General practice

Spending on general practice has increased for the past six years – but GPs are having to work harder as demand for care increases. General practice has managed these higher workloads by becoming more efficient and making greater use of physiotherapists and health care assistants to provide care.

But decreasing continuity of care and lengthening waits for appointments suggest that these new working practices have not been enough to keep up with demand, resulting in falling patient and public satisfaction.

The funding outlined in the NHS long-term plan and the 2019 GP contract should be enough to allow GPs to meet rising demand over the next four years, but is unlikely to be enough to achieve all of the improvements in access to and expansion of services outlined in the NHS long-term plan.

General practice addresses a broad range of medical needs within the community. Staff diagnose and manage symptoms and conditions, and in addition to undertaking consultations for single issues and de-medicalising problems where appropriate, manage health care for people with complex long-term conditions. If patients require urgent or specialist treatment, they are referred to hospital or specialist units – but general practice is in essence the ‘front door’ of the NHS, and its staff work closely with health visitors, social care staff and charities.

Spending on general practice has increased over the past six years

Change in total current and capital spending in general practice in England since 2010/11 (real terms)

Real-terms spending* on general practice increased by 17.9% between 2010/11 and 2018/19, an average of 1.8% a year; after an initial fall, it grew on average 2.7% each year after 2012/13.[1] Average spending per registered GP patient rose from £136 in 2013/14 to £152 in 2017/18 – a real-terms increase of 4.9%.[2],[3]

After 2016, higher spending was driven by NHS England’s promises in its General Practice Forward View. This committed to increase spending on general practice by an additional £2.4 billion (bn) a year by 2020/21, and to increase the share of NHS spending allocated to general practice.[4] Spending on general practice did rise after 2016, but not as quickly as some other health services – by 6.1% between 2016/17 and 2018/19,** a slower rate of growth compared with specialist NHS trusts (10.8%) and ambulance trusts (16.6%), although faster than mental health NHS trusts (5.0%) and acute NHS trusts (4.2%). Consequently, the share of NHS spending allocated to general practice slightly reduced, from 7.3% in 2015/16 to 7.1% in 2018/19.[5]

The NHS long-term plan published in January 2019 again committed to increase spending on primary and community health services, including general practice, by £4.5bn by 2023/24, promising that spending on these services will increase faster than the overall NHS budget.[6] The 2019 GP contract, a new employment contract for GPs used to implement the plan, specified how general practice funding will increase. The 2019 contract will increase core contract funding by £978 million (m) by 2023/24.[7]

In addition, some practices will receive funding for additional staff such as clinical pharmacists and physician associates who will work with GPs to provide care in Primary Care Networks (PCNs).[8]

This additional funding will be worth £1.8bn by 2023/24 for primary care services. Together, the core contract and additional funding amount to a 22.6% real-terms increase in funding for general practice between 2018/19 and 2023/24.

* This includes some capital investment such as building and ICT programmes, and some general practice services provided in A&E departments. See NHS Digital, Investment in General Practice 2013/14 to 2017/18 England, Wales, Northern Ireland and Scotland, 2018, p. 4.

** These and the following NHS trust figures are taken from the consolidated NHS provider accounts. See NHS England, Consolidated NHS Provider Accounts 2017/18, HC 1349, 2018, www.england.nhs.uk/publication/ consolidated-nhs-provider-accounts-2017-18

Demand is increasing – particularly among the groups who use GP services most intensively

Change in estimated demand for general practice consultations since 2010Demand for general practice services has risen as the population has increased, and aged – and in addition to this, patients with multiple chronic conditions (such as diabetes and arthritis) are also raising demand for GPs’ services. At the same time as these demands have gone up, so too have patients’ expectations of general practice.

The population in England grew 6.4% between 2010 and 2018.[9] But the parts of the population that use GP services most intensively – typically older people – rose faster than the population as a whole: the number of people aged 65 or older increased by 19% between 2010 and 2018.

