Collaboration in general practice

The Nuffield Trust have published a new report[1] on how collaboration between GP practices has developed over the last 2 years. It is based on a survey of 565 GPs and practice based staff, and 51 CCG chairs and accountable officers. It makes for fascinating reading. But what can we learn from it?

The first point is the findings have been skewed slightly by the availability of funding for extended access to general practice, including recurrent funding from this year onwards. As a result, over half of collaborations made improving access one of their priorities, and it was also the highest ranked potential benefit. The access funding has not been available to individual practices, and even if it was few were keen to take it up. Consequently, it has ended up almost as a system lever to provoke more joint working between practices. The concern is that its success in that regard may lead to similar types of “incentives” in the future.

But that aside there is much to consider. I have two hypotheses about federations. The first is that the current crisis in general practice is driving collaboration between practices to support delivery at practice level. In the past, federations were primarily about transferring services to the community, but I would suggest this has changed to a focus on practice-sustainability over recent years.

Does this hypothesis stack up in light of these survey results? It would seem so. 67% of respondents identified improving the financial and organisational stability of practices as a potential benefit of collaboration, higher than the 53% who identified the transfer of services into the community.

But interestingly only 46% of respondents reported their collaboration had identified improving the financial and organisational stability of practices as a priority in 2016/17 (the exact same percentage who identified transferring services into the community).

Why might this be? If GPs and practices are joining federations to improve the stability of their own practice, why is there this discrepancy in the number of federations who then prioritise it? Other survey responses provide clues. Smaller collaborations, covering less than 100,000 population, were much more likely (47%) to have it as a priority than larger collaborations of 100,000 population plus (37%). And collaborations formed more than two years ago were more able to fully or partially achieve the aim of improving practice sustainability.

It is because the ability to improve practice sustainability requires trust. It requires practices to trust the federation enough to allow them to take control of parts of the business that have historically always been within their control, right through from ordering supplies to employing staff and managing their visits. Smaller groups of practices, and practices that have been working together for a longer period, are more likely to trust each other (because they know each other), and as a result encourage and enable the federation to take steps that might benefit them, even if it means ceding bits of control.

If federations really are going to make a difference to member practices then this journey of building trust is one they and their practices will need to go on together.

My second hypothesis is that federations are needed to ensure GP practices as providers have a voice in the emerging new models of care. Well at present, it would seem, GPs don’t agree, with less than 9% of respondents identifying it as a potential benefit of a collaboration, and an even lower percentage reporting it as one of their collaboration’s 2016/2017 priorities.

At the same time over half of GPs responded that general practice had been not at all influential in shaping their local Sustainability and Transformation Plan (STP).

Maybe GPs don’t see it as the federation’s role to represent them in discussions about new models of care. But if it is not the role of the federation, whose role is it? The GPs in the CCG have to go to great lengths not to be seen to be favouring practices over other providers in their role as local commissioners, so it can’t be them. LMCs are the only other option, and other providers do not see LMCs as a fellow-provider they can collaborate with in an accountable care set up. Like it or not, it has to be the federation.

In summary we have learned that clear financial drivers like the access funding can successfully drive collaborative working across practices. Practices want collaborative working to help them with the challenges they are facing, but the reality of making that happen is proving difficult. It relies on trust, which is a hard won and easily lost currency. And finally the need for practice leadership within the accountable care arena by federations is one that has not yet been fully recognised.

[1] Kumpunen, S. Curry, N. Farnworth, M. Rosen, R. (2017) “Collaboration in general practice: Surveys of GP practice and clinical commissioning groups” Nuffield Trust, Royal College of General Practitioners survey www.nuffieldtrust.org.uk/research/collaboration-in-general-practice-surveys-of-gp-practice-and-clinical-commissioning-groups

What does accountable care mean for general practice?

The NHS world is changing. I wrote last week about the impact of commissioning on general practice, and this week I consider what the move towards accountable care organisations and systems means for GPs and practices.

