What are the organisational options for GP networks?
As part of the Whole Systems programme, GPs in each locality will need to work together in networks.
These GP networks will eventually be part of larger provider networks that will be responsible for the new care models. This section will describe the governance and organisational options for GPs when they are developing their networks.
There is a spectrum of organisational development that GPs can go through together, with distinct network model options on how to organise themselves. These options are shown in the exhibit below.
Two case studies are presented on the following pages. The Hurley group is an example of a centralised shared services model, where a single group at the centre of the network organises shared services and back-office functions. The Vitality Partnership is more similar to a practice merger, where all the GPs are equal partners and cover a large population.
The organisational models described above can be supported by formal legal structures. For more detailed information on these structures and agreements, refer to the chapter on Legal Options in Supporting Material G: Legal Issues Compendium.
The important factors to consider once the decision has been made to form a Network are the specific details of form, legal status, ownership, governance and leadership, in particular;
- Form follows function e.g., purpose, size, membership, activities, funding, risk etc.
- Legal form, the type of organisation that the law recognises – It may be unincorporated (e.g., partnership) or incorporated (e.g., Private Company Limited by Shares). The company may be regulated by statute (e.g., the Companies Act 2006) or not (e.g., an unincorporated association)
- Framework- or constitution of ownership, governance and management – including the designated leadership, corporate team, structure, accountability and reporting arrangements
- Managing conflicts of interest – particularly where commissioning and provider roles overlap
When developing their networks, GPs will finally need to remember to engage with the public and people who use services. The overarching goal of any network creation or development plan is to improve care for individuals who use services. By creating a comprehensive plan to engage with service users across the system during the process of network development, GPs will be able to ensure that their network proposals are not only meeting their own needs, but also the needs of the people they care for. This will ensure a more collaborative environment in which primary care is provided, and will incorporate the voices of those who will benefit the most from GPs working in a more collaborative way.
Eight networks of GP practices each covering 30-40,000 patients were formed in 2006 and launched in 2009. The Networks started as loose associations but by 2010 had begun to form legal structures. The initial impetus was to focus on population health across a geographical patch (particularly long-term conditions), encourage collaborative working with a wide range of partner organisations and to have sufficient scale to allow specialisation of staff. Funding of a management allowance from the PCT allowed the each network to appoint a manager and a coordinator and to release GPs to provide clinical leadership. The PCT provided a bespoke organisational development programme focusing on governance, culture creation, teamwork, leadership and management development and IT.
Care Packages were developed (initially for diabetes then followed by other long-term conditions) which established standards of care that practices would follow and clinical outcomes that exceeded the existing QoF. The Packages also required practices to work collaboratively and 30% of incentive payments were based on performance across the network in improving care outcomes.
Service agreements were initially pooled into a single APMS (Alternative Provider Medical Services) contract between the PCT and each of the networks. With the advent of CCG’s Networks have changed to NHS contracts held by the CCG. Member practices have become limited liability partnerships to hold these contracts – jointly accountable for performance.
Network members meet on a regular basis to review performance and ensure they collectively achieve required standards of care. In some network performance review meetings are combined with continuing professional development – forming an accredited cdp session on the clinical condition under consideration. General practices in Tower Hamlets are now among the best performers in the country against the nine measures of high quality diabetes care having previously been very poor performers.
The Hurley Group is an example of a regional multi-practice organisation, which is a GP partnership or GP-led company that has partners and salaried GPs dispersed over a wider geographical area. The group has 120 clinicians and over 260 staff across London. The partnership centralises management and back-office functions on behalf of its multiple constituent practices. The distinctive aspect of this model is the smaller ratio of partners to employed clinicians, the latter dispersed over a wide area and supported by a single, small, central management team.
The aim of this model is to improve the quality and range of primary care provision through greater organisational scale, standardising clinical and managerial practices across all care settings. For more, see hurleygroup.co.uk.
This partnership was a merger of seven practices and 40 GPs serving a population of 51,000 population in Central and West Birmingham. Vitality has had to put in place a completely new model of decision-making and accountability, as it has grown too large for all partners to take part in all decisions. An executive board has been put in place, led by an executive partner (effectively the chief executive) and a chief executive officer) and a shareholder group of partners engaged in strategic planning and oversight of the executive board.
Lead GP management roles have been created for all strategic areas (these GPs report to the board and to the shareholder group), and a board-level medical director is responsible for clinical governance across the organisation and its component practices. Extensive work has gone into the development of clinical quality standards, and the measurement of these feeds into a performance management framework for the organisation. In addition, every outlet has a clinical director, akin to a hospital divisional structure, who is held to account for the day-to-day operational and performance issues at each site.
The Vitality Partnership, Birmingham – organisational overview