Applying an estimate of the consultation needs of men and women of different ages produced by the Department of Health (DH) in 2011, we estimate that demand for GP consultations and prescriptions rose by 9% and 11.5% respectively between 2010 and 2018.[10],[11]

These figures do not, however, account for the impact of rising prevalence of multimorbidity – people who have more than one chronic illness – on demand for general practice.* In 2012, the DH estimated that people with long-term conditions accounted for 50% of general practice appointments[12] – and that the number of people with more than one chronic illness would rise from 1.9m in 2008 to 2.9m in 2018.[13]

In addition to these demographic factors, some qualitative evidence suggests that patients now expect GPs to be more accessible and provide a wider range of services – such as antibiotic prescriptions and specialised tests. If these increased expectations were widespread, then demand – if not need – for general practice will have increased further still.[14]

* There is evidence that people with multimorbidity use more health services. For example, people with multimorbidity have more GP consultations than people without multimorbidity. See Salisbury C, Johnson L, Purdy S, Valderas J and Montgomery A, ‘Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study’, British Journal of General Practice, 2011.

GP numbers remain below target, but the number of other general practice staff is increasing

Number of general practitioners and other staff involved in direct patient care within general practiceThe government’s aim is to increase the number of GPs by 5,000 – but it is nowhere close to achieving this. In fact, the numbers of GPs are falling – and have been doing so steadily since 2015, when the target was first set.

Between September 2010 and September 2014, the number of GPs, nurses and other staff in general practice all increased: GPs by 6.2%, nurses by 2.9% and other direct patient carers by 31.9%, an overall increase of 6.6%. Following a change in the way the data is collected,[15] the number of staff classed as GPs fell by 1.5% between March 2016 and March 2019 (the longest period we can compare the same month with the latest data)*. The number of GPs increased very slightly over the last full year of data, from 32,586 (June 2018) to 32,799 (June 2019) – a 0.7% increase. However, this was not enough to reverse declines since September 2015.

The number of GPs – and the hours they are working – have not kept pace with the number of patients on GPs’ registers. The average number of minutes per year that regular GPs (excluding locums – doctors who temporarily fill in positions) had available per patient fell from 69.2 in September 2015 to 65.5 in March 2019.[16] Including locums, the figure fell from 70.4 to 68.1 minutes.**

The government is yet to achieve its aim of increasing the net number of GPs by 5,000. The Cameron government originally aimed to achieve this increase in GPs between 2015 and 2020, although the May government removed the time limit in 2018.[17] There were 33,657 GPs in September 2015 compared with 33,327 in September 2018 – indicating that far from reaching the 5,000-GP increase, the government is in fact more than that number (5,330) short of its original target.[18]

While GP numbers fell after 2015, the number of other staff working in general practice increased. Nurse numbers increased by 6.8% between September 2015 and September 2018, although growth over the past year has slowed; the number rose by only 0.2% between June 2018 and June 2019.

The number of other staff involved in direct patient care – such as clinical pharmacists and physiotherapists – increased by 18.1% between September 2015 and September 2018. The number of full-time-equivalent (FTE) locums increased by 9.7% between June 2017 and June 2019, to 1,316.[19] The total number of staff working in general practice increased by 4.9% between September 2015 and September 2018.

It is hard to interpret why the number of locum GPs is rising faster than the number of regular ones. Locums could be retired GPs supplementing their income (and so contributing to the workforce) or newly qualified GPs who have chosen to become locums because of greater flexibility (so contributing to the fall in full-time numbers). If most locums are newly qualified, then this suggests that changing attitudes to work–life balance among a new generation of clinical professionals will change the general practice workforce.

The government should collect and publish data on the breakdown of the locum workforce by age to better understand the rise in locum doctors.

There is some survey evidence that those GPs who do work full time are working more hours. The 2017 GP Worklife Survey, an annual survey of GPs conducted by the University of Manchester’s Policy Research Unit, reported that, on average, a GP’s weekly hours were 41.8 hours, up from 41.4 hours a week in 2010.[20]

The proportion of GPs working full time (37.5+ hours a week) decreased from 33.1% in March 2016 to 28.7% in March 2019,[21] suggesting that the increase in working hours has not been due to an increase in the share of GPs working full time.