What is accountable care? The Kings Fund has helpfully described it as comprising of three core elements,

First, they involve a provider or, more usually, an alliance of providers that collaborate to meet the needs of a defined population. Second, these providers take responsibility for a budget allocated by a commissioner or alliance of commissioners to deliver a range of services to that population. And third, ACOs work under a contract that specifies the outcomes and other objectives they are required to achieve within the given budget, often extending over a number of years.”

Rune reading, particularly in the NHS, is a difficult game. But all the signs point to accountable care organisations and systems (often used interchangeably to describe very similar arrangements) as the direction of travel. STP plans, NHS leaders and politicians are all making noises to suggest it is exactly where we are heading, despite the reticence to create new legislation with the disaster of the last NHS legislation so fresh in people’s minds.

If accountable care is where we are going, what does it mean for general practice? To help answer that, there are three further questions for us to consider.

1. What role will general practice play in an accountable care system?

Here the options appear to be threefold. General practice could choose simply not to engage. Indeed, some of the early accountable care pilots report engaging GPs to be one of their key challenges. The problem here is some of the budget for general practice will transfer from local commissioners to the accountable care system. If this is dominated by the acute hospital and other large provider organisations there is an obvious risk some funding streams will dry up.

Conversely, for accountable care systems seeking to deliver outcome rather than activity goals within a fixed funding envelope, international examples such as the Canterbury Health Board in New Zealand have shown the rate of growth of hospital activity can be moderated by investing in services in the community. There is opportunity for general practice within accountable care systems, meaning active engagement could well benefit the profession as well as the local population.

General practice could choose to play the role of “strong voice around the table”. It could ensure it is involved in accountable care system decision making, and almost take on an LMC type role to ensure risk to practices is minimised and funding streams are maintained and, where possible, developed.

Or it could attempt to play a leading role. Accountable care systems are very much at the developmental stage. There is no fixed blueprint for how they will look or how they will operate. Active leadership now could drive the evolution of these systems to ensure they are built around core general practice and the delivery of joined up and effective prevention and out of hospital care.

2. What scale will the accountable care system operate at?

Equally, the answer to this question is not clear yet. On the one hand we have the devolution project in Manchester creating an accountable care system spanning the whole of Greater Manchester. On the other, the primary care home (PCH) initiative is promoting accountable care for populations of 30-50,000.

In most places, size has not been determined. It may be that “layers” emerge, with smaller local areas where they exist (maybe PCH size) feeding in to larger areas (maybe acute hospital catchment area size), in turn feeding into even larger areas (whole STP size, a la Manchester). What “feeding into” in this context means is anybody’s guess.

For general practice, the scale chosen is likely to be important. If an accountable care system operates at acute hospital catchment area size, general practice would need to be well led and organised to be able to match the voice of its acute counterpart. At STP level, how does it prevent its voice being drowned out by the multitude of other big voices around the table?

Even operating at a locality or neighbourhood level of 30-50,000, practices will need to find a way of working well together and creating a strong single voice. To influence the scale at which accountable care operates locally practices will need to be involved at an early stage of the discussions. Once final decisions are taken, they will be hard to undo.

3.How will general practice build the relationships it needs to participate in accountable care?

It is clear a system reliant on collaboration between providers is going to be a challenge for general practice which is currently organised into nearly 8,000 individual business units. Practices will first and foremost need to build relationships with each other. Some practices are merging themselves into a size that means they will individually be ready. Some are forming federations. For others the currently existing CCG localities may provide a platform practices can build on. Key here is if practices want accountable care systems to work for them, as opposed to simply becoming their new masters, the ability to work effectively together is undoubtedly task one.

Equally, GP groups (whether it be large practices, federations, or localities) have to find a way of working together. Ultimately there is going to be one GP voice in an accountable care system. For that voice to be effective it will need to be unified. The acute trust, for example, will have a single, clear voice. If general practice cannot create the same level of cohesion, its voice will be diluted, and influence correspondingly diminished.

Finally, GP groups will need to be able work collaboratively with other providers. The aim is not that these systems become the fora within which providers fight each other for their share of the fixed amount of funding available. Rather, it is for barriers between organisations to be removed and for more effective ways of delivering care to be developed for patients. This requires productive relationships based on trust. For general practice it will require strong local leadership that practices believe in and are prepared to back when decisions are made – there will not be the time or opportunity for every decision to go back to each practice for a vote.

