Performance Tracker 2025: General practice

General practice has proved its ability to adapt time and again this decade. Just a matter of weeks into 2020 it was required to adjust to nationwide lockdowns, with staff in practices across England adapting the way they had delivered care for decades. When the Covid vaccine was rolled out, to the tune of many millions, general practice again led the way.

The end of the pandemic did not mark the end of change in the service. The system has continued to evolve, delivering more appointments – a greater proportion of them remotely – than ever before, via a workforce that has changed beyond recognition. Practices have integrated tens of thousands of non-GP staff, improving patients’ access by expanding existing services and creating new ones.

In short, Labour inherited a service in 2024 that was vastly different to how it looked even in 2019, let alone the last time the party was in power.

That has all been achieved with constrained finances. Recent Conservative governments increased funding for the service, but higher-than-anticipated inflation meant that total spending on the service fell in real terms in 2022/23. Funding also came with limited flexibility. Much of the recent increases have been tightly ringfenced for the hiring of those non-GP staff, which while helpful in expanding access has made it difficult for overstretched GP partners to direct funding where they think it is most needed.

Nor is funding well matched to demand for the service today. Practices in more deprived areas receive less funding compared to those in less deprived ones, despite the latter’s evidently greater need. Inequities do not stop there, either: practices with more deprived patient lists have fewer GPs per patient and, often relatedly, lower levels of patient satisfaction.

The GP partnership model – a foundational principal since the NHS’s inception where the NHS relies on independent contractors called GP partners to deliver general practice services – is buckling under multiple pressures. The number of GP partners has dropped by more than a quarter in the last decade, with the largest falls among GPs aged under 40. More partners work in wealthier parts of the country. The Labour government has so far done little to improve the attractiveness of partnership, making it likely that the model will continue its drawn out decline. The GP partnership model is not the only option for delivering primary care services – but the government has not articulated any vision for a future in which there are not enough partners to run general practice.

That does not bode well for the government’s reform programme. A well-functioning general practice service is key to delivering two of the government’s three intended “shifts” for the NHS: ¹ Parr E, ‘Streeting sets out three NHS ‘shifts’ ahead of Darzi review publication’, PULSE, 9 September 2024, retrieved 27 October 2025, www.pulsetoday.co.uk/news/politics/streeting-sets-out-three-nhs-shifts-ahead-of-darzi-review-publication/  from hospitals to the community, and from sickness to prevention. GPs are closer to their communities than most other doctors in the NHS and act as a conduit between health services and other services operating in a neighbourhood. The government deserves real credit for rapidly accelerating the growth of the salaried GP workforce. That was achieved by loosening a ringfence around money previously reserved for non-GP staff. The government could continue to grow the workforce and make the partnership model more attractive by extending that flexibility. If it continues to tie GP partners’ hands, recent growth in the salaried GP workforce will be undermined if the partnership model withers away without being replaced by a sustainable alternative.

This section looks at the health of general practice in England, since 2010 but also since Labour won the election in 2024, to assess how it has performed in the year and a bit since the Starmer government has been in office. For the first time this year, we are including data for primary care networks, as these employ increasing numbers of staff – particularly salaried GPs – and carry out increasing numbers of appointments.

Spending

Spending on general practice fell in 2022/23, partly due to high inflation

Spending on general practice was particularly low for the first half of the 2010s. The coalition and then Conservative governments cut spending on the service in real terms between 2009/10 and 2013/14, before then raising it in the years following – by 2018/19 spending was roughly one-sixth (16.7%) higher in real terms than it had been in 2009/10.

The May government and the British Medical Association (BMA, the union that represents most doctors) agreed a new five-year contract that started in 2019/20. That contract laid out cash-terms increases for core GP funding^* for each of the following five years. ² British Medical Association and NHS England, Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan, NHS England, 2019, p. 51, www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf  Based on forecast inflation in 2019, the government and BMA anticipated a real terms increase in funding over the course of the contract. That contract also introduced a funding stream for the newly created primary care networks (PCNs^**) through which the government would subsequently direct most of the uplift in funding for general practice, as described in more detail below.

Initially, total spending – which includes funding for PCNs and from sources such as the quality outcomes framework (QOF) – increased as anticipated. In the first three years of that contract (2019/20 to 2021/22), spending grew by 6.0%, 6.9% and 3.9% in real terms, even excluding additional Covid spending.

However, after rising during the pandemic, sharp increases in inflation from 2022/23 meant that total real-terms spending on general practice (excluding Covid income) was some 2.8% lower than in 2021/22. Excluding spending on PCNs, spending on the rest of general practice declined by as much as 7.1% in real terms.

Despite that shock in 2022/23, total spending on general practice grew 14.5% in real terms between 2018/19 and 2022/23 – though again when excluding spending on PCNs the picture is less bright, with just a 1.6% real terms increase. This means that much more spending on general practice is now going through PCNs than before the pandemic. Indeed, in 2022/23, more than £1 in £10 (11.3%) that the government spent on the service was directed through PCNs, up from £1 in £50 (2.0%) in 2019/20.

That matters because the Conservative governments in that period created quite a tight ringfence around PCN funding and intended that it be mostly used to support the hiring of additional non-GP staff, such as pharmacists, physiotherapists, and care coordinators. As discussed in more detail below, this lack of flexibility makes it more difficult for GP partners to allocate funding where it is most needed in their practice. By creating difficult financial trade-offs, this could contribute to some of the unattractiveness of partnership.

When inflation hit practices hard in 2022, the Johnson, Truss and then Sunak governments could have increased funding to compensate general practice for the unexpected additional costs. But those governments declined to do so, arguing that funding had been agreed as part of that 2019/20 five-year contract. In response, the BMA refused to agree to the GP contract in either 2022/23 ³ PULSE, ‘Main changes in the 2022/23 GP contract in England’, PULSE, 1 March 2022, retrieved 27 October 2025, www.pulsetoday.co.uk/resource/contract/main-changes-in-the-2022-23-gp-contract-in-england/  or 2023/24, ⁴ Iacobucci G, GPs to consider industrial action after NHS England imposes contract, BMJ, 2023, www.bmj.com/content/380/bmj.p549  despite these being the final years of the contract that had already been agreed in 2019.

That led to the Conservative governments unilaterally imposing those contracts on the service. Bringing core contract funding fully in line with the real terms expectations from 2019 would have required the government to spend an additional £571.5 million on the service in 2022/23 and £982.0 million in 2023/24 – in the latter case, 0.5% of the total day-to-day spending by the Department of Health and Social Care (DHSC) in 2023/24.

The Conservative government and the BMA could also not agree the terms of the GP contract in 2024/25, the first year after the 2019 contract expired, resulting in the Conservative government imposing a single year contract on the service. ⁵ British Medical Association, ‘Background to the imposed 24/25 GP contract changes’, BMA, 2024, retrieved 27 October 2025, www.bma.org.uk/pay-and-contracts/contracts/gp-contract/gp-contract-changes-england-202425  That caused the BMA general practice committee (GPC, the body that represents GPs) to formally enter an industrial dispute with the NHS in April 2024, with GP partners then voting to undertake industrial action in August 2024 ⁶ Fisher B, ‘GPs are taking ‘collective action’. What does that mean?’ Nuffield Trust, 9 August 2024, retrieved 27 October 2025, www.nuffieldtrust.org.uk/resource/gps-are-taking-collective-action-what-does-that-mean-0  – just weeks after the Labour government entered office.

_{*    Core GP contract funding does not include funding like the quality outcomes framework (QOF) or network directed enhanced service (DES) but is most funding for general practice and is largely un-ringfenced. According to plans laid out in 2019/20, core contract funding in 2022/23 was £8.7bn. Given the total spent on general practice was £14.8bn in that year, 59% of spending on general practice came through the core contract.}

_{**    PCNs are organisations that were created in 2019 in which a group of practices coordinate between themselves and other parts of primary care to deliver improved care. There are 1,250 across England. They are vehicles which allocate cash to practices, though that cash is usually ringfenced for specific purposes.}

Spending likely increased in 2023/24, driven by more funding for PCNs

There is currently no spending data for 2023/24, but from available information, it is likely that spending increased somewhat compared to 2022/23. As previously mentioned, the government decided to maintain core funding at the cash level agreed in 2019, meaning that this core funding for practices likely declined again in real terms in 2023/24, by 3.2%. But, at the same time, the NHS stated that it expected PCN funding to increase to £2.4bn in 2023/24, up from £1.7bn in 2022/23. This would be a 35.2% real terms increase and would offset the decline in core contract funding.