In contrast, other staff in general practice are increasingly working full time. Between 2015 and 2018, the share of nurses working full time rose from 13.2% to 15.8%, and the share of other direct patient carers working full time increased from 9.9% to 14.6%.[22]

* Staff numbers vary between seasons, so we compare the same months to avoid seasonal changes. Data for September 2019 is not yet available, so March 2016 to March 2019 provides the longest consistent time series. There is no data for June 2016.

** These figures are calculated by dividing the total number of minutes worked each year by GPs by the number of patients registered with GP surgeries.

The NHS is purchasing medicines used in primary care at a lower price

Change in the net ingredient cost (NIC) of medicines prescribed in the community since 2010/11 (real terms)The NHS has managed to make considerable savings in spending on medicines – despite an increase in the number of items prescribed – and there may be potential for further savings in the future.

Estimated real-terms spending* on community-prescribed medicines (prescription items dispensed by community pharmacists, appliance contractors and dispensing doctors in England) decreased 12.4% between 2010/11 and 2018/19. At the same time, the number of community-prescribed items increased 19.6% between 2010/11 and 2018/19, from 0.96bn to 1.1bn.[23] GPs are getting medicines they prescribe at a cheaper price – the mean cost per item dispensed in the community declined from £9.53 in 2010/11 to £7.96 in 2018/19, a real-terms decrease of 26.8%.[24]

The NHS was able to make these savings due to greater use and falling costs of generic medicines – medicines that are not marketed under a brand name and are available once the original patent has expired.[25]

More competition to provide generic medicines has led to a reduction in their cost. For generic cardiovascular medicines such as statins, for example, competition has helped cut the average cost by 57.7% between 2006 and 2016[26] – more than offsetting the 36.2% increase in the number of such prescriptions over the same period.[27] The NHS also has a policy to favour cheaper generic medicines where possible. Generic medicines accounted for 35% of drugs dispensed in primary care in 2018/19, up from 29.5% in 2010/11.[28]

But not all medicines prescribed as generics will end up being dispensed as such. A GP may prescribe a generic medicine, but a pharmacy may give the patient a proprietary – branded and patented – medicine, depending on what they have in stock. So while 35% of drugs dispensed in primary care in 2018/19 were generics, the share that were prescribed as such was in fact 59.5%, showing a shortfall in the ratio of prescribed and dispensed medicines.

This suggests scope for further savings, as it indicates that pharmacies are dispensing more expensive medicines than are prescribed. This might be because new generic medicines are not always easily available, and they may have to put in time to establish new accounts with diff  rent suppliers.[29] Whatever the reason, given that the NHS long- term plan envisages a greater role for community pharmacies in providing direct patient care,[30] they will have to overcome these barriers as their responsibilities increase.

* We can only estimate spending because NHS Digital reports figures for the NIC of medicines prescribed in the community – the cost of all the medicines prescribed in a given year at their list price. This does not account for the cost of VAT or dispensing, or any reduction the NHS can secure through discounts. See NHS Digital, Prescription Cost Analysis England: 2018, 2019, p. 6.

General practice activity has risen

The population is growing larger and older. At the same time, the NHS is directing more people to general practice. The fragmented data available suggests that this combination has seen GPs’ workloads increase considerably.

The most common activity in general practice is consultations – where patients book appointments with GPs, nurses, physician associates or physiotherapists. But unlike hospitals, there was no nationally consistent time-series data on consultations in general practice until April 2018. We know that there was a steady growth in consultations before 2008: a study of consultations estimated that there were 300m consultations in England in 2008, a 38% increase on 1995.[31] But we cannot know how the number of consultations changed in the interim decade.*

NHS Digital estimated that there were 332m consultations in England in the year ending in April 2019.[32] This is clearly more than in 2008 – although the numbers are not directly comparable as the methodology used to calculate them was different.

GP appointments often end with a prescription for medicines that are then dispensed from community pharmacies. Prescriptions dispensed in the community increased by 18.6% between 2010 and 2017, from 0.9bn to 1.1bn[33] – but some of this increase is due to the growing number of people with multimorbidity, rather than an increase in appointments. Most prescriptions that GPs issue do not require an appointment – The King’s Fund, a health think tank, estimates that 70–80% of prescriptions are issued ‘on repeat’ – where a prescription that has been issued to a patient previously is signed off by a GP without an appointment.[34] This still, though, requires time on the part of GPs.

