Handbook

Directory of federation services

How can we help? A snapshot of services delivered by primary care federations across England.

4 November 2021

Introduction

As a network of federations, the Primary Care Federation Network prides itself in the range of support and services it offers primary care and the wider system. We are at-scale primary care providers, routed in the NHS and our local populations. As networks of GP practices and primary care networks (PCNs), we can have different names including alliances and networks of networks. We use our knowledge of the primary care landscape, our relationship with practices, PCNs and other system partners and our ability to quickly mobilise to meet emergency demand to deliver and improve care for our location populations.

As most federations have developed organically, so too have the services and support they offer. This means that not all federations look the same and the services they offer differ based on local need.

To help provide a better picture of what federations are doing, we have developed this directory. The directory offers a snapshot of the services federations are delivering across the country, from extended access and developing primary care collaboratives to elective care redesign and education and training. This live resource will help you better understand what federations do and how these services add value to the system and improve care. The directory also aims to show the art of the possible for federations that are growing and diversifying their offer to the system.

We encourage you to look through this document. Do get in touch if you have any questions about the case studies, or if you have another service to add to the directory.

The role of federations in the primary care system

As integrated care systems grow, collaboration between primary care providers and their wider system partners is growing too. Many primary care providers are taking advantage of the independent layers of scale to deliver for patients, reducing duplication, improving equity of access and delivering the right care at the right time in the right place. There is not a one-size-fits-all model and there is still a long way to go for many primary care providers. But we are beginning to see robust primary care systems that benefit from the different expertise and opportunities available at neighbourhood, place and system.

As providers at place and system, PCNs, federations and networks of networks are important if care is to be delivered at the appropriate scale. Federations are working to create the at-scale provider infrastructure to allow general practice and primary care to flourish, either through direct delivery or through the support of members. They are working to ensure primary care takes advantage of the unique offer provided at neighborhood, place and system. This document gives some insight into how this is working in practice.

Directory list

These are examples of services that federations can provide, but this may not be appropriate to all systems.

Enhanced services

Delivering services at scale that integrate at the interface between core GP and wider NHS and social care provision, aligning to place partnership and ICS objectives and the integration of secondary care, social care and communities with primary care team.

Extended access

Federations offer additional out-of-hours capacity in their locality. Providing extended access above neighbourhood-level improves equity of access across a place and reduces pressure on practices.

These services are not only integrated with core general practice, but also provide wider-system resilience and reduce pressure on A&E departments and other parts of the urgent care system. Through their scale, federations are best placed to bridge the gap between continuity of care in-hours and access to urgent primary care 24/7. Some federation are connecting extended access, out-of-hours services, urgent and intermediate care. Examples of these services are also included in this directory.

  • Milton Keynes GP Federation have established an extended access service across Milton Keynes. Initially this was across six hubs covering a population of approximately 250,000 people and every practice was able to book appointments to the hub, mainly with GPs and nurses. Today, the service is growing to meet current and future local demand.

    During COVID-19, Milton Keynes GP Federation became the green hub for 8am-8pm seven-day access for non-symptomatic patients and the extended access service provided surge capacity. In October 2020, three extended access hubs resumed and the service began to offer multi-disciplinary team appointments. All appointments are split by PCN and access clinical leads work with PCN clinical directors to establish service requirements.

    Due to population need and COVID-19 recovery, it was agreed across practices, PCNs and federation colleagues that the service should be transformed and updated again. PCN and federations agreed a review of services to help support recovery and resilience post COVID-19 and beyond.

    To aid this transformation, clinical directors meet weekly and regularly with Milton Keynes Federation with a focus on the patient need, while also recognising the background pressures of increased demand. Primary care leaders are shaping the service by examining this patient need, reviewing the ten high-impact actions that release capacity in the Five Year Forward View and focusing on new consultation models.

    PCNs note that working with the federation means they can ‘work smarter not harder’ and make sure ‘every contact counts’. The transformation plans recognise that PCNs are in their infancy and are at different levels of maturity. Some are better prepared to manage and implement changes. The transformation also recognises that PCNs know what works at a local level and the federation can offer system level supports.

    Planning is still underway to develop future service models, but current aims include:

    • the extended access service will be open to all aspects of primary care
    • models for how ARRS roles are employed will be reviewed looking beyond the 9-5 contract
    • the service will focus on the right person, time and place – making it easy for all groups to access health and wellbeing services in a place that is convenient to them
    • flexible appointment times where different services can be offered at the same time, so patients only need to be seen once
    • group consultation pilots for long-term conditions, shifting from educating patients to empowering patients.

    Through this collaboration, PCNs and practices are given the head space to develop a service model that is reflective of local needs, now and in the future. It offers flexible services that work for patients, practices and PCNs and it does not deliver a one-size-fits-all model.

Improving access for vulnerable communities

Improving access to primary care continues to be a top priority for the health and care system. Unfortunately, when demand increases in primary care and accessing services becomes more difficult, it is often the most vulnerable in society that are impacted the most.

Federations are able to provide tailored access schemes at scale to help target vulnerable communities and support practices to develop services specific to local need and work with system partners to provide an approach that ensures every contact counts, with numerous services, healthcare checks and support options available at one time.

  • Manchester Primary Care Partnership worked with GPs across seven practices to establish the newly commissioned homeless access service and improve access to healthcare for some of the most vulnerable people in the community.

    The approach supports practices to ensure people who are homeless receive improved access to healthcare. In some cases, practices are already carrying out some, so practices are supported to continue to deliver these services

    Each participating practice receives funding to support them to provide sustainably improved access. Mobilisation has been staggered and each practice participates in the scheme for 12 months, over which time they can refine and improve their services. Each practice will tailor their service offer to their local population needs, in addition to delivering a core set of services. Practices participate in training for homeless and inclusion health for all team members, including receptionists who register people from hostels, hotels and other homeless people from within the neighbourhood, using the practice address where needed. Practices also review provision of responsive access to appointments for those who are homeless and provide a new patient health check including BBV/STI and health plan to every new registration.

