Is collaboration the future?

Over the last year or so, the number of GP practices working in collaborative arrangements has accelerated. So much so that research by the Nuffield Trust think tank on behalf of the RCGP reckons three in every four practices have some sort of collaboration in place and 44% of these new ways of working were set up in the past 12 months.

And who can blame practices? Financial pressure in general practice, staff shortages, encouragement from CCGs and the drive to expand primary care services are all driving the shift to collaborative working. Of those working in collaboration, two thirds of the systems adopted by GP practices are federations, with only a tiny proportion (2%) choosing to form super-practices, the research suggests. Others reported being part of clusters or organisations such as the multispecialty community providers and primary and acute care systems being rolled out under NHS England’s Five Year Forward View plans.

RCGP Supporting Federations programme lead Dr Mike Holmes said: “There is no doubt that the challenges we are currently facing in general practice are contributing to the decision to work at scale. However our survey is clear that the most common reasons given relate to patient care – extending services, improving clinical outcomes and increasing patient access to primary care. In addition there is a clear desire to support development of our staff in primary care and enhance the effectiveness and efficiency of our back office teams.”

Decision time

While many practices already have collaborations in place an estimated three quarters of them are informal agreements, while the decision over more formal changes are considered – especially whether to go for a formal federation-style set-up or to form a super practice. So what are the pros and cons of each option?

The decision can be a difficult one. For an independent GP practice, establishing some form of shared relationship with other practices in the same area seems like an obvious choice – the transformational change can be easier to put into place. But there are alternative options to consider. Horizontal integration with another community-based provider, or a vertical integration with a hospital, are both reasonable ideas. We’ll look at those in a future blog.

The main difference between a super practice and the GP federation is that a super practice is a full merger. As a result of the merger, practices lose independence and the ability to pick and choose areas they wish to opt in or out of, but the ability to streamline management and capitalise on additional money-making services is perhaps easier. On the other hand, federated practices retain more autonomy and, therefore, flexibility. The economies of scale are still there too, as they are with super practices.

Both options provide the ability to negotiate better contracts with suppliers, CCGs and trusts, and the provision of more specialist services to patients becomes easier if staff with specialist skills can be shared. It’s also easier to cover staff absence if GPs, nurses or admin staff can be shared.

In a nutshell, there are similar benefits to be had regardless of whether practices opt for the super-practice or federation option, which means the real difference is about management structure and emphasis.

A word of caution

While collaborations are taking off, it’s not all positive surrounding collaborations. The research referred to earlier revealed that collaborative working has taken a significant amount of time to get off the ground. Most focused initially on extending services and investment in staff and training, but in many areas the full benefits took two years to materialise. GPs involved in collaborations also reported a struggle to engage practices that were under significant pressure and had little time to spare.

GPs have also expressed concerns about moving to larger-scale services around continuity of care, and some felt the move could increase workload rather than reduce it.

However, on the whole most practices that have formed collaborations ay it has been for the best. Working in a cluster to undertake projects that suit patients and on things that practices might gain from – bulk buying or economies of scale for example, or joining with other clusters to bid for commissioned work all prove the benefits of collaborative working.

A case study

One super-practice – the Our Health Partnership in Birmingham – was formed out of 35 GP practices serving more than 270,000 patients across two Birmingham CCGs. Practices ranging in size from 1,500 patients to 26,000 have joined, and each will continue to operate under their existing contracts.

The partnership is run along the lines of a typical accountancy or legal firm. Each constituent practice is responsible for running its own affairs and, in order to retain autonomy, each practice holds their own contract, is a registered site with CQC and will still be inspected.

The benefits of the practice mainly surround cutting bureaucracy by centralising back-office tasks, centralising CQC policies and appointing a single accountancy firm. For example, practices spend a huge amount of time tracking and chasing payments, not only from NHS England, but also payments for teaching or training roles. Our Health Partnership says it’s much more efficient to do this centrally, with one person tracking payments on behalf of all practices rather than 30 or 40 practice managers all doing a bit of the same work.

The partnership also hopes to set up a pool of salaried GPs – with the option to develop a varied portfolio career within the group – as part of a drive to create a sustainable workforce model for all primary care staff. It’s also hoped that this could attract older GPs who have set a retirement date, ultimately reducing the amount spent on locums.

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