Some of GPs’ increased workload is because of changes in other parts of the health system. The NHS has increasingly encouraged people to use NHS 111 – its direct line for urgent, but not emergency, medical problems brought in to ease demand on the 999 service – to try and direct people to the most appropriate health service for their needs, and to reduce pressure on A&E. This has increased awareness of the health services on offer that, combined with people’s high expectations of access to care, has increased calls made to NHS 111.

In 2014/15, the first full year the service was accessible to the whole of England, there were 12.9m calls to NHS 111. By 2018/19, this had risen to 16.8m – an increase of 30.3%.

NHS 111 may be directing some people away from general practice, as more people are calling in rather than going straight to their GP. The proportion of triaged calls where the patient was recommended to speak to or attend some form of primary or community care decreased from 62.4% in 2014/15 to 58.9% in 2018/19. But the higher volume of 111 calls means the number of people recommended by operators to speak to or attend primary care increased from 6.5m to 7.7m between 2014/15 and 2018/19.[35] The Nuffield Trust, a health think tank, estimates that the number of people NHS 111 diverted from A&E to general practice increased from 875,235 to 1,258,176[36] between winter 2013/14 and winter 2015/16.

Another reason for increased workloads may also be because of supply-induced demand, where an increase in services available leads to greater use (even when unnecessary). The share of general practices offering full extended access – bookable appointments outside of core contractual hours, such as during evenings and weekends – increased from 17.7% in October 2016 to 38.4% in March 2018.[37]

This risks extending GPs’ workloads as more patients turn up who would otherwise not have[38] – although some of this may be meeting previously unmet need.

* Smaller studies suggest that consultations continued to grow, potentially faster than growth between 1995 and 2008. A retrospective analysis of 100m consultations between 2007 and 2014 estimated that general practice workload increased by 16%; and The King’s Fund has estimated that there was a 15% increase in consultations between 2010/11 and 2014/15. See Hobbs FDR, Bankhead C, Mukhtar T, Stevens S, Perera-Salazar R, Holt T and Salisbury C, ‘Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007–14’, The Lancet, 2016, vol. 387, no. 10035, retrieved 15 September 2018; Baird B, Charles A, Honeyman M, Maguire D and Das P, Understanding Pressures in General Practice, The King’s Fund, 2016, p. 3.

Public and patient satisfaction with general practice is falling

Patient satisfaction in the NHS as a whole has fallen slightly over the past decade; public satisfaction, however, has fallen dramatically. This appears to be due to difficulties accessing primary care[39] – as there is no sign of a decline in the quality of care offered by GPs.

Overall patient satisfaction has fallen slightly. The share of patients responding to the GP Patient Survey who rated general practice as Good or Very Good decreased from 88.4% in 2012 to 84.8%[40] in 2017 (prior to a methodology change in 2012, 90% of patients were Very or Fairly Satisfied with general practice in 2010). Following a methodology change* in 2018, the proportion of respondents rating general practice as Good or Very Good fell slightly from 83.8% in 2018 to 82.9% in 2019.

This decrease in satisfaction comes alongside an increase in the number of written clinical complaints, which rose from 16,300 to 31,559 between 2009/10 and 2015/16. Following a change in how clinical complaints are recorded,** the number rose more slowly between 2016/17 and 2017/18, from 11,744 to 11,870.[41]

The satisfaction of patients who use GP services most intensively follows a similar pattern. The share who agreed they have enough support to manage their long-term health conditions over the past six months fell from 54.1% to 50.5% between 2012 and 2017, with the proportion feeling they do not have enough support increasing from 14.6% to 16.7%.[42]

However patient satisfaction is measured, it has declined only slightly while public satisfaction with general practice has fallen dramatically – and is at its lowest level in 35 years.[43] The share of the public who are Very or Quite Satisfied with general practice decreased from 77% to 63% between 2010 and 2018, while the proportion who are Very or Quite Dissatisfied increased from 14% to 24%.[44]

