Sharon Lamb, Partner at Capsticks LLP, presents some practical insights into governance structures for large-scale primary care organisations.

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
Federation Merger

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