    Any new homeless patients with a long-term condition are treated to Quality and Outcomes Framework standards and no homeless patient will be penalised DNA (Did Not Attend) if they are unable to attend scheduled appointments. To facilitate peer learning and improvement in services, all practices on the scheme also link with ‘Be Well’ and other neighbourhood support organisations and attend a quarterly best practice group. Part of this process includes participating in developing improved approaches to supporting patient transfer between access hubs.

Supporting elective recovery

Cross-system integration is vital to managing the elective backlog and recovery. Primary care has an important gatekeeper role and supports large lists of waiters to ‘wait well’. Working alongside system partners, federations are also helping to redesign and deliver integrated services that reduce waiting times and improve care pathways. This includes, but is not limited to, cardiology, dermatology, general surgery, gynaecology, audiology, orthopaedic and pain management.

Using existing relationships between federations and secondary care has helped create more joined-up care with stronger integration of strategies, services and staff, which is essential to the COVID-19 recovery.

  • Primary Care Sheffield has developed an elective care redesign programme that aims to reduce the pressure on elective services and makes sure that patients in Sheffield receive their care in the most appropriate setting from the most appropriate clinician.

    The programme, called Clinical Assessment, Support and Education Service (CASES), covers ten specialties including dermatology, general surgery and gynaecology. A team of Sheffield GPs, who have additional training and mentoring from hospital consultants, provide support and guidance to primary care colleagues who think a patient needs to be referred into secondary care. Sometimes the patients may not need to go on to hospital and can be treated by their GP with appropriate advice and guidance, or additional tests or information may be suggested.

    Alternatively, community-based services can be recommended as an alternative to a hospital outpatient appointment. This helps to ensure that patients receive the help they need closer to home without needing to go to hospital. It also improves the quality of referrals and enhances the knowledge of GPs.

    The last year saw more than 27,500 patient referrals being GP peer reviewed with advice and guidance offered to referring GPs, and learning shared through briefing documents and learning events. Overall CASES has resulted in an average 23.7 per cent reduction in referrals across all specialties.

     The GP federation has provided a vehicle for employing peer reviewers and secondary care mentors and has built the infrastructure for shared learning through the development education resources and guidance. We have created a rich data set of referrals and can target service development and education as a result

Integrated urgent care

Many federations are working with their local system partners to create an integrated urgent care service which brings together local primary care services with urgent care and therefore helps to develop stronger care pathways.

Federations are able to bridge the gap between primary and secondary care by working with practices and PCNs to ensure primary care collaboration; using their insight to help develop streamlined clinical pathways to improve patient experience and offer clinical leadership for both strategic and operational elements of services. This helps to improve patient access, takes pressure off other areas of the system and helps ensure every contact counts.

  • Hartlepool and Stockton Health (H&SH), along with the University Hospital of North Tees and Hartlepool NHS Foundation Trust and North East Ambulance Service, are part of an Alliance Partnership formed to design, launch and run new integrated urgent care centres based in the hospital sites in Stockton and Hartlepool. These centres provide GP out-of-hours, walk-in and minor injuries support for the local population.

    A team of healthcare assistants, nurses, minor injuries specialists and advanced practitioners (paramedics) are clinically led by one of H&SHs team of 67 GPs, on site 24 hours a day, 365 days a year in both the Hartlepool and Stockton centres. The service encourages people who need support to call the NHS 111 service, where one of the team can book an appointment with the right professional, in the right place.

    The service is run in SystemOne, as is the local seven-day improved access service, COVID-19 care clinic and 95 per cent of practices, which means that clinicians can see and update records in real time under a federation data-sharing agreement, to provide a more comprehensive service. As they are federation led, the urgent care, seven-day and COVID-19 services can all book patients into each service, working together to maximise capacity for patients in the local system

    “…almost certainly the best period of my entire professional career." Team member at Integrated Urgent Care Service

Ambulatory ECG service

Federations are enabling GPs to directly access ambulatory ECG monitoring within a neighbourhood area. By delivering this at scale, federations can centrally manage referrals across PCNs and determine best use of staffing resources to support the delivery across a bigger area.

In addition to managing staff, federations often manage their own estates across each PCN, and are able to determine where patients would benefit from accessing a central hub managed by the federation, making efficient use of estates and staff. 

  • In Sunderland, patients who meet the criteria for ECG monitoring are referred by a GP, using the ECG cloud. Patients are then given an appointment for fitting a Holter device within five working days. When the monitor is returned, the data is then forwarded to ECG cloud for interpretation by the supplier (Technomed).  The results are reported by a UK-based cardiac physiologist and then uploaded back to the ECG cloud for the referring GP to access to determine the patient’s ongoing care needs.   

    If federations were not delivering this service, a backlog of diagnostic monitoring would be created and the patients would experience increased waiting. Moreover, the federation ensures patients are not putting strain on the wider system by saving on the cost and staffing resource of monitoring within secondary care. 

    More than 50 per cent of patients have reported that it was important to them to have their monitor fitted in their community and over 80 per cent would recommend this service to a family or friend who required treatment. Overall, patients reported positive experiences with getting an appointment that suited them and satisfaction with the service. 

Federations are working with system partners to deliver integrated social prescribing services, which helps to tackle many of the underlying issues that can result in a person accessing primary care. Social prescribers are embedded within PCNs to empower people to take control of their health and wellbeing. They give time to focus on what matters to patients and help to build trusted relationships with people to create a shared personalised care and support plan, connecting them to local, diverse and culturally appropriate community groups, voluntary, community and social enterprise (VCSE) organisations and services. 

Federations are able to deliver this at scale across numerous PCNs and practices and create opportunities to have a diverse range of health and wellbeing groups based on local interest.

