What is the future of GP federations?  Do they have one, or does the emergence of PCNs mean that the days of GP federations are essentially over?

The best place to start when searching for answers to questions like these in the NHS is generally the wider policy context, and this is no exception.  The existing set of GP federations can be by and large split into two categories.  The first set of federations formed in c2007 at the height of the commissioner/provider split, when ‘world class commissioning’ was a thing, and when a primary care provider vehicle was needed for the delivery of services in primary care.

The second set of federations formed 10 years later in c2017 in response to the extended access funding that was made available to general practice and in response to the increasing pressure that general practice was finding itself under.  Funded through the delivery of the access hubs, federations were able to play a wider role in supporting individual member practices.

But the end of the commissioner/provider split was formally (if not explicitly) announced by the publication of the Long Term Plan in January 2019.  It signalled instead a shift to integration.  System Transformation Plans (STPs) were to be implemented and Integrated Care Systems (ICS) developed.

Over the last 30 years a range of GP commissioning organisations have all come and gone, from GP fundholding, through primary care groups and practice based commissioning organisations, right up to the current embodiment as CCGs.  These are in terminal decline, as the NHS moves to replace the legacy of commissioning organisations with the new integrated arrangements.

The new, non-commissioning, integrated entity for general practice are Primary Care Networks (PCNs).  First mentioned in the Long Term Plan published at the start of 2019, they are described as the enabler of “fully integrated community based health care”.

Without a commissioner/provider split, and with the establishment of PCNs as the statutory (or as close to statutory as can be achieved with a set of independent contractors) integrated community provider, it is not clear what role a separate primary care provider like a federation can play.

So far existing federations have been able to co-exist with PCNs, primarily by using the funding in their extended access contracts.  But the funding for extended access shifts to PCNs next year.  While federations will struggle to replace the lost income, PCNs will continue to grow and develop as integrated community providers, with nationally mandated funding streams alongside additional local ones.

It will be tough for federations to continue to exist in isolation from PCNs.  PCNs mean there is no need for a separate provider arm of general practice within an integrated care model, because PCNs are that provider arm.  In the world of integrated care, without the commissioner/provider split, where does an independent provider like a federation receive its funding from?

The future of federations, if there is to be one, can only lie as an enabler of PCNs.  The real barrier to progress for many PCNs is their size, and by working together through a federation they can move faster and more effectively than they can on their own.  Federations could take on delivery of extended access, and indeed of a range of PCN delivery requirements, but only if the PCNs want them to do so.

Federations are currently viable as a result of the provider contracts that they hold.  As integrated care develops, these contracts will shift into the realms of PCNs and the joint working between the statutory providers.  Crunch time is coming soon with the shift of the extended access contracts, and it is hard to see federations surviving it if they are not built on joint working between PCNs.