Public attitudes to general practice

The dramatic fall in public satisfaction is most likely being caused by people struggling to book GP appointments, and/or not being able to see their preferred GP. In addition to longer waiting times (discussed below), there has been a decline in the continuity of care – that is, patients seeing the same doctor. The proportion of patients seeing their preferred GP always, almost always or most of the time decreased from 77.0% to 50.2% between January–March 2009 and August 2018.[45]

This may explain some of the decline in satisfaction as the higher trust and better communication associated with continuity of care are strongly correlated with overall satisfaction.[46]

While the public is less satisfied, there is no sign that the quality of care provided in general practice has declined – further suggesting that the primary cause of dissatisfaction is lack of access. Practices’ Quality and Outcomes Framework (QOF) scores – a raft of metrics used to measure clinical quality and distribute additional funding for good practice – have improved. The percentage of practices achieving maximum QOF points increased from 5.8% in 2014/15 to 12.5% in 2017/18.[47] The Care Quality Commission (CQC) rated the vast majority of practices (90%) as Good or Outstanding, and only 10% as Inadequate or Requires Improvement, in May 2017.[48]

* In 2010, the survey question was: “In general, how satisfied are you with the care you get at your GP surgery or health centre?”, with respondents choosing from ‘satisfied’ and ‘very satisfied’. This question was replaced in the 2011 survey with the question: “Overall, how would you describe your experience of your GP surgery?”, with respondents rating their experience as ‘good’ or ‘very good’.

** The 2016/17 data expanded the number of complaint categories, meaning that some complaints that were categorised as clinical in 2015/16 are likely to have been reclassified in 2016/17.

Has general practice become more efficient – and if so, can that be maintained?

GPs now tend to operate from larger practices, make more use of physiotherapists and health care assistants to treat patients, and conduct more consultations online or by phone, than they did nine years ago, meaning they are stretching their budgets further. But the current model of general practice is under strain.

More and more doctors want to leave general practice: the age of retirement among GPs is falling and many are increasingly dissatisfied with their level of pay and the hours they work. It will be difficult to sustain the current level of efficiency in general practice without further reform to the way GPs work.

The public sector pay cap did not apply to general practice in the same way as it did to other parts of the NHS.* But general practices have made savings by merging practices, conducting more consultations online or over the phone and buying cheaper, generic medicines. GP Online reports that more than 1,000 GP practices, covering 4.2m patients, closed or merged[49] between 2013 and 2018. NHS Digital data shows that there were 611 fewer practices in March 2019 than there were in September.

These remaining practices have a larger number of GPs – between March 2016 and March 2019, the share of practices with five or more GPs increased from 45.8% to 48.8%, while the number of practices with more than 10 increased from 7% to 10.1%.[50] It is difficult to quantify the implications of larger practices for running costs but an inquiry by the CQC concluded that merging practices allowed GPs to consolidate resources and provide better care.**

GPs are conducting more remote consultations, which are typically quicker and cheaper than meeting patients in person. The share of consultations by telephone increased from 5% (2012) to 9.3% (2018). Online consultations increased at a slower rate, from 0% in 2016 to 0.1% in 2018.[51] Between November 2017 and November 2018 there were 40.8m telephone consultations and 1.4m online consultations.[52]

However, without data on follow-up appointments, it is difficult to tell if these remote consultations are quite as efficient as they appear or whether patients who have them later come in in person for a face-to-face appointment about the same problem.[53]

Patients are increasingly being seen by nurses and other lower-paid practice staff, rather than GPs. The number of nurses in general practice increased by 6.8% between September 2015 and September 2018, while the number of other staff providing care increased by 18.1%.[54] Assuming that follow-up appointments with GPs are not required, it is less expensive for these other staff to see patients[55] – and could free up GPs to deal with patients with complex conditions.

