GP Federations in 2024

It has been a rocky few years for GP federations as the emergence of PCNs has relegated them to second class citizens in most places when it comes to at scale general practice.  What does the future hold now? Is there a still place for GP federations, or have they reached the end of their natural life?

The context, of course, is the parlous state of practice finances.  General practice funding already has to cover the PCN infrastructure, and so the question is whether a continued investment in a federation infrastructure is a sensible one.  Can the benefits the federation delivers outweigh the costs they necessarily incur?  This is a question largely for practices as the days of the system covering federation infrastructure costs in nearly every area seem to be behind us.

The main role that federations play is the delivery of at-scale services.  The logic of this is that for some services it will be cheaper for them to be delivered  at scale rather than at the level of the individual practice or PCN.  If a service is being organised and delivered once across a wider area the costs can be lower than if it is being organised multiple times at a smaller scale.

Previously the motivation for asking federations to take on some of this work for practices was that practices did not want to do this work themselves, and so it was a way of ensuring the delivery requirements were fulfilled without placing an additional workload burden on practices.  The federation would receive the funding available and carry out the work, and use any surplus to fund the organisational overhead that would then allow it do other work.

The problem that many federations are coming up against now is that the financial situation means that practices do not have the luxury of outsourcing this work simply because they do not want to do the work.  Practices need the margin they can generate from doing this work themselves.

The principle still holds, however, that it can be cheaper for some services to be delivered at a federation scale.  But federations now need to find a way of making sure that there is a return to practices and PCNs at least in the ball park of what they would gain if they delivered the service themselves.  The numbers can still work, but federations will need to cut their cloth accordingly.

Federations need to be alive to this issue, and be willing to adapt accordingly.  Discussions between PCNs/practices and federations about service delivery often manifest in ones focussed on unhappiness with the offering being provided.  But the real issue is the money, and so being upfront and having a discussion about this is vital.

Federations can play other roles, but the problem with these is that they don’t generate income directly.  They can provide HR, finance and other support for PCNs, but only at cost.  They can host the local network of PCNs that encourages and enables learning between them.  They can hold relationships with the local ICB and NHS organisations so that each PCN does not have to do this individually.  They can influence and negotiate on behalf of PCNs with the ICB and the place-based boards.  They can work to ensure that any shift of services from secondary to primary care is appropriately funded.  And, maybe most importantly, they have the ability to hold contracts, which in effect is future proofing general practice should it come to a place where “integrated contracts” across a place area are to be awarded that include swathes of general practice funding.

But despite the importance of these other roles, PCNs and practices have to be convinced about their value.  As these roles have no clear return on investment (other than maybe keeping PCN infrastructure costs to a minimum), then the challenge for federations is convincing PCNs and practices to buy into the need for them.

This is not an easy challenge.  Real practice financial challenges today are by and large going to overrule potential future strategic challenges tomorrow.  So federations will need to provide tangible value now for practices and PCNs, as well be convincing about the need to keep on working as a collective if they are to continue to have a future.

Are Practices Making the most of PCN Resources?

Roughly 20% of the total resource for general practice is tied up in PCNs.  But are practices making the most of this resource?  And is the need for equity across practices preventing this opportunity from really being taken?

Practice finances are tight across the country this year as a result of the third consecutive imposed contract by NHS England.  With so much of the resource (£2.5billion+) for general practice now tied up in PCNs, practices have no choice but to find ways of accessing it.

Interestingly, the PCN DES now defines one of the core functions of the PCN as, “To coordinate, organise and deploy shared resources to support and improve resilience and care delivery at both PCN and practice level. (This could also include the PCN delivering practice-level contractual requirements such as vaccinations, screening and health checks, provision of personally administered items, QOF and IIF-related activity during core hours).

So the contract is actually encouraging practices to consider how the PCN can support individual practice resilience.  But the reality is that there are not many PCNs where the PCN (or a practice within the PCN) is carrying out core practice activity on behalf of other practices.

There are a number of reasons for this.  The first is that for most practices the independence of the practice is sacrosanct, and that includes from the PCN.  So while the practice may be prepared to participate in joint PCN ventures, it is quite another thing to give up some of the core practice activity so that it can be provided by the PCN.

This is one of the reasons why there is so much resistance to the attempted imposition by some ICBs of mandatory same day access hubs at a PCN level.  Most practices regard delivering on the day urgent care to their patients as a core part of what they do, and they are not prepared to give this up  to the PCN.

So if a PCN is going to get into some of the core practice activities suggested by the PCN DES then the first thing it will have to do is overcome the innate resistance that exists to this from member practices.  Practices will need to believe that the PCN is not taking away the things that make up the core practice identity, but instead is offering a new more efficient and effective mechanism by which these things can be carried out.  This is no easy challenge.

