Post Darzi Review and RCGP concept of Federations of Practices
In April 2008 there was an open day with CATS providers in St Albans.. There was quite a buzz and enthusiasm there, akin to the fundholding days. It looked quite impressive – with many pathways and mini-contacts involved, ranging from ophthalmology to gynaecology.
We still do not like CAS and CATS. Setting up these services has had transactions costs. Many had to go out to tender – a risky business if you first thought of the ideas or wished to run the services, even below tariff. It strikes me as simpler and neater to allow GPs to extend our services as practices working in NHS body federations without the bother of little APMS and service contracting which can take care outside the NHS.
CAS/CATS fragment care and often add to the patient pathway, shift responsibility of care, diluting our professional responsibility, and give rise to clinical governance issues. For example, the companies involved fall outside FOI (Freedom of Information Act). Some of the contracts are legally binding, as they are with private providers.
Following on from the RCGP thinking about federations of practices, and what has been discussed with the RCGP Darzi review, this is my penny’s worth, which others may have thought of, which may be able to run using the current legislation-
The Cunning Plan:
1. Current practices form joint working agreements, agreeing to work together on provision of extra services within the NHS.
2. These groupings or federations become NHS bodies in their own right. This means that contracts and Service Level Agreements go to NHS arbitration. It means that the new body is within the NHS, and subject to FOI enquiries, and NHS information Governance, as apply to the constituent practices.
3. The PCT provides contracts or SLAs for the enhanced pathways of care, and the federations are given budgets. As per fundholding days, these partial budgets are real, with the PCTs acting as bankers and making payments to providers and to the federations themselves. The contractual framework for this may already exist in the form of EPMS contracts.
4. The federations will have to produce audited accounts. They have to produce evidence of Quality of Care and professional probity. The professional interest that GPs have in patient care is not a ‘conflict of interest’; it is the working of a principle that, when providing more services of high quality, one’s rewards increase. Immunisation and QOF achievements have demonstrated the benefit of that approach for the NHS. It does not matter if this is capital or revenue gain. The gain needs to be open, and not hidden behind service companies.
5. The groupings may then deliver services how they wish, and vire money accordingly, and they may make contracts themselves.
6. The current CAS/CATS systems, if liked by the GPs, would be rolled into the grouping or federation as a provider, scrapping the plethora of mini contracts and contractors.
7. The groupings or federations would be able to employ staff and healthcare professionals, including NHS consultants, GPs, and nurses [the shared chambers], by means of one or more of the existing practices being the employer(s). The employer(s) would agree to share employed staff with the rest of the federation, which would compensate the employing practice(s).