Taken together, spending on general practice would grow by 1.1% in real terms. This would mean that more than 15% of funding for general practice would have gone through PCNs in 2023/24.

2024/25 was the first year after the expiry of the five-year contract agreed in 2019. There is even less information about funding increases for that year (for example, there is no information about the total amount of PCN funding). But the King’s Fund report that the government increased funding by 2.2% in cash terms in 2024/25 compared to 2023/24. ⁷ Baird B and Wickens C, GP contract 2024/25 explained: funding, incentives and the workforce, The King’s Fund, 2025, www.patientlibrary.net/cgi-bin/download/file/244992  Inflation was at 3.8% in 2024/25 compared to 2023/24, meaning that total spending on general practice would have fallen in real terms (by 1.5%) between those years.

Labour provided a relatively large uplift in 2025/26, though it may not keep pace with costs

After winning the election, the Labour government and the BMA agreed a one-year contract for 2025/26, ⁸ British Medical Association, ‘BMA accepts 2025/26 contract for GPs in England as a ‘starting point’’, press release, BMA, 28 February 2025, www.bma.org.uk/bma-media-centre/bma-accepts-202526-contract-for-gps-in-england-as-a-starting-point  with the government committing to working with the BMA to secure a longer-term contract by the end of 2026 that will start from April 2028 at the latest. ⁹ Parr E, ‘BMA wants wholesale new GP contract to be agreed ‘by end of 2026’’, PULSE, 10 April 2025, retrieved 27 October 2025, www.pulsetoday.co.uk/news/contract/bma-wants-wholesale-new-gp-contract-to-be-agreed-by-end-of-2026/  This will likely mean that the BMA and the NHS will negotiate single year contracts for any years which are not covered by that multi-year contract.

Industrial action was “paused” when the BMA and the NHS agreed the 2025/26 contract. ¹⁰ Parr E, ‘GP collective action paused as BMA ‘no longer in dispute’ with Government’, PULSE, 28 February 2025, retrieved 27 October 2025, www.pulsetoday.co.uk/news/breaking-news/gp-collective-action-paused-as-bma-no-longer-in-dispute-with-government/  Under that agreement, the government initially agreed to provide general practice with £889 million worth of additional funding through the core practice contract and the PCN funding route. ¹¹ NHS England, Changes to the GP Contract in 2025/26, NHS England, 2025, www.england.nhs.uk/long-read/changes-to-the-gp-contract-in-2025-26/  The government later provided an additional £127 million to cover things such as higher costs from a pay uplift for salaried GPs. ¹² NHS England, Financial implications and actions for integrated care boards (ICBs) following the mid-year updates to the 2025/26 GP contract, NHS England, 2025, www.england.nhs.uk/long-read/financial-implications-and-actions-for-integrated-care-boards-icbs-following-the-mid-year-updates-to-the-2025-26-gp-cont…  It has said that this will take the combined value of the core contract and PCN funding from £12.3bn in 2024/25 to £13.3bn in 2025/26, a real terms increase of 5.5%. ¹³ NHS England, Changes to the GP Contract in 2025/26, NHS England, 2025, www.england.nhs.uk/long-read/changes-to-the-gp-contract-in-2025-26/ ^*

The government has also created an additional £80 million pot of money to compensate practices with £20 each time they request specialist advice from colleagues in hospital.^** This is activity that was previously not reimbursed and is discussed in more detail below.

There are, however, other cost pressures which will reduce the generosity of the funding uplift. Practices employ staff in roles such as administrative support and on reception who are paid at the national living wage (NLW) level. This means that practices will be affected by the 6.7% increase in the NLW in 2025/26, both by having to pay those staff more, but also by having to raise the wages of staff further up the payscale, to maintain wage differentials. ¹⁴ Low Pay Commission, ‘National Living Wage to increase to £12.21 in April 2025’, press release, GOV.UK, 29 October 2024.

The government also chose not to compensate GPs for the increase in employers’ national insurance contributions (NICs) announced at the 2024 autumn budget, unlike with other public services. ¹⁵ British Medical Association, Impact on GPs of increases to Employer National Insurance Contributions, BMA, 2024, www.bma.org.uk/media/jddkjznc/impact-of-nics-changes-member-briefing.pdf  This means that again GPs’ funding will be eroded by having to meet those costs. ¹⁶ Tonkin T, ‘NI hike fuelling crisis in general practice’, BMA, 23 June 2025, retrieved 27 October 2025, www.bma.org.uk/news-and-opinion/ni-hike-fuelling-crisis-in-general-practice  The BMA estimates that the cost of the increase in the NLW and employer NICs would be £187 million across England. ¹⁷ British Medical Association, ‘GP contract changes England 2025/26’, BMA, 2025, retrieved 27 October 2025, www.bma.org.uk/pay-and-contracts/contracts/gp-contract/gp-contract-changes-england-202526 ^*** This would reduce the generosity of the uplift in the core contract and PCN funding from 5.5% in real terms to 4.0%.

As part of the NHS’s 10 Year Health Plan for England the government committed to directing a greater proportion of NHS funding towards out-of-hospital care. ¹⁸ Department of Health and Social Care, 10 Year Health Plan for England: fit for the future, CP 1350, The Stationery Office, 2025, p. 137.  That includes general practice. Spending on the entire English NHS is due to rise by 3.0% in real terms per year between 2025/26 and 2028/29. If the government sticks to its pledge, that means that funding for general practice is likely to increase at a greater rate than that, though it has not yet confirmed how it intends to split funding between different parts of the NHS.

_{*    This is lower than the numbers quoted above because there are other funding streams which are not captured in this number.}

_{**    This is when a GP consults with a specialist colleague in secondary care before making a referral, with the hope that it reduces the number of unnecessary referrals.}

_{***  This is likely an underestimate, because it does not include the cost of practices increasing pay above the NLW
rate to maintain wage differentials.}

New ways of funding general practice provide less certainty and autonomy

As noted above, most of the additional funding for general practice since 2019 has been directed through PCNs and tightly ringfenced for spending on specific staff groups. Multiple interviewees told us that the tight ringfencing of funding that goes through PCNs is a symptom of the lack of trust that central government (the Treasury, the Department of Health and Social Care, and NHS England) has in practices to spend money effectively. ¹⁹ Institute for Government interview  Many said that the government and NHS worry that if they put funding increases through the core contract (which has fewer ringfences) then it would result in partners drawing more money out of the service, rather than spending it on improved care for patients.

This reveals a contradiction in how the government approaches general practice. GP partners are independent contractors that deliver services to the NHS for a fee; they have an incentive to work efficiently because they can then draw more earnings from the practice, after meeting contractual requirements. As a result, the NHS often benefits from GP partners’ high levels of discretionary effort – as our Performance Tracker Local report from earlier this year showed, an additional GP partner is associated with more appointments than other GPs and patient satisfaction is higher in practices that have more partners. ²⁰ Hoddinott S, General practice across England, Institute for Government, 2025, www.instituteforgovernment.org.uk/publication/performance-tracker-local/general-practice-england

Partners are also free to deliver services in ways that best suit their patients’ needs. In other words, partner autonomy and freedom to innovate is a key strength of the partnership model. But successive governments’ decision to increase funding ringfences ties partners’ hands, undermining those fundamental benefits of the model. The current government has continued to use the PCN funding stream, albeit while loosening some of the restrictions over how practices can spend the money, as discussed in more depth below.

The government has announced further intended reforms to the operating model of general practice. As part of the NHS’ 10 Year Health Plan for England (10YHP), the government proposed the introduction of two new types of contracts for GPs. These are the “single neighbourhood providers” and “multi-neighbourhood providers”, which will be comprised of multi-disciplinary teams (MDTs) working in the community. ²¹ Department of Health and Social Care, 10 Year Health Plan for England: fit for the future, CP 1350, The Stationery Office, 2025, p. 32.  The former will operate across a population of approximately 50,000 (roughly the same size as existing PCNs, which the 10YHP describes as “a springboard for this type of working” ²² Department of Health and Social Care, 10 Year Health Plan for England: fit for the future, CP 1350, The Stationery Office, 2025, p. 32. ) and the latter across a population of roughly 250,000 patients.

