voice to general practice, as arbiters of how the NHS pound would be spent. No need, then, for federations to take on this role. Indeed, where they tried to assume this role, GPs were herded in and out of rooms to satisfy increasingly confusing conflict of interest requirements. But now power is shifting away from CCGs and away from commissioning. As CCGs get bigger, the local GP voice is getting smaller. As STPs and accountable care systems develop, the influence of general practice via commissioning continues to diminish.

Suddenly, we have a really clear role for federations: to support local practices to meet their current (and growing) challenges and to provide a strong voice for general practice as local systems move towards integrated models of working. Whereas in the past federations were something of an optional extra, it no longer feels like that. The challenges facing general practice and the wider integration agenda require an ability for practices to function coherently as a collective.

Federations provide that acceptable middle ground, where individual units can retain the independence and individuality they prize so highly, while at the same time gaining the benefits of joint working. They provide a vehicle for collective voice and collegiate working without necessarily requiring wide-scale restructuring into larger, formal organisations. Where trust levels grow between practices, and the ambitions for working together become greater, some are starting to move beyond loose federations into more formalised joint working arrangements, such as super practices.

Federations will play a key role in the development of general practice into the future. Where they are successful, owned by and adding value to practices while at the same time leading them through the integration agenda, they may well evolve into more formal partnership structures. Where leadership is weak and trust levels remain low, they may fall by the wayside, most likely to be taken over by more successful groups seeking to expand their footprint. Either way, we are already seeing well-developed federations able to play a leading role in local system integration plans. Moving forward, federations will have a critical role in both supporting the transformation of general practice into new sustainable ways of working, and shaping the role general practice plays within accountable care models and systems.