Identifying at-scale general practice providers in England: a cross-sectional study of routine NHS data

Identifying at-scale general practice providers in England: a cross-sectional study of routine NHS data | Research Square Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Identifying at-scale general practice providers in England: a cross-sectional study of routine NHS data James Scuffell, Joseph Hutchinson, Deepthi Lavu, Rochelle Velho, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9162485/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background At-scale working is increasingly prominent in English general practice, but no registry of at-scale general practice providers (AS-GPP) exists. In the NHS Ten Year Plan, Multi Neighbourhood Providers have been proposed to deliver integrated, preventive, community‑based care for populations over 250000. As existing at-scale organisations will influence the success of widening at scale working for general practice, patients and commissioners; it is important to understand their geographic location, current activity and contractual/governance structure. We aimed to describe these factors for existing AS-GPP in England. Method All organisations from the Care Quality Commission registered primary medical service providers (June 2025) and NHS Integrated Care Board (ICB) expenditure data reporting transactions over £25000 (April 2024–May 2025) were gathered. A structured review was conducted to define these as AS-GPP (or not), alongside gathering information on their location, associated general practices, primary care networks, ICB, organisational activity and structure. Each AS-GPP was linked to list-size weighted administrative and census data from the associated practices Lower layer Super Output Area (LSOA); specifically deprivation, population density and age profile. Descriptive statistics were used to analyse AS-GPP, map their distribution by ICB and examine organisational activity and structure. Results We identified 165 AS-GPP providing services to > 100000 patients. The median number of patients served by each was 307183 (IQR: 200000–449060), with some serving > 4 million patients. The number of AS-GPP per ICB ranged from 0 to 11, representing important geographic variation. 69% of English practices were linked to one or more AS‑GPP. These were in slightly more densely populated areas than the average GP practice in England. The type of activity provided varied substantially with majority (84%) providing out-of-hours services (including extended access). Other frequent activities included at-scale back-office support, enhanced services and core general practice. Majority (58%) of these are GP federations or alliances, where practices remain organisationally separate but collaborate to share resources and services. Conclusion There is important variation in the geographic location and activity of AS-GPP. This variation will shape the success of future at-scale health policies, such as multi-neighbourhood healthcare, and warrant accounting for in their implementation, commissioning and evaluation. At-scale working General Practice Service provision Health Services Research Descriptive analysis Multi Neighbourhood Provider Primary Care Out of hours Federation Collaborative Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction In England, the past few decades have seen a gradual shift in general practice working from small partner-led surgeries towards larger group practices. 1 , 2 With most organisations having independent contracts with the National Health Service (NHS) to provide a registered population in a local area with state-funded care, in addition to practice expansion, new organisational structures have emerged which include federations, super‑partnerships and multi‑site provider organisations. 3 Since 2016, the national strategy has explicitly advocated for ‘working at scale’. 4 Estimates for the proportion of practices ‘working at-scale' vary widely, ranging from less than 5% to over 80% in 2018, in part due to differences in definitions of collaboration and ‘at-scale’. 5,6 By 2019, 55% of general practices were working at scale, defined as serving > 30000 patients. 5 More formal collaborative working was supported on a contractual basis by the introduction of Network Contract Directed Enhanced Services (DES) in 2019. 7 This new contract created the primary care networks (PCN) as groupings of general practices, generally across a geographically contiguous area to provide services across a neighbourhood of 30-50000 patients. 7 Subsequent roll-out of the PCN policy was variable, as general practices were found to be less willing to work with people they have not done before. 8 Meanwhile, greater cohesion within the existing collaborations was associated with greater utilisation of schemes, such as the additional roles reimbursement scheme which was a key aspect of the policy designed to increase multi-disciplinary working in the sector. 