Single neighbourhood providers are intended to deliver services for populations whose needs can be met with more universal services, while multi-neighbourhood providers will deliver more specialised services, such as end-of-life care. ²³ Department of Health and Social Care, 10 Year Health Plan for England: fit for the future, CP 1350, The Stationery Office, 2025, p. 32.  The explicit purpose of these larger providers is to “unlock the advantages and efficiencies possible from greater scale”. ²⁴ Department of Health and Social Care, 10 Year Health Plan for England: fit for the future, CP 1350, The Stationery Office, 2025, p. 32.  This will be achieved through, for example, shared back-office functions between practices, improved data analytics, and economies of scale that will come from providing specialised care to a larger population.

The Plan also proposed the rolling out of Integrated Health Organisations (IHOs) – when a foundation trust “hold[s] the whole health budget for a local population”. ²⁵ Department of Health and Social Care, 10 Year Health Plan for England: fit for the future, CP 1350, The Stationery Office, 2025, p. 81.  Once again, the government has not explained the full implications of this proposal. But it seems likely that GP partners would have less control over spending in areas with IHOs.

Other models of delivering general practice are appearing as the GP partner workforce declines. For example, in a handful of areas acute hospital trusts have taken on the contracts for general practice, meaning that all GPs working in those practices become salaried GPs.26 This is known as “vertical integration.” One study estimated that there were  ²⁶ Sidhu M, Pollard J and Sussex J, Vertical integration of GP practices with acute hospitals in England and Wales: rapid evaluation, NIHR, vol. 10, no. 17, June 2022, p. 6, www.journalslibrary.nihr.ac.uk/hsdr/TLLA3317  acute trusts running 85 practices in 2021, ²⁷ Davies C, Saunders C, Olumogba F, Sidhu M and Sussex J, Identifying where hospital and community trusts are managing general practices in England: a service mapping study, BJGP Open, vol. 8, no. 3, 2024, https://bjgpopen.org/content/8/3/BJGPO.2023.0173  less than 2% of practices in England.

Overall, this and the last government have done little to reverse the decline in the number of GP partners (described in more detail below) and have even taken steps – such as directing funding through PCNs – which make it more difficult for partners to perform their roles effectively.

There is a real risk that the partnership model will continue to decay without a clear plan of what should take its place. Instead, there may evolve a patchwork, unplanned service with different models operating in different parts of the country, and no coherent vision of how they should work with other parts of the NHS.

Funding is lower in practices with more deprived patient lists

Between 2018/19 (the first comparable year in the time series) and 2023/24, funding per weighted patient for the 20% of practices with the most deprived patient lists was consistently lower than for other practices. In 2023/24, those practices received £155.90^* (in 2025/26 prices) for every weighted patient^** on their list. In comparison, the practices with the 20% least deprived patients received £169.12, a difference of 7.8%. This is despite strong evidence that there is greater need for care in more deprived parts of the country. ²⁸ Marmot M, Fair society, healthy lives : the Marmot Review : strategic review of health inequalities in England post-2010, GOV.UK, 2010, www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf

Since the high point of funding in 2018/19 – when the average payment per weighted patient to practices in England was £182.55, in 2025/26 prices – there have been steady falls. In 2023/24 the England average payment was £163.83, again in 2025/26 prices, meaning that funding had fallen by 10.3% in real terms. The fall was largest in the 20% of practices with the most deprived patient lists, at 11.8%

This difference is at least partly explained because the Carr-Hill formula – which the NHS uses to determine the distribution of a large part of GP funding – does not fully adjust funding to account for deprivation ²⁹ Fisher B, Loftus L, Holdroyd I, Ford J, Fairer funding for general practice in England: what’s the problem, why is it so hard to fix, and what should the government do?, Nuffield Trust, 2024, www.nuffieldtrust.org.uk/resource/fairer-funding-for-general-practice-in-england  and is based on decades-old data for some metrics.

The Nuffield Trust argues that the Carr-Hill formula is designed to allocate funding based on how much of a GP’s time a patient uses, rather than the need of those patients. ³⁰ Fisher B, Loftus L, Holdroyd I, Ford J, Fairer funding for general practice in England: what’s the problem, why is it so hard to fix, and what should the government do?, Nuffield Trust, 2024, www.nuffieldtrust.org.uk/resource/fairer-funding-for-general-practice-in-england  For example, one study found that the formula underrated the needs of younger patients and therefore directs more funding towards older patients, who tend to live in more affluent areas. ³¹ Holdroyd I, Appel C, Massou E and Ford J, Adjusting primary-care funding by deprivation: a cross-sectional study of Lower layer Super Output Areas in England, BJGP Open, vol. 9, no. 1, 2025, https://bjgpopen.org/content/9/1/BJGPO.2024.0185  The same study found that adjusting the formula for more up to date age and deprivation data would increase the extent to which funding allocations met needs. ³² Holdroyd I, Appel C, Massou E and Ford J, Adjusting primary-care funding by deprivation: a cross-sectional study of Lower layer Super Output Areas in England, BJGP Open, vol. 9, no. 1, 2025, https://bjgpopen.org/content/9/1/BJGPO.2024.0185

The Carr-Hill formula does account for the increased workload associated with patients that live with long-term conditions (morbidity) and higher rates of deaths in a population (mortality). But to do so, it uses survey data that was collected between 1998 and 2000, reducing its usefulness in allocating funding to areas with higher care needs now. ³³ British Medical Association, Focus on the global sum allocation formula (Carr-Hill Formula), BMA, 2015, p. 3, www.northstaffslmc.co.uk/website/LMC001/files/Focus-on-the-Global-Sum-Allocation-Formula-July-2015.pdf

The formula also uses other data that is decades out of date. As of April 2025, it calculated the average cost of hiring staff using earnings data from 1999 to 2001, population density data from 2001 and data about GPs’ expenses from 2000 to 2001. ³⁴ Kinnock S, General Practitioners: Finance, UIN 42330, written questions, 28 March 2025, https://questions-statements.parliament.uk/written-questions/detail/2025-03-28/42330

It is important for the government to try and direct more funding towards more deprived areas because health outcomes are worse in those parts of the country. Work from the Health Foundation shows that people living in poorer areas have a lower life expectancy, spend more time living with an illness, and are more likely to be living with multiple long-term conditions. ³⁵ Watt T, Raymond A and Rachet-Jacquet L, Quantifying health inequalities in England, The Health Foundation, 15 August 2022, retrieved 27 October 2025, www.health.org.uk/reports-and-analysis/analysis/quantifying-health-inequalities-in-england  There are also, it describes, “higher rates of diagnosed mental health conditions, chronic pain and alcohol problems” among younger adults in more deprived areas, “starting to develop as early as the late teens and early twenties”. ³⁶ Watt T, Raymond A and Rachet-Jacquet L, Quantifying health inequalities in England, The Health Foundation, 15 August 2022, retrieved 27 October 2025, www.health.org.uk/reports-and-analysis/analysis/quantifying-health-inequalities-in-england  Many of those younger people will not have been born when the data used to assess their need was recorded, emphasising the need for updated calculations.

This discrepancy in funding may also explain why there are so many fewer GPs per patient in more deprived parts of the country; practices in those areas may simply not have the money to hire enough GPs.

It is therefore welcome that the government has committed to reviewing the Carr-Hill formula in the 10 Year Health Plan for England, ³⁷ Department of Health and Social Care, 10 Year Health Plan for England: fit for the future, CP 1350, The Stationery Office, 2025, p. 137.  following campaigns from organisations such as the Nuffield Trust to shift funding towards more deprived areas. ³⁸ Fisher B, Loftus L, Holdroyd I, Ford J, Fairer funding for general practice in England: what’s the problem, why is it so hard to fix, and what should the government do?, Nuffield Trust, 2024, www.nuffieldtrust.org.uk/resource/fairer-funding-for-general-practice-in-england  As part of that commitment, it launched a six-month consultation in October 2025, as this report was being drafted. ³⁹ Department of Health and Social Care, NHS England and Stephen Kinnock MP, ‘Patients in poorer areas to get better access to GPs’, press release, 9 October 2025, www.gov.uk/government/news/patients-in-poorer-areas-to-get-better-access-to-gps

_{*    This is total payment to practices minus deductions. These deductions include things like payments for pensions and professional levies which are paid to pension providers and professional bodies by the NHS on behalf of practices, meaning that practices never control that money.}

_{**    ‘Weighted patients’ is a measure created by NHS England that adjusts a practice’s patient list to better reflect the level of need. NHS England weights patients according to age and gender, patient morbidity and mortality, list turnover, market forces, rurality, and whether the patient is in a nursing or residential home.}

Staffing

Salaried GPs earn less than they did before the pandemic

Between 2006/07 and 2019/20, partners’ and salaried GPs’ earnings declined by 19.1% and 12.9% in real terms respectively, after reaching lows of -25.9% and -20.7% in the 2010s. This did, however, follow a large increase in GP partners’ earnings between 2002/03 and 2006/07.^* In that time, average partner earnings^** increased from £139,326 (in 2025/26 prices) to £192,975, a rise of 38.5% in real terms, or 8.5% per year. In its 2008 report on GP pay modernisation, the National Audit Office (NAO) attributed this to implementation of the new GP contract in 2004/05 which aimed to increase funding and pay for GPs to attract more doctors into the service – a goal that the NHS achieved. ⁴⁰ Comptroller and Auditor General, NHS Pay Modernisation: New Contracts for General Practice Services in England, Session 2007-2008, HC 307, National Audit Office, 2008, p. 8.  In 2019/20, the average GP partner earned £156,151 (in 2025/26 prices).

