At-scale working in general practice has a chequered past.  While there are obvious economy of scale benefits, the reality is that many attempts to function at-scale have floundered.  What can we learn from the past, and what might the implications be for PCNs and their development?

Although PCNs are only approaching their 5^th birthday, at-scale working in general practice has been around for much longer.  Federations, super-practices and even CCGs have all attempted to bring practices together in different ways.

The key lesson from all of these is that a dissonance, or even a perceived dissonance, between the at-scale organisation and the practice unit causes challenges and impacts the ability to work collectively.  Where there is a perfect unity of the at-scale entity and the individual practice units then much can be achieved, but where cracks between the two appear then the ability to deliver the benefits of working at-scale quickly dissipate.

We see this with federations.  The most successful federations have a strong relationship between the practices and the federation, and a high level of trust between the practice partners and the federation directors.  Conversely, federations struggle where the practices have concerns that the federation may be in competition with its practices (for example over the delivery of enhanced services or a local APMS practice), may be working for its own ends rather than those of the member practices, or may be taking on a performance management rather than support function for its members.

Super-practices may be one organisation but in some tensions can exist between the individual practice units and the ‘centre’.  While the ability to make collective decisions is certainly easier as a single entity, if trust between the practice units and those running the wider entity break down cohesiveness is still difficult to achieve.

CCGs, meanwhile, really had no chance.  Right from the outset the CCG authorisation process made clear that CCGs had to prioritise the wider health economy over general practice, and put in place systems to ensure that CCGs did not make any decisions that might favour general practice.  It was no surprise, then, that practices quickly worked out that the CCG was something separate from them and paid little attention to requests for collective action.

PCNs have two advantages that these previous attempts at at-scale working did not.  First is that they are an extension of the GP contract.  They are formed out of a shared enhanced service contract (the PCN DES) and as such are firmly rooted in core general practice.  They are not a separate entity that exists in addition to the practices , but rather are an extension of the practices themselves.  This means the sense that PCNs are somehow in competition with the practices does not exist, as the separation that particularly federations intrinsically begin with is not present for PCNs.

This brings a word of warning for PCNs that choose to incorporate.  While incorporation brings a protection for individual practices from PCN liabilities, it also creates a new distance between the PCN as an entity and the practices themselves.  Once incorporated the PCN is very clearly something different from its practices, which could in time lead to more of a separation between the two.

The second advantage that PCNs have is the limit to their size.  It is much easier to maintain trust, aligned values and strong communication across a small number of practices and GP partners over (say) a 50,000 population than it is for those at-scale entities serving 100,000+ populations.  The more people involved and the wider the geography served the harder it is to maintain the alignment needed for practices to move together as one.

The most successful PCNs are groups of practices working together to be able to better serve their population both collectively and individually.   They trust each other and identify where working at a PCN or a practice scale is better for any given situation.  Other PCNs either have a divide between the work of the PCN and the work of the practices and a conflict between the two, e.g. in the deployment of ARRS roles, or have no sense of the collective and instead have a constant pull for any PCN resources to the individual practice level.

For many PCNs getting this right remains a work in progress.  The danger is this journey may be derailed by changing what PCNs are too quickly.  If the system becomes impatient for Integrated Neighbourhood Teams (INTs) that pull the focus of PCNs into whole system working and away from their practices too quickly, they risk ending up the same way as many previous attempts of at-scale working, i.e. disconnected from practices and not able to take the service with them.