1. The document discusses lessons learned from the development of primary care federations in England. It addresses common questions around the appropriate size for federations, what organizational form they should take, and how to operate effectively once formed.
2. The document emphasizes that the most important factors are establishing a clear shared purpose to improve patient care, investing in leadership development, and deliberately designing the organizational form to achieve the goals of being bigger in scale while maintaining personal care.
3. An effective primary care federation is described as having an at-scale organizational form that makes it a sustainable platform for expanded services, an attractive system partner, and a credible employer, while taking steps to preserve the personal aspects of care that are essential
3. www.england.nhs.uk @robertvarnam
An example of this in practice at the
moment is the Prime Minister’s GP Access
Fund. Now covering a significant
proportion of the country, practices in this
are implementing quite wide-ranging
redesign of their services, acknowledging
that extended hours are only one part of
good access. The practices participating in
this programme are already beginning to
implement many of the transformational
changes envisaged by the Five Year
Forward View. This is generating valuable
learning about the specific changes
required, including the ways in which the
system can make progress easier and
more sustainable.
Wave one Wave two
57 schemes
2500 practices
18m patients
Learning from the PM Challenge Fund
4. www.england.nhs.uk @robertvarnam
What are PMCF schemes doing?
Wider primary care at scale
Reshape
demand
Active
front-end
Contact
modes
Match
capacity &
demand
Rapid
access
model
Extended
hours
Release capacity Service redesign team
Broaden
skillmix
Complex
care model
Premises I.T. Workforce
ServicecomponentsSystemenablers
Lessons learned & innovation showcases:
bit.ly/PMCFresources1
5. www.england.nhs.uk @robertvarnam
Purpose > function > formPurpose > function > formPurpose > function > formPurpose > function > formPurpose > function > formPurpose > function > formPurpose > function > formPurpose > function > form
8. www.england.nhs.uk @robertvarnam
• Ad hoc
• Relational network
• CCG locality
• Collaboration agreement
• Seed funded company
• Jointly owned company
• Single company
Form
12. www.england.nhs.uk @robertvarnam
Purpose > function > formPurpose > function > formPurpose > function > form
1. Stop obsessing about form
Purpose > function > form
a) Pick something to improve for patients
b) Improve it together
c) Build infrastructure to enable, accelerate & sustain
13. www.england.nhs.uk @robertvarnam
2. Create shared purpose
• A sense of shared identity sufficiently
strong to allow collaboration that
crosses boundaries of organisational
sovereignty.
• We share ideas, data, resources
• We will adopt a standard approach
• We can call on each other
• A purpose beyond ourselves,
orienting us around the needs of our
patients.
• Commitment to us and our purpose
sufficiently strong to make compliance
unnecessary
15. www.england.nhs.uk @robertvarnam
Leadership
Creating shared
purpose
Strategic planning
& partnerships
Leading through
change
Being a leader
Improvement
Patients as
partners
Processes and
systems
Using data for
improvement
Rapid cycle
change
Business
Governance
Operations
management
HR
Business
intelligence
Capabilities
Enablers
Innovation spread
Policies &
permissions
Contracts &
incentives
Infrastructure
Productive
federation
Transparent
measurement
3. Invest in development
What do teams
and individuals
need?
These are
interdependent
How can the
system catalyse
& accelerate
change?
16. www.england.nhs.uk @robertvarnam
At an organisational level, what will wider primary care at scale look like? Again, the precise details
should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to
patients and staff, not just creating a new organisation because it makes us feel safer. Our new
networks, federations or mergers should have enhanced capabilities, for leadership, management,
services and improvement. We also need to ensure that, as we operate at large scale, we maintain the
personal care which is so hugely important for many patients (and staff). That will take deliberate design:
it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the
same sense of belonging, ownership and commitment as in the best practices now. Regardless of the
actual business model. That, too, will take planning and skill.
At an organisational level, what will wider primary care
at scale look like? Again, the precise details should be
locally determined. But we should aim for it to be
bigger, in a way that brings real patient to patients and
staff, not just creating a new organisation because it
makes us feel safer. Our new networks, federations or
mergers should have enhanced capabilities, for
leadership, management, services and improvement.
