Did you ever have a mullet? Regularly wear flares? Decide tattooing your eyebrows was a good idea? I suspect not (or not that you would admit to!). As we all know, things come in and out of fashion, and sometimes there is a real art to avoiding something popular in the moment that later we might come to regret.

A common question I get asked is whether the move to working at scale in general practice is just a trend. The profession has been burnt before (think PMS contracts, fundholding, even CCGs), and it is reasonable to consider whether operating at scale is just another in a list of initiatives that demand energy and time but leave little or no lasting benefit.

It could be a short term trend. It feels like there is pressure in the system on practices to operate at scale, and yet history suggests that changes practices have made because others want them to (like the move to PMS contracts) are often best ignored, because the fickle nature of health policy is such that there is likely to be an opposite policy (PMS reviews) a few years down the line.

When we look at joint working between practices we find the benefits are not always that great: purchasing gains can be limited; extra services can be time limited or put out to tender with little or no margin included; and the additional overheads of working at scale can quickly absorb any financial gains made leaving little or no benefit for the member practices.

Bigger practices can create bigger problems. Communication can be difficult (poor), practices become impersonal and it can feel like the soul of general practice has been removed. Individual disputes do not disappear, and where they are not tackled divorce can follow quickly on the heels of the marriage.

Working at scale itself has now been around for some time. Average practice size has grown steadily from 6250 in 2005 to 7860 in 2017, and according to the Nuffield Trust three quarters of GP practices are now in some form of collaboration with other practices. Could, then, we be heading in the wrong direction? Could working at scale be just a trend, something we will inevitably later regret?

The best way to determine whether something is likely to be a short term trend or something more permanent is to consider the causal factors affecting the change.

There are, as you are no doubt fully aware, some long term trends impacting general practice. Demand is rising. There are more patients, more GP visits per patient, more over 85s and more patients managing one or more long term conditions. This demand is highly likely to continue to rise. The supply of GPs to meet this demand is going down. In the time period from September 2015 to December 2017, the total number of GPs decreased by 720 full time equivalents, despite the national pledge to increase the number by 5000. Less and less GPs want to work full time, or to be partners.

Funding for general practice has fallen from 11% to under 8% of the NHS budget. The promised extra £2.4bn in the General Practice Forward View is hardly touching the sides. The recently announced 3.4% growth for the NHS means no windfall for general practice is coming any time soon. The national policy is towards integration, and providers working together. A 10 year plan for the NHS is expected this year, built on exactly these principles. 7,435 practices operating independently in this environment are unlikely to be able to articulate their need for resources as well as, for example, the 135 non-specialist acute trusts.

Ultimately, working at scale is a reasonable response to these long term trends impacting general practice. Simply deciding to work at scale will not in itself deliver benefits (for all the reasons outlined earlier), but using the opportunities that scale provides to find new ways of managing demand, to expand the workforce and incorporate new roles, to deliver efficiencies and respond to the opportunities that the new integration agenda presents is one of the few things practices can proactively do to meet the challenges they face.

Working at scale is a trend. But it is a trend that is a response to underlying changes affecting general practice. Sometimes working at scale becomes the change itself (which is where problems set in) rather than understanding that its function is to enable the continued challenges to be met. Because the demand, supply, financial and policy changes are all continuing to move in the same direction, my view is that working at scale won’t go the way of mullets and flares, but will continue long into the future.