Title: Learning about and learning from GP Federations in the English NHS – a qualitative investigation
Funder: Department of Health and Social Care

Abstract: GP federations, defined as groups ‘of practices and primary care teams working together, sharing responsibility for developing and delivering high quality, patient focussed services for their local communities’(RCGP Toolkit 2010) are emerging in response to the pressures facing primary care(Kings Fund, 2013: 5). Federations are a supra-practice level of organisation. They vary in scope and organisational form, from loose alliances of a small number of local practices, to much larger publicly limited provider companies.Potential benefits of federations include efficiencies of scale and scope, strengthening capacity to deliver services outside hospital and improving local integration. Federations present many challenges including balancing individual practice ways of working, autonomy and identity with the requirements of more centralised and standardised procedures which federations imply. Federations are substantially different to the traditional partnership model, however,little is known about how federations are working in practice and the implications of different organisational forms for the organisation of primary care. We will explore how GP federations are working in practice. The aims of the research are to: • Provide a wide ranging and in depth exploration of GP federations in England • Strengthen the evidence base on the organisation and management of general practice for the twenty first century. Based on our earlier study of 2 federations, we suggest that it is not possible at this stage to simply measure the impact of changes on health (proxy) outcomes, given the diverse objectives of federations and evolving nature of the organisations concerned. Yet it is important to understand how federations are emerging and operating and produce early lessons to inform their future development. In addition to a mapping exercise to construct a national picture of the types of federations and their locations, this study will involve in-depth qualitative research in three federation and 1 non federation case study sites. We will use qualitative methods to explore the stated aims of federations and the mechanisms by which such aims are intended to be achieved. We will also assess progress against these aims. Other foci will include the mechanisms by which practices are working together within the federation, enabling and constraining factors regarding establishment and operation of the federation and the impact on the constituent practices (in the widest possible sense including practical impacts on their work, impacts on practice identity etc.). In addition, we will explore impacts on patients in our case study sites using interviews. Data collection will include interviews with a range of stakeholders. Our selection of interviewees will in part be guided by the stated aims of the federations involved but as a minimum it will include patients and carers, practice staff, acute and community care providers and representatives of the social care sector. We will also observe relevant meetings and conduct documentary analysis to add to our understanding of what is happening in case study sites. Study outcomes will be • A typology of federations • A national picture of federations, classified according to our typology • An in-depth understanding of how federations are working in a small number of case study sites • Lessons for the wider implementation of new organisational forms in English primary care

Lay abstract: What we know: GP federations, defined as groups ‘of practices and primary care teams working together, sharing responsibility for developing and delivering high quality, patient focussed services for their local communities’(RCGP Toolkit 2010) are emerging in response to the pressures facing primary care(Kings Fund, 2013: 5). There are various ways in which practices might work together and these can range from from loose alliances of a small number of local practices, to much larger publicly limited provider companies. Potential benefits include more 'joined up' working and improved service provision, as well as cost savings. There are risks, however, which include a 'one size fits all' approach to care delivery and a loss of local freedom for GPs. What we don't know: Little is known about the number of federations across England. We know very little about how each of the different federations is organised, what their aims are and the impact on staff and patients. We also don't know how working in or being a patient in a federation compares with non-federation settings. What we aim to produce: Our aims are • To provide a wide ranging and in depth exploration of GP federations in England • To strengthen the evidence base on the organisation and management of general practice for the twenty first century How we will do this: We will build on work that is being undertaken in 2 counties (Notts & Derbys.) where a picture of the number and type of federations is being captured, as well as our local knowledge of federations in Greater Manchester to construct a national picture of the number of federations. We will classify these into federation types. We will then use this to choose 3 federations which have different forms, as case study sites. We will also choose 1 non-Federation site. We will follow what happens at these sites over a period of 15 months. We will interview patients, carers and staff who are involved in these sites. We will also interview staff from local hospitals and community health services as well as relevant local authority staff. We will also observe relevant meetings and examine documents to obtain as complete a picture as possible of what is happening in each of the sites. We will not measure performance of federations across the country, but we will examine the declared aims of each of the 3 federations in our study and assess the extent to which these have been achieved. We will also look at the assumptions amongst the people leading the federations about how they are supposed to be working to produce the expected benefits. We will not use large surveys as we think (based on what we know) that this will not give a high response. We will not try to quantify the impact as we need to know more about how and why things are happening before we can try to do this at some point in the future. We will not try to cover a large number of organisations because that would mean spreading ourselves too thinly.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE