Intended for healthcare professionals


The battle to retain GPs: why practice culture is critical

BMJ 2023; 380 doi: (Published 16 February 2023) Cite this as: BMJ 2023;380:p344
  1. Rebecca Fisher, Commonwealth Fund Harkness fellow in healthcare policy and practice1,
  2. Aoife M McDermott, Commonwealth Fund Harkness fellow in healthcare policy and practice2, professor of human resource management3
  1. 1University of California, San Francisco
  2. 2University of California, Berkeley
  3. 3Cardiff University
  1. Twitter: @becksfisher

Primary care needs to create a culture where the job satisfaction and wellbeing of staff is prioritised, say Rebecca Fisher and Aoife M McDermott

In September 2022, the Royal College of General Practitioners (RCGP) published a paper on retaining the GP workforce.1 This is a sensible priority. Recent workforce projections by the Health Foundation highlight major concerns about ongoing GP shortfalls.2 In the best case scenario, we can expect a shortage of around one out of 10 GP posts by 2030/31 (currently around one out of eight posts are vacant). In a pessimistic scenario, half of GP posts may be vacant by the end of the decade. Retaining current GPs—and increasing the time they spend providing direct clinical care—will be a key determinant of which outcome transpires.

The policy recommendations set out by the RCGP are rational and challenging. National problems—like enormous and increasing workload, staff shortages, and negative press—require national responses. Accordingly, the RCGP calls upon the government to act. But alongside this sits the suggestion that local initiatives should be developed to “improve the work environment and encourage a positive workplace culture.”

Culture is often described as “the way we do things around here.”3 It is informed by values, passed on through socialisation and brought to life in the decisions, actions, and behaviours of organisational members. Importantly, culture change is not a goal in itself, but a tool for supporting key organisational goals.4 In primary care, practice cultures need to prioritise retention as a shared and valued outcome, encouraging and enabling staff to have this at the forefront of their day to day thinking and actions.

How can we change culture to prioritise retaining GPs?

Evidence strongly supports the RCGP’s focus on work environment and workplace culture. Key factors shaping staff turnover include satisfaction with work itself, with supervisors, and with coworkers. A common thread that underpins all this is the importance of enabling relationships and connection at work.5

Relationships with patients

An important source of dissatisfaction for GPs is the lack of time they have to spend with patients.6 Trusting relationships between patients and their doctors are associated with a range of benefits, including better health outcomes, better patient experience, lower mortality rates, and higher clinician satisfaction.78910 Offering a greater volume of shorter appointments may seem reasonable in the context of soaring demand and pressure to improve access, but risks undermining job satisfaction and GP retention. Prioritising retention therefore requires practices to act in ways that enhance the provision of relationship based care.

Relationships with peers

Coworkers and collegiality count. Relationships with colleagues are particularly important in primary care; doctors can feel isolated and lonely, and finding time to tackle this in the face of workload pressures can be hard.11 However, high quality relationships have been associated with productivity, including of healthcare teams, and so may themselves reduce the adverse effects of time pressures.12 Relationships with colleagues can be facilitated by creating shared spaces,13 time for teambuilding, team meetings, and training, 11 and huddles with structured agendas.13

Relationships with practice management

Day to day management matters. Two key predictors of turnover across sectors are the extent to which employees think that their organisations and managers value their contributions and care about their wellbeing.14 So, while it is especially worrying that GPs often feel underappreciated and under-supported, local interventions can help.15 In healthcare, effective management has been linked to increased job satisfaction and employee retention.16 However, GP appraisals are often confined to national processes and it is rare to have practice-based line management.11 This may be a missed opportunity for GPs to receive feedback and recognition for their unique contributions. It raises questions of who might undertake this kind of line management and support in primary care, how time can be generated for this, and what kinds of training and support those undertaking it might need.

What support is required from the wider system?

Good leadership and management in surgeries is key to making them attractive places to work and stay working. For some surgeries this is already in place. For others, help—including with developing a more positive workplace culture—is needed. This poses challenges for a system that has historically undervalued and underinvested in leadership and management support for general practice.17 It is even more challenging at a time of considerable system flux in the NHS, when organisations that might previously have provided necessary support—such as clinical commissioning groups and Health Education England—are being disbanded or merged. Calling for “cultural change” without providing the necessary infrastructure and support risks setting practices up to fail.

Wider NHS culture must also positively reinforce practices in prioritising GP retention. Introducing targets around access that drive up workload, or “naming and shaming” practices for perceived poor performance (for example, on face-to-face appointments),18 undermines attempts to reduce workload and centre practice culture around retaining staff.

Ultimately, many factors driving poor job satisfaction for GPs lie outside the direct control of individual practices. Challenges are magnified in socioeconomically deprived areas, where workload pressures and GP turnover are highest.1920 Making general practice an attractive place to work requires national action to increase investment, reduce workload, and change rhetoric to reflect greater appreciation for the role of general practice in the NHS. Yet local action is needed too. For practices, delivering sustainable patient care means creating cultures where the job satisfaction and wellbeing of staff is prioritised—with decisions taken through this lens. Local NHS bodies should support practices in these goals.

Therapeutic relationships have long been at the heart of general practice. Their importance—and the importance of practice culture in GP retention—should not be underestimated.


  • Competing interests: RF declares that in the UK she is a GP and senior policy fellow at the Health Foundation.

  • The views expressed in this article reflect those of the authors, neither of whom have further conflicts of interest to declare.

  • Provenance and peer review: Not commissioned; not peer reviewed.