We also need to ensure that, as we operate at large
scale, we maintain the personal care which is so
hugely important for many patients (and staff). That
will take deliberate design: it won’t just happen.
Finally, it should like it’s ‘yours’ – by which I mean that
staff will need to have the same sense of belonging,
ownership and commitment as in the best practices
now. Regardless of the actual business model. That,
too, will take planning and skill.
4. Design the form deliberately
Bigger
Personal
Capable
Connected
17. www.england.nhs.uk @robertvarnam
Delivering improved access and expanded care in the community require primary care providers to be
working in significantly enhanced partnership with other bodies across the health and care system. In
many respects, this will feel like a return to the roots of general practice, acting as an integral part of the
local community. However, realising this promise in the present day will involve a great deal of work to
establish strategic relationships and formal partnerships.
At an organisational level, what will wider primary care
at scale look like? Again, the precise details should be
locally determined. But we should aim for it to be
bigger, in a way that brings real patient to patients and
staff, not just creating a new organisation because it
makes us feel safer. Our new networks, federations or
mergers should have enhanced capabilities, for
leadership, management, services and improvement.
We also need to ensure that, as we operate at large
scale, we maintain the personal care which is so
hugely important for many patients (and staff). That
will take deliberate design: it won’t just happen.
Finally, it should like it’s ‘yours’ – by which I mean that
staff will need to have the same sense of belonging,
ownership and commitment as in the best practices
now. Regardless of the actual business model. That,
too, will take planning and skill.
4. Design the form deliberately
Bigger
Personal
Capable
Connected
Step change in
partnership working
• acute & specialist
• community services
• voluntary &
community sector
• public health
• housing
• education
18. www.england.nhs.uk @robertvarnam
The creation and ongoing delivery of enhanced 7 day services in the community will require a range of
capabilities in providers. Leading service transformation and working at greater scale will involve a new
corporate infrastructure, with specialised professional management and exceptional clinical leadership.
Traditionally general practice has operated much more on the basis of goodwill and hard work than is
appropriate for at-scale operations. The NHS has not invested in developing leadership, management
and business capabilities in primary care, but this is now a significant and pressing requirement before
enhanced services or improved access can be delivered.
At an organisational level, what will wider primary care
at scale look like? Again, the precise details should be
locally determined. But we should aim for it to be
bigger, in a way that brings real patient to patients and
staff, not just creating a new organisation because it
makes us feel safer. Our new networks, federations or
mergers should have enhanced capabilities, for
leadership, management, services and improvement.
We also need to ensure that, as we operate at large
scale, we maintain the personal care which is so
hugely important for many patients (and staff). That
will take deliberate design: it won’t just happen.
Finally, it should like it’s ‘yours’ – by which I mean that
staff will need to have the same sense of belonging,
ownership and commitment as in the best practices
now. Regardless of the actual business model. That,
too, will take planning and skill.
4. Design the form deliberately
Bigger
Personal
Capable
Connected
Highly capable
infrastructure &
leaders
• Transformational
system leadership
• Engaging, inspiring
& supporting the
team
• Service redesign,
innovation &
improvement
• Ops management,
HR, etc
• Business
intelligence
19. www.england.nhs.uk @robertvarnam
All of the above requires primary care to operate at larger scale. This may provide economies of scale
which will sustain providers through the current workload challenges. More fundamentally, working at-
scale is necessary to generate the kind of critical mass required for working in greater partnership as a
credible system partner in the local health and care system. In operational terms, it allows financial and
staff headroom to be created, making service improvement easier, and it increases the attractiveness of
primary care as an employer for staff from other parts of the health and care system.
At an organisational level, what will wider primary care
at scale look like? Again, the precise details should be
locally determined. But we should aim for it to be
bigger, in a way that brings real patient to patients and
staff, not just creating a new organisation because it
makes us feel safer. Our new networks, federations or
mergers should have enhanced capabilities, for
leadership, management, services and improvement.
