My first executive director role was at a hospital. I was very excited. Finally, I was going to get the chance to be part of the team who would make all the decisions about the running of the hospital. It was all new to me, and I wasn’t sure what to expect.

Some things, however, became clear immediately. When the Director of Nursing spoke (which was infrequently), her opinion did not carry weight and had little influence on the decisions the team made. But when the Director of Operations spoke (which was frequently), her opinion carried a lot of weight and frequently swayed the Chief Executive into decisions in line with what she had said.

In that same role I went to meetings of the hospitals across the local area. The same thing happened there: some hospitals had a much more influential voice than others. It happens everywhere.

The lesson, of course, is that simply being at a meeting does not mean that you have a voice.

General practice is seeking a “voice” around the table of providers who will be making decisions in the post-commissioner landscape of the NHS. GP federations are being established in many places to be the voice of general practice within this arena. But what exactly does this mean? I looked up the definition of voice (the meaning that we are thinking about here):

“A particular opinion or attitude expressed

• An agency by which a point of view is expressed or represented
• (in singular) the right to express an opinion”

What particular opinion or attitude are GP federations seeking to express at the integrated care table? This is a more difficult question than you would think. If they are seeking to represent the views of practices, isn’t that the role of the LMC? Don’t they have a statutory role to do just that? What do the practices expect – are they expecting the federation to sign them up to new ways of working, or are they really expecting the federation to be representing the potential delivery of services outside of hospital rather than anything to do with what actually happens within the walls of their own practice?

And what do the other providers around the integrated care system table expect of federations? Do they think the federations are representing what happens in core general practice as well as the delivery of additional services? If the federation only represents the delivery of extended access (or the like) how influential a voice is it likely to have? Possibly more Director of Nursing than Director of Operations…

The aim of integrated care is not to hold meetings where representatives make the case for their individual areas, but rather that organisations partner with each other. This is why LMC representation at this level rarely works, because the other organisations see the LMC not as a partner but more as a trade union. It is hard for an organisation perceived as a trade union to persuade others it is there as an active partner.

So here is the challenge for federations to think through: how will they establish a mandate from practices that will enable them to be confident that when they speak at the integrated care system table they have the support of the practices behind them? And how will they deliver that voice within that arena in a way that influences decisions rather than is ignored? And when faced with making difficult decisions (which they inevitably will be) how will they keep credibility with both the practices and the system partners?

Over the course of the next few weeks I will consider this challenge in more detail. While there are no easy answers, having a clear approach and preparing effectively can reap significant rewards down the line.