The rapid emergence of Primary Care Networks (PCNs) has led practices in many areas to consider the question of whether they are better off as part of a federation, or whether it would simply be better to go it alone as a PCN. So which is better, a PCN or a federation?

What criteria do you use to make this decision? Generally, it comes down to a “what have the Romans ever done for us” consideration. Has the federation/PCN had a beneficial impact on practices? Or does it feel like an entity ploughing its own furrow without really impacting on member practices?

The answers to these questions will vary locally. But the opportunity federations and PCNs can provide for member practices is clear. Federations can provide an organisational structure that PCNs (that are not legal entities) can harness to employ staff, manage risk, and take away any personal or practice liabilities. They can deliver benefits of operating at a greater scale than PCNs, such as attracting higher calibre staff, establishing central functions (such as finance and human resources), and reducing costs through better purchasing power as well as attracting funding for general practice. They operate at a scale where they can build and maintain organisational relationships with all of the local health and social care organisations in way that an individual PCN cannot hope to. General practice itself can have a much stronger voice in the system if the federation is speaking on behalf of all practices, where six PCNs wanting six different things can quickly dilute the collective voice of the profession.

A PCN on the other hand can have a much closer and more intimate relationship with its member practices. It can take time to fully understand the individual challenges each of its practices is facing and take tailored action to support them. It can be nimble and change direction quickly. If the focus needs to change from one challenge to something more pressing it can be reactive and responsive. Each practice can be part of the decision making, and understand exactly what has been decided and why. There can be a transparency about funding, use of resources, and exactly where everything is going. They can make change happen at a local level in a way federations could never hope to, because of the relationships they have in place.

For those of you with longer memories, you may remember back in the days when CCGs were being formed one of the key questions was – what is the right size of the CCG? Should they be small and closer to practices, or should they be large and able to consolidate resources and the available funding to maximise the impact the CCGs could have? In the end both arguments were right: the smaller CCGs didn’t have the resources, influence and financial stability needed to be effective, and the larger CCGs quickly became distant from practices.

The lesson here is that you need both. You need to be large to be effective, and you need to be small to remain relevant to local practices and local populations. The incredible opportunity that general practice has in areas which have federations in place is to have both: they can use the federation to achieve all the benefits that size requires, and the PCN to maintain the localism and energy to drive locally relevant change.

The difficult question, then, is not whether a federation or a PCN is better, but how to bring federations and PCNs together in a way that maintains the trust and confidence of local practices, and allows the two to work effectively together for the benefit of all.