Can a federated practice succeed?

Prisca Middlemiss looks at how the RCGP's alternative to polyclinics is faring in Staffordshire.

The RCGP's response to polyclinics - the GP-led federated or 'networked' practice - sounds much less of a threat than the 'open-all-hours to all comers' model imposed by central diktat.

Surprisingly, the RCGP's variant apparently has the blessing of health minister Lord Ara Darzi.

Lord Darzi reassured GP earlier this year that 'the first and preferred model, in London, will be the federated model, as supported by the RCGP'.

The vision is loose and inclusive - virtually any practice could qualify. But does it work?

Well, yes, it does. In rural Staffordshire, the five-doctor health centre at Gnosall, 'the biggest village in England', has been working as a federated practice for years.

The £4 million, 20,000 square feet health centre, open since 2006, is a one-stop shop, offering 'polyclinic-style services on the federated route' outside practice-based commissioning (PBC).

It has facilities for physiotherapy, chiropody, audiology, scanning, mental health services and minor surgery, as well as a pharmacy. Future plans include a dentist as well as outpatient clinics for gynaecology, psychiatry, dermatology, rheumatology and urology.

Junior doctors from the local acute trust are attached to the surgery and consultants come out to hold clinics there.

But there's no APMS contract (it is a PMS Plus practice), no 8am to 8pm opening and the GPs, and in particular partner Dr Ian Greaves, are in the driving seat.

Gnosall is federated with Mid Staffordshire Acute Trust, Staffordshire and Shropshire Mental Health Trust, Staffordshire social services, a private audiology company and the provider arm of South Staffordshire PCT.

The basis of the federation is, said Dr Greaves, mutual trust.

'Relationships and trust matter as much as process in team work,' he said.

'We have invested a lot of time and wine into the acute trust and the PCT and have a trusting relationship. We need both to be successful and they need us.'

Under a service level agreement between the practice and the PCT, with PBC board approval, the 7,200 patients at Gnosall can attend hospital outpatient clinics at their own surgery.

Financially, the scheme misses out on potential PBC savings, but stands to improve referral quality and so achieve indirect savings.

Care pathways developed for specific conditions ensure that appropriate patients, investigations and histories are in place before the first consultant appointment.

Both new and follow-up appointments are down, freeing up resources that the practice hopes to reinvest in the clinics.

The hospital superintendent radiographer provides general and specialist diagnostic ultrasound, proving a better fit than the PCT's orthopaedic triage service.

Consultant involvement
'The consultants felt left out of the triage system and felt it may increase delay. This system involved them and they were reassured,' said Dr Greaves.

An exciting current pilot allows the Gnosall GPs access to the same X-ray images on their computer screens as consultants view on the wards.

This is not diagnostic, but allows GPs to visualise the pathology detailed in consultants' reports and to show patients.

Using its PMS contract, the practice seconds the PCT's district nurses and health visitors to form an integrated nursing team with its own nurses and health care support workers.

This provides a community workforce that can safely care for patients at home and keep them out of hospital.

Junior hospital doctors attached to the practice form a 'bridge of trust' between the hospital and the community.

'This workforce will give a capacity to move care safely into the community,' said Dr Greaves.

Audiology comes from a private provider (Hidden Hearing) in a deal under which they offer free diagnostics in return for the opportunity to promote its products to patients, who are informed in advance.

'The only reason this works is because the NHS service was so poor,' said Dr Greaves.

Funds raised by 'very active' patient groups, pharmaceutical company donations and savings from the Prescribing Incentive Scheme have paid for 'a range of near-patient testing equipment from simple INR monitors to uroflowmetry'.

These 'very active patient groups' are, said Dr Greaves, 'our first line of defence against any private company takeover or centrally imposed policies'.

Under a pilot scheme, junior hospital doctors come to the practice to work up patients awaiting referral for urology, dermatology and rheumatology.

Gnosall Health Centre also has its own wholly-owned pharmacy and is seeking a 'socially motivated' dentist to offer affordable dentistry.

But the service is not provided without personal cost. Last November, when Dr Greaves developed pericarditis, he was advised to scale back - shelving groundbreaking plans to allow junior doctors who had missed specialist training posts to run an out-of-hours urgent care system. So is he a lone beacon of excellence?

Dr Greaves admitted that he has 'an insight and acquired knowledge and skills that are a mystery to many'.

But he insisted: 'There are many like me. I meet dozens of capable competent enthusiastic doctors in every locality I visit. This energy needs to be harnessed.'

The government, he suggested, should support 'regional discussion groups where ideas can be shared'.

So it is all the more dispiriting that he notes: 'There remains little central support for grass-roots innovation.'


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