  • Sunderland GP Alliance currently host 24 social prescribing Additional Roles Reimbursement Scheme (ARRS) roles who work across six PCNs and 40 practices in the city. The service was developed to enable GPs, nurses, and other primary care professionals to refer people to a range of local, non-clinical services to support their health and wellbeing. The service runs Monday to Friday between 8am and 6pm, but is flexible around patient need.

    The team includes:

    • Six care coordinators who are the first point of triage for all referrals into the social prescribing service. These staff will support low-level need and signpost to appropriate services to meet the patient’s need.
    • Six health coaches who focus on patients with long-term conditions through motivational Interviewing and behaviour change models.
    • 12 social prescribers who deal with all aspects of ‘social’ detriments for patients.

    This service engages people to work on their wider health and wellbeing, such as debt, poor housing and physical inactivity, as well as other lifestyle issues and low-level mental health concerns by increasing people’s active involvement with their local communities. 

    All roles link with both statutory and VCSE services to enable the patient to receive the best possible outcome.

    Since the service began in February 2020, they have received over 4,200 referrals to the service with over 30 per cent of these referrals for patients with poor mental health which is impacted by a social or health factor. 

    Patient feedback on the service:

    “My link worker was sympathetic and listened to my needs. Always available and never judged my situation, offering help and direction to resources that I needed.”

    “Very kind. Not judgemental. Easy to talk to. Thank you.”
     

Health checks

NHS health checks can be delivered at scale by federations to enable primary care locally to target bigger populations and provide this important screening and early intervention services to groups with different needs while reducing pressure on practices.

The federations are supporting practices to deliver the service and offer equity of access across place.

  • Wakefield has higher than average rates of smoking. West Yorkshire and Harrogate Cancer Alliance developed a service specification which required a primary care provider to develop and deliver a managed lung health check service for three practices in the most deprived areas in the district and highest smoking rates, with a population size of 30,000 patients.

    The main health outcomes for the programme were to increase the proportion of lung cancers diagnosed at an early stage, proportion of lung cancers that are treated with curative interventions, and number of sustained quits in people who smoke.

    Conexus healthcare, working with partner organisations and practices across Wakefield and District, mobilised England’s first general practice-based lung health checks service. All 4,231 patients eligible for a lung health check were invited by the three pilot practices to a lung health check appointment.

    This was a system-wide collaboration where general practice input and support was facilitated and led by the federation. Through use of an innovative workforce scheduling tool, Lantum, a team of ten specially trained and experienced general practice nurses, signed up to support Conexus healthcare deliver the service. 

    As a result of the service, 1,990 lung health checks were completed and 17 instances of cancer were detected that may have been otherwise missed or been detected much later. There was a 160 per cent increase in diagnosis of COPD with 72 patients referred for smoking cessation advice. The nursing team behind the service were finalists at the HSJ Partnership Awards 2019.

Supporting the vaccination programme

Federations have played a vital role in the COVID-19 vaccination programme, often leading the programme on behalf of their local area, setting up vaccination centres at short notice and offering workforce support and solutions. This involvement has enabled local systems to benefit from at-scale service delivery and reduce pressures and risk on other primary care providers.

Federations’ role included:

  • Facilitating greater collaboration
    • Using established partnerships at all levels to deliver a coordinated programme.
    • Helping to bring together a collective voice for primary care to engage with others in the system.
    • Using the expertise of the local system to truly understand patients and local community need for vaccination uptake.
  • Providing workforce solutions
    • Providing logistical support for the hosting of workforce and volunteers.
    • Recruiting and training volunteer workforce.
    • Reducing workload pressures on PCN and practice staff.
  • Supporting PCNs and practices
    • Providing back-office infrastructure including data capture, finance and HR.
    • Supporting business-as-usual services to reduce pressure on PCNs and practices.
    • Offering communications and publicity support to encourage vaccination uptake.
  • Finding innovative ways to target local communities
    • Coordinating and delivering at-home vaccinations for practices.
    • Integrating systems and introducing new software to plan routes that increase efficiency and time to care.
    • Coordinating managing pop-ups vaccination clinics and vaccination buses in areas with low uptake.
  • Bolton GP Federation runs the COVID-19 Vaccination Programme across two main designated sites on behalf of four of Bolton’s primary care networks, including those covering Bolton’s most deprived communities.

    As of 12 July 2021, the vaccination programme had delivered 117,067 vaccines at their main sites and through targeted activity including a vaccine bus, housebound vaccination, care home vaccinations and pop-ups. The federation worked in collaboration with the CCG, council, voluntary sector, community trust, practices and NHSE to ensure vaccination deliveries requirements were met.   

    They rapidly developed a large multi-disciplinary team that included clinical and non-clinical staff and developed innovative and targeted programmes to reach vulnerable communities.

  • In January 2021, Barking and Dagenham GP Federation noticed that people with learning disabilities and severe mental health illnesses (LD/SMI) were not coming forward for COVID-19 vaccination when invited. Federations are able to support targeted activity for vulnerable groups by dedicating resources to those otherwise underrepresented groups who are often reluctant to come forward for vaccination for all manner of reasons. The annual uptake of flu vaccinations among LD/SMI people is also challenging with COVID-19, this was made more important by increasing evidence confirming that people within this vulnerable cohort are six times more likely to die from a coronavirus infection.

    The concept of a dedicated COVID-19 vaccination clinic for LD/SMI people was proposed after investigating the issues with bringing in these people for vaccination and best solutions to help them. Barking and Dagenham were vaccinating LD/SMI people in routine vaccination clinics, but those who did come in at the more severely impacted end of the registers often required far longer to get through the vaccination safely and with the right level of consent in place. This isn’t ideal as the site is designed to handle large footfalls quickly, often aggravating anxiety about the whole process for people with LD/SMI conditions and made them less likely to come in for their second dose

    It was decided the most effective plan was to dedicate clinics exclusively to people within these groups who needed better and more personalised care. A series of adaptations were implemented to make the vaccination experience as friendly, comfortable and positive as possible. From removing some barriers to having easy-to-read visuals that explained the process at each station. We also worked with LBBD and NELFT (North East London NHS Foundation Trust and local community and mental health trust) to use clinicians and staff that the people due for vaccination knew and trusted.

