General practice across England: Introduction

General practice occupies a unique position in the consciousness of the British public and GPs are often the first medical professional someone will see when they or their loved one become ill. The Labour Party sought to connect to this in its 2024 manifesto, promising to “bring back the family doctor”. ²⁴ Labour Party, Change: Labour Party manifesto 2024, 2024, p. 100, https://labour.org.uk/wp-content/uploads/2024/06/Change-Labour-Party-Manifesto-2024-large-print.pdf  

That might be easier said than done. General practice is vastly different now than it was even at the end of the last decade. The workforce has changed dramatically, with the expansion of non-GP roles and the continued decline of the GP partner workforce. When patients contact a practice, they are much more likely to do so through a digital platform and be triaged using pro-forma questionnaires. When they access the service, they are much more likely to have a remote appointment, either on the phone or through a digital consultation. Respondents to the GP patient survey report that they now find it more difficult to see their preferred GP when they would like to do so. 

General practice has also dealt with several external shocks in recent years. The Covid pandemic forced staff to rapidly adopt new ways of working. The global inflation shock from 2022 eroded the real terms value of the GP contract that was agreed in cash terms in 2019 – spending on the service fell in real terms between 2021/22 and 2022/23 by 2.8%. And while spending grew in real terms between 2019/20 and 2022/23 (by 7.0%), general practice funding has not kept pace with other parts of the NHS. For example, spending on hospitals grew much faster, by 12.1% between 2019/20 and 2022/23. 

These changes raise questions of how performance in general practice has changed in recent years, how much variation there is across practices, and which characteristics of general practice are associated with better or worse performance.* 

It is notoriously difficult to judge quality in general practice. Much of the publicly available data relates to GP activity, but less is available on the outcomes of that activity. There has been a large increase in the number of appointments in general practice (22.5% more in 2024 than in 2019, a result that is in line with the government’s ambitions to increase access to general practice) but the type of these appointments has changed, with most of that increase in appointments being delivered by non-GP staff. Of the 67.4 million additional appointments delivered between 2019 and 2024, 56.2 million were provided by nurses and direct patient care staff. 

More appointments also doesn’t necessarily mean improved quality of care. It could be that GPs spent less time with patients, or that patients did not see their preferred GP. There is also no way of determining whether the number of appointments, though clearly higher, was enough to match demand.

Changes in the way that general practice is organised could also reduce the quality of the service. There is evidence that patients find it difficult to navigate recently expanded ²⁵ Department of Health and Social Care and NHS England, Delivery Plan for Recovering Access to Primary Care, NHS England, 2023, www.england.nhs.uk/long-read/delivery-plan-for-recovering-access-to-primary-care-2  digital systems. ²⁶ Payne R, Dakin F, MacIver E and others, ‘Challenges to quality in contemporary, hybrid general practice a multisite longitudinal case study’, British Journal of General Practice, 2025, vol. 75, no. 750, e1-e11, https://bjgp.org/content/75/750/e1  Some patients, hearing of the problems in general practice or experiencing frustration trying to access it, may simply ‘give up’ or at least raise their thresholds for seeking care. ²⁷ Fisher R, Beech J, Alderwick H and others, Rethinking access to general practice: it’s not all about supply, the Health Foundation, 2024, www.health.org.uk/reports-and-analysis/briefings/rethinking-access-to-general-practice- it-s-not-all-about-supply  

There are, in short, few ways that we can observe quality comprehensively through publicly available data. 

One metric of quality that can be usefully applied to the performance of general practice, however, is patient satisfaction. By digging into the annual GP patient survey, ²⁸ NHS, ‘GP patient survey’, (no date), www.gp-patient.co.uk  this metric shows how patients experience general practice and how closely general practice meets their expectations. There are a few characteristics of this dataset that suit our purposes for this analysis. First, it is available at a practice level, allowing us to look at variation across practices and compared to other characteristics of that practice. Second, it is available since 2012, allowing us to assess variation over time. 

