It is not long ago that at-scale general practice primarily meant the merger of practices into bigger practices, the emergence of super-partnerships and the development of GP federations.  But all that has now changed.

This change has come about because the unit of at-scale general practice has changed.  It is now the Primary Care Network.  The PCN is the unit through which investment is made into general practice, through which delivery is expected, through which the workforce is being developed, and through which general practice will have its voice within integrated care systems.

Historically practices were moving towards at operating at greater scale for three reasons: financial, workforce and influence.  In the last two years since PCNs came into existence it has become abundantly clear the best way for general practice to achieve any of those gains is through PCNs.

As with any change, there are winners and losers.  Those most adversely affected are the large and dispersed super-partnerships, and GP federations.

The large super-partnerships spread out across large geographical areas were built on the establishment of a centralised resource whose cost was prohibitive for small partnerships, but is continually reduced by larger and larger numbers.  These partnerships worked to grow their numbers across the country, and in doing so reduced costs and overall profitability.  But PCNs are based on co-located practices serving specific communities rather than isolated practices joined together by a shared central resource, and so the new PCN environment will not enable this model to thrive.

GP federations were a relatively safe unit of at-scale general practice, that allowed practices to retain their individual identity and ways of working but come together on shared initiatives to secure contracts (such as extended access) and funding (such as for GP Forward View work like care navigation and workflow optimisation).  But with practices now within PCNs, and PCNs receiving any shared initiative funding including extended access, the future for federations as a model for individual practices working together seems very limited indeed.

But the shift of focus of at-scale general practice also creates opportunities.  The biggest opportunity comes for practices working together within a PCN.  The closer those practices can work together, and blur the lines between core practice business and PCN business, potentially to the point of full merger, the greater the opportunity for those practices to use PCNs to stabilise and sustain the core practice model.  If the practices can incorporate the ARRS roles along with the PCN DES requirements into its core business, they have a much greater chance of a sustainable long term future than those that treat all of the PCN investment and work as separate to core business.  We will see this disparity magnified as extended access moves into the jurisdiction of PCNs.

The other main opportunity comes for practices to change the function of their federations.  As I have discussed previously, the limits that PCNs put around at-scale general practice (ongoing and increased individual partner liability, a disparate voice across multiple PCNs within an integrated care system area, a limited ability to support and maximise the value of the new ARRS roles) can all be overcome by PCNs working together within a federation.  While the unit of scale for individual practices is now the PCN, the unit of scale for PCNs could usefully become the federation.

Like it or not PCNs are now established as the primary unit of at-scale general practice. The question for practices to consider is how best to adapt to make the most of the opportunities of this new environment.