However, The Kings Fund has raised concerns that these other staff might simply be supplementing GP appointments – and that care led by other staff may not actually reduce costs.[56] Nurses, for example, tend to provide longer consultations and recall patients more frequently.[57]

Despite these concerns, the 2019 GP contract provided funding to recruit another 20,000 of these staff by 2023/24 – including clinical pharmacists, physician associates and first-contact physiotherapists. This represents a big shift: if successful, this would more than double the numbers of these other direct patient care staff (which stood at 19,490 in June 2019).[58]

These extra staff members could help bring about what appears to be a required shift in working practices in general practice. The sector has historically been reliant on GPs to deliver patient care but the NHS has struggled to recruit for the position in recent years and a growing share of those GPs currently working for the NHS say they are dissatisfied with their working conditions and are planning to leave.

The share of GPs responding to the GP Worklife Survey who said that they have a high or considerable intention to leave direct patient care within the next five years increased from 22% to 39% between 2010 and 2017.[59] The number of GPs retiring early (before the age of 50) rose from 513 in 2011/12 to 721 in 2016/17; the average age of retirement also fell – from 60.4 years to 58.5 years – over the same period.[60]

This growing dissatisfaction is due to both pay and workload. Ranking satisfaction on a scale from 1 to 5, GPs’ average satisfaction with their pay decreased from 4.9 in 2010 to 4.2 in 2017. At the same time, average satisfaction with hours of work decreased from 4.4 to 3.6. Rating job stressors on the same scale, the average rating for long working hours as a stress factor increased from 3.44 to 4.11 over the same period.[61]

Other survey data also suggests that work–life balance is also a growing problem. In 2016, a survey for The King’s Fund found that 31% of trainee GPs intended to be in full-time clinical work a year after qualification, but only 10% planned to be 10 years after qualification. By 2018, these had fallen to 21.7% and 5.4%, respectively.[62],[63]

That survey showed that the most common reason cited for not wanting to work as a GP full time was the intensity of the working day.

The decreasing proportion of trainees intending to be in clinical work full time and choosing instead to pursue a part-time or portfolio career – coupled with the government’s inability to meet GP recruitment targets – suggests that general practices will have to either use more nurses, pharmacists and physiotherapists to provide care, or find other ways to address the excessive workload that is causing trainee GPs to want to work part time.

Constraints on GPs’ time also has an impact on patients. The Royal College of General Practitioners has argued that the current use of short appointments is unsustainable and has called for the average length of a GP consultation to be increased to 15 minutes, up from the current average of nine.[64] Its chair has stated that “it is abundantly clear that the standard 10-minute appointment is unfit for purpose”, arguing that patients with more than one health condition can rarely be adequately dealt with in 10 minutes.[65]

* GP partners take a profit share from their practice, as opposed to a salary. Nurses and other staff working in practices are salaried employees – but practices were not restricted by public sector pay controls. See Dr Paul Neil’s Blog, ‘How GPs are Paid’, Blog, (no date) retrieved 9 October 2019, www.drneilpaul.blog/articles/how- gps-are-paid

** A 2018 Care Quality Commission report analysing 10 GP practices found that mergers allowed practices to offer a wider range of services, such as simple operations, and increased take-up of services such as smoking cessation clinics, for example. See Care Quality Commission, Driving Improvement: Case studies from 10 GP practices, 2018, pp. 11, 19, 36.

Have efficiencies been enough to manage demand?

Longer waiting times for appointments and increasing numbers of practices closing their lists to new patients both suggest that general practice has struggled to keep up with growing demands – but caution is needed in interpreting these figures.

There is some evidence that GPs have increasingly tried to limit the number of patients they treat. The number of applications for list closures – where a practice applies to NHS England to temporarily refuse to accept new patients if it believes that the volume of demand is jeopardising standards of care – has risen. In 2012/13, 40 practices (0.5% of all GP practices) made such applications, but this rose to 231 in 2016/17 (3%), before falling to 148 in 2017/18 (2%).[66],[67],[68] The share of list closures that NHS England approved increased from 62% in 2016/17 to 72% in 2017/18.

Patient waiting times for an appointment with a GP or a general practice nurse

Politicians – including Prime Minister Boris Johnson[69] – often point to waiting times as evidence that general practice is failing to meet patients’ needs. As Figure 2.6 shows, the share of patients being seen the same day as they requested an appointment or on the next working day has fallen, while the share waiting a week or more has risen.