8 As such, it is likely that pre-existing work at scale influences the subsequent success of any policy designed at this scale. Working ‘at-scale’ has several claimed benefits, such as improved access for patients, greater opportunities for innovation and staff development, and better value through economies of scale/operational efficiency. 4 The evidence base for these benefits is scarce and mixed, 9 and international literature is similarly equivocal. 10 – 14 Emerging evidence suggests that PCNs promoted collaborative working, exemplified by supporting the rapid and successful rollout of the COVID-19 vaccination, and that they acted to reduce inequality through more pro-poor distribution of funding and some staff groups. 15 , 16 However, there are concerns that working at-scale provided more challenges in providing continuity of care. 17 Further, it is not clear whether the benefits of at-scale working are simply a function of the policy mechanisms, which may have been delivered through pre-existing practices. The 10 Year Health Plan for England signals the intention for further future working ‘at-scale’ with the introduction of Multi-Neighbourhood Providers (MNPs) as organisations delivering community-based healthcare to populations of greater than 250000 people. 18 This is with the purpose of shifting care from hospitals to the community through Neighbourhood Health by “unlocking the advantages and efficiencies from greater scale. ” 18 Existing at-scale general practice providers (AS-GPP), such as GP federations, super-partnerships and corporate chains, may be the most likely prospective organisations to take on these contracts, therefore, the success of MNPs for a given area may depend on the presence (or not) and maturity of these pre-existing relationships and organisations. Currently, there is no unified registry of the variety of different AS-GPP in England. As such, it is a potentially significant policy risk and commissioning challenge to have no reliable understanding of the location and activity of these organisations. This study aims to identify, map and characterise AS-GPP organisations in England that could function as prospective MNPs. Specifically, the study intends to describe their geographical distribution, organisational structure, activities and demographic characteristics of the population served, which includes organisational patient size, socioeconomic deprivation, ethnicity, age profile and rurality. 2. Methods 2.1 Study design A cross-sectional study of all AS-GPP as of June 2025 using routine administrative NHS and census data. It involved a structured review of Care Quality Commission (CQC) registered primary medical service providers (June 2025) and NHS Integrated Care Board (ICB) expenditure data reporting transactions exceeding £25000 (April 2024–May 2025). 2.2 Setting and participants We defined an AS-GPP as ‘a provider of general practice services to a population of at least 100000 people within a contiguous geographical area who provide at least one clinical service’. We chose the patient list size of 100000 as the minimum threshold to align with two (multi) neighbourhoods, having a population of up to 50000 patients each. 7 This is smaller than the 250000 threshold used in the 10-year health plan to define MNPs, but organisations between 100000 and 250000 will likely be able to easily scale to this size. This definition was reached by consensus of the research team, who have experience in clinical, academic and policy work in England. We excluded acute NHS hospital trusts (vertical integration) and community NHS trusts (horizontal integration) that directly run a small number of general practices, as their principal function was not to provide at-scale general practice services. A shortlist of potential AS-GPP was gathered from the Care Quality Commission (CQC) register and ICB expenditure data. The CQC is the independent regulator for health and social care in England and maintains a register of all organisations providing these services. 19 ICBs are statutory bodies that commission NHS services in defined geographic regions in England, with populations ranging from 500000 to 3 million. 20 CQC data: We gathered all organisations within the CQC register as of June 2025 that are providers of primary medical services. 21 We extracted all providers operating at more than one location; all community interest companies (CICs); and performed a keyword search for possible providers for words such as ‘Alliance’, ‘Federation’, ‘Healthcare Partnership’ and ‘Collaborative’. A full list of search terms is available in Supplementary Material 1 (Table S1 ). ICB expenditure data: Every NHS ICB is required to publish monthly reports of any expenditure exceeding £25000. We downloaded each report from all 42 ICB websites from April 2024 to May 2025 and included all organisations that were incorporated as CICs, private limited companies and limited liability partnerships (LLP). We extracted the names of each organisation receiving a payment and matched, by text and geographical distance, this organisation name to CQC provider data. We included only organisations with a matching CQC record. In addition to the above, a third source was used. NHS England maintains a list of PCNs and general practices in England along with their associated list sizes. 