Is bigger better for primary care groups and trusts?(Education and Debate)

Summary points

The size of primary care organisations is only one of the factors that affect their performance: others include their policy priorities, functions, other organisational features, and the environment in which they operate

There is no evidence that increases in size of primary care groups and trusts beyond 100 000 patients will automatically generate substantial improvements in overall performance or economies of scale

Optimal size varies substantially for different functions of primary care groups and trusts

Organisational structures and organisational alliances can be used to achieve the different optimal sizes for different functions

One size will not suit all: bigger may be better for some functions and worse for others

The organisation of primary care services and their role as gatekeepers to more expensive specialist services have become key issues for policymakers, managers, and health professionals in many healthcare systems. The importance of primary care in delivering accessible, high quality services while constraining escalating costs is widely recognised.

In England the Labour government elected in 1997 made the formation of primary care groups and trusts the organisational centrepiece of its reforms to the NHS.[1] Primary care groups, established throughout England in 1999, are expected to play a leading role in improving health, reducing inequalities, managing a unified budget for the health care of their registered populations, modernising services, improving quality, and integrating services through closer partnerships. Initially operating as subcommittees of health authorities, they bring together general practitioners, nurses, other health professionals, managers, and representatives of other service providers to manage local services. As they show their ability to manage their budgets and services, they take increased responsibility by becoming freestanding primary care trusts. In April 1999, 481 primary care groups were established in England; 17 of these became primary care trusts in April 2000, and many more are currently in the process of moving to trust status.

The NHS white paper The New NHS suggested that primary care groups would typically serve populations of about 100 000,[1] reflecting a policy of devolving responsibility and decision making to local communities. Although this recommended size did not seem to be based on a systematic review of evidence about optimal size, it probably reflected a mixture of experience (such as in relation to various models of commissioning) and consultation with managers and health professions involved in primary care.[2] When primary care groups were established in 1999, they did indeed conform broadly with the policy, having average populations of about 100 000--though with a range from South West Shropshire's 43 618 patients, 29 general practitioners, and 8 practices to Brighton and Hove's 277 160 patients, 140 general practitioners and 53 practices. It has rapidly become apparent, however, that many health authorities and primary care groups consider a population of 100 000 to be too small, particularly for transition to mast status. Two thirds of trusts were considering mergers within their first six months,[3] seemingly reflecting a widely held view that the optimum size was probably closer …