Patient satisfaction is not necessarily related to clinical outcomes, and is also a function of patients’ expectations, meaning it is possible that patient health could improve while satisfaction with general practice declines, or vice versa. ²⁹ NHS, ‘GP patient survey – technical annex’, (no date), www.gp-patient.co.uk/technical-annex-introduction-2024 ,** But despite these limitations, there are valuable lessons to draw from variation in patient satisfaction, the primary metric of performance we use in this report. 

Another metric we will use to assess performance is a practice’s achievement on ‘quality and outcomes framework’ (QOF) metrics. The QOF is a voluntary scheme that rewards GP practices with additional funding for meeting targets set by the government. In 2023/24, the QOF allocated practices points based on their achievement against 76 quality indicators across five domains (clinical, public health, additional public health services, vaccination and immunisation, and quality improvement). ³⁰ NHS, ‘Quality and Outcomes Framework 2023-24 results’, NHS.UK, https://qof.digital.nhs.uk  

The NHS publishes data showing the proportion of QOF metrics that a practice achieves each year, offering us another metric against which we can assess practice performance. We will cross-reference findings from the satisfaction analysis to see if there is also a relationship with QOF outcomes. 

This report draws on publicly available data, as well as qualitative interviews with GPs and health policy experts.

_{*We conduct most of the analysis in this report at a practice level. When we do it excludes activity and staff in primary care networks. We do this because it allows us to conduct analysis at a more granular level which therefore creates more variation.} 

_{**We do, however, conduct analysis at a primary care network level to check the robustness of our practice-level analysis. We also note that questions in the GP patient survey change over time, although we think that the metric of overall patient satisfaction is broadly comparable between 2012 and 2023. It is only in 2024 that the time series is no longer comparable, due to a change in methodology.}

Satisfaction has worsened nationally since 2012 

There has been a steep recent decline in patient satisfaction with general practice. Patients report far worse experiences of general practice now than at the start of last decade: in 2012, 88.4% of patients said they had a ‘fairly good’ or ‘very good’ experience of general practice. By 2023, this had fallen by 17.1ppt to 71.3%.* 

Much of that fall happened in the last few years. The decline in satisfaction between 2021 and 2022 was the largest on record: between 2012 and 2019 the average change (either way) had never been more than 1ppt; in 2022 it was 10.6ppt. It is difficult to say exactly why this happened, but there are a few likely reasons. One reason could be changes in how patients accessed, and so perceived, the service in the late stages and immediate aftermath of the pandemic. A far smaller proportion of appointments are delivered face-to-face (just over a third; 66.2% in 2024 against 80.7% in 2019), and many patients’ interactions with general practice is now mediated through an online platform. 

Another might be from patients’ frustration as general practice struggled to meet higher demand built up over 2020 and 2021, when many people did not present to GPs as the government encouraged people to “protect the NHS”. This view is supported by the Royal College of General Practitioners (RCGP). ³² Royal College of General Practitioners, ‘RCGP Briefing: GP Patient Survey 2022’, RCGP.ORG.UK, July 2022, www.rcgp.org.uk/getmedia/6ba2c631-6924-4d81-b040-2b4e76dc194e/RCGP-Brief_GP-Patient-Survey-2022.pdf  The continued decline in 2023 may indicate that higher demand has not dissipated in the wake of the pandemic.

Our analysis shows that patients tend to report higher satisfaction with practices that have more GPs (particularly GP partners), provide more appointments (particularly GP appointments), deliver more face-to-face appointments, and have smaller patient list sizes. Except for the headline number of appointments, all these metrics have trended in the opposite direction to that which would improve patient satisfaction in recent years.

_{*We compare 2023 to 2012 because there was a change in the GP patient survey methodology in 2024, which means it is no longer comparable with the longer time series. Due to this, we will use 2024 satisfaction when we are looking at a cross-section of satisfaction throughout this report, but we will use 2023 results when comparing satisfaction with previous years. These numbers also differ to Figure 1 because that shows the result in the median sub-ICB rather than the England total.}