Following a long decline and then flattening out of partners’ earnings between 2006/07 and 2019/20, earnings then spiked during the pandemic years of 2020/21 and 2021/22. In the latter year, their earnings were only 1.6% lower in real terms than in 2006/07. This increase was due to practices earning more money from the Covid vaccine rollout, which then flowed through to partners’ earnings. ⁴¹ Bostock N, ‘COVID jabs drove rise in GP income in 2021/22 but pay data mask pressure on practices’, GPonline, 1 September 2023, retrieved 27 October 2025, www.gponline.com/covid-jabs-drove-rise-gp-income-2021-22-pay-data-mask-pressure-practices/article/1835820  In 2022/23, as the payments for Covid vaccinations fell sharply and inflation rose, partners’ earnings dropped back to approximately pre-pandemic levels: 17.5% lower than in 2006/07 in real terms. That inflation also affected salaried GPs’ earnings, which fell by 6.7% in real terms between 2021/22 and 2022/23, leaving them 15.5% lower in real terms than in 2006/07.

The Conservative government agreed to a 6% nominal pay rise for salaried GPs in 2023/24, ⁴² Department of Health and Social Care, GP Pay Award, blog, GOV.UK, 3 August 2024, https://healthmedia.blog.gov.uk/2024/08/03/gp-pay-award/  and the Labour government accepted the Doctors’ and Dentists’ Review Body’s (DDRB, the independent organisation that recommends NHS doctors’ pay levels) call for a further 6% and 4% in 2024/25 ⁴³ British Medical Association, ‘Confirmation of increased 2023/24 staffing expenses funding uplift’, BMA, 29 September 2023, retrieved 27 October 2025, www.bma.org.uk/advice-and-support/gp-practices/funding-and-contracts/confirmation-of-increased-202425-contractor-pay-and-staffing-expenses-funding-up…  and 2025/26 ⁴⁴ Colivicchi A, ‘England GPs to receive 4% pay uplift backdated to April’, PULSE, 22 May 2025, retrieved 27 October 2025, www.pulsetoday.co.uk/news/breaking-news/england-gps-to-receive-4-pay-uplift-backdated-to-april/  respectively. Despite those relatively large cash terms increases, salaried GPs’ earnings may only recover slightly between 2022/23 and 2025/26, due to continued high inflation and are forecast to still be 13.6% lower in real terms in 2025/26 than in 2006/07.

_{*   2006/07 is the first year for which there is consistent data for salaried GPs and therefore there is no data before
this year shown in Figure NHS 2.3.}

_{**  This is done on a headcount basis and includes partners’ earnings from work in a practice and other income from self-employment. Because this is done on a headcount basis, it does not account for changing working patterns that are explored in more detail below.}

There is a wide range in partners’ earnings

While on average GP partners earned £158,700 before tax in 2023/24 (without adjusting for inflation) there was a large spread of values around that number – meaning some partners earned a lot more and some earned considerably less. More than one in five partners^* (21.0%) earned less than £100,000 before tax – more than £5,000 lower than the lowest level of a hospital consultant’s pay. ⁴⁵ British Medical Association, ‘Pay scales for consultants in England’, BMA, 3 September 2025, retrieved 27 October 2025, www.bma.org.uk/pay-and-contracts/pay/consultants-pay-scales/pay-scales-for-consultants-in-england  A further 3.0% earned less than £50,000, though this may be because some partners work less than full time. At the other end of the scale, 22.2% (equating to 3,940 partners) earned more than £200,000. This may not all come from practice drawings, however. These income figures include all income from medical self-employment a GP partner might earn in a year, of which drawings from their practice is part, though not necessarily all. ⁴⁶ NHS England, ‘GP Earnings and Expenses Estimates, 2023/24: Methodology’, DIGITAL.NHS.UK, 28 August 2025, retrieved 3 November 2025, https://digital.nhs.uk/data-and-information/publications/statistical/gp-earnings-and-expenses-estimates/2023-24/methodology

The government has concerns that any additional funding for general practice could result in partners taking much higher salaries, rather than investing in improving access to or quality of care. From available data, it is difficult to know to what extent this happens. That is partly because partners’ “earnings” in this context includes money that they earn outside their practices. But also because there is no practice-level data which would allow comparisons of increases in funding and changes in partners’ earnings

These suspicions on the government’s part could explain why it is choosing to ringfence an ever-greater proportion of funding – but as discussed above this undermines the fundamental model of GP partnerships that had existed for decades.

_{*    This is on a headcount basis and therefore does not account for whether or not  a partner works full time. This is
because there is no FTE data available.}

Labour has accelerated an already growing GP workforce

Between September 2015 and June 2023, the number of fully qualified, permanent GPs (the sum of salaried GPs, GP partners and GP retainers) working in primary care^* fell from 28,590 to 26,576 on a full-time equivalent (FTE) basis, a decline of 7.0%. This was despite repeated attempts by successive governments to increase GP numbers. ⁴⁷ Rimmer A and Mahase, ‘GP numbers pledge: health secretary admits government won’t deliver’, BMJ, 2 November 2021, retrieved 27 October 2025, www.bmj.com/content/375/bmj.n2666  Since June 2023, there has been steady growth, however, and by September 2025 there were 28,703 fully qualified permanent GPs working in primary care, which means that numbers have exceeded 2015 levels for the first time on record (0.4% above September 2015 levels).

_{*    This is general practice and primary care networks, where an increasing number of salaried GPs are hired.}

The recent increase in the fully qualified permanent workforce has been driven by rising numbers of salaried GPs, which has accelerated since 2024 (discussed in more detail below). Between June 2024, (the last month before the government came to power) and September 2025, there was an increase of 2,219 FTE salaried GPs in primary care, a rise of 20.5%. That means the salaried GP workforce grew at a rate of 147.9 FTEs per month between June 2024 and September 2025.

For context, the salaried GP workforce grew at a rate of 25.0 per month between September 2015 and December 2019. At those rates it would take almost seven and half years to grow the workforce by the same amount the current government has done in little over one year.

This is a genuinely substantial change in the service which should expand access for patients and improve satisfaction with the service.

Rising salaried GP numbers is partly the result of newly qualified GPs joining the workforce

Since 2019, there has been a rapid expansion of the number of GP trainees in the workforce, from 6,547 in September 2019 to 10,873 in September 2025 – a rise of 62.6%. That has mostly been driven by a large increase in international recruitment. In September 2019, 28.3% of trainees had completed their initial medical training outside the UK. In September 2025, following successive governments’ expansion of international GP recruitment, this had increased to more than half: 50.3%.

Previous IfG work has shown that international GP trainees were less likely than their British counterparts to join the GP workforce in the years after qualifying, though the rate has equalised in the last two years. ⁴⁸ Hoddinott S, General practice across England, Institute for Government, 2025, p. 22, www.instituteforgovernment.org.uk/publication/performance-tracker-local/general-practice-england

In the 10 Year Health Plan for England, the new government explicitly said that it wants to end the reliance on overseas recruitment, reducing “international recruitment to less than 10% by 2035”. ⁴⁹ Department of Health and Social Care, 10 Year Health Plan for England: fit for the future, CP 1350, The Stationery Office, 2025, p. 110.  How this will work, or what it will mean for the source of GP trainees, is still unclear but it could have a disproportionate impact on more deprived areas, where there are fewer British trained GPs. In the 10% of practices with the most deprived patient lists, six in ten staff completed their initial medical training in the UK (63.0%), compared to eight in ten in the practices with the least deprived 10% of patients (79.2%).