We also need to ensure that, as we operate at large
scale, we maintain the personal care which is so
hugely important for many patients (and staff). That
will take deliberate design: it won’t just happen.
Finally, it should like it’s ‘yours’ – by which I mean that
staff will need to have the same sense of belonging,
ownership and commitment as in the best practices
now. Regardless of the actual business model. That,
too, will take planning and skill.
4. Design the form deliberately
Bigger
Personal
Capable
Connected
At-scale
organisational form
• Attractive system
partner
• Sustainable platform
for expanded
services
• Intrinsic headroom
• Credible NHS
employer
20. www.england.nhs.uk @robertvarnam
In the course of the transition to being more corporate entities, it will be important for primary care
providers to include measures to preserve and even enhance aspects of the status quo which are
essential to the value of primary care. The role of primary care at the heart of the local community, and
connected with people and their families throughout their life, is a valuable aspect of its ability to
contribute to wellbeing and population health. Similarly, the personal continuity of care provided in
general practice adds considerable value to patients with complex needs as well as to taxpayers. Finally,
the small scale nature of traditional practices creates a level of personal commitment and discretionary
effort which the NHS can ill afford to lose.
It should be noted that all three of these potential benefits of the traditional ‘cottage industry’ model of
primary care organisations are already waning in England. Patients at larger GP practices already report
lower satisfaction with continuity of care, and there are growing concerns about the disenfranchisement
of many salaried GPs.
Providers will need to ensure there are specific measures in place to ensure that the personal touch is
not only preserved but enhanced. This is likely to have implications for ownership models, organisational
culture, structures and processes, as well as the design of teams and clinical care models.
At an organisational level, what will wider primary care
at scale look like? Again, the precise details should be
locally determined. But we should aim for it to be
bigger, in a way that brings real patient to patients and
staff, not just creating a new organisation because it
makes us feel safer. Our new networks, federations or
mergers should have enhanced capabilities, for
leadership, management, services and improvement.
We also need to ensure that, as we operate at large
scale, we maintain the personal care which is so
hugely important for many patients (and staff). That
will take deliberate design: it won’t just happen.
Finally, it should like it’s ‘yours’ – by which I mean that
staff will need to have the same sense of belonging,
ownership and commitment as in the best practices
now. Regardless of the actual business model. That,
too, will take planning and skill.
4. Design the form deliberately
Bigger
Personal
Capable
Connected
Deliberate design to
stay personal
• Lifelong family care
• Integral part of the
community
• Personal LTC & EOL
care
• Sense of commitment
& ownership for all
staff
** ADD NARRATIVE TO EVERY SLIDE **
NB Each slide has white text in the background, to provide narrative notes for SlideShare
An example of this in practice at the moment is the Prime Minister’s GP Access Fund. Now covering a significant proportion of the country, practices in this are implementing quite wide-ranging redesign of their services, acknowledging that extended hours are only one part of good access. The practices participating in this programme are already beginning to implement many of the transformational changes envisaged by the Five Year Forward View. This is generating valuable learning about the specific changes required, including the ways in which the system can make progress easier and more sustainable.
One of the tasks of the Call to Action was to identify the actions necessary to promote, support and sustain the adoption of the kind of innovation and improvements we seek. We consulted with practice managers, clinicians, commissioners, policy makers and improvement experts, as well as drawing on the experience of building primary care improvement capability in the UK and internationally. A comprehensive list of areas emerged from this process. This has been tested and refined through ongoing consultation with innovators and professional leaders.
The framework describes a set of intrinsic capabilities required by practices to lead service change rapidly, safely and sustainably, and a set of enablers which can be used by policymakers and commissioners to make change easier and more sustainable.
Since April 2014, we have had the opportunity to use this framework in support of 1100 GP practices across England in the Prime Minister’s Challenge Fund. As these 20 groups of practices have introduced a range of service innovations, they have received a bespoke programme of capability-building and direct access to national support for key enablers. Feedback from practices and leaders has been very positive, with many examples of faster and better progress being made as a result of it.