    During LD/SMI clinics, 341 people on LD or SMI registers received their first dose and 280 received their second.  Barking and Dagenham GP Federation want to take the learnings from these clinics and apply them to all future vaccination clinics, enhancing regular clinics to make them more accessible to everyone. For future vaccination campaigns, including booster doses and flu, the learning generated by these clinics will prove invaluable in getting earlier and higher quality programmes in place for these most vulnerable of people.

COVID-19 PCR testing service

Federations have developed PCR testing services for their local communities to help quickly respond to pandemic demand. They have worked with the volunteer and community sector to build infrastructures and workforce and also to ensure vulnerable adults and children has access to at-home services.

  • Conexus healthcare was approached by the local authority to support with establishing a local COVID-19 PCR testing service with a focus on vulnerable residents. They leveraged their agility, can-do attitude and excellent local relationships to respond on behalf of general practice to design and build a service in less than six weeks. They identified the risks to delivery and worked quickly to establish a meaningful partnership with whoever was going to be able to help the programme get started quickly. They needed a call-handling facility, so worked with a local small elective care provider to use their infrastructure that was effectively mothballed due to the pandemic. 

    They also needed a workforce able to support vulnerable adults so worked with local voluntary, community and social enterprise (VCSE) to collaborate with a number of community hubs who were already delivering support in their districts.

    They needed a team who could swab children in their homes and worked with the 0-19 service provider to get this capacity available. Conexus supported and coordinated the work of the partners to ensure that it was as easy as possible for people to access a PCR test when they couldn’t or wouldn’t access the national service.

    By delivering as a federation, the service takes advantage of previously developed relationships with local VCSE and other local small providers and the connection to the local communities. 

    The service so far has delivered 4,220 calls, 2,310 community tests, 2,329 home visits and 18 tests for workplace outbreaks.

Supporting primary care

Back-office support for practices and PCNs

Practices and PCNs are small provider units that do not always have the business support and human resource capacity of larger organisation’s. Federations offer services to their members to reduce administrative pressures on staff, this includes HR, finance, training, communication and data sharing support. As federations operate at a larger scale, they are able to offer business expertise, reduce duplication and mitigate financial risks.  

They are responsive to the changing needs of their practices and PCNs. As PCNs grow and mature and as patient needs change, federations can be a contact point for practical guidance, support and to help test new ideas, develop business cases, and manage projects.

These support packages make local primary care systems more efficient, resilient and cost effective. Freeing up capacity so PCNs and practices can focus more on service delivery, improving population health and reducing inequalities.

  • Rugby and Coventry GP Alliance recognised the growing pressure and workload on PCNs and practices, coupled with a global pandemic. The alliance spotted an opportunity to provide additional support and economies of scale to PCNs and developed the business support unit (BSU). Built on the principles of ‘right work, right person, best value’, they developed a PCN BSU to provide the right balance of administrative and management skills and expertise to support PCNs to optimise the PCN network contract DES investment and deliver the contract requirements, as well as other programmes of work.

    The intention of this service has been to try and separate the demands imposed by the PCN DES from day-to-day practice requirements. PCNs have a choice of four different service levels from Bronze to Platinum and currently 50 per cent of Coventry PCNs are on the Platinum package.

    This level of support has enabled the PCN clinical directors and their practice managers to focus on delivering the general practice priorities such as COVID-19 vaccination clinics, seeing patients and other core business.

    PCNs have recognised the value of the support offered by Rugby and Coventry GP Alliance stating:

    “CW Unity is very happy with the service we have received from the Business Support Unit. We have found the strategic support invaluable in planning for our workforce and managing our budget. The network coordination and administrative support has also been beneficial in helping with ongoing PCN projects." Clinical Director for CW Unity PCN

    “Go West has purchased the Platinum Service from the Alliance, and this has really helped us with our organisation and future planning for the network. The Alliance supplies all our admin support, and this has taken the pressure off the practices and helped us secure PMS bids and new Additional Roles Reimbursement Scheme (ARRS) roles.” Clinical Director for Go West PCN

Data sharing and system synchronization

Integration across practices is key to the success of PCNs however without the infrastructure to support this, practices can find it difficult to build relationships and collaborate.

While there remains a need for national-level support and funding, federations are working with practices to improve digital capabilities to enable better integration. Alongside digital partners, they support practices and PCNs so their systems are able to ‘talk to each other’ and share data where appropriate. Federations help train staff to use new systems and provide any additional support needed.

  • In Wakefield, extremely vulnerable and housebound patients were vaccinated through an at-scale delivery hub that included multiple PCNs and practices. At a practice level the model was originally manual, and time consuming without effective route planning and use of workforce capability. Conexus led the adoption of the Doc-Adobe software which was able to schedule routes and allocate appropriately qualified staff to undertake the vaccinations.

    Conexus brought together experienced stakeholders to support the project and communicated with the workforce regularly to support the development and uptake of the software. The federation was able to support the bid writing process working with ICS partners and the software provider, using existing relationships and capacity to develop a strong vision for the project. They also acted as a conduit for the software provider to engage with practices ready to adopt and deploy.

    One of the organisation’s advance nurse practitioners undertook a manual process initially before the Doc-Abode platform was available and his preparations for the first vaccine delivery for housebound patients took ten days. When using Doc-Abode for the second round of planning, that ten days disappeared into a single mouse click. This also meant safer working for staff through real-time oversight and visibility of key journey details and reduced vaccine wastage by easily updating and optimising schedules in real-time to the most appropriate in-field vaccination team.