22 Any of these respective organisations with > 100,000 patients were included as additional AS-GPP. As such, AS-GPP identified as PCNs or single practices during the survey phase were removed from the analysis to avoid duplication of organisations. Multiple data sources were chosen to help triangulate and improve the sensitivity of the search by including organisations that might have been missed in one dataset alone. For example, GP federations that are only registered at one address would be missed in the CQC search but would be identified in the ICB expenditure data. Each organisation was screened by two reviewers from the authorship pool using the organisations’ webpages and companies house registration to determine if it fulfilled our definition of an AS-GPP. Any discrepancies received a third review where a consensus decision was reached. We also extracted information on the practices and PCNs associated with each provider, organisational structures, and the categories of services offered. Data extraction occurred from October 2025 until March 2026. The extraction form (Table S2 ) and decision tree (Figure S1 ) are detailed in Supplementary Material 1. 2.3 Linkage to primary care networks and general practices The set of organisations fulfilling our definition of an AS-GPP was linked to their associated set of PCNs and general practices. First, any available data on the link to a PCN and practice was gathered from the organisation’s website. Second, if missing, the geographic area of the organisation’s services was gathered from the website. Practices were then assigned to that geographic area. For example, if they state they serve all patients in Lincolnshire then all practices located in Lincolnshire would be linked. The full list of NHS PCNs and practices were gathered from the NHS England organisational data service. 22 We then matched the practices and PCNs identified through the websites to official NHS organisations. This was a multi-stage process using fuzzy text, geographic, large language model and manual matching. Full details of this matching process are available in Supplementary Material 1 (Table S3). To ensure data quality of these matches, each organisation’s practice and PCN linkages were then manually reviewed. The associated ICB for each AS-GPP was gathered directly from the website or assigned from the linked PCNs and practices. 2.4 Organisational characteristics Many organisations directly reported the number of patients they serve, which we gathered (organisation size by survey collection). We also gathered the list sizes of each general practice and the number of patients aged ≤ 4 and ≥ 65 years old from the April 2025 NHS England Patients registered at a GP practice dataset. 23 The sum of the linked practices list size for each organisation was calculated (organisation size by linked practices). We used the larger of these variables as the organisation’s patient size variable. We then calculated the proportion of these patients that were aged ≤ 4 and ≥ 65 years old respectively. Proportion of people of White ethnicity, income deprivation score and average population density (people per square kilometre) were gathered at the lower layer super output area (LSOA), which are geographical groupings of 1000–1500 people in England. 24 – 26 We then gathered the number of patients in each LSOA registered at each general practice in England. 23 We calculated the population weighted average for our ethnicity, socioeconomic deprivation and population density variables at the practice level, followed by calculation of the population weighted average for our AS-GPP from the practice data. Categories of organisational activity were defined within the research team, and their information was then gathered from the associated AS-GPP webpages. Specifically, organisational activity gathered included: Core GP services, including home visits Out of hours services, including extended access Emergency care / urgent care centres / walk-in centres Enhanced primary care services – including dermatology, minor surgery, physiotherapy, etc. At-scale back-office support – any non-clinical service provided to more than one practice. Human resources (HR), training, estates, research, population health management, etc. Psychosocial interventions – smoking cessation, link workers, social prescribing, etc. Diagnostic services – phlebotomy, radiology, etc. Vaccination hubs Intermediate care services – frailty hubs, virtual wards, community engagement response teams, etc. Categories of organisational structure were also categorised and gathered during the survey phase, specifically: GP Federation or GP Alliance Super(partnership) Primary Care Networks Other organisational structure We consider a GP federation as practices linked by a legal contract which enables them to share front and/or back office functions whilst maintaining their own separate organisational structure as practices. 