NHS England are now considering ways in which this framework can be used to secure support for other national initiatives, for example further extension of access improvements, support to workforce innovators and a programme to release capacity through reducing workload and working differently.
One of the tasks of the Call to Action was to identify the actions necessary to promote, support and sustain the adoption of the kind of innovation and improvements we seek. We consulted with practice managers, clinicians, commissioners, policy makers and improvement experts, as well as drawing on the experience of building primary care improvement capability in the UK and internationally. A comprehensive list of areas emerged from this process. This has been tested and refined through ongoing consultation with innovators and professional leaders.
The framework describes a set of intrinsic capabilities required by practices to lead service change rapidly, safely and sustainably, and a set of enablers which can be used by policymakers and commissioners to make change easier and more sustainable.
Since April 2014, we have had the opportunity to use this framework in support of 1100 GP practices across England in the Prime Minister’s Challenge Fund. As these 20 groups of practices have introduced a range of service innovations, they have received a bespoke programme of capability-building and direct access to national support for key enablers. Feedback from practices and leaders has been very positive, with many examples of faster and better progress being made as a result of it.
NHS England are now considering ways in which this framework can be used to secure support for other national initiatives, for example further extension of access improvements, support to workforce innovators and a programme to release capacity through reducing workload and working differently.
At an organisational level, what will wider primary care at scale look like? Again, the precise details should be locally determined. But we should aim for it to be bigger, in a way that brings real patient to patients and staff, not just creating a new organisation because it makes us feel safer. Our new networks, federations or mergers should have enhanced capabilities, for leadership, management, services and improvement. We also need to ensure that, as we operate at large scale, we maintain the personal care which is so hugely important for many patients (and staff). That will take deliberate design: it won’t just happen. Finally, it should like it’s ‘yours’ – by which I mean that staff will need to have the same sense of belonging, ownership and commitment as in the best practices now. Regardless of the actual business model. That, too, will take planning and skill.
Delivering improved access and expanded care in the community require primary care providers to be working in significantly enhanced partnership with other bodies across the health and care system. In many respects, this will feel like a return to the roots of general practice, acting as an integral part of the local community. However, realising this promise in the present day will involve a great deal of work to establish strategic relationships and formal partnerships.
The creation and ongoing delivery of enhanced 7 day services in the community will require a range of capabilities in providers. Leading service transformation and working at greater scale will involve a new corporate infrastructure, with specialised professional management and exceptional clinical leadership. Traditionally general practice has operated much more on the basis of goodwill and hard work than is appropriate for at-scale operations. The NHS has not invested in developing leadership, management and business capabilities in primary care, but this is now a significant and pressing requirement before enhanced services or improved access can be delivered.
All of the above requires primary care to operate at larger scale. This may provide economies of scale which will sustain providers through the current workload challenges. More fundamentally, working at-scale is necessary to generate the kind of critical mass required for working in greater partnership as a credible system partner in the local health and care system. In operational terms, it allows financial and staff headroom to be created, making service improvement easier, and it increases the attractiveness of primary care as an employer for staff from other parts of the health and care system.
In the course of the transition to being more corporate entities, it will be important for primary care providers to include measures to preserve and even enhance aspects of the status quo which are essential to the value of primary care. The role of primary care at the heart of the local community, and connected with people and their families throughout their life, is a valuable aspect of its ability to contribute to wellbeing and population health. Similarly, the personal continuity of care provided in general practice adds considerable value to patients with complex needs as well as to taxpayers. Finally, the small scale nature of traditional practices creates a level of personal commitment and discretionary effort which the NHS can ill afford to lose.
It should be noted that all three of these potential benefits of the traditional ‘cottage industry’ model of primary care organisations are already waning in England. Patients at larger GP practices already report lower satisfaction with continuity of care, and there are growing concerns about the disenfranchisement of many salaried GPs.
Providers will need to ensure there are specific measures in place to ensure that the personal touch is not only preserved but enhanced. This is likely to have implications for ownership models, organisational culture, structures and processes, as well as the design of teams and clinical care models.