HR support

Federations offer employment support to practices and PCNs, this includes developing job specifications, recruitment tools, supporting interview processes, managing the onboarding and HR requirement of employing staff and even completing hosting roles for PCNs and practices.

Federations can support multiple PCNs and practices with similar issues, preventing duplication of resources. They work closely with primary care leaders to provide impartial advice, guidance, and support to improve their local primary care workforce now and in the future.

  • Primary Integrated Community Services in Nottingham provide full recruitment and employer service for Additional Roles Reimbursement Scheme (ARRS) roles for their 11 PCNs’ clinical directors (CDs), including reviewing future opportunities and creating new career pathways.

    PICS manages the full employee life cycle, starting with advertising, support with job descriptions, arranging and supporting interviews and pre-employment checks. All prospective candidates are thoroughly vetted before meeting a CDs, saving them an enormous amount of time.

    Once onboarded and on the payroll, all staff get a thorough and tailored induction and continuous support from experienced PICS managers and clinical leads. Staff are developed to fulfil their potential through a variety of opportunities. Clinical governance processes are in place to ensure patients and staff are safe and to provide assurance to CDs. 

    Dr James Cusack, CD for Newark PCN with 76,000 patients across seven practices stated: “When we first formed there were challenges such as financial governance and how to employ our additional roles staff in a safe and effective way. PICS has been a huge help. Recruitment has been a great success and we now have in place nine clinical pharmacists, four social prescribing link workers, two first contact practitioners, a care coordinator, a dietician, a paramedic, two nursing associates and two care homes advanced nurse practitioners. Our new colleagues have contributed enormously to the care of patients within our PCN and have all been received extremely well by both patients and practices.”

    Gerald Ellis, PICS’ lead for a group of PCNs also highlights a, sometimes unseen, benefit: “PICS works closely with the PCNs in providing support but also in dealing with HR, personal development and performance issues.”

    The organisation can evidence high levels of engagement with a 97 per cent retention rate and 83 per cent response rate for the 2020 staff survey that included PCN staff. 93 per cent said they felt safe at work. 88 per cent of respondents recommended working at PICS and 96 per cent agreed that patients are the organisation’s top priority.

    In October 2021, PICS won Employer of the Year at the Nottinghamshire Live Business Awards after demonstrating investment in employees and a strong commitment to wellbeing and safety. In March 2021, Best Companies named PICS ‘one of best large companies to work for in UK' and the sixth best health and social care company to work for in the UK.

Communications support

It is important for PCNs and practices to be able to engage with their local communities and patient populations. Good communication allows primary care teams to, for example, keep their patients up to date with new services, help patients feel connected with their local practice staff and, particularly during COVID-19, helps inform patients quickly and clearly about changes to services such as location, safety precautions. A good communication and online presence for a practice or PCN also helps improve recruitment processes as jobs can be advertised to a wider audience. While primary care teams often see the value of good communications this can be time consuming. Some newly formed PCNs also find it difficult to know where to start as there is such a variety of communication channels and opportunities available locally. Federations provide education and training, communication toolkits and resources and many have communication leads within their own organisation to support primary care teams.

This support can help reduce workload pressure, build confidence and ensure patients are receiving up to date and relevant information from their care providers.

  • Alliance for Better Care offers a communication package to its PCNs that aims to broaden their public profile and increase engagement with their peers and practices.

    While PCNs rarely communicate directly with patients, they recognise that PCNs can enhance the support given to surgeries and in doing so, work towards improving community engagement. They understand the growing need for PCNs to create their own clear and consistent brand and in turn employ multiple channels to help disseminate messages.

    Through the packages and communication framework they:

    • provide resources that can fill gaps in knowledge
    • help PCNs to create a professional and consistent approach to their communications
    • highlight the huge professional value in contributing to peer discussion, developing and sharing best practice and publicly supporting and promoting the work of employees
    • help PCNs to identify ways to improve patient experience and community engagement
    • help PCNs to identify how best to support their GPs to engage with different social media and community platforms in a transparent and authentic way.

Using data to optimise service delivery

Across the health and care system, local intelligence is vital to understand and optimise how, where, why and when care is being delivered. It is more complex to capture data within primary care, compared to other parts of the system however good quality data informs service planning. This will be more important than ever as we move into integrated care systems.

Due to their scale and expertise, federations are able to conduct research across place and system to help provide a better picture of what is happening across primary care services. They work with their members to improve local intelligence, use evidence to fuel local innovation and help future proof their local primary care systems.

  • In response to the continued pressures on capacity and national concern over general practice, Access Barking and Dagenham conducted research to better understand the nature of the pressure on front door activity within general practice. The aim of the project was to demonstrate the realities of what was taking place at the front door to the NHS and make evidence-based recommendations to help manage demand.

    Barking and Dagenham Federation worked with seven Barking and Dagenham practices over 44 days to collect front door activity. The project did not aim to analyse clinical appointments or outcomes but enabled the federation and practices to get a better understanding of patient need and demand at the first contact points with practices.

    The federation outlined the limitation of the analysis that took place. This was not intended to reflect the wider system however the analysis would be used to help optimise front-door activity for the practices within the pilot and possibly those within a similar demographic locally.

    As a result of the analysis, they found that just under 60 per cent of front-door activity was administrative with medication queries taking up a further 20 per cent. As a result of the project Barking and Dagenham Federation was able to provide recommendations to their practices. This included recruiting pharmacy technicians to support with medicine queries, recruiting additional medical secretaries and increasing resources such as FAQs to support with administrative workloads.

    The federation was able to help practices by providing informed recommendations and is working to expand this project to support more practices locally.

Workforce

Hosting training hubs

Training hubs deliver training, education and workforce development projects to support recruitment, retention, and upskilling of the primary care workforce. Working with partners, training hubs hosted by federations facilitate placements, support education programme development, deliver workforce projects, enable resource sharing and empower practices to consider their own workforce and skill-mix needs. 