6 , 27 Alliances are a less well defined term, but often closely relate to federations, however they may have a looser legal agreement more akin to a King’s fund definition of a network. 27 Super-partnerships are large-scale single partnerships which directly run multiple practices, but practices do not maintain their own separate organisational strucuture. 6 , 27 Primary care networks are organisations holding the PCN DES contract described above. We intended to further categorise organisational categories (e.g. community interest company), however this proved challenging from their web presence. We therefore chose to present these organisational categories as “other”. 2.5 Data analysis Descriptive statistics were calculated for our AS-GPP and comparisons made with all general practices in England. We used median and inter-quartile range as our measure of central tendency and variation due to organisational list size being right skewed. We then calculated descriptive statistics for subgroups by organisational structure (GP federations AND alliances, primary care networks, super-partnerships and other organisational structures) as well as AS-GPP serving < 250000 and ≥ 250000 patients. Choropleths of the count of AS-GPP in each ICB as well as the proportion of patients in the ICB linked to at least 1 AS-GPP were created. Groupings of AS-GPP were plotted using a co-occurrence matrix and a bar chart of the cumulative number of our activity characteristics in each AS-GPP. Data analysis was done in R4.3.0, R 4.5.0 and Python 3.11, with coding support from large language models (Claude Opus 4.6 and Sonnet, Anthropic PBC, San Francisco, USA). Screenshots of the web applications used are available in Supplementary Material 1 (Figures S2 and S3), and the code used for analysis is available on Figshare ( https://doi.org/10.6084/m9.figshare.31625656 ) 3. Results 3.1 Organisation identification Details of the selection process are in Fig. 1 . 8337 organisations were gathered from the CQC register, of which 358 were possible AS-GPP. NHS ICB expenditure data was available for all 42 ICBs, with a total of 558 ICB-months of data available. The number of months of financial data available is detailed in Supplementary Material 1 (Table S4). 979772 payments over £25000 identified 401 possible AS-GPP. After deduplication, 615 unique organisations were assessed for screening. Of the 615 organisations doubly screened, 142 (23%) were included for further analysis and 473 were excluded. The most common reasons for exclusion were: not providing NHS-funded care (n = 147, 31%), being a PCN (n = 115, 24%) as these were appended later, having organisational reach of less than 100000 (n = 64, 14%) and not providing primary medical services (n = 53, 11%). A final total of 165 AS-GPP were identified, with 142 identified via double-screening, 22 large PCNs (> 100000) and 1 large practice added from NHS datasets. Details of missing data are provided in Supplementary Material 1 (Table S5). 3.2 Organisational characteristics The count of AS-GPP identified per ICB varied from 0 in NHS Dorset ICB to 11 in NHS North Central London ICB, NHS North East London ICB and NHS North East and North Cumbria ICB (Fig. 2 and Supplementary Material 2 (Table S6)). However, the proportion of patients in each ICB linked to at least one AS-GPP ranged from 0 to 1.00. NHS North Central London ICB, NHS West Yorkshire ICB and NHS South East London all had all patients linked to an AS-GPP, as well as the greatest proportion of AS-GPP in England (6% each). 68% of practices and 69% of patients in England were linked to at least one AS-GPP, with 21% of practices linked to ≥ 2 AS-GPP. 58% of the AS-GPP were GP federations and alliances, with a further 13% being PCNs. 25% of the AS-GPP had other organisational structures which represent organisations like multi-site practice organisations. 27 Descriptive statistics are detailed in Table 1 and Table 2 . Table 1 Descriptive statistics All at-scale providers N = 165 General practices in England N = 6,307 Provider characteristics Organisation patient size. Median (IQR) 307183 (200000–449060) - Income deprivation score Median (IQR) 0.13 (0.10–0.17) 0.12 (0.08–0.18) Proportion of patients of White ethnicity Median (IQR) 0.82 (0.62–0.90) 0.83 (0.64–0.94) Average Population Density (people per square kilometre) Median (IQR) 4,033 (2,781-6,181) 3,897 (2,251-5,914) Proportion of patients aged ≤ 4 years Median (IQR) 0.05 (0.04–0.05) 0.05 (0.04–0.05) Proportion of patients aged ≥ 65 years Median (IQR) 0.18 (0.14–0.21) 0.18 (0.13–0.23) Number of patients linked to 1 or more AS-GPP Sum (%) - 43871857 (69%) Number of linked practices Median (IQR) 27 (17–37) - Number of linked AS-GPP per general practice N (%) - 0 AS-GPP 2045 (32%) 1 AS-GPP 2909 (46%) 2 AS-GPP 1166 (18%) 3 AS-GPP 182 (2.9%) 