The overriding message for general practice is accountable care is coming. As such, practices may want to consider how they want accountable care to work locally, to identify what role they want to play in both shaping and delivering this future, and to reflect on how ready they are for this new system which has significant implications for the future of general practice.

The impact of commissioning on general practice

At an appearance before the Commons Public Accounts Committee in February this year, Simon Stevens signalled the end of the purchaser provider split, indicating that the development of accountable care organisations by STPs would dissolve historical boundaries between commissioners and providers.

These boundaries were first established by the NHS and Community Care Act in 1990. Even then two types of “purchasers” were created: Health Authorities, and general practice through fundholding. Fundholding was abolished by Tony Blair and the new labour government in 1997. Instead, Primary Care Groups and then Primary Care Trusts emerged, with GPs given a voluntary role through practice based commissioning. This voluntary role became compulsory in 2013 with the establishment of CCGs.

The commissioner/provider split has always been an artificial one, particularly for general practice. It was introduced to create a healthcare market, based on the theory it would create value for money by purchasers shopping around for care provision. But the requirement to sustain existing providers, the creation of perverse incentives to increase activity, and transaction costs not being matched by innovation has led many, including it seems Mr Stevens, to the conclusion it just does not work.

The entire commissioning “experiment” has not served general practice well. Divisive at first (e.g. fundholding vs non-fundholding practices blamed for creating a two tier system for patients), a “primary care led NHS” became one of the mantras of the late 1990s and 2000s, using the public trust of GPs to soften the blow of a nominally left-wing government maintaining the internal NHS market. With the advent of CCGs, all practices were mandated to become part of the commissioning system. All practices were to become both providers and commissioners of care. Conflict of interest regulations were developed to manage this dual role, which became increasingly cumbersome over time. In turn, practices had to split their leadership resources, energy, focus and talent between these commissioner and provider roles.

This happened at a point where the profession (as providers) was plunging into crisis. Ironically, the boundaries between the commissioning and provision roles of GPs left them powerless to use their position as commissioners to ensure the required shift of resources into the provision of general practice actually took place.

And now the purchaser provider split is to end. What does this mean for general practice? Most obviously it means the role of local GP commissioners will be side-lined, to be replaced by providers working together in accountable care systems. However, this shift will evolve locally, meaning GPs will continue to expend effort, time and energy into commissioning, while providers develop a new future.   The artificial split between commissioning and provision enforced upon practices in 2013 is to be abandoned, but not yet.

General practice as providers, however, are to be included in the development of accountable care organisations. But not as individual practices. Instead they need some at-scale representation. Here general practice is at a real disadvantage. Some of its limited pool of leaders, talent and energy remain tied up in CCGs. At-scale organisations in some areas do not even exist, and in many areas are new, and not really able to partner as equals with established local hospitals and the like.

There are, however, opportunities. The capitated based budget systems for accountable care organisations may incentivise systems to strengthen general practice, and remove the incentives for growth in secondary care activity that the internal market has generated. The removal of the artificial commissioner/provider split for general practice is an opportunity for the profession to become “whole” again with a much clearer identity. And for all their ills, CCGs have enabled a cadre of GP leaders to gain system leadership skills over the last 4 or 5 years, that can be deployed by the profession within the new care delivery systems.

Making the most of these opportunities requires action. The world is changing quickly, and in many places general practice has been slow to respond. The cohesion of practices attempted (but often never really achieved) by CCG locality structures and the like needs to be delivered by practices themselves. A strong, single voice is required. Practices need to ensure they are around the STP and accountable care “table” as providers, represented by their best leaders. In some places it will need early decisions by GP leaders to move out of the commissioning arena to focus on provision.

The purchaser/provider split has not served general practice well, but it is coming to an end. It is time to draw a line under it, to focus time and energy solely on the provider role, and to build a strong future for general practice in the post-commissioning world. Lack of action now, however, could lead to a new (albeit different) set of problems that may pose a more fundamental challenge to general practice in the future.

General Practice in 10 Years’ Time – Part 3

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.

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