Training hubs hosted by federations have a local focus while also reflecting wider system workforce priorities. As networks of networks, federations are well placed to support and plan for the introduction of new roles within primary care, particularly those being introduced as part of the Additional Roles Reimbursement Scheme (ARRS). PCNs and practices can feel confident that their local workforce needs are not being overlooked by top-down structures and therefore they are able to focus on care delivery and patient need.  

  • BEMS set up a training hub that was co-terminus with the B&NES CCG at the time. When the CCG merged to become the B&NES, Wiltshire and Swindon CCG BEMS has continued to provide training and support for the B&NES locality as part of the BSW Training Hub.

    Their locality is formed of six core members with representation from BEMS, GP practices and a Health Education England funded education facilitator. Building on the success of the last three years they continue to develop GPs with extended roles, support specialist staff new to working in GP practices like clinical pharmacists and paramedics, promote student placements and run the practice nurse and healthcare assistant and deputy practice manager forums. 

    BEMS also produces tools to help practices think about skill mix. This professional education framework was taken up by the local medical committee and adapted, it identifies a structure that assists practices and PCNs to ensure efficient ways of working so that care is being delivered by the right person with the right skills within the right time frame. This framework describes how there can be career progression in primary care.

    The practice nurse forums cover topics that are important to nurses and help them on a daily basis and the federation have run training sessions on wound management, eating disorders, vaccinations and infection control, supporting 23 practices. They launched a brand new forum for our BANES practice-based deputy managers and operations managers in 2020 and despite not being able to meet face to face, they have so far successfully hosted four sessions via Microsoft Teams. This has already had a positive impact by forging a communication link for those in this role across BANES. The most recent forum covered basic SystmOne training and a QoF update, along with many other discussion points suggested by the group.  

    Feedback from the session included:  

    ‘These forums are a great way to keep in touch with colleagues and look at ways in which we can support each other.’  

    ‘It’s good to hear that other practices are dealing with similar situations and hear how they are managing these.’  

Multidisciplinary teams and ARRS support

Primary care offers more than a single approach to patient care, and this is reflected in the teams that deliver it.  The future of primary care requires multidisciplinary teams (MDTs) with diverse skills, experiences and expertise. The Additional Roles Reimbursement Scheme (ARRS) helps supports PCNs to increase their non-GP workforce. As set out in the ARRS guidance, each PCN is allocated an Additional Roles Reimbursement sum, based upon the PCN’s weighted population share. PCNs can recruit from within the reimbursable roles as they require to support delivery of the network contract DES.

For the average PCN this means around an additional seven full-time equivalent staff. This offers significant opportunities for PCNs but does not come without its strategic and operational challenges. PCNs have found it challenging to recruit into ARRS roles, have highlighted issues with supporting and retaining staff and have found hosting staff across a number of practices challenging.

Federations help PCNs grow multidisciplinary teams through ARRS roles by hosting roles within the larger federation structure. This means staff can be supported, deliver services at a bigger scale and still support service delivery at practice level. They also help PCNs to maximise the benefits of the ARRS by working with PCN leaders to identify workforce needs and support MDT workforce planning.

Federations help primary care make the best use of ARRS roles, helping to improve services for practices, PCNs, systems and most importantly patients.

  • As part of the wider Enhanced Health in Care Homes (EHCH) framework, Cambridgeshire and Peterborough CCG were awarded funding by NHS Digital to develop virtual MDT support to care homes, enabled by Microsoft Teams via the three local GP federations. In Peterborough this was 42 care homes with 2,096 beds.

    Greater Peterborough Network recruited six care coordinators to support the programme. This helped to optimise current models of care and lessen admin burden for clinicians, freeing them up for more appropriate work and offer a single point of contact. By providing simple training manuals and templates the care coordinator team within the programme was able to help practices and homes to:

    • cut their meeting schedules, in some cases by half
    • reduce ad-hoc calls from their homes by a third
    • hold nearly 350 meetings over the project
    • provide robust evidence for unannounced CQC inspections
    • share data safely via NHSMail
    • build new pathways for tasks such as repeat prescriptions.

    Care coordinators were supported to engage with care homes and establish specific service need for each home. The uptake of the project across practices quickly increased as the successes of using care coordinators became clearer.

    Delivering this at federation level meant they could ensure consistency of approach across all of Peterborough. By working using the same documents and guidelines they could be sure that the service available to the patient was equitable regardless of which surgery or care setting they were with. They were also able to split the workload differently; some of the teamwork across two PCNs which would not have been easy to arrange if employed at PCN level and meant that annual leave or sickness cover could be provided easily within the team.

    Hosting the team through the federation also ensured that the team worked as a collective so that all the homes were supported. This was essential during COVID-19 as when individuals needed to isolate the work still progressed at pace and the MDTs were able to continue undisrupted.

Additional training and education packages

Federations provide a variety of education and training packages to their PCNs and practices based on local need. Packages are developed by working closely with primary care team leaders to help understand current need and longer-term requirements for future care needs. Federations can deliver education and training packages at scale across numerous providers and they differ in size based on local need. This includes toolkits, webinars, peer support, mentoring and working with external training providers.

PCNs and practices can be offered support so they can take greater ownership over their staff development without the practical resource and capacity pressures that would be created if managed independently.  

  • In early 2018, Milton Keynes GP Federation (MKGP) developed a training and education scheme which includes events and seminars for clinicians within their member practices. Event topics have included sepsis, family planning, COPD and vulnerable health. All clinicians are welcome to attend the events including those outside their member organisations and community pharmacists, district nurses, locum GPs are all encouraged to join.

    The MKGP training and education team meets every six weeks to review the opportunities they can provide to members. The additional training is flexible to members’ needs and is vital to their own professional development. They look at recent referral data and look to target areas where improvements to services can be made via additional training. 

