GP federations have not had much luck in recent years.  Many were set up with the Prime Ministers Challenge Fund and set up services to deliver enhanced access, and there was a time when the system seemed to be moving towards working with GP practices at scale via GP federations.  Many ICBs even started commissioning their local enhanced services through federations, and for a while the future looked bright for them.

But things took a turn for the worse when PCNs came along with the new GP contract in 2019.  This meant the unit of at-scale working legitimised by the system suddenly became the PCN.  Whilst PCNs were not NHS statutory bodies their basis in the national contract meant they were a recognised part of the NHS architecture.

Many federations, however, were able to adapt accordingly.  Local PCNs often turned to their federation for support with their infrastructure, in particular hosting the ARRS staff with their ability to offer limited liability, and the role of federations evolved.

However, things took another turn for the worse when responsibility for enhanced access shifted from local commissioners to PCNs.  This happened at the same time as NHS England stopped negotiating the annual contract and instead imposed the terms agreed in 2019 despite record inflation figures, leading to significant financial challenges at practice level.

While enhanced access represented the lifeblood for many federations, PCNs and practices were now forced into thinking about how they might be able to provide this service directly themselves.  Now life is even more difficult for federations, as they have sought to adapt and find a way to add sufficient value to their local practices, PCNs and commissioners to be able to survive.

But a new opportunity for GP federations may be around the corner.  We first got an inkling of this in the Fuller Report of 2022.

This report is over 2 and half years old, but it is only now that we are starting to see a real push for the development of the integrated neighbourhood teams that formed the centrepiece of it.  No doubt this is because of how well it aligns with the new government’s desire for a neighbourhood health service.  The report was clear that these teams will require support from at-scale providers,

“System-level expertise on primary care should go beyond contracting to building relationships and developing capabilities within systems as they build their new teams. We heard throughout the stocktake of the importance of a core set of capabilities to support improvement and transformation, with quality improvement; digital, data and analytics; understanding local communities and user experiences; physical infrastructure; workforce planning and transformation; service design; and the development of the primary care provider landscape coming up most frequently.

These key primary care capabilities need to be in place for all systems, but not all need to be provided in-house – some may be brokered or commissioned from other providers at scale: eg GP federations, acute, community or mental health providers, or commissioning support services.” p30

This idea has since developed.  Local manifestations of integrated neighbourhood teams (e.g. NW London ICB) have started to be accompanied by the notion of an “integrator” function.  This is an entity to provide the kind of infrastructure support envisioned by Fuller, as well as play a key role in enabling the different providers within these teams to work effectively together and become more integrated over time.

This may prove to be a make-or-break moment for GP federations.  If they can take on this role there are potentially huge benefits.  The federation will once again become firmly established in the NHS infrastructure, with a line of funding to secure its future.  For general practice it means the role GPs and their leaders within the new neighbourhood teams will be much greater than it would be if this role lands with another provider.  And for the system it means buy in to the new teams from general practice (arguably the most important contributors) is likely to be much greater than with any alternative arrangement.

But if GP federations miss out it is unclear what role will remain for them.  The support services they provide to PCNs will doubtless ultimately be taken on by the new support provider, which will leave the federations in a very difficult place indeed.

The question is whether the GP Federations that remain can adapt and develop sufficiently to be able to take on this integrator function.  The window of opportunity is now for them to work with their PCNs and practices and prepare and actively work so that they are in a position to take on this role whenever it comes up locally.  It is vital federations get themselves ready as quickly as possible, and do all they can to grasp this opportunity with both hands.