Amongst all the furore that primary care networks are creating it is easy to lose sight of GP federations. The role of federations in the new world of primary care networks is unclear and not prescribed. So do they really have a future? If they do, what will it be? This week, I explore how federations could help the nascent primary care networks meet four of the biggest challenges they face.

Challenge 1: Managing the new clinical staff and the associated liability

By 2024 a typical (50,000 population) primary care network will have 5 clinical pharmacists, 3 social prescribers, 3 first contact physiotherapists, 2 physician associates and 1 community paramedic. That is a lot of staff. Who is going to manage the employment risk (and associated liability) for these staff? Some will arrive with considerable amounts of NHS service, making the potential employment liability very high.

Federations established as limited liability vehicles can not only take this risk away from GP partners, but can also add real value to the recruitment, management and development of these staff. When multiple networks are seeking to recruit from this limited pool of new staff, why will they select one area over another? If a federation can offer peer support, professional development, and (probably most importantly) structured support for both practices and staff in the implementation of these new roles, they will make their area more attractive to these staff, as well as ensuring the networks gain the greatest possible benefit from them. It is hard to overemphasise the importance of change management support to go alongside the recruitment of these new roles.

Challenge 2: Maximising the available financial resources and minimising the financial risk to practices

The new GP contract suggests that a typical network will have funding for additional role reimbursement of £726,000 by 2023/24. At 70% this creates a potential cost pressure for networks of up to £311,000. As a side note it has been suggested (e.g. in the BMA primary care handbook) that the £1.50 management allowance could be used to offset this, but the total management allowance for a 50,000 network is £75,000 – well short of the total amount potentially required.

It is on the finance side and meeting the “30% challenge” that federations can really come into their own. Federations can:

• Limit liabilities through an incorporated structure
• Attract further investment. Many CCGs and local integrated systems will want to invest in general practice, but will want to do it at a scale that maps to boroughs or historic commissioning areas, and federations providing an infrastructure across multiple networks will be an attractive vehicle for them to do so.
• Make the £1.50 management allowance go further. A typical network can’t hope to include delivery support, administrative support, communications and engagement, HR, financial support and leadership support with £75,000. But multiple networks working together could easily do this.
• Create other economies of scale. The £6 per head for extended access is a great example of a resource that if used collectively across a wider area through a federation could generate a significant return to constituent networks.
• Establish strong financial governance. A small but effective finance team within a federation can ensure financial risks are minimised, financial efficiencies are delivered (e.g. in relation to what funding is superannuable), and income opportunities are maximised.

Challenge 3: Ensuring delivery both across practices and with other organisations

Networks are not simply constructs that need to be created. There is a delivery expectation upon them, both across constituent practices and with local organisations. Five new network specifications kick in in April 2020, probably alongside the requirement to sort out extended access, plus any local enhanced serviced the CCG may want to add in to the mix. How will one network operating on its own get its head around all of the new delivery requirements? The nature of the new specifications mean it will not be as simple as passing them on to the member practices and simply asking each to do its share. New delivery models will need to be developed, agreed with practices and local organisations, and implemented.

It may be on the delivery requirements of networks that federations can add the most value. Resources can be dedicated to each of the network specifications, for example a clinical lead and a lead manager for each, who can negotiate with local practices, organisations and commissioners to create locally-tailored delivery models. Sharing resource and expertise in this way through a federation can reduce duplication and enhance local delivery.

Challenge 4: Meeting the leadership challenge of networks and creating a powerful local voice

Much is expected of the new “accountable” network Clinical Directors. They are to become the voice of the network in the plethora of integrated care meetings locally, as well as leading the development and delivery of new services, and sorting out any inter-practice issues – all in roughly one day a week. Nationally we have heard of a desire for new leaders to emerge from practices to take on these roles. These could be very challenging and isolating roles for potentially inexperienced leaders.

Networks operating together within a federation can do a number of things. They can provide leadership development. They can ensure the leaders work together to support each other, and share ideas, approaches and learning. The incessant representation requirements from the wider system can be prioritised and shared across the group. Equally, a strong collective voice for primary care and the area can be established through a federation (whereas multiple network voices, potentially contradicting each other, is likely to weaken the overall general practice system voice).
Primary care networks are not in competition with each other, and working together through a federation can help meet some of the major challenges they will inevitably face. It does of course rely on trust, and a belief that the federation will operate to serve and support the new networks. It may be that governance changes, such as ensuring there are at least a majority of network clinical leads on the federation board, are needed to establish the future role of the federation in support of networks. But however it is done, it does seem there could be a very important role for federations in support of general practice as we move into the new world of primary care networks.