The authors are grateful to the many staff at the Health Foundation who contributed to this work, and to The Commonwealth Fund for their work in conducting the survey. Errors or omissions remain the responsibility of the authors alone.

The Commonwealth Fund provided core support for the survey, with co-funding from the following organisations: The NSW Agency for Clinical Innovation; Victoria Department of Health and Human Services; Health Quality Ontario; the Canadian Institute for Health Information; Commissaire à la Santé et au bien-être du Québec; La Haute Autorité de