    The training team works hard to secure training or funding for members via different sources, working in collaboration with various companies to deliver smaller training afternoons and has connections to organise specialised training where identified. This has led to hosting pharmacy and physician associate student placements in primary care and an ongoing development programme of Additional Roles Reimbursement Scheme (ARRS) support and supervision.

Shared workforce pool

Flexible workforce pools support PCNs to increase capacity in general practice and create an offer for local clinicians wanting to work flexibly. Practices and PCNs can benefit from reduced burden in accessing temporary staff and the opportunity to build better relationships with pool members.

Federations manage the administrative pressures that come with developing and maintaining a shared workforce pool and means practices and PCNs can be reassured that all clinicians accepted into the pool have undergone appropriate HR checks.

These workforce pools have been particularly valuable during the COVID-19 vaccination programme and as part of the extended access services delivered across the country. Through federations, primary care workforce pools can increase resilience, respond to short-term demand quickly and reduce expenses from locum and agency staff.

  • Conexus healthcare has developed a shared workforce pool that works across three distinct areas:

    • Extended access services (evening and weekend) – Since 2017 they have built a 225 strong workforce (106 active members) of local practice employed staff (GP, advanced nurse practitioner, practice nurse, HCA and reception/administration) who are engaged on a sessional basis to staff their extended access services. They publish and fill shifts for all workforce requirements across the service.  This gives flexibility to add or reduce capacity and appointment type tailored to demand.
    • Vaccine workforce – a pool of 86 local practice-employed staff, retired and returners and staff employed substantively by other local employers who are also employed by Conexus and deployed to local practices to deliver capacity into the PCN vaccine hubs. The roles included registered and non-registered vaccinators, administration staff, pharmacists, GPs and nursing clinical leadership, and management capacity.  As a result of the workforce pool they filled 1,806 shifts and more than 8,000 hours of activity from the sessional worker bank to local vaccine centres. 
    • Local practice resilience – the ability to publish shifts to their sessional workforce bank to fill unexpected and unplanned short-term need across the breadth of general practice workforce for practices who request this. This helped 14 practices fill over 50 shifts in the first five months of 2021 and this process continues to grow.

    As a result of the work pool, workforce availability and capacity is increased, staff retention and earning potential is improved, workforce risk is removed from individual practices and primary care is able to coordinate staffing across the place.  By having the workpool at federation level, compliance checks are only done once and staff can be deployed anywhere they have the relevant skills. Staff trust the umbrella organisation so feel more confident working in different practices. This process also facilitates sharing and adoption of best practice, especially among non-clinical staff who see new ways of working from other practices and bring them back to their home practice.

Visa sponsorship

Many federations are licensed sponsors under the tier 2 visa scheme. This means they are able to offer certificates of sponsorship for tier 2 migrant workers seeking to work as GPs within practices or within medical services supported by their organisations respective PCNs.

Federations are able to take the risk and administrative pressures away from practices and PCNs when they are recruiting GPs. Not all employers are accepted as licensed sponsors andthe scale of federations means, where they do hold licenses, they can support multiple primary care providers at once.

  • Primary Care Doncaster (PCD) offers tier 2 visa sponsorship for their practices and PCNs. As a sponsor license holder, PCD enables their local practices and PCNs to recruit international GPs without the time-consuming additional administrative pressures.

    As a result of the visa sponsorship programme, PCD has been able to hire approximately six international GPs annually. The visa process can take approximately 6-8 weeks with numerous checks and administrative requirements, the federation is able to take the risk and pressure from the practices so they are able to hire the best candidate for the role.

    One practice manager stated:

    "Our federation, Primary Care Doncaster (PCD), provided us with excellent support in our practice with visa sponsorship. PCD made the process seamless with minimal input needed from ourselves. PCD took care of the whole process, including the employment checks and government visa requirements, and held our hand navigating the system, which without them would have been intense and time consuming. We benefitted from this process as we were able to employ an excellent salaried GP, who wouldn’t have been able to stay working in Doncaster without the visa sponsorship from PCD."

Primary care leadership

Primary care leadership is defined as coordinating GP leadership, bringing together the collective voice of general practice provision and wider primary care. It also influences system change and strengthens the voice of primary care by bringing together practices and PCNs with wider health and social care partners.

Developing primary care leadership at system level

It is important to acknowledge the interdependence and interrelationships between practices, PCNs and federations. Without a shared voice and vision for primary care, it’s not always clear how other system partners can engage with primary care at place or system level. Federations are working to bring PCNs, practices, federations and other local primary care partners together to develop a collective voice.

Federations have built relationships over many years with primary care providers at place and system and therefore many have been able to build accountability and representation for primary care at neighborhood, place and system.

This is allowing systems to work more closely with primary care and primary care can then make strategic and service planning decisions collectively at an appropriate level.

 

  • Until recently, the six South West London federations were operating under an informal ad-hoc arrangement. They would meet, share good practice and learning. COVID-19 brought local primary care partners closer together as they worked in collaboration to manage service demand. Alongside this, the continued growth of the integrated care system meant a growing need for primary care to develop a unified system voice.

    Over two years South West London federations developed their relationship at system level and were able to come together as a formalised alliance. All six federations and their member PCNs and practices, with support from their ICS and CCG, took the decision to move to a formalised alliance, accountable from practice up to system with representation and appropriate services at all levels. Developing the alliance took time and support from external experts to help formulate a vision, memorandum of understanding and formal structure.

    Today, the South West London Alliance has formalised as a community interest company. Due to its scale and formal structure, other system partners in South West London are beginning to work with primary care at system level. The alliance can bid for contracts, work more closely with system partners and ensure strong primary care representation within the ICS.

    You can learn more about the South West London Alliance in our recent webinar.

