There is a longstanding debate about what scale primary care should be delivered at. The pendulum can quickly swing between whether the future of primary care lies in small, relational GP practices – intimate, personal, and embedded in their communities – or at-scale large multidisciplinary providers with the resources to meet growing demand.
But the scale debate is a distraction from the real question: what kind of primary care delivers the best outcomes for people and communities? Whether large or small, the truth is that both models can succeed or fail depending on design, leadership, and culture. The obsession with scale risks fragmenting our focus and wasting energy that should be directed toward making care more accessible, coordinated, comprehensive, continuous, and person-centred.
The argument often gets dressed up in moral language. Small practices are portrayed as guardians of continuity and compassion, defending the sacred doctor–patient relationship from corporate blandness. Large organisations are championed as the realistic route to sustainability, integration, and modernisation. Each side casts the other as either naïve or mercenary. It’s an easy narrative to sell – but it’s wrong.
This is the false choice of scale. It assumes size determines quality, when in fact the real drivers are system design, purpose, values, and behaviours. A small practice can be impersonal and unsafe; a large provider can be highly relational and accountable. Form follows function – not the other way around.
What defines high-performing primary care?
High-performing primary care has five defining attributes: it is accessible, coordinated, comprehensive, continuous, and person-centred. These are not new ideas; they’ve been the hallmarks of strong primary care for decades. But we’ve lost sight of them in the noise of organisational reform.
Accessibility isn’t about getting through to reception at 8:30am. It’s about whether patients can consistently get the right care from the right person at the right time.
Coordination isn’t a spreadsheet – it’s the sense that systems work together, connecting the dots when life gets complex.
Comprehensiveness means addressing physical, psychological, and social needs, not reducing care to single issues.
Continuity is about relationships and information – being known, not just processed.
And person-centredness is what turns all of this into care rather than service delivery.
When we focus on these attributes, scale becomes secondary. It’s one of many design levers: an enabler when it provides the infrastructure, governance, and workforce flexibility to support consistency and resilience. But a barrier if it creates distance, bureaucracy, or disconnection from the people and places we serve.
The same is true in reverse: intimacy and agility at small scale can foster continuity and trust but also breed insularity and fragility. The variable isn’t the size – it's how the system behaves.
So why does the scale debate persist?
Because it’s simple. It offers the illusion of clarity in a complex world. Policymakers, commentators, and professional leaders often gravitate toward organisational form because it’s easier to model than relationships, behaviours, and purpose. It’s a comfort zone: we can draw neat diagrams and set national frameworks, avoiding the harder work of cultural and operational change.
The consequences of the false choice of scale
But this fixation with form has consequences. It creates division – smaller practices feeling threatened, larger organisations feeling vilified – when we all want the same thing: a system that allows us to deliver excellent, humane care.
It also fuels policy swings that disrupt local progress. Each shift invites structural redesign, leaving teams disoriented and cynical. Meanwhile, the challenges of workload, workforce, inequity, and access, remain unresolved.
It’s time for a more honest conversation. Instead of asking, “how big should primary care be?”, we should ask how to design systems of any size that deliver high-quality care. What matters most is clear purpose, shared values, and smart design. Scale can help when it supports data sharing, learning, and teamwork, but only adds value when it’s locally governed, relationally led, and centred on people, not processes.
We need leaders to be brave, step away from false choices, and focus instead on what really matters. Patients don’t care whether their GP is part of a six-partner practice or a federation of 60, they care whether someone listens, coordinates, and follows through.
If we can redirect our collective effort toward designing care that consistently achieves those five attributes, scale will find its natural level. Some places will flourish small; others will thrive large. The goal is not uniformity – it’s high performance with humanity; no single model owns the moral or practical high ground.
The challenge is building systems, at any scale, that stay true to their purpose, foster connection, and deliver care people trust.
Dr Duncan Gooch is chair of the Primary Care Network at the NHS Confederation and managing partner and clinical Director of Erewash Health Partnership, a consortium of practices that provides healthcare services to over 100,000 people. This is his first quarterly column for Pulse PCN.