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Brave new world for GP groups

Jamie Foster says joining forces with other practices is a good move but there are issues to resolve

What will be the impact of the Conservative/Liberal Democrat government on primary care and how should this affect GPs' thinking and planning for the future?

The coalition's Our Programme for Government and the Health Bill announced in the Queen's Speech last month give some indication of what is to come.

There are plans in England to establish an independent NHS Board to allocate resources and provide commissioning guidance, and also in England, to strengthen the power of GPs to commission services on behalf of their patients.

In practice this is likely to lead to GPs being given greater control of the purse strings (and therefore overall control).

Real commissioning with hard budgets is likely to replace practice-based commissioning. So on this basis there are opportunities for GPs.

New types of organisation
Today's primary care world offers GPs the option to join a range of new types of organisation: commissioning clusters, federations, consortia, polysystems, super-practices, provider companies and integrated care organisations to name but a few.

But what are these organisations and how do they differ from each other?

The terms used for these organisations are non-specific and do not have legal meanings.

But their common characteristic is they all refer to a group of GP practices acting collectively for a particular purpose or purposes.

What are their purposes?

Generally, they carry out one or more of these functions:

  • Commissioning Co-ordinating GP commissioning activities for practices.
  • Service delivery Providing services under contracts transferred from existing providers (such as hospitals) or newly won contracts.
  • Referrals management Acting as a gateway for referrals to specialist services.
  • Back office support Providing management and support functions for the practices in the group.
  • Integrated care Integrating provision of care and/or the commissioning of it.
  • So should your practice join one of these groups?

There is currently no legal requirement to get together with other practices and form a group. But in some areas PCTs are urging GPs to do so. Also the change of government may well make this more common or even impose a legal requirement to do so.

So now may well be the time to get ahead of the game. What are the benefits?

Where a GP group carries out commissioning, the 'weight' of a number of practices should help it to wield more influence over providers. A commissioning group can also link up with a provider organisation to establish an integrated care organisation (ICO).

The attraction of an ICO is its potential to combine service provision with referral management so that the ICO can take responsibility for all of the care needs of its registered population.

Forming GP provider groups is a way of expanding practices' range of service provision. The drive to move care out of hospital and into community and primary care settings means PCTs are increasingly likely to offer contract opportunities for new and redesigned services, often using tender processes and the 'any willing provider' model.

The latter is a system whereby any provider that meets criteria for entering a market can compete within that market.

Greater expertise and scale
Being part of a group, with the greater expertise and scale this brings, puts practices in a better position to win these contracts and generate new income streams. It also enables practices to share resources and costs.

It can therefore lead to cost savings and reductions in overall tax liability, for example by running the group via a company.

For individual GPs, being part of a group can allow for a focus on specialisms, improved professional development and training opportunities and exit/retirement strategies.

It may also meet some of the challenges on the primary care horizon: the demand for greater access to GP services, the introduction of hard budgets and reforms to GP contracts.

There are a range of governance models for setting up a group with other practices, ranging from loose contractual arrangements to a company limited by shares, a company limited by guarantee, a community interest company limited by shares or guarantee (a social enterprise model) or a limited liability partnership.

When choosing the form of your group there are a range of issues you need to consider including who its owners are and how it is to be run (see box).

But perhaps most important of all is the ability to ensure your model enables you to obtain or maintain access to the NHS Pension Scheme as this is not possible with all models

You will need legal advice to set up a GP group. You may also need tax and accounting advice depending on what your plans are. But whatever the professional advice you need, the earlier you get it the better.

The opportunities are there but if you fail to grasp them, you run the risk that decisions about your practice will be taken for you rather than by you.

Setting up a GP group

Issues to sort out:

  • Who owns the group? Practices, patients, other stakeholders?
  • Management of the group. Who has the right to be represented on the board?
  • Conflicts of interest. How will they be managed?
  • Profits. How will they be distributed?
  • Premises and equipment. Will the group own them?
  • Workforce. Will the group employ and manage staff?
  • Contractual arrangements with PCTs. What will these be?
  • Support functions including IT and human resources. How will the group access them?
  • Clinical governance. What will the arrangements be?
  • Indemnity cover. How will be this be procured?
  • Intellectual property. Will the group own or use any?
  • Procurement law. What are the implications?
  • Taxation. What will the impact be?

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