The latest figures on GP practice size indicate that the number of GP practices has fallen from over 8,000 when the NHS England first published the statistics to 6,708 in September this year.  Fewer practices, as well as an increase in the size of the registered population, has meant the average practice list size has risen from 5,891 in 2004 to 9,007 now.

GP practice size has always been a (relatively) controversial issue. There are fierce defendants of small practice sizes and the relationship it creates between the practice and the population it serves.  At the same time there has been a move to larger (sometimes much larger) practices as a response to workforce, workload and financial pressures.

Research on the issue is generally inconclusive.  The 2014 study by the Institute of Fiscal Studies Does GP Practice Size Matter? GP Practice Size and the Quality of Primary Care, while it found that, “all three indicators of quality that we examined show that smaller practices are associated with poorer quality in primary care services”, it equally had to caveat, “The relationships between GP practice size and GP behaviour are not necessarily causal. This report controls for differences in the characteristics of the practice population, the local area and the GPs themselves in order to adjust for factors that may impact on both practice size and the indicators we examine. However, a considerable number of unobservable factors remain, such as the underlying health status of the practice populations, and could explain why smaller practices tend to perform differently.”

The Nuffield Trust 2016 report “Is Bigger Better? Lessons for large scale general practice” found that although, “larger scale has the potential to sustain general practice through operational efficiency and standardised processes, maximising income, strengthening the workforce and deploying technology”, the “evidence that these organisations can improve quality is mixed. Patients had differing views about the benefits of large-scale organisations. Some appreciated increased access, while others were concerned about losing the close relationship with their trusted GP.”

Overall the research is inconclusive.  A bigger practice feels more resilient, but brings with it concerns around quality and losing the ‘essence’ of general practice.

All of this research was of course before Primary Care Networks were introduced.  Before last year the range of at-scale options available to practices was essentially mergers, super-practices, and GP federations.  Each had varying losses of autonomy and potential associated benefits (ie merging meant changing the core functionality of the practice but with a huge possible upside, whereas joining a federation meant minimal change but with a much more limited upside).

Why PCNs are interesting is they signal a clear commissioner intent to drive the majority of investment in general practice through PCNs.  All previous movements towards at scale working were in the context of a core contract centred on the individual GP practice.  Now there is the PCN contract and all that entails to take into account.

If we add in the RCGP Fit for Future 2019 report, which basically establishes the future role of general practice as that attempting to be played by the PCN (an expanded multi-professional team, joint working across practices and collaboration with other local organisations to serve a local population), then it doesn’t take a huge leap of faith to think the PCN contract may ultimately become more important (in terms of financial and workload implications) than the GP practice contract.

PCNs are developing their infrastructure, staffing and delivery capability as we speak.  The obvious question, then, is whether it is sensible to have parallel practice and PCN delivery structures?  If one practice was the PCN, it would have the governance, be able to flex the utilisation of the staff, and be able to build on existing delivery capacity.

Is it really stretching the imagination for practices to start to consider whether the answer to what is the optimum practice size is actually that of the PCN?  I understand the resistance to this, why fears of exactly this is what fuelled the backlash against the PCN DES, but as a neutral observer looking at the strategic options for practices this is definitely the direction I would head if I was running a practice right now.