Education And Debate

Is bigger better for primary care groups and trusts?

BMJ 2001; 322 doi: (Published 10 March 2001) Cite this as: BMJ 2001;322:599
  1. Chris Bojke, research fellowa,
  2. Hugh Gravelle, professora,
  3. David Wilkin (, professorb
  1. a National Primary Care Research and Development Centre, Centre for Health Economics, University of York, York YO10 5DD
  2. b National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL
  1. Correspondence to: D Wilkin
  • Accepted 9 February 2001

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.

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 …

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