We discussed in last week’s blog the importance of federations establishing a mandate from their practices, but that is only half of what is needed. To have influence, federations also need to build relationships with other organisations.

A common misconception is that attendance at meetings is the same as having a voice. It is not. If a GP sits through a meeting and has no impact on the outcomes then general practice has not had a voice. In fact it is worse, because other organisations can point to the fact that general practice was represented, even though it didn’t influence any of the decisions made.

This is not an uncommon situation. Understaffed federations, often reliant on the goodwill of a small number of individuals, are asked to attend a plethora of system wide meetings as the NHS works up a head of steam in its shift towards integrated care. It becomes a case of finding someone to go, and the poor GP who attends sits there, often without a clue what is going on.

The reality is, of course, that while meetings are often the end point of a decision making process, they are rarely the start of it. In a world of integrated care, the starting point is much more about relationships.

I was working in an area where the federation formed a strong relationship with the local acute trust. The Chief Executive of the hospital was supportive of the local GPs. They worked together on creating a primary care front door at A&E. When the federation needed someone to host the employment of the pharmacists to work in practices, the hospital stepped in. Then the CCG put community services out to tender. The hospital Chief Executive and the federation leadership had a conversation and decided to put a (ultimately successful) bid in, in a model whereby the hospital hosted the contract, but looked to primary care to provide leadership as to how it would be delivered in the local areas (which is exactly what the GPs had been asking for).

This change came about not because of what happened in meetings, but because the federation had built a relationship with the local hospital. To have a voice, to have influence, federations need to build relationships.

There are some really important relationships federations need to have in place. The LMC for one. Federations and the LMC need to work hand in glove together to ensure the voice of general practice is as strong as it can be. Practices are not going to trust the federation if the LMC doesn’t.

Other local federations in the same area are also key. Ultimately they are not competitors but collaborators seeking (more or less) the same thing.   Disagree in private, work out a way forward, and agree in public. If general practice is arguing with itself around the integrated care table, the power of any individual federation’s voice will be lost.

And as in the case of the federation who ended up being able to control the shape of community services in their area, a strong relationship with at least one local statutory organisation (whether it is the hospital, or the community trust or the mental health trust matters less) means when the bigger opportunities come along, the federation is in a realistic position to be part of the conversation.

These are the two foundations federations need to develop to create a strong voice: a mandate from their practices; and strong relationships across the health and social care economy. Next week we will explore how federations can turn these foundations into a voice which has impact.

Vineet Nayar is famous for what he stood for: “employees first, customers second”. He became CEO of HCL technologies and transformed its fortunes. He believed passionately that the firm itself did not add value to customers, but its employees did. The role of the firm was to build trust with its employees and empower them to make the changes that might at first sight appear impossible.

He was transparent about information and about the firm’s weaknesses with his employees in ways most companies would never dream of. He did this to build trust between the leadership of the firm and those who worked there. The firm was not telling its employees the answers, it was being honest about the challenges of the current situation, and enthusing, encouraging and enabling the employees to make a difference to it.

There is a 10 minute YouTube interview with Vineet about “employee first, customer second”. It is well worth a watch. I think it is entirely relevant to federation’s thinking about their role and the mandate they have from practices. What do federations stand for? Is it “practices first, patients second”?   Is the role of federations to transform patient outcomes directly, or to enthuse, encourage and enable practices to work together and do this themselves?

Federations need to stand for something. To be the “voice” of general practice in the new world of integrated care, federations need a mandate from their practices. To gain that, they need to be clear what it is they are articulating on behalf of their practices. They cannot claim to be the voice of general practice without agreeing with practices what it is they are going to say on their behalf.

They will need some form of agreed vision/strategy with their practices. This will be some version of:

• A strong and vibrant general practice with the registered list as the foundation of local healthcare delivery
• Service delivery tailored to naturally occurring local populations of c50,000
• Integrated primary and community care teams at a locality level
• The removal of barriers between primary and secondary care, between health and social care, and between physical and mental health
• A greater focus on health and prevention

You will have your own version of this. Whatever it is, the important part is that it is developed with the practices, not for them. But turning this into a mandate involves not only agreeing the what, but also the how – how will any agreements that are made actually be delivered? The lesson from Vineet Nayar is that it is not only ok for federations to stand for empowering, enabling and supporting general practice, it is what is needed because it is practices not federations that will make a difference to patient care. Federations are not around the table to get more for themselves; they are there to ensure practices get what they need to deliver change locally.

The important conversation with practices is to agree the nature of this relationship. The federation will use its “voice” to get the resources, the support, the infrastructure, the tools and whatever else practices need to make changes locally. But it is the practices that will make change happen. Change is done by the practices not to the practices. Ultimately, it is a two-way agreement, each side with its own part to play.

This is how federations can create a powerful mandate from practices, one where what they agree turns into action. This mandate is based on trust, the hard won and easily lost trust federations build with their practices. Without this mandate, even though it might be at the table, the federation does not really have a voice.

Throughout August we’ve run a series of blogs where Ben has considered various aspects of the independence of general practice. In this fifth and final blog in the series he asks

Is operating at scale necessary to protect the independence of general practice?

There is something counter-intuitive about the notion that practices would operate at scale to protect their independence. Many GPs resist any notion of operating at scale precisely because of the restrictions they feel it places on their autonomy. The perceived wisdom is at-scale general practice is a step away from independence, not a move towards it.

But is it? I was struck by the tale of the practices in Wolverhampton. Recently a ninth local practice has handed over its list to the local hospital trust there, taking the total population now under the hospital’s control to 70,000. Now, I am not close to what is happening in Wolverhampton but local GP leaders said the GP partners were motivated by financial ‘non-viability’ and workforce shortages, with the move viewed as ‘handing over the problem to someone else’.

One of the practices put this on its website as it announced it was joining the hospital, “Without the help of The Trust we would definitely have left and would have had no option but to close the practice and split our list up amongst other local Practices. The Trust have been able to find us new Partner GPs, a new site and the funding to refurbish it into a modern GP Practice.”  The local practices, it seems, felt like there was no alternative.

I am sure everyone reading this is aware of the pressures currently facing general practice. Those pressures are not going away. There are no new GPs. Demand is continuing to rise. The financial pressures remain significant. At some point, almost inevitably, practices (like those in Wolverhampton) will reach the point where they decide to hand over the pressure of running the practice, to let someone else take on the responsibility, and to simply focus on the patients in front of them.

In a period of sustained pressure on general practice, where salaried doctors are increasingly earning more than the GP partners, more and more practices will reach this ‘enough is enough’ point. And if the local hospital, or community trust, or whoever, offers to take on the responsibility, increasingly practices will make the decision to trade their independence for the relative security and simplicity of salaried life.

If we take the practices in Wolverhampton back 3 or 4 years, would they have made the same decision then? Could they have envisaged then that things would get to the point where this was the choice they would make? And if they had known this would happen would they have chosen to do things differently?

But what could they have done? Well, the opportunity that practices working together (“operating at scale”) presents is for practices to support each other, and to work together to tackle the workforce, demand and financial pressures all are experiencing.

Here is the irony: practices resist operating at scale in the name of keeping their autonomy, but by doing so are keeping themselves on a track that is taking them to the ‘enough is enough’ point when they will hand their list over to whoever will take it. The status quo is unlikely to remain an option for much longer. However counter-intuitive it feels, it is choosing to work together with other practices that is most likely to protect the independence of general practice.