One of the mysteries of the last few years was why so few GP trainees were recorded as making it into the fully qualified GP workforce – though this seems to have been resolved with the recent uptick in the number of salaried GPs. ⁵⁰ Hoddinott S, General practice across England, Institute for Government, 2025, p. 20, www.instituteforgovernment.org.uk/publication/performance-tracker-local/general-practice-england

New rules around hiring salaried GPs have also contributed to an increase in the workforce

One of the main sources of PCN funding described above was the Additional Roles Reimbursement Scheme (ARRS).  ⁵¹ NHS England, Changes to the GP Contract in 2025/26, NHS England, 2025, www.england.nhs.uk/long-read/changes-to-the-gp-contract-in-2025-26/  This was a ringfenced pot of money which previous governments allocated to PCNs to use to massively expand the non-GP workforce – staff such as pharmacists, physiotherapists, and care coordinators – but explicitly not GPs. That was successful, with primary care hiring many more non-GP staff, as discussed in more depth below.

One of the first steps that the incoming Labour government took in summer 2024 was to allow PCNs to use ARRS funding to hire salaried GPs, and set a target to “employ over 1,000 additional GPs” through this route. ⁵² NHS England, GP contract changes: government response to Doctors and Dentists Remuneration (DDRB) and the Additional Roles Reimbursement Scheme (ARRS), NHS England, 2024, www.england.nhs.uk/long-read/gp-contract-changes-government-response-to-ddrb-and-arrs/  This target has been met: NHS management data shows that in August 2025,^* there were 1,098 FTE GPs working in PCNs as part of the ARRS. ⁵³ NHS England, Primary Care Workforce Recruited through the Additional Roles, NHS England, 23 October 2025, https://digital.nhs.uk/data-and-information/publications/statistical/mi-primary-care-workforce-recruited-through-the-additional-roles-reimbursement-s… 30-september-2025

There are still a few problems with the design of this scheme. It is still restricted to GPs that qualified in the last two years but who have not yet been employed in a “substantive role”, limiting the pool of possible employees. Those staff can be forced to work across multiple sites which the Royal College of General Practitioners (RCGP) argued is “impractical, unrealistic and not conducive to job satisfaction, morale or retention. It also fails to facilitate continuity of care”, and may harm the training and development of those GPs. Finally, there is little job stability for those GPs, as ARRS funding is typically renewed on an annual basis meaning that there is only ever funding for one year at a time.

Despite those issues, the government’s decision to widen the ARRS scheme to GPs has been incredibly effective. It shows there was substantial pent-up demand to hire GPs, though no funding available to do so. The lesson for the government should be that giving the service more flexibility over funding results in better allocation of funding. If the government believes in and wants to support the partnership model then it should provide this funding to partners through the core contract, with no limits on how it is spent.

_{*  We use data for July here rather than August (which is the most recent month) because the NHS says that the data for the most recent month is often an undercount due to a lag between employment and PCNs entering claims into the system.}

The GP partner workforce is still declining rapidly

Despite the positive news on salaried GPs, the trend of declining numbers of GP partners continues. In September 2025, there were 29.1% fewer partners than in September 2015 on an FTE basis. This is mostly driven by a decline in younger GP partners – for partners under 40 the drop off is 61.3% in the same period. This trend has not stopped since Labour won the election. Between June 2024 (the last month of the last government) and September 2025, the number of FTE partners declined by 4.1% (649.5) and the number of partners under the age of 40 declined by 17.0%. Labour has not fixed this crisis.

This has changed the age profile of the profession. In September 2025 the proportion of the partner workforce that is aged under 40 is just 10.5%, roughly half of that in September 2015 (19.2%). At the other end of the scale, the proportion of partners aged over 60 rose from 9.4% to 15.5%.

If this trend continues general practice may find itself in a position where partners start retiring with fewer and fewer qualified GPs to replace them, again undermining the entire model. As discussed, this and previous governments have introduced policies which may hinder rather than help this situation.

Stopping and then reversing this decline should be a pressing priority for this government if it intends to continue to use the partnership model to deliver general practice services.

Low leaver rates and record joiner rates, particularly for younger GPs, is contributing to a growing workforce

Labour has also benefited from record low leaving rates among GPs. From the year ending June 2024 onwards, the leaving rate for all GPs has been below 7%. There was never a year before the pandemic in which the leaver rate dropped beneath 7.3%. This reached a record low in the year to March 2025, when only 6.2% left the service. Since then, the rate has ticked up slightly, with 6.6% of GPs leaving the service in the year to September 2025. This change has happened across all age groups, but has been particularly low for GPs aged 40 to 49, where the leaver rate was only 4.1% in the year to September 2025.

There is variation in the patterns and extent of GPs leaving their roles around England. The South West had the highest rate of GPs leaving in 2024/25, at 8.1% compared to the England average of 6.2%. That is driven mostly by high rates of older GPs (those aged 60 to 64 and over-65) leaving the service.

London had the highest rate of GPs under the age of 40 leaving general practice, at 10.2% compared to an England average of 6.8% but far lower rates of older GPs (aged 50 to 59, 60 to 64 and 65 and over) leaving the service than other regions, meaning GPs in London work longer after the age of 65 than GPs in other areas. This is supported by the age data: the average age of GP partners is highest in London at 53.9 years old, compared to the England average of 50.3, and more than three years older than the next highest, which is 50.7 years in the East of England. The region with the youngest average age of GP partners is the South West at 48.8. It is unclear why GPs work longer in London than in other regions.

At the same time, joiner rates (the number of new joiners divided by the number of exiting GPs) for fully qualified GPs have been very high, particularly among GPs under the age of 40. In that age group, there has been more than 22% of the workforce joining in the years ending March 2025, June 2025, and September 2025. There is no other 12-month period on record in which that is the case. That has pushed total joiner rates for the entire workforce consistently above 9% since March 2024, a feat which only happened in a handful of times before the pandemic.

The picture on GPs’ workloads is mixed

The NHS defines a GP as working full-time if they work 37.5 hours a week. ⁵⁴ NHS England, ‘General Practice Workforce’, 31 May 2023, NHS England, 22 June 2023, https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/31-may-2023/glossary-and-definitions  Data published by NHS England shows that there has been a long-term trend of GPs increasingly working less than full time.

In March 2016 (the first month for which there is data), a third of GPs were working full-time or more than full-time in their practice (33.1%). By March 2025, this had dropped to a fifth (20.0%), a fall of 13.1 percentage points (ppts).

There are distinct differences between age groups. Younger GPs have always been less likely to work full time equivalent hours, but that is also the age group with the largest drop between 2016 and 2025, at 16.4ppts.

There are several reasons for this long-term decline. Partly this is due to an increasing desire among GPs to work a ‘portfolio’ career – when GPs work in settings other than their practice, for example as a GP in a prison or in a leadership role in their PCN. ⁵⁵ BMJ, ‘A Day in the Life of A Portfolio GP’, BMJ Careers, 27 April 2023, retrieved 27 October 2025, www.bmj.com/careers/article/a-day-in-the-life-of-a-portfolio-gp  There is some evidence that younger GPs view this as offering them a better work-life balance, compared to older colleagues. ⁵⁶ Schrimpf A, Scheiwe E and Bleckwenn M, Insights from end-of-career general practitioners on changing working conditions and generational differences: considerations for future strategies, BMC Primary Care, 18 May 2024, https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-024-02419-z

But there is also evidence that the NHS’s data does not adequately capture changing patterns of work in general practice. The NHS calculates the number of FTE salaried GPs by the number of hours for which they are contracted, rather than for what they work. ⁵⁷ NHS England, ‘General Practice Workforce, 30 April 2025’, NHS England, 22 May 2025, https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services/30-april-2025/using-this-publication  But a GP may work beyond the hours they are contracted. This is supported by polling of GPs which shows that “hours of work” is the element of their jobs with which GPs are least satisfied in 2024 and that GPs report “increasing workloads” as the most significant contributor to stress in their job. ⁵⁸ Checkland K, Sutton M, Walker B, Bullen H, NIHR Policy Research Unit in Health and Social Care Systems and Commissioning (PRU HSSC), NIHR, 2025, p. 18, https://pru.hssc.ac.uk/assets/uploads/files/12th-gpwls-2024-.pdf  If GPs work many hours beyond their contracted hours, then they may reduce their contracted hours to maintain some semblance of work-life balance. This would then make it appear as though full-time working was declining.

Overall, the picture on GP working is mixed. Official data shows declining rates of GPs working full time, though this likely reflects under-reporting of the true extent of the work that GPs carry out.