4 AS-GPP 5 (< 0.1%) Organisational activity Emergency and urgent care N (%) 55 (35%) - At scale back-office support N (%) 100 (64%) - Enhanced services N (%) 119 (76%) - Core general practice N (%) 105 (67%) - Intermediate care N (%) 60 (38%) - Psychosocial care N (%) 76 (48%) - Out of hours work N (%) 132 (84%) - Diagnostic services N (%) 52 (33%) - Vaccination hubs N (%) 43 (27%) - Organisational structure Federation or Alliance N (%) 96 (58%) - Super partnership N (%) 5 (3.0%) - Primary care network N (%) 22 (13%) - Other organisational structure N (%) 42 (25%) - Table 2 Descriptive statistics stratified by organisational structure and dichotomised by less than 250000 patients (or not). GP Federation or Alliance N = 96 Other organisational type N = 42 Primary care network N = 22 Super partnership N = 5 < 250,000 patients N = 66 ≥ 250,000 patients N = 99 Provider characteristics Organisation patient size. Median (IQR) 322864 (227251–427236) 385278 (239606–1000000) 113499 (104317–128493) 348292 (168020–696416) 161922 (116591–221464) 402732 (329239–600628) Income deprivation score Median (IQR) 0.13 (0.09–0.17) 0.14 (0.12–0.19) 0.11 (0.10–0.16) 0.10 (0.09–0.19) 0.12 (0.09–0.16) 0.14 (0.11–0.17) Proportion of patients of White ethnicity Median (IQR) 0.78 (0.60–0.89) 0.83 (0.62–0.91) 0.86 (0.72–0.92) 0.85 (0.71–0.85) 0.87 (0.77–0.91) 0.74 (0.58–0.88) Average population density (people per square kilometre) Median (IQR) 4026 (2770–6632) 4175 (2864–6281) 3604 (2991–4870) 2483 (2481–4264) 3672 (2611–4870) 4181 (2876–7752) Proportion of patients aged ≤ 4 years Median (IQR) 0.05 (0.04–0.05) 0.05 (0.04–0.05) 0.05 (0.04–0.05) 0.05 (0.04–0.05) 0.05 (0.04–0.05) 0.05 (0.04–0.05) Proportion of patients aged ≥ 65 years Median (IQR) 0.17 (0.14–0.20) 0.18 (0.13–0.21) 0.20 (0.17–0.21) 0.20 (0.18–0.22) 0.20 (0.16–0.22) 0.16 (0.13–0.20) Number of linked practices Median (IQR) 28 (21–35) 32 (20–57) 12 (8–15) 13 (13–56) 15 (11–20) 33 (28–47) Organisational activity Emergency and urgent care N (%) 36 (38%) 19 (49%) 0 (0%) 0 (0%) 13 (21%) 42 (44%) At scale back-office support N (%) 72 (75%) 19 (49%) 6 (35%) 3 (60%) 33 (54%) 67 (70%) Enhanced services N (%) 80 (83%) 23 (59%) 15 (88%) 1 (20%) 50 (82%) 69 (72%) Core general practice N (%) 66 (69%) 24 (62%) 10 (59%) 5 (100%) 38 (62%) 67 (70%) Intermediate care N (%) 42 (44%) 12 (31%) 6 (35%) 0 (0%) 22 (36%) 38 (40%) Psychosocial care N (%) 48 (50%) 13 (33%) 14 (82%) 1 (20%) 32 (52%) 44 (46%) Out of hours work N (%) 88 (92%) 29 (74%) 13 (76%) 2 (40%) 50 (82%) 82 (85%) Diagnostic services N (%) 40 (42%) 10 (26%) 1 (5.9%) 1 (20%) 16 (26%) 36 (38%) Vaccination hubs N (%) 28 (29%) 9 (23%) 4 (24%) 2 (40%) 19 (31%) 24 (25%) Organisational structure Federation or Alliance N (%) - - - - 30 (45%) 66 (67%) Super partnership N (%) - - - - 2 (3.0%) 3 (3.0%) Primary care network N (%) - - - - 22 (33%) 0 (0%) Other organizational structure N (%) - - - - 12 (18%) 30 (30%) The median number of patients AS-GPP serve is 307183 (IQR: 200000–448060). However, there is large right skew with a small number of AS-GPP serving over 4 million patients (Fig. 3 ); this is over 8 times larger than the 75th centile. The distribution of organisation list size reported by the AS-GPP was similar to that of the practices in which they are linked. AS-GPP that were PCNs had a smaller list size (113499 (IQR: 104317–128493)) than GP federations/alliances (322864 (IQR: 227251–427236)), super-partnerships (348292 (IQR: 168020–696416)) and other organisational structures (358278 (IQR: 239606–1000000)). The AS-GPP identified had a median population density of 4033 (IQR: 2781–6181) patients per square kilometre which is marginally higher than the median for all general practices in England (3897 (IQR: 2251–5914)). However, our AS-GPP that were PCNs and super-partnerships had a lower median population density of 3604 (IQR: 2991–4870) and 2483 (IQR: 2481–4264) respectively. There was minimal difference in other patient characteristics. 132 (84%) of our AS-GPP were providing out-of-hours services (including extended access). This is marginally concentrated in GP federations/alliances where 92% of these organisations are providing this service. 76% of AS-GPP provided enhanced primary care services, 67% core general practice including home visits and 64% provided at scale back-office support. Again, these were concentrated in GP federations. However, different organisational categories provided a lot of certain activities. For example, 88% and 82% of our AS-GPP that were PCNs provided enhanced primary services and psychosocial services respectively. Majority of AS-GPP provided several of our activity categories, with the mode being six (Fig. 4 ). Of these combinations, the most common is out-of-hours, including extended access with enhanced primary care services; however, all two-way combinations have > 5% frequency. 