Primary Care at Scale: Beyond PCNs - Time to Think Bigger?

As we move through 2025, primary care leaders across England are grappling with a fundamental question: are we thinking big enough about our future organisational structures and what does primary care at scale mean for us?

The signals are becoming clearer, with messages surrounding the NHS 10-year plan pointing toward healthcare integration on an unprecedented scale.

Recent speeches at the NHS Confederation have emphasised the need for primary care to step up as system leaders. The direction of travel is unmistakable: scale matters, and the window for strategic positioning is finite.

My Take: The Strategic Reality

In previous articles, I've questioned whether PCNs will naturally become the integrator entities that our healthcare system needs. That sentiment still stands – and recent developments only reinforce my view.

The London Target Operating Model is explicit about scale requirements. We're talking about primary care organisations that mirror acute trust footprints – potentially hundreds of thousands of patients across multiple PCN areas, not the 30-50,000 population neighbourhoods that PCNs were designed around.

The evidence is mounting from multiple directions. We need primary care organisations that can think strategically about population health, not just chase activity payments.

The question every primary care leader should be asking is: are you positioned to be that organisation in your area?

This isn't about eliminating PCNs – they'll remain crucial for neighbourhood-level delivery. But strategic influence sits at a different level entirely. The organisations making the biggest impact are those that can credibly claim to represent general practice across their entire place footprint.

The risk for areas that don't position themselves strategically is significant. When ICBs need primary care leadership, when transformation opportunities arise, when new contracts get awarded – they're going to the organisations that look and feel like strategic partners.

Ruth's Legal Perspective

I asked Ruth Griffiths from Hill Dickinson, who works with federations across the country, to share her insights on what this strategic shift means from a legal and governance standpoint.

“The announcement this week on the future of Neighbourhood working and new primary care contracts creates opportunity and threat for general practice in equal measure,” Ruth observes.

“Opportunities of the potential magnitude of the Multi-Neighbourhood Provider (MNP) role have historically been reserved for NHS bodies only. Even in the hours since its release, we are seeing false narratives being pushed that the MNP cannot be hosted or lead by a GP owned and led entity. There are many NHS providers out there keen to demonstrate why they can be the MNP for their Place; it is critical therefore for general practice to consider its role and voice at this scale and let its abilities and intentions be known.”

"The federation organisations that will thrive in this environment and are ready to take on the role of MNP, share a common characteristic: they've moved beyond collaboration agreements to robust corporate structures that enable them to operate at scale yet have not lost sight of who their ultimate members are and their needs," Ruth explains.

Ruth points out a critical risk for general practice:

"In this new landscape, essential funding streams needed by general practice to “keep the lights on” are no longer contracted through “practice-up” channels but instead will becoming from “at-scale-down”. To be able to at best control, or at least, influence to ensure adequate funding reaches general practice, practices and PCNs (as Neighbourhoods) need to come together as a strong voice and form at Place: essentially through new or existing federation vehicles.”  

According to Ruth, in their experience, a company limited by shares model, with a CIC coating, gives you the flexibility needed to be responsive to these opportunities. It allows practices, Neighbourhoods and smaller federations to retain their independence and sovereign identity while participating in something bigger.

Critically, it positions networks to lead on the types of contracts that are emerging from this system transformation."

Where Strategy Meets Structure

Healthcare integration is accelerating, and the organisations positioned for success are those that combine strategic scale with operational sophistication.

But as Ruth highlights, strategic positioning without proper legal structures is just aspiration. You can't be an integrator entity without being properly constituted to integrate.

Questions for primary care leaders

• Do we truly represent general practice across our place footprint?

• Are our current collaboration agreements fit for the scale of opportunity ahead?

• What existing federation structures already exist in our area that we should be engaging with?

For Federation Leaders:

• What would need to change for us to take on the role of the MNP?

• Are our corporate and governance structures sophisticated enough for complex contracting and representative of our Neighbourhoods?

• What PCNs remain outside our membership that we need to bring into the fold?

Consolidation is happening whether individual practices engage with it or not. The question is whether you'll be part of shaping what comes next.

Ruth Griffiths leads primary care contracting and corporate structuring at Hill Dickinson and can be contacted here: ruth.griffiths@hilldickinson.com

About Us

THC Primary Care is an award-winning healthcare consultancy specialising in Primary Care Network Management and the creator of the Business of Healthcare Podcast. With over 20 years in the industry, we've supported more than 200 PCNs through interim management, training, and consultancy.

Our expertise spans project management and business development across both private and public sectors. Our work has been published in the London Journal of Primary Care, and we've authored over 250 blogs sharing insights about primary care networks.

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