The number of GPs per patient is still far below 2015 levels and lower in more deprived areas

Despite rising number of fully qualified GPs, there are still fewer GPs per patient than in 2015. Patient lists have naturally grown since 2015 as the population has grown. There were 12.3% more patients registered in September 2025 than in September 2015.

This has meant that, as the number of GPs fell between 2015 and 2023, the ratio of GPs to patients declined. The growth in fully qualified GP numbers since 2023 has outstripped patient growth in that time, meaning that there has been some improvement in the number of GPs per patient since. However, by September 2025, there were 44.9 fully qualified FTE GPs per 100,000 patients, which is still 10.6% lower than in September 2015.

GPs are also not distributed equally across the country: there are fewer GPs per patients in the most deprived areas. There were 38.3 GP partner and salaried GPs for every 100,000 weighted patients in the practices^* with the 10% most deprived patients, while there were 48.1 (or 25.8% more) in the least deprived areas.

_{*    Unlike the analysis directly above which includes GPs employed in PCNs, this is only the GPs employed in practices. We do not include PCN GPs because there is no way to allocate them to practices, which is the level at which there is data about the deprivation of patient lists.}

The number of direct patient care staff in primary care has stopped rising

Labour inherited a primary care workforce with a markedly different composition to the one they passed on in 2010. Since 2019, there has been rapid growth in the number of what are known as direct patient care (DPC, which includes staff such as physiotherapists and pharmacists) staff employed in PCNs, funded by the ARRS.

But that growth stopped after March 2024, when the number of DPC staff reached a peak of 50,794. In June 2025, there were 48,495 DPC staff working in PCNs, a drop of 4.5% from March 2024. In June 2025, the two largest DPC staff groups were pharmacists (8,023 or 16.5% of the total) and care coordinators (6,860 or 14.1% of the total).

As a result of the growth in these staff groups there has been a large rise in activity carried out by non-GP staff. Despite this increase in activity, there are still questions about the benefits that patients feel from these additional staff: previous Institute for Government work has shown that additional DPC staff in a practice or PCN are not associated with any meaningful increase in patient satisfaction. ⁵⁹ Hoddinott S, General practice across England, Institute for Government, 2025, p. 17, www.instituteforgovernment.org.uk/publication/performance-tracker-local/general-practice-england

Given the limited nature of activity data in primary care, it is difficult to know what type of work these staff are conducting, other than simply that they are carrying out more appointments. Some of these staff work in ways that is not easily captured by primary care activity data. For example, a care coordinator is unlikely to deliver an appointment – the traditional metric of primary care “activity” – but is instead likely to be involved in connecting patients to the right people in other services or providing patients with health information, making other staff better able and more efficient in delivering care to patients. This may be useful activity, but is currently not captured by the NHS’s metrics, except to the extent that it frees up other staff time to carry out appointments.

The workforce in general practice is changing, again. Unlike the last government, this government’s focus seems to be less on DPC staff, and more on increasing the number of salaried GPs. Given the steady erosion of fully qualified GPs between 2015 and 2023, the recent increase is extremely welcome and should result in an increased access and patient satisfaction. Despite that excellent progress, this government has still not found a way to halt the ongoing decline in GP partners – arguably the most important staff group in the service. Without a change in that trend, it is difficult to see how general practice can survive without major reform to the underlying model and principles of the service.

Activity

The number of GP appointments is not keeping pace with rising number of GPs

Labour inherited a system where the number of appointments had grown consistently since 2019. In that year, staff in primary care^* delivered 300.0 million appointments. Following a dip during the pandemic, this then rose steadily to 377.4 million in 2024/25 – an increase of 25.8%.

This was largely driven by rising numbers of appointments delivered by non-GP staff. Those staff delivered 136.8 million appointments in 2019, compared to 201.5 million in 2024/25 – an increase of 47.3%. This has been driven by the large increase in non-GP staff described above.

The number of appointments delivered by GPs was also higher in 2024/25 than in 2019: 168.1 million compared to 155.1 million (up 8.3%). But growth in GP appointments since the election has been relatively slow. Compared to 2019, there were 8.4% more GP appointments in the year to July 2024, when Labour came to power. That number has not increased much since: in the year to September 2025, there were 9.1% more GP appointments compared to 2019. That is despite rising numbers of GPs in that time: there were 12.1% more FTE GPs^** in the year to September 2025 than 2019. That means that there was a 2.7% decline in the number of appointments delivered per GP compared to 2019.

_{*    We use primary care here because the NHS started recording appointments delivered in primary care networks separately to the appointments delivered in general practice from April 2023 onwards meaning that if we do not include all of primary care, we are undercounting activity by about 2.5% per year.}

_{**    Unlike other measures of GPs that we use in this report, this metric includes GP trainees. We include them here because they also deliver GP appointments, and to exclude them would therefore mean undercounting the denominator of the appointments per GP.}

That decline in appointments per GP has happened since Labour won the election. In the year to July 2024, there was no change in the number of appointments per GP compared to 2019.

One explanation could be related to the increase in salaried GPs since mid-2024, described above. Those staff are likely less experienced than other GPs that have been in the service longer, meaning that they are not as able to deliver as many appointments in the same amount of time as some of their more experienced colleagues. This is supported by the fact that much of the increase in salaried GPs has been through the ARRS scheme, which is restricted to GPs that have qualified in the last two years and have never been “substantively employed as a GP in general practice”. ⁶⁰ NHS England, ‘Changes to the GP Contract in 2025/26 ‘, ENGLAND.NHS.UK, 28 February 2025, retrieved 4 November 2025, www.england.nhs.uk/long-read/changes-to-the-gp-contract-in-2025-26/  If this is the case, then it is likely that the gap will close over time as new GPs gain experience.

Some of the flatlining in GP appointments may also be explained by poor coding and a lack of recording of online and remote appointments. There is evidence that some systems do not effectively record online appointments, meaning that the NHS could be missing a chunk of activity, as discussed in more depth below. ⁶¹ Wyatt S, Long-term trends in GP practice consultation rates, NHS England, 2024, pp. 27–28, www.strategyunitwm.nhs.uk/sites/default/files/2024-09/1-Long-term-trends-in-GP-Practice-consultation-rates-MDSN-240220.pdf

But this should still be worrying to the government. Rising levels of GP activity had been one of the NHS’s major success stories since the pandemic. If the number of appointments delivered per GP does not keep pace with rising numbers of GPs, then it might make it harder for people to get appointments with their “family doctor” ⁶² The Labour Party, ‘Labour Party health policy: How we will build an NHS fit for the future’, LABOUR.ORG.UK, 24 June 2024, retrieved 4 November 2025, https://labour.org.uk/updates/stories/labour-party-health-policy-how-we-will-build-an-nhs-fit-for-the-future/  as Labour has promised.

The government is pushing GPs to reduce referrals for elective care

During the pandemic, the Johnson government encouraged the expansion of the “advice and guidance” (A&G) scheme, where a GP consults with a specialist colleague in secondary care before making a referral – with the aim of reducing the number of unnecessary referrals to the elective waiting list. Since taking office, Labour have continued this initiative and are pushing it further.

Between 2019 and 2022/23 (the period for which the NHS released A&G data), the number of GP requests for A&G rose from 602,458 to 1.6 million – an increase of 160.3%. The average annual increase between 2019 and 2022 was 35.1%.

Since then, the number of requests for all pre-referral specialist advice (which includes but is not limited to A&G and about which the NHS now publishes data) has continued to rise. GPs made 2.9 million requests in 2024/25 compared to 2.1 million in 2022/23 (the first year for which there was data), an increase of 38.1% or 17.5% per year.

As part of its elective reform programme, the Labour government announced that it would pay GPs £20 per request for pre-referral specialist advice – activity that they previously carried out for free – in an attempt to push the number to 4 million in 2025/26 (from 2.9 million in 2024/25). ⁶³ Department for Health and Social Care, Reforming elective care for patients, NHS England, January 2025, pp. 10–11, www.england.nhs.uk/wp-content/uploads/2023/04/reforming-elective-care-for-patients.pdf  The policy has helped hold down the number of additions in recent years (as discussed in more detail in the hospitals chapter): after five months of 2025/26, there have been 1.4 million requests for specialist advice, up from 1.2 million in the same time in 2024/25. If this rate continues, GPs will make 3.5 million requests by the end of the year. That would be roughly 500,000 short of the government’s target, but still an 18.8% increase compared to 2024/25.