The second barrier that prevents provision at a PCN versus a practice level is the implicit belief that exists in nearly all PCNs that any split of resources or activity between practices needs to be equal.  If a PCN service is set up, it needs to be equally available to the patients of each practice.  Where PCN staff are employed, each practice needs to receive their fair share of time of clinician time or appointments.

But practices do not have an equal need for the same staff.  They don’t have the same amount of space available.  They don’t have the same need for the PCN services that are provided.  They don’t have the same practice populations, or practice staffing profiles.  It doesn’t actually make sense then for all the PCN resources to be divided equally, if the goal is to ensure that they add the maximum amount of value.

So for example it may make sense for the PCN to set up a home visiting for 3 of the practices in a PCN, while the other two continue to do their own (if the two practices have a good system for visits in place, enjoy and want to continue doing them, but the other three are struggling with the capacity and time to carry these out).

But what happens is the need for the services to be “fair” overrides everything, and so the two practices who don’t need the service object and it never gets set up.  Rather than spending time working out what the different needs of those two practices are and how those could be met, instead the only things that get agreed are those where all practices can benefit. This is significantly limiting the benefits PCNs can bring to practices.

The financial situation facing general practice is such that practices may need to start being more flexible and creative in their thinking as to what the PCN do, if they are really to make the most of the resource that is tied up within them.

Is it time for Mass Resignations?

The UK LMC Conference passed a motion last week that “being prepared to walk away may be more effective than industrial action”, and that empowered the GPC to “use the threat of mass resignation to improve the NHS offer to practices”.  So what should we make of this idea of mass resignations?

General practice has a history when it comes to the threat of mass resignations.  The episode that most stands out was in 1965 when the profession was in crisis with morale and earnings low, at a time when consultant career earnings were reportedly 48% higher than that of a GP.  As a result, 18,000 of the then 22,000 GPs signed undated resignation letters from the NHS.  Consequently the GPC was able to negotiate the 1966 contract which addressed the major grievances of the profession.

But that was nearly 60 years ago, and only 17 years after the NHS was formed.  There was talk of mass resignations in 2001 and the new GP contract of 2003 followed, and also in 2016 prior to the GP Forward View being published.  But on neither of these occasions did the action go as far as collecting undated resignation letters.  The political context was also different then – these were both during a time when the NHS wanted an internal market with general practice driving the purchasing side.

What is different now is that there is a possibility that the resignation letters could be accepted.  The total primary care medical spend is in the region of £13bn.  If practices resigned and provided services privately to the population, and (if we take dental services as the best example we have of the impact that would have on spending) just over half of this funding could potentially come directly from patients.  This means the government/NHS could save in the region of £6-7bn by simply accepting the GP resignation letters.

While such a move would be deeply unpopular with patients, there may be a belief that the “blame” could be focussed on the (greedy) GPs choosing to leave, and there are not many ways to come up with that kind of additional funding.  It is hard to see how a largely private general practice service fits with the policy agenda of integration, but it may be that the financial advantages would outweigh the inevitable internal challenges, and many other countries function with a hybrid funding model for general practice.

I don’t believe any incoming government would want a shift from an NHS to a privately funded arrangement, but my point is that general practice should not offer undated resignation letters unless it is prepared for its bluff to be called.

I am sure it is with this in mind that the conference motion that was passed also mandated, “the GPCs to develop viable alternatives to GMS, including actively supporting GP practices to work outside the NHS”.   What would a direct funded alternative look like?  How will it prioritise continuity of care, prevention and all the other aspects that are important to general practice in a way that the current NHS contract does not?  How can it work in a way that doesn’t immediately exacerbate health inequalities but can support attempts to tackle them?

To date there has not been enough serious thought given to what this alternative could look like.  Professional negotiators use the term “BATNA” – the best alternative to a negotiated agreement.  This is what they use as their walk away option, and refuse to agree anything that is not better than this.  One of the reasons that the GPC has suffered in recent years is that their BATNA has been the continuation of the existing contract, which has worked very well thank you for the government and NHS England.

It is only by creating a more powerful BATNA (mass resignation from the NHS contract with a clear plan for what would come instead) that general practice will be able to wield any real negotiating power in the current climate.  But it is risky, because it will only work if practices really are prepared to walk away and accept that this is what it may come to, and this can only happen if we develop a much clearer picture of what this alternative future would look like.

Communicating Across a PCN

Nearly all PCNs struggle with effective communication across the member practices of the PCN.  Despite each practice having representatives in PCN meetings, frequently practice staff beyond the practice representative are oblivious to much of what the PCN is doing.  How, then, can PCNs make their communication effective?

