Building castles on sand: reforming primary care What the 2019 Commonwealth Fund survey tells us about the foundations for primary care reform

12 March 2020

About 4 mins to read

The starting gun has been fired, the new GP contract has already been updated and there is at least a degree of agreement around the first service specifications. You’d be forgiven for thinking then that the Primary Care Network (PCN) show is already well on the road. But PCNs still face an identity crisis. Policymakers want them to simultaneously stabilise general practice and to transform it. Expecting both to be done at once is a massive ask.

In Feeling the strain, the Health Foundation analyses data from the 2019 Commonwealth Fund survey of GPs in 11 high-income countries. It doesn’t tell us how GPs feel about PCNs, but it does help us understand how GPs currently view their jobs. These roles are the foundations on which PCNs are being built.

Compared to GPs in nearly all the other countries surveyed, and just as in the 2015 survey, UK GPs report very high stress levels and low satisfaction with workload. Getting more doctors in to general practice and keeping the existing workforce remains the biggest challenge facing primary care. 

Before 2015, this wasn’t an explicit policy goal, but between the 2015 and 2019 surveys, considerable effort has been made to try and address workload and retention. That GPs continue to report high stress and low satisfaction despite these efforts is worrying. Either the action taken has fallen short of what is required, or the wrong strategies are still being used.

Around 49% of UK GPs say that they plan to reduce their working hours in the next 3 years. That’s a real challenge for policymakers, especially as this was across all age groups. The new GP contract includes efforts to attract more trainees to general practice, to strengthen GP training and to incentivise partnership, but will only go so far if current GPs make good on their intentions to cut back.

This survey did not ask GPs what would keep them in practice, but it does give us some interesting leads. Only 5% of UK GPs are ‘extremely’ or ‘very’ satisfied with the amount of time they can spend with patients – significantly lower than in any other country. The RCGP has been very clear that it no longer considers 10-minute GP appointments to be fit for purpose. But as the demand for GP appointments continues to rise, enabling GPs to offer longer appointments is a challenge. Policymakers hope that additional new allied health professionals, working in PCNs, will free up GP time, but that’s by no means a given. For a start, we don’t actually know that all those staff will be recruited, let alone recruited in proportion to need. It’s also likely that their employment will uncover unmet need, so it’s not simply the case that having more staff in primary care equals more time for GPs.

It’s very clear that workload remains a big problem. Just 6% of UK GPs are ‘extremely’ or ‘very’ satisfied with their workload, and there is worrying evidence that attempts to manage it are falling short. Policymakers hoped that the wider adoption of telephone consulting and ‘digital-first’ options would reduce pressure on GPs, but the GPs surveyed report spending more time on all types of consultation. Generating extra work for GPs risks becoming an unintended consequence of efforts to improve access.

Continuing to duck the issue of pay risks overlooking an important topic for UK GPs, who report lower satisfaction with renumeration than any of their international counterparts. The 2004 GP contract, described by former Secretary of State for Health and Social Care Jeremy Hunt as a ‘historic mistake’, was initially lucrative for some GPs but there’s since been a decrease in GP income over the past decade. Fear of being perceived to give GPs a windfall of the sort that followed the 2004 contract has become a spectre haunting contract negotiations some 15 years on. Allowing it to linger may not be wise.

The survey does point to some promising building blocks for general practice in the UK, which leads the field in the use of electronic medical records and utilising data to review and improve care. Importantly, UK GPs are broadly supportive of ambitions to improve the integration of services.

So how do the survey results square with current attempts to reform primary care? Our findings add to alarm bells which should sound a note of realism for policymakers. Foundations must be shored up before the building can begin in earnest, and there’s a risk that the mandated pace of transformation undermines much needed stabilisation. PCNs – and reform efforts more widely – can succeed, but need adequate time and resource to stabilise general practice first.


Rebecca Fisher (@BecksFisher) is Senior Policy Fellow at the Health Foundation.

This article was originally published in Pulse on 5 March 2020.

Further reading

Research report

Quality improvement in general practice: what do GPs and practice managers think?

December 2019
Research report

Our research shows that most GPs and Practice Managers see quality improvement as a core aspect of...


Primary care networks and the deprivation challenge

10 May 2019

The newly emerging PCNs provide an opportunity to tackle health inequalities in England but they...

You might also like...

Press release

Decades of insider experience of the NHS will be crucial for the work ahead

Press release

Health Foundation response to the announcement of Amanda Pritchard as the new Chief Executive of NHS...


Low life expectancy in Glasgow, and what to do about it


Episode 10. In the UK, life expectancy is lowest in Glasgow. Why is this? And what can we all learn...

Press release

NHS pay offer is 'treading water'

Press release

Our response to the announcement of a 3% pay rise for NHS Agenda for Change staff.

Kjell-bubble-diagramArtboard 101 copy

Get social

Our #REALCentre analysis shows that several NHS staff groups have seen real terms pay cuts over the past decade. R…

Follow us on Twitter
Kjell-bubble-diagramArtboard 101

Work with us

We look for talented and passionate individuals as everyone at the Health Foundation has an important role to play.

View current vacancies
Artboard 101 copy 2

The Q community

Q is an initiative connecting people with improvement expertise across the UK.

Find out more