Interviews revealed mixed feelings about this policy. One made a fairness argument in favour of it, pointing out that the NHS already pays hospitals for the additional work that comes with responding to requests for specialist advice, so it seems perverse not to also pay GPs for the additional work that comes from corresponding with specialists compared to just making a referral. ⁶⁴ Institute for Government interview  From a GP’s perspective, one interviewee reported that they like using specialist advice as they feel it provides them with more certainty when making a referral decision, improving patient care. ⁶⁵ Institute for Government interview

But they also questioned whether paying for expanded use represents good value for money, or if it could even reduce the effectiveness of the scheme as it currently works. They said that it could change the current threshold at which a GP might use specialist advice: when previously they might not have made a request and would have not referred, they may now submit a request. At the other end of the spectrum, they speculated that a GP who intended to make a referral anyway, might submit a specialist advice request just to trigger the tariff.

Access

The proportion of appointments delivered online is growing rapidly

The way that patients access general practice and wider primary care has changed considerably since Labour was last in power. The pandemic triggered a large-scale acceleration towards more telephone appointments – a pattern that only partially reversed after lockdowns were lifted. And since April 2023 there has been a rapid expansion in the proportion of appointments delivered online.

This trend is striking because even at the height of the pandemic there were never more than 0.6% of appointments delivered online in any given month: in September 2025, a record 8.6% of appointments (2.9 million out of 33.0 million) were.

Part of the reason for this shift is likely wider implementation of ‘Modern general practice access’ that the Sunak government expanded as part of its Delivery plan for recovering access to primary care, published in 2023. ⁶⁶ NHS England, Delivery plan for recovering access to primary care, NHS England, 9 May 2023, www.england.nhs.uk/long-read/delivery-plan-for-recovering-access-to-primary-care-2/  This aimed to increase the availability of online tools as a means for patients to contact their practices – known as “digital triage”.  ⁶⁷ NHS England, Digitally enabled triage, NHS England, 12 June 2023, www.england.nhs.uk/long-read/digitally-enabled-triage/  These tools typically require a patient to submit a request to a practice’s online platform which is either reviewed automatically by the platform or else by a member of staff (not necessarily a GP). Following that review, the practice books the patient into the most appropriate type of consultation which could be a face-to-face, telephone appointment or online consultation,^* or no follow up at all.

When asked about the rise in online appointments since 2019, one interviewee gave an alternative perspective:

“I’m surprised how low it is. There’s been a debate about how much of general practice is online and yet secondary care has gone online for its outpatient appointments, and no one’s batted an eyelid. I’m on a […] committee. All our meetings are online. My father is on an […] association. All their meetings are online. Five years ago, we would have had this meeting face-to-face. Now it’s online and you’re transcribing it as we speak. I’m shocked only 5% [of GP appointments are online] really” ⁶⁸ Institute for Government interview  – Interviewee

This increase appears to be coming at the expense of face-to-face appointments more than telephone appointments. Staff delivered 26.6% of appointments by telephone in March 2023, compared to 24.8% in September 2025, a decline of 1.8ppts. In contrast, staff delivered 69.8% of appointments face-to-face in March 2023 compared to 63.1% in September 2025 – a fall of 6.7 percentage points.

_{*    An “online consultation” includes a lot of different means of a patient interacting with a practice. According to NHS guidance, an online/video appointment could include a video call, a call carried out on “voice over internet protocol” (VoIP) and a live chat through a platform. One interviewee said that there’s nothing to stop practices from coding things such as one online message in a longer conversation as a single appointment, though it would likely require a lot of work for them to do so.}

There is not much variation between staff groups in the extent to which they deliver online appointments. There have been large rises among both GP and other practice staff since 2023, though the rise has been slightly faster for GPs (9.0% of appointments delivered that way in September 2025 compared to 8.6% for non-GP staff).

The growth of online appointments is being driven by a handful of practices

The shift to online appointments is happening at varying rates across England. The nationwide increase described above is being accelerated by a small subsection of practices that have rapidly adopted online appointments. In the 12 months to September 2025, the 10% of practices that used online appointments the most delivered more than a third (33.5%) of all their appointments online. The average among the remaining 90% was 4.9%, compared to 8.8%^* for the entire country. The top 10% of practices were also responsible for more than half (55.8%) of all online appointments conducted in general practice in the 12 months to September 2025.

There is also a substantial minority that delivered no appointments online (see Figure NHS 2.21). In the year to September 2025, almost three out of every ten practices delivered no appointments online at all (29.8%)/

_{*    This differs slightly to the number referenced above, because those include appointments carried out in PCNs, whereas this includes just appointments in general practice. We do not include PCN appointments here because it is impossible to do when conducting practice-level analysis.}

The 10% of practices that delivered the most online appointments in the 12 months to September 2025 are also the practices that have seen relatively fast growth in the total number of appointments that they deliver. Between the year ending September 2023 (the first full year of practice-level data) and the year ending September 2025, the total number of appointments in those practices grew by more than a quarter (28.1%). Appointment growth was slowest in the practices that delivered no appointments online in the year to September 2025: 5.3% compared to the average for all practices of 9.5%.

This could indicate either that providing online appointments allows practices to work more efficiently, meaning they have been able to grow the total number of appointments much more quickly than other practices. Or it means that practices now record online activity as an appointment, where it would have previously not shown in the appointment data. This could be for activity such as triaging a patient, which might have previously happened without being recorded. As the Nuffield Trust said in a report on the topic: “the boundary between triage arrangements… and remote consultations could be blurred”. ⁶⁹ Rosen R and Leone C, Getting the best out of remote consulting in general practice, Nuffield Trust, June 2022, p. 25, www.nuffieldtrust.org.uk/sites/default/files/2022-06/1656424637_nuffield-trust-remote-by-default-web-final.pdf

Or it could be because a single online consultation could include several messages exchanged between the practice and a patient across a day, each of which is recorded as an appointment, but that face-to-face would be finished with a single appointment. The balance between these explanations is unclear and requires more work with patient-level data to determine the impact of this shift towards more online appointments.

Clearing this up matters. Data is notoriously limited in general practice and the number of appointments is one of the only metrics of activity and access for the service. If appointment data are misleading or misunderstood, the government’s ability to assess how well the service is performing will be severely limited.

A remote-first approach can be unpopular with patients

There are advantages and disadvantages to this shift towards more remote or online appointments and triage. For patients able to navigate the system easily, it can be a time-saving and efficient model. ⁷⁰ Rosen R and Leone C, Getting the best out of remote consulting in general practice, Nuffield Trust, June 2022, p. 2, www.nuffieldtrust.org.uk/sites/default/files/2022-06/1656424637_nuffield-trust-remote-by-default-web-final.pdf  But not everyone finds it to be straightforward.

One qualitative study of remote care shows that general practice has become more complex and difficult for patients to navigate over the last five years due to a proliferation of communication channels, ⁷¹ Payne R, Dakin F, Maclver E and others, Challenges to quality in contemporary, hybrid general practice a multi-site longitudinal case study, BJGP, vol. 75, no. 750, 2025, https://bjgp.org/content/75/750/e1  and that patients from more deprived backgrounds and those with low digital literacy struggled most. ⁷² Payne R, Dakin F, Maclver E and others, Challenges to quality in contemporary, hybrid general practice a multi-site longitudinal case study, BJGP, vol. 75, no. 750, 2025, https://bjgp.org/content/75/750/e1  From available data, there are differences in how practices conduct appointments based on deprivation. The 10% of practices with the most deprived patient population delivered only 7.2% of their appointments online in the year to September 2025 compared to 9.6% in the least deprived 10%. (If it is true that patients in more deprived areas find it harder to navigate these tools, this could indicate that practices respond to lower demand by offering fewer online appointments).

Age could also affect digital access. Another study shows that patients aged 21 to 40 accounted for 40.9% of online consultations, while patients aged 65+ accounted for only 8.9%. ⁷³ Kerr G, Greenfirld G, Bottle A and others, Patterns of online consultation use in Great Britain, 2019–2023: an observational analysis, BMJ, 3 July 2025, https://bmjdigitalhealth.bmj.com/content/1/1/e000032

Our own previous work shows that patient satisfaction is higher in practices that carry out a greater proportion of appointments face-to-face. ⁷⁴ Hoddinott S, General practice across England, Institute for Government, 2025, p. 42, www.instituteforgovernment.org.uk/publication/performance-tracker-local/general-practice-england  This is likely more reflective of views of telephone appointments (which continue to account for most remote appointments) than online appointments. But if there is a genuine demand for more face-to-face appointments, then the government should be wary of pushing practices too hard towards a remote-first approach.

