The pressures on general practice

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2580 (Published 11 May 2016) Cite this as: BMJ 2016;353:i2580
  1. Veronica Wilkie, professor of primary care1,
  2. Alwyn Ralphs, director of postgraduate programmes2
  1. 1Institute of Health and Society, University of Worcester, Worcester WR2 6AJ, UK
  2. 2School of Medicine, Keele University, Staffordshire, UK
  1. Correspondence to: V Wilkie v.wilkie{at}worc.ac.uk

A new King’s Fund report tries to explain them

Hot on the heels of NHS England’s General Practice Forward View1 2 comes the King’s Fund’s analysis of the pressures affecting British general practice.3 It seeks to explain the burnout among GPs and their staff and their accelerated departure from primary care.

The exhaustive analysis reviewed 30 million patient contacts from 117 practices. More than 300 GPs in training were surveyed, and 60 in-depth interviews were carried out with practice staff. The findings are consistent with other recent reports of rising consultation rates, particularly telephone consultations.4

The King’s Fund’s report echoes the Commonwealth Fund’s report on UK general practice in 2015.5 6 GPs feel isolated from those who commission them and stressed by their inability to influence what they regard as unnecessary workload. At the same time, they’re expected to provide continuity of care to those that need it and timely access to all who want to see them. Meanwhile, they have to manage variations in the increasingly complex performance indicators emanating from clinical commissioning groups.

The report highlights how general practice is having to deal with the overflow and off-loading of work from an overwhelmed secondary care system. It is struggling to manage an increasingly frail population with a progressive reduction in funding—from 8.4% of the NHS budget to 7.9% over the past four years.7 8

Although the reasons for the burnout have been identified before, this report tries to analyse why it has happened. It highlights pressures on other parts of the system, where reductions in funding may have an accelerated effect on GPs. Examples include the removal of district nursing teams from practice premises and the inaccessibility of mental health services. Practice managers are struggling to chase payments from a confusing plurality of sources, adding further to a reduction in income and uncertainty in maintaining staff salaries. The NHS system no longer measures NHS activity and fails to evaluate the effect on general practice as it tries to increase care in the community.

The King’s Fund report comes up with similar solutions to the General Practice Forward View3: recruiting more GPs and other primary care staff, cutting unnecessary bureaucracy, widening the healthcare team, enabling smarter use of IT, and improved career design and development. But it also adds new insights. It identifies the attributes of more stable and resilient practices—for example, good team relationships and clear leadership. It also identifies that the wish for part time work is not limited to women. Many men cannot cope with the workload and want to work part time or in mixed work patterns, with time away from the front line.

What recent reports, including this one, make light of is the need to develop clinical skills and careers as the population changes. If GPs are to have a greater role in professional teams managing patients with more complex needs, current development and training will not necessarily enable professional skills to fit with 21st century healthcare needs. Shared leadership in healthcare is vital for all; validated development of clinical skills is as important in the middle and end of a career as it is at the start. Too little recognition is given to the need to develop clinical knowledge and skills, alongside leadership skills. A clinical path needs to be valued as a career choice for doctors as well as careers in academic medicine or management. Supervision and mentoring skills will be vital in the multiprofessional clinical teams of the future, and the structure of the working day needs to be able to factor this in. The demand for ever increasing productivity and unevidenced measurement is leading to system collapse, and general practice needs strong support for change from those who commission its services.

As Roland and Everington argued recently in The BMJ,2 any rescue package for general practice has to be in conjunction with the rest of the NHS. GPs cannot be separated from their role as gatekeepers and as the final common pathway after discharge from other NHS care. The NHS is recognising that it cannot be right for the most complicated part of a clinician’s role to be how to navigate care for patients through a fractured system.3

It is encouraging that the NHS is beginning to acknowledge what has led to the crisis in British general practice, and that research is helping us to understand the underlying problems and identify potential solutions. Integration is vital; proper evaluation of changes must look at workforce development and ensure it is fit for the future. If general practice fails, the whole NHS fails.2 We now have the evidence, and it is time for change.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare we are both practising GPs.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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