Two years in and we are already starting to see questions emerge as to whether the PCNs that we have are appropriately sized.  But what is the right size for a PCN?

The rapid development of Integrated Care Systems (ICSs) is the main reason for the questioning.  New system leaders understand there is an important role for PCNs, particularly within place-based arrangements, and so inevitably are starting to question whether the arrangement in their particular area is the right one.

The main question these leaders are posing is whether we have too many PCNs.  If the place based population size is around 300,000 and there are (for example) 7 or 8 PCNs, the challenge is whether there are really 7 or 8 Clinical Directors (CDs) ready to be local leaders of the place-based arrangements, and whether the 7 or 8 can really operate effectively together as a unit.  Does it create too many points of contact to make place-based working really effective, due to the number of local relationships it necessitates with the local acute, community, mental health, social care and voluntary sector providers?

The other question it poses is whether the smaller PCNs can create the infrastructure needed to be able to deliver all that is expected of them.  Can they find the HR, payroll, finance, communications, IT, estates, strategy (etc etc) expertise needed to be effective?  And where will PCNs end up – is the expectation really that there will be 7 or 8 limited companies all operating alongside each other?

The questions around PCN size from a practice level are more frequently the other way round.  Practices who are part of larger PCNs are beginning to question whether this is really the right option for them, or whether they should actually be part of a smaller group of practices.

The problem practices experience is that when the population size starts to get up towards 70,000, and the number of practices gets much beyond 3 or 4, then there is always a challenge with engagement at practice level.  There always seem to be one or two “passenger practices” who at best contribute very little, and at worst block and slow down initiatives and any changes the PCN wants to introduce.

What this in turn leads to is the smaller group of more proactive practices starting to question whether they would be better off on their own, particularly as the value of the PCN contract, the value of the Investment and Impact Fund, and the number of staff that can be employed via the Additional Role Reimbursement Scheme is becoming more and more significant each year.

Larger PCNs have also not been helped by the continual “one per PCN” ruling that comes out for any PCN with a population under 100,000, such as mental health practitioners this year, which favours those areas that have opted for a larger number of PCNs with a lower population size.  It is not that surprising, then, that practices looking to maximise the value of the PCN DES are wondering whether what they actually need is a smaller PCN.  I did suggest at the start of the year that this might be the case.

Where does this all leave us?  What is the right size for a PCN?  The important thing to remember is that there will always be a trade-off between engagement and delivery/effectiveness.  Smaller PCNs can build more engagement, larger PCNs can create a better infrastructure to enable delivery.  It is difficult to deliver without engagement, and it is difficult to create the necessary infrastructure without scale.  There is no right answer, no perfect size for a PCN.

What is most important is that practices work in PCNs that work best for them.  If you are small and it is working, don’t bow down to any ICS pressure that comes down the line to get bigger.  If you are large and it is working, keep going as you are.  Changing PCN size and structure is of itself distracting  and challenging, so any planned change would not just have to be sensible, it would have to outweigh all the disbenefits that would come with making such a change.  Most of the time it will be better to understand the weaknesses of your current situation and work to mitigate them, as well to exploit the strengths that you have, rather than change the configuration of the PCN.