One interviewee argued that patients generally don’t prefer face-to-face appointments, citing Health Foundation work which shows that, when asked, only a minority of patients express a preference for those appointments. ⁷⁵ Clarke G, Dias A and Wolters A, Access to and delivery of general practice services, The Health Foundation, March 2022, p. 2, www.health.org.uk/reports-and-analysis/briefings/access-to-and-delivery-of-general-practice-services  That same interviewee speculated that higher satisfaction in practices that deliver more face-to-face appointments could be due to poor implementation of online triage and consultation tools in those practices. There is certainly variation in both the types of tools that practices procure and the effectiveness with which they implement them. That study also found that practices receive very little support from integrated care boards (ICBs) or other parts of the NHS to make best use of these tools. ⁷⁶ Health Services Safety Investigations Body, Digital tools for online consultation in general practice, HSSIB, 10 July 2025, www.hssib.org.uk/patient-safety-investigations/workforce-and-patient-safety/second-investigation-report/#33-implementation-of-online-tools

There are similarly mixed benefits to GPs and other staff from a shift towards more remote/online working. In work carried out by the Nuffield Trust, some staff reported that they valued the autonomy and flexibility that the approach provided. ⁷⁷ Rosen R and Leone C, Getting the best out of remote consulting in general practice, Nuffield Trust, June 2022, p. 28, www.nuffieldtrust.org.uk/sites/default/files/2022-06/1656424637_nuffield-trust-remote-by-default-web-final.pdf  But there were also concerns that remote consultations and triage could increase the duration of consultations ⁷⁸ Rosen R and Leone C, Getting the best out of remote consulting in general practice, Nuffield Trust, June 2022, p. 27, www.nuffieldtrust.org.uk/sites/default/files/2022-06/1656424637_nuffield-trust-remote-by-default-web-final.pdf  – a finding that is supported by other work ⁷⁹ BMJ, Evaluation of telephone first approach to demand management in English general practice: observational study, BMJ, 2017, www.bmj.com/content/358/bmj.j4197  – adding to GP workloads. Another study raises the potential of increased clinical risk resulting from a GP not being able to physically assess a patient. ⁸⁰ Rosen R, Wierings S, Greenhalgh T and others, Clinical risk in remote consultations in general practice: findings from in-COVID-19 pandemic qualitative research, BJGP Open, vol. 6, no. 3, 2022, https://bjgpopen.org/content/6/3/BJGPO.2021.0204

As part of the 2025/26 GP contract, the government implemented a requirement that practices keep their online systems open during “core hours” (8:00am to 6:30pm) for non-urgent appointment requests from 1 October 2025. ⁸¹ NHS England, Changes to the GP Contract in 2025/26, NHS England, 28 February 2025, www.england.nhs.uk/long-read/changes-to-the-gp-contract-in-2025-26/  That contrasts with the previous approach, under which a practice could close its online system when it reached capacity for same day appointments. ⁸² MacConnachie V, ‘GP Contract 2025/26: what you need to know’, NHS Confederation, 28 February 2025, retrieved 27 October 2025, www.nhsconfed.org/publications/gp-contract-202526-what-you-need-know

The BMA entered into dispute with the government on this point, on 1 October 2025, ⁸³ British Medical Association, ‘GPs enter dispute with Government over unsafe online access rules’, press release, BMA, 1 October 2025, www.bma.org.uk/bma-media-centre/gps-enter-dispute-with-government-over-unsafe-online-access-rules  claiming that the government had not implemented the promised safeguards to prevent patients from submitting urgent requests through online systems and that the increase in requests would consume disproportionate amounts of GPs’ and other staff’s time, resulting in fewer appointments overall. ⁸⁴ British Medical Association, ‘GPs in England give Health Secretary 48 hours to avoid dispute over unsafe online access plans’, press release, BMA, 29 September 2025, www.bma.org.uk/bma-media-centre/gps-in-england-give-health-secretary-48-hours-to-avoid-dispute-over-unsafe-online-access-plans  Regardless of the merits of the BMA’s dispute, it is clear that some practices have integrated an online approach far more deeply than others.

The expansion of online triage and appointment systems has contributed to the growth in the number of appointments and, if rolled out effectively, could improve access and patients’ experience. But there are still substantial questions about whether they are being used effectively and if they create more barriers to access than they remove, particularly for groups of patients that already struggle to access care.

Performance

One of the clearest metrics of quality of general practice is patient satisfaction with the service. This gives some insight into the quality of the appointments that are carried out and whether patients feel that practices are meeting their needs.

Satisfaction improved slightly in 2025 – and by more in the most deprived areas

The NHS’s GP Patient Survey shows a steady decline in the proportion of patients that reported satisfaction^* with general practice between 2012 and 2020 (mostly conducted before the start of the pandemic): from 88.4% to 81.8%, a fall of 6.6ppts. There was then a large drop in 2022, during the pandemic, to 72.4% and then further still in 2023, to 71.3%.

The NHS changed how it surveys patients in 2024, ⁸⁵ NHS England, ‘Changes to the GP Patient Survey’, NHS England, 2024, https://gp-patient.co.uk/report-summary-of-changes-for-the-year-2024  meaning that results from that year onwards are not directly comparable to earlier years. But there was a slight increase in satisfaction between 2024 and 2025, from 73.9% to 75.4%, or 1.5 percentage points.

_{*    This is the proportion of patients who responded “very good” or “fairly good” in response to the following question for the 2025 GP patient survey: “Q32: Overall, how would you describe your experience of your GP practice?”.}

As has been the consistent pattern since at least 2012, practices with more deprived patient lists had lower satisfaction in 2025. Some 73.8% of patients in the 20% of practices with the most deprived patient lists reported being satisfied with their practice in 2025, compared to 80.1% in the practices with the least deprived 20%.

Satisfaction improved in all quintiles of deprivation in 2025 compared to 2024, and by the most in the most deprived quintile: 2.0 percentage points, compared to 1.1 in the least deprived quintile. That means that the gap between the practices with the most and least deprived quintile of patients shrank from 7.1 percentage points in 2024 to 6.2 percentage points in 2025.

Targeting improvements in access and quality of care in the most deprived parts of the country should be a focus of the government, as these are places with the greatest health inequalities and highest rates of illness. This is therefore an encouraging step for the government, though still leaves plenty of work to return satisfaction to anywhere near the levels seen at the start of last decade.

Patients are less likely to see their preferred GP than in the past

In lieu of good data about continuity of care in general practice, we can look at patients’ responses to the GP patient survey. In that survey, the NHS asks patients first if they have a preferred GP or healthcare professional in their practice and then asks those who responded that they do, how frequently they can see or speak to that member of staff when they ask to.^* There has been considerable decline in both those metrics since 2012, even accounting for two methodology changes.

_{*    Before 2024 the NHS only asked whether the patient had a preferred GP and then how frequently they were able to see that GP. From 2024 onwards, they now ask if they have a preferred GP or healthcare professional.}

A smaller proportion of patients report even having a preferred GP or other staff member now than in the past. In 2012, more than half of patients (57.4%) said they had a preferred GP. This fell to 46.9% in 2017. There was further decline between 2018 and 2023 (following a change in the wording of the question), from 53.7% to 41.5%.

The proportion of patients that reported they could see or speak to their preferred GP either ‘always or almost always’ or ‘a lot of the time’ fell from 65.7% in 2012 to 56.0% in 2017 and then again from 50.2% in 2018 to 35.4% in 2023.

2025 appears relatively stable on both metrics compared to 2024, with less than a third of patients (32.1%) having a preferred GP or healthcare professional and 40.0% seeing them when they ask to.

While not a perfect proxy, this does indicate that continuity of care has declined since 2012. This should worry the government. There is consistent, strong evidence that continuity of care leads to improved health outcomes. One study shows that seeing the same GP likely leads to lower premature mortality rates, a lower likelihood of a patient being admitted to hospital, and a lower risk of a patient visiting emergency departments. ⁸⁶ Engström SG, André M, Arvidsson E and others, ‘Personal GP continuity improves healthcare outcomes in primary care populations: a systematic review’, British Journal of General Practice, 2025, vol. 75, no. 757, pp. e518–e525, https://bjgp.org/content/75/757/e518  Pursuing improved continuity of care in general practice should therefore be seen as a key pillar in the government’s preventative health agenda.