When considering this question most PCNs come up with a range of transactional responses. For example, we will add a section to the PCN website that all practice staff can access, with ‘how to’ guides for all the PCN services.  We will create a monthly newsletter to go out to all practice staff.  Or we will set up some additional WhatsApp groups so that people can learn about what is happening directly.

But despite the good intention, what happens is that these things make little or no difference to the awareness and understanding of practice staff of what is going on across the PCN.

The reason that these things don’t work is that communication is far more effective when it is directly between people.  Communication relies not just on the information being passed on, but also the person receiving it engaging with it.

This means that the PCN meeting is by far the most important when it comes to communicating.  The first question for PCNs to consider is whether attendees are engaging with what is being communicated in those meetings.  It is hard to believe that this is the case if the meeting is full of attendees on mute with cameras off.  Actively seeking feedback from all on issues that are raised is one way of building engagement with them.

The second step is to consider the practice representatives.  Who is coming?  Are they the right people to be attending from the practice?  Do they have influence back at the practice?  How likely are they to be feeding information back into the practice?  We may be getting information through to the PCN meetings attendees, but is it going any further?

Where this is identified as the issue, a good strategy is for the Clinical Director to attend a round of member practice meetings.  Here they can feedback the work of the PCN.  They can also stress that this should not be news to the practice as you would expect the practice representative to be feeding this back to them.  If they are open to it, you can then ask how they would like to receive this information more regularly.

Another key set of individuals when it comes to effective communication across practices are the practice managers.  A strategy that is proving increasingly popular across PCNs is for the PCN manager or Digital and Transformation lead to meet regularly (often weekly) with the practice managers.  This is particularly good because it keeps this key group of individuals engaged and up to date with what it going on across the PCN, and they in turn are best placed to ensure anything important gets onto practice meeting agendas.

The third area that can be targeted is PCN all practice events.  These can be held quarterly or bi-annually, and are best done on a face to face basis.  These are not a luxury, but should rather be considered as a vital component of PCN working.  They allow the wider membership of PCNs to review progress and agree a way forward, and (more importantly than anything else) they strengthen and renew engagement of member practices in the work of the PCN.  These events should always include a reminder of everything the PCN is doing/has done – while PCN CDs feel that practices know all this anyway, the reality is they often either do not or have forgotten and so a reminder is always useful.

Ultimately effective communication is a result of strong engagement from practices in the PCN.  Where engagement is good, communication is relatively straightforward.  It is where engagement is poor that communication is often difficult, and so rather than treat the symptom (poor communication) it is much better to treat the cause (lack of engagement).

It is time to bring back face to face meetings

Back in 2019 it was normal for meetings between practices to be face to face.  Protected learning time sessions (or academic half days, or whatever they are called locally) were normally carried out face to face.  But then in 2020 everything changed.  The pandemic meant that face to face meetings were no longer an option, and suddenly every meeting was on Zoom or Teams.

4 years later most PCN meetings are still virtual.  It is much more convenient for practice leads to meet regularly with the other practice leads via a Team meeting than face to face.  There is no travel time and the time out of the day caused by these meetings is massively reduced.  Plus it allows opportunities for multi-tasking when agenda items lack any obvious relevance…

But this is having a negative impact on relationships between practices.  When people are not meeting face to face relationships inevitably suffer.  Maintaining relationships requires at least some face to face meetings.  We know if we need to have a difficult conversation it is better to do it face to face, yet PCNs will often have these conversations in an online environment.  We miss nonverbal communication cues that help us understand what people are saying when we meet remotely (especially when cameras are off!), and as a result misunderstandings and conflict are much more common.

The interpersonal connections that are vital to building trust are missing when we only meet online, and without trust PCNs run into serious problems.  With practices now under such financial and workload pressure relationships are inevitably going be strained, and the virtual meeting environment is making this worse.

Protected learning time events have suffered the same fate.  It is a source of consternation for some that their ICB do not support these, but that aside and for those areas where they do happen the majority still take place virtually.  This used to be the time when all the GPs and practice staff in an area connected, and developed their sense of collective identity.  With the turnover and changes in personnel that we have had in the last five years there will now be many staff who know almost no-one from any other practice outside of their own PCN, because they have not had the chance to meet regularly together.

This in turn creates tension between PCNs.  Whereas previously local GP leaders could cultivate and call on a sense of collective identity, now if a PCN decides to go its own way regardless of the impact on the rest of local general practice there are often no longer the relationships in place to enable sensible local cohesion.

The simple reality is that given the political context that general practice is operating in right now the biggest support available for GP practices lies within general practice itself.  To get through this current set of challenges practices need to stand together and support one another.  By continuing to only meet virtually we are making this harder to achieve, exacerbating tension and conflict within and between PCNs.  So even though it might feel inconvenient it is important that at least some of the time we bring back face to face meetings.

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