However, these figures must be interpreted with caution. Part of this shift is likely to reflect the growing prevalence of chronic conditions: patients with chronic health conditions (who account for a growing share of appointments) are more likely to book appointments further in advance. As such, some of the increasing share of appointments happening a week or more after booking may simply reflect an increase in patients with chronic health conditions receiving the sort of regular or pre-arranged monitoring they require.

But responses to the GP Patient Survey suggest that this is not the whole story – there are also a growing number of patients who struggle to make an appointment at all. In 2019, just over two thirds (67.4%) of respondents rated their overall experience of making an appointment as Good or Very Good, down from nearly four fifths (79.0%) in 2012. Similarly, in 2019, one in three patients said that it was not easy to get through to their GP practice by phone, compared with one in five in 2012.[70]

How will demand for general practice change?

Demand for general practice is likely to increase considerably as the population in England grows and ages – particularly if chronic conditions continue to become more prevalent. The funding increases that have already been announced for the NHS over the next four years will help to meet that demand, but there is unlikely to be much money left over to make the sorts of improvements set out in the NHS long-term plan. Without extra money, the ambitions given in the NHS long-term plan will be hard to reach, unless further efficiencies can be found.

Based on analysis conducted by The Health Foundation,[71] we project that demand for general practice – that is, the number of people who will require appointments or other general practice services – will increase by 22.6% between 2018/19 and 2023/24. To maintain the scope and quality of care in general practice in the face of rising demand, general practice spending will also need to grow by 22.6%.

The government set out a five-year spending plan for the NHS in The NHS Long Term Plan, with a specific plan for general practice confirmed in the 2019 GP contract.[72] This contract allocated £1.8bn more (in 2018/19 prices) for general practice in 2023/24 than in 2018/19 – a 22.6% increase in real terms. This is slightly faster than the 18.3% real-terms spending growth set out for the NHS as a whole in the plan.

If spending on general practice grows at the rate implied by the 2019 GP contract, GPs should then have enough money to meet demand – but it is unlikely to allow for improvements.

Projected spending and demand for general practice

General practice

Projected increase in demand by 2023/24 22.6%
Spending scenario GP contract Recent trajectory Meet demand
Change in real-terms spending by 2023/24 22.6% 21.9% 22.6%
Spending in 2023/24 (2018/19 prices) £13.8bn £13.7bn £13.8bn
Projected gap (2018/19 prices) £0.0bn £0.1bn £0.0bn

Source: Institute for Government calculations. See Chapter 13, Methodology.

However, a quarter of general practice funding is not covered by the 2019 GP contract – including some medicine prescription costs. If these other areas of funding grow instead in line with the overall NHS settlement,* overall funding for general practice would increase by 21.9% in real terms between 2018/19 and 2023/24. That would leave spending £100m below what we estimate would be needed to meet demand while maintaining existing standards.

But the government intends not only to maintain, but also to improve, access to and the scope of general practice services. Among other things, NHS England intends to:

  • provide patients with a definitive cancer diagnosis within 28 days, with 75% of cancers diagnosed by stages I or II by 2028[73]
  • prevent 150,000 cases of heart attack, stroke and dementia over the next 10 years by offering community-based, preventative programmes[74]
  • provide education and exercise programmes to “tens of thousands” of patients with heart problems[75]
  • provide primary care for an additional 380,000 adults to access care for common mental health conditions by 2023/24 via the Improving Access to Psychological Therapies (IAPT) programme.[76]

These targets do not, however, include the objective that Johnson hinted at in his first speech as prime minister – to reduce the number of patients waiting at least three weeks for an appointment.[77]

The reforms outlined in the The NHS Long Term Plan – such as the introduction of Primary Care Networks – may mean that practices can deliver services more efficiently. There may also be more scope to save money if GPs and pharmacists prescribe and distribute more generic medicines and if GPs make greater use of online and phone consultations.

However, it is unlikely that these efficiencies will be enough to enable the government to realise its ambitions to improve general practice – at least with the level of funding implied by the government’s spending plans.

* For full details, see methodology