4. Discussion 4.1 Summary We identified 165 AS-GPP operating in England as of June 2025, each providing services to populations exceeding 100000 patients. These organisations are present across most ICB regions, although they are particularly concentrated in London and the North of England. This geographic concentration in London likely explains the slightly higher population density observed in areas served by AS-GPP, compared with the median for general practices across England. The median population served by AS-GPP was 307183 patients (IQR 200000–449060). However, the distribution is highly right-skewed, with a small number of organisations serving populations exceeding four million patients. The majority of AS-GPP are GP federations and deliver a broad range of activities. The activities most commonly reported were out-of-hours services (including extended access), enhanced primary care services, core general practice including home visits and at scale back-office support. Together, these findings suggest that a substantial infrastructure for delivering primary care at scale already exists within the English healthcare system. 4.2 Strengths and limitations This is the first study, to our knowledge, which examines AS-GPP providing NHS healthcare to greater than 100000 patients. We also used a novel methodology to identify organisations which have no presence in widely used administrative datasets. This has provided useful insights into organisations working at scales beyond the PCN DES, which should be useful for policymakers and commissioners. However, there are some limitations which need to be considered. The geographical location and organisational characteristics rely on the accurate matching of PCNs and practices to our AS-GPP. We conducted quality checks of these links. Additionally, the distribution of list sizes is similar to those stated by the AS-GPP. However, these findings should be interpreted cautiously, and the study should be repeated if these organisations form part of administrative datasets in the future. We could not gather data on 34 organisations that had unidentifiable or insufficient information. We assumed that organisations working at this scale would have a web presence, however there is a risk that these organisations would have been included in our AS-GPP definition. Our categorisation of organisational activity and structure is as stated by the AS-GPP on their website. This cannot be verified. Organisational structures likely vary within our stated categories, for example GP federations may function differently from each other. There is also likely to be variation in the scale of these clinical activities within and between AS-GPP. Similarly, it is not possible to assess the clinical quality of this activity. We used 100000 patients as our cut-off for AS-GPP, as we deemed this as covering two neighbourhoods and therefore might be considered prospective MNPs. However, the importance of size to AS-GPP may vary across England. For example, in areas of lower population density a smaller organisational size may still be an AS-GPP. For reasons previously detailed in the methods, we did not examine acute NHS hospitals and community trusts although these organisations may also be considered prospective MNPs. Despite the clinical, academic and policy experience of the authors, defining organisational activity and structure was challenging and required several consensus decisions. This uncertainty needs to be considered when interpreting the results. 4.3 Comparison with existing literature Evidence on working at-scale in primary care beyond PCNs is limited. Early work from 2018, suggested that only around 5% of practices were working at scale covering populations greater than 30000 patients. 5 Our findings indicate a substantial growth in at-scale working, as they demonstrate that organisations providing services to > 100000 patients are now present in all but one ICB in England. This trend aligns with longstanding policy ambitions to expand collaborative models of general practice to support population health management and service integration promoted by NHS England. 18 Findings from the rollout of PCNs nationally, showed that pre‑existing at‑scale arrangements influenced both the speed and success of PCN formation. 8 This is likely to shape the implementation of future policy initiatives such as MNPs proposed in the 10 year plan, as areas with established collaborative infrastructure may progress more rapidly. 18 Our study found that the proportion of patients in an ICB linked to at least one AS-GPP ranged from 0 to 1. Of ICBs with all patients linked to an AS-GPP, NHS North Central London ICB, NHS West Yorkshire ICB and NHS South East London ICB had the greatest proportion of AS-GPP in England (6% each). Given the high resource demands associated with establishing new organisational forms, e.g. during the PCN conception phase, 8 existing variations in the location of AS-GPP should be considered carefully when designing the rollout of MNPs to avoid widening geographic disparities in capacity and readiness. AS-GPP are not part of NHS routine data collection, which is also the case for private general practice. Previous research found private general practices are concentrated in London. 