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