1. #largescalegp Large scale general practice: can we rise to the challenge? Effective governance of multi-site general practice organisations Sharon Lamb, Partner, Capsticks LLP @sharonm_lamb Chair: Dr Rebecca Rosen, Senior Fellow in Health Policy, Nuffield Trust @DrBekkiR

2. Agenda  Governance in large scale general practice providers – core general practice  Professional Partnerships – stages of growth  Evolving GPs – gearing up for large scale practice: working with other GP practices  Evolving governance:  Change to deliver with other providers?

3. Effective governance: finding the right balance – flexibility and strength to take the load for the journey ahead

4. The paradox: growing financial and operational pressures on GPs but increasingly ambitious plans for primary care to transform and modernise NHS delivery of care

5. GP practices – multiples layers of governance The challenges of Professional Partnerships Working with other GP practices Working with other providers

6. Organisational Development Changes in governance

7. The challenge of professional practices Applying the Greiner curve Founder Focussed Collegial Phase Committee Phase Delegation Phase Corporate Phase

8. Applying the Greiner Curve to professional practices relatively simple: the founders are also the managers systems and structures are limited and informal alignment of personal risk and entrepreneurial attitudes Founder Focussed Power of collective and collegiate group Decision making still consensus based, often through weekly meetings Often – ill-defined management systems and structures Collegiate Phase Recognition that not everyone can be involved But not ready for external managers Structures of committees for hiring, promotion, budgeting, strategy and core tasks Committee Phase Partners delegate a limited degree of power to one or two individuals. No real split in the principle of power, benefit and accountability Delegation Phase Corporate Phase Established and centralised systems of delegated responsibility; federated controls for central management and local offices

9. GP Practices – working with other GP practices The challenges of Professional Partnerships Working with other GP practices Working with other providers

10. Working with other GP practices Single GP Partnership Informal Alliances Collaborations Formal FederationMerger

11. Working with other GP practices Structure – finding the right balance between ownership and management to enable the organisation to grow Single GP Partnership Structure - non binding affiliation/collaboration/high ease of exit Key governance Considerations – personality based? low level of investment and shared risk can mean less commitment to shared decision making; To succeed – may require stronger governance structures and processes Informal Alliance Structure – association of GP practices range of structures to support back office sharing or specific tenders Key governance considerations - clear shared purpose and effective communication; Line of sight and assurance to avoid double running costs; Resolving disputes effectively; Poor governance may lead to stasis or dormancy GP Federation Structure - GMS/PMS contracts held by the partnership; Formal partnership or company Key Governance considerations - split between ownership and control – communication; remuneration and personal connection between owners Merger

12. Introduction – working with other providers The challenges of Professional Partnerships Working with other GP practices Working with other providers

13. Governance: working with third parties What can go wrong? Contractual control and structure of the relationship Finance – Payment and financial risk Who bears financial risk? Staffing – disputes over redundancies and TUPE Relationships: personality issues; changes in leadership; lack of trust Control and sovereignty: who is seen to lead? Change in strategic priorities

14. Solutions Ensure contract and corporate structure matches clinical priorities Finance – Deal with Payments and Risk share at an early stage Clarity over staffing models and shared roles Clarity over contracts and clinical governance, especially over shared pathways Robust governance for flexibility and clear communication that will survive changes in personnel Clear mechanisms for changes and dispute resolution

15. Any Questions ? Contact Information Sharon Lamb Partner | Commercial Capsticks Solicitors LLP T: 0208 780 4874 | M: 07894005531 Sharon.Lamb@capsticks.com | www.capsticks.com