28 This raises concerns about geographic inequalities in access to healthcare, which may be poorly captured by routine data collections. It is important for the healthcare commissioning to have a good understanding of active organisations, particularly as AS-GPP are prescribing NHS services. Therefore, we would encourage mandated reporting of key organisational activity for all organisations providing general practice in England. 4.3.1 Organisational structure Intrinsic to our definition of an AS-GPP, all AS-GPP provide care across a large population size. Half of these organisations provide care to between 200000 and 449060 patients; with 25% below and above. Meanwhile, our AS-GPP which are also PCNs were all serving population < 250000. The NHS delineates at-scale working into neighbourhoods (30-50000 people), place (250000–500000 people) and systems (1 million-3 million people). As such, most of these organisations are working at neighbourhood or place level. 29 MNPs are expected to serve populations greater than 250000 and 60% (99/165) of our AS-GPP identified meet that threshold. However, there are a few outlier organisations working at the system level. Policy initiatives aimed at expanding multi-neighbourhood provider models may be able to build upon this existing infrastructure, where these system level providers may take on the contract for several MNPs or form the basis of an Integrated Health Organisation (IHO), rather than requiring entirely new organisational structures. 30 A previous Nuffield trust and Royal College of General Practitioners survey highlighted the increasing role of federations in enabling practices to deliver at scale working with 45% of GP collaborations noted to be federations. 6 In our study, 58% of AS-GPP are GP federations or alliances, increasing to 67% when only considering organisations providing services to ≥ 250000 patients. Meanwhile, a further 12% are PCNs. These organisational forms represent relatively loosely integrated collaborative structures, in which practices maintain organisational independence while achieving economies of scale in workforce deployment, administrative infrastructure and shared service delivery arrangements. Such models contrast with “super-partnership” organisational structures, where practices merge into a single legal entity. 27 , 31 However, there is limited evidence to whether this is the optimal form of organisational structure at this scale. 31 It is vital that the importance of the diversity of organisational models operating at scale is recognised, 32 as this will require policymakers to plan future service‑delivery in ways that enable participation and build on of established locally developed collaborations, rather than relying on new uniform, centrally imposed organisational models. 4.3.2 Organisational maturity The finding that majority (84%) of AS-GPP provide out-of-hours or extended access services suggests that many organisations may have developed from collaborative arrangements formed following the 2004 changes to the general practice contract, which allowed practices to opt out of providing out-of-hours services. 31 It is not possible from our approach to know what proportion (if any) have been in existence since 2004. However, if many have been, then these may be mature organisations. Previous research conducted by the Royal College of General Practitioners and The Nuffield Trust suggests that collaborative primary care organisations often require significant time (25 + months) to reach organisational maturity which allows expansion of their service portfolios. 6 The wide range of activities delivered by AS-GPP in this study may therefore reflect relatively mature organisational structures. 4.4 Implications for health inequalities and population health We found no evidence that AS-GPP are disproportionately distributed in areas of socioeconomic deprivation, regions with large proportion of ethnicities other than White or places where a large proportion of people are aged ≤ 4 or ≥ 65 years of age. Although these are univariate statistics and the associations may be more complex when considered together, from a public health perspective, this suggests that the presence of large-scale primary care organisations is not inherently associated with specific demographic or socioeconomic contexts. The presence of an organisation does not necessarily reflect the scale, accessibility or quality of services delivered. 33 , 34 As such, this study cannot determine whether AS-GPP influence access to care, continuity of care, or health outcomes. Future research should therefore examine whether AS-GPP influence key indicators such as appointment availability, continuity of care, workforce sustainability, service integration, and population health outcomes, particularly in areas experiencing workforce shortages or high levels of health inequalities. 