  • Taurus Healthcare GP federation has facilitated a place-based general practice leadership team to enable a collective voice for general practice and to help provide a single coordinated point of access through which partners can link with.

    While this model is explicitly for general practice, the governance, collaboration, and representation within this leadership model could apply to broader primary care collaborations. 

    In Herefordshire, all practices are members of Taurus Healthcare. This made it practical for the federation to manage and develop daily meetings to help coordinate GP operational activity. As the success of these meetings became clear the group also took on more of a strategic planning role aiming to remove some of the traditional contractual approaches to working with CCG and other providers, and instead focus on collaboration and dealing with shared challenges together.

    The group is made up of PCN clinical directors, GP federation leaders, the medical committee secretary and the CCG director of primary care. GP leaders are accountable to the general practice leadership team and are expected to represent the collective voice of Herefordshire General Practice when engaging with system leaders, championing the role of place #OneHerefordshire.

    The group are committed to engaging and communicating with system partners, providing clinical leadership and being the voice of Herefordshire General Practice. As a result, Herefordshire has a strong and clear voice for general practice, systems have a strong link to the ‘coal face’ of primary care and the leadership team remain clinically led in decision making ensuring that patients and local population are at the heart of every decision.

    You can hear more about the Herefordshire model.

  • Greater Manchester (GM) GP Provider Board is a formally constituted arm of the governance of the Greater Manchester Health and Social Care Partnership.

    It is the formal arrangement whereby medical committees (LMCs), PCN clinical directors (CD) and federations sit together to represent primary care as providers at each of the spatial level in a collaborative and collective way. With an inclusive by design approach, each borough has a seat for its LMC, a PCN CD and the federation to ensure each level of provision is able to play its part.

    With oversight and accountability for a number of key ICS primary care priorities, the board has developed beyond primary care into an invaluable system partner across a number of key strategic programmes  – ICS system finance leadership, elective reform and recovery and commissioning spatial level design as well as practically supporting the implementation of key ICS strategic priorities such as cancer, digital primary care and population health.

    In advance of April 2022, the board has explored and facilitated a number of practical examples of balancing the benefits of ICS-wide consistency to facilitate quality with the need for place-level population-specific focus and continues to engage in positive discussions to place general practice at all levels in the best possible place in the new world. 

Improving integration between different parts of the health and care system

Integration is far more than provider trusts talking to provider trusts – vertical integration with PCNs and federations is a critical component of joined-up care. Breaking down barriers between primary and secondary care for the benefit of patients must be a priority if the ICS is to succeed.

Many federations are already working closely with their secondary care, local authority, community and voluntary sector partners to build integration and ensure quality care pathways for patients.

Many services federations deliver benefit from integration with system partners. This means that there is a joined-up approach to care delivery, providers can share learning and patients can receive the best and most appropriate care.

  • Bath and North East Somerset Enhanced Medical Services (BEMS) has worked alongside its secondary care partners to develop an outpatient redesign programme to drive down waiting times and improve care pathways across six specialties. Working with their local acute trust they wanted to embed some of the learning, best practice and infrastructures from COVID-19 and build on the relationship between primary and secondary care for better system integration.

    Both BEMS and the acute trust recognised the value of this programme to develop increased integrated care and ensure a ‘whole pathway approach’ to care. The federation’s specific value to the programme included:

    • offering of dedicated management support
    • broad knowledge of primary care pressures
    • clear understanding of commissioning and pathway design.

    One of these specialities in the programme was dermatology. Dermatology had seen increasing waiting times over a period of 12 months. The spike arose because of the dwindling number of dermatology consultants and difficulties with recruitment. In response, the GP federation using training hub resources worked with the acute trust training lead to agree GP accreditation, training and ongoing supervision arrangements. This resulted in monthly joint dermatology clinics with hospital consultants. The GP federation hosts a referral support service and has live data on waiting times, activity and knows where there are blocks in the system from a patient and GP perspective.

    As a result, the new community dermatology service is provided in three local GP practices using minor surgery suites closer to where patients live, waiting times have been shortened, the service provides 2,600 appointments a year and there is good patient feedback.

    “First class service. Doctor very informative and caring.”

    “The venue is very convenient easily accessible for me, better than travelling all the way to the local hospital.”

Improving primary care service models for the future

Federations are well placed to help redesign service models and ways of working to improve patient care in primary care and beyond. They work closely with their members and many work in collaboration with national health and care organisations to support local innovation and improvements in primary care.

At a member level, they work with organisation leaders to identify concerns or goals for the future, help evaluate current services and areas for improvement and work with members to make necessary changes for local growth.

At a national level, due to their scale, federations are able to work with national organisations to pilot new schemes, engage with primary care research and provide local insight on primary care services to inform guidance, frameworks or service specifications for the wider primary care community.

  • Morecambe Bay Primary Care Collaborative and One Care have worked together to develop a toolkit for GP practices on improving continuity as part of The Health Foundation's Improving Continuity of Care in General Practice Programme alongside the RCGP.

    The toolkit is a consolidation of learning and resources from the projects and is designed to guide practices through the continuity improvement journey by supporting patient and staff engagement and providing tools to measure continuity as well as the impact and change of improvement interventions.

    The toolkit provides an explanation of the different ways to measure continuity and includes a tool practices can use to measure continuity. Based on quality improvement methodology and the NHS Improvement's six steps to project management, the toolkit allows practices to better understand challenges which are preventing continuity of care in their specific context, to understand where they are in their continuity journey and provides a combination of tailored guidance and off-the-shelf resources (videos, leaflets, social media posts) to enable general practice to improve continuity.

About us

The Primary Care Federation Network offers a unified voice for primary care at place. We develop population-based strategies, coordinate service delivery, provide governance and assurance, and share innovation and best practice.

We support federations to work collaboratively with primary care networks and other local partners across health, social and community care to provide better integrated, innovative and responsive care for patients, reduce health inequalities and improve the health of the local population. Find out more.