General practice across England: Summary

General practice has changed radically in recent years. The complexion of the workforce is markedly different than before the pandemic, with far fewer GP partners but far more direct patient care staff such as pharmacists, care co-ordinators and physiotherapists. The level and type of activity of that workforce has also changed, with many more appointments being delivered in 2024 than in 2019 – far more of these are, however, now done remotely. The number of practices has also fallen, continuing a trend of more than a decade, resulting in larger patient list sizes. 

General practice holds a particular place in the minds of the public. For many, their local GP will be their first point of contact with the health system, the place they go when they or their loved ones are unwell. So understanding how the changes that have been made to it have affected its performance – and how this is perceived by the public – is important. 

On this point there is not much good news for a government that has promised to “bring back the family doctor” as part of its plans to reform the NHS. Patient satisfaction dropped precipitously during the pandemic and has barely improved since. Understanding what characteristics of practices are associated with higher satisfaction and better ‘quality and outcomes framework’ (QOF) scores will be essential to improving the picture in general practice. 

This report is the latest in the Institute for Government’s new Performance Tracker: Local series, supported by the Nuffield Foundation, that analyses the performance of England’s key public services at the subnational level. In it we use multivariate regression analysis to look at the effects of factors such as numbers and types of staff, mode of appointment, and levels of funding on metrics of general practice performance such as patient satisfaction. We conclude by offering recommendations on how the government can interpret our findings to begin to improve general practice.

Key findings 

• More GPs are most closely associated with both higher patient satisfaction and QOF scores.
• The effect is strongest for GP partners (self-employed GPs that own and manage practices), then salaried GPs (who are employed as staff by a practice) and GP trainees (doctors that have finished their medical degree and are undertaking a three-year training course after which they are eligible to become either a salaried GP or GP partner): one additional GP partner in a practice is associated with a 1.4 percentage point increase in the proportion of patients reporting that their GP practice provides a good service. An additional salaried GP and GP trainee are associated with a 0.9 and 0.3 percentage point increase respectively.
• More nurses are also associated with higher patient satisfaction, though the effect is not as strong as for GPs, with a 0.2 percentage point satisfaction increase.
• More direct patient care (DPC) staff have no significant effect on satisfaction or QOF scores.
• Patient satisfaction tends to increase with more GP appointments, but not significantly so with non-GP appointments.
• Patient satisfaction is higher in practices that provide more appointments face-to-face, especially where a larger proportion of patients are aged over 65.
• Patients report higher satisfaction in practices with smaller list sizes.
• Other than appointments, all of these trends have gone in the opposite direction to patients’ preferences since 2019. 

We also assess the factors that are associated with practices delivering more appointments: 

• An additional GP partner is associated with the largest increase in appointments in a practice: a rise of 4,256 GP appointments per year in a practice and a rise of 5,439 for all appointments in a practice.
• Additional GP trainees are associated with less than a quarter as many additional appointments as a salaried GP or GP partner (1,477 total appointments in a practice).
• An additional nurse is associated with more than twice as many appointments as an additional DPC staff member: 4,976 appointments compared to 2,279 appointments (though DPC staff carry out other, unmeasured activity).
• Remote appointments allow staff to deliver more appointments overall, but the added patient satisfaction from additional appointments does not offset the decline in satisfaction from fewer face-to-face appointments.

Recommendations in brief 

To address waning satisfaction in general practice the government should: 

• Urgently address some of the factors that make being a GP partner less attractive, including: the high cost of entering partnership, the unlimited financial liability that comes with most partnerships (particularly related to the ownership of premises), fears of being the ‘last partner standing’, and increasing workloads.
• Assess whether other models could be more appropriate and plan accordingly, if it thinks that the partnership model is no longer a feasible way of delivering general practice.
• Better understand why more GP trainees don’t join the fully qualified workforce and take action to address these problems through an updated NHS Long Term Workforce Plan.
• Make better use of the massively expanded direct patient care workforce. As a start, it should improve the quality of data collected about their activity.
• Better communicate the reasons for the expansion of the direct patient care workforce to the public.
• Be clear about the role that it wants general practice to play in a reformed NHS. There is likely a trade-off between increasing access to general practice through expanded use of remote appointments and a decline in some indicators of service performance such as patient satisfaction and continuity of care. If the government does choose to prioritise access, it must communicate its reasons for doing so and attempt to mitigate some of the negative consequences.