5. Conclusion This first mapping of at-scale primary care providers in England reveals 165 organisations working at-scale (> 100000 patients) in general practice. They are present in all but one ICB in the country, but with a concentration within London and the North of England. Most of these organisations provide out-of-hours services (including extended access), alongside a wide range of other organisational activity. Meanwhile, most organisations are GP federations or alliances or primary care networks. These findings have important implications for decision makers involved in the design and implementation of the policy for multi-neighbourhood providers. First, the initiatives aimed at expanding multi-neighbourhood provider models could build on the substantial number of organisations already operating at scale. Second, as routine NHS administrative datasets poorly capture information on collaborative primary care organisations, improved national data collection would support better decision-making and population health impact evaluation. Finally, flexible policy frameworks should be considered to utilise established locally developed collaborations rather than imposing uniform organisational models to address primary care population health needs in England. Abbreviations AS-GPP At-scale general practice providers ICB Integrated care board PCN Primary care network NHS National Health Service CQC Care Quality Commission DES Directed Enhanced Service MNP Multi-Neighbourhood Provider LSOA Lower Layer Super Output Area Declarations Ethical approval and consent to participate All methods were performed in accordance with relevant guidelines and regulations. Ethical approval was not required as the study only utilised publicly available data. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. The code used in the analysis is available on figshare (https://doi.org/10.6084/m9.figshare.31625656) Competing interests JS is employed as a salaried general practitioner in an NHS general practice and is a member of Lambeth Local Medical Committee. JH has recently been employed as a salaried general practitioner in a NHS general practice. He continues to work clinically in this setting. DL is a general practitioner working clinically in a NHS general practice and a member of the Devon Local Medical Committee. She is also a nationally elected member on the Royal College of General Practitioners Council. DD is currently an academic GP registrar. He was seconded to NHS England from September 2024 to August 2025. AHS is a salaried general practitioner in an NHS general practice. He was on secondment to NHS England from September 2024 to March 2026. Funding JS is funded through a National Institute for Health Research In-Practice Fellowship [NIHR303520]. JH is funded through the Wellcome Trust via the Leicestershire Health Inequalities Improvement Programme at Loughborough University and the University of Leicester [Grant 223512/Z/21/Z]. DL is funded through the Wellcome NIHR School for Primary Care Research (SPCR) Primary Care Clinician Doctoral Fellowship Programme at the University of Exeter [Grant 223501/Z/21/Z]. She is also a recipient of the WONCA Europe 2025 scholarship. Authors contributions JS: Conceptualisation, Software, Methodology, Data curation, Formal analysis, Writing - Original draft, Review and Editing. JH: Conceptualisation, Methodology, Data curation, Formal analysis, Writing - Original draft, Review and Editing. DL: Conceptualisation, Data curation, Methodology, Resources, Writing – Review and Editing. 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All authors are either academic general practitioners working in NHS general practices or are general practice doctors in training. JS is a member of Lambeth Local Medical Committee. He is funded through a National Institute for Health Research In-Practice Fellowship [NIHR303520]. JH is funded through the Wellcome Trust via the Leicestershire Health Inequalities Improvement Programme at Loughborough University and the University of Leicester [Grant 223512/Z/21/Z]. DL is a member of the Devon Local Medical Committee. She is also a nationally elected member on the Royal College of General Practitioners Council. DL is funded through the Wellcome NIHR School for Primary Care Research (SPCR) Primary Care Clinician Doctoral Fellowship Programme at the University of Exeter [Grant 223501/Z/21/Z]. She is also a recipient of the WONCA Europe 2025 scholarship. DD was seconded to NHS England from September 2024 to August 2025. AHS was on secondment to NHS England from September 2024 to March 2026. Supplementary Files SupplementaryMaterial1.docx SupplementaryMaterial2TableS6MultineighbourhoodprovidersbyIntegratedCareBoard.xlsx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 16 Apr, 2026 Editor invited by journal 20 Mar, 2026 Editor assigned by journal 19 Mar, 2026 Submission checks completed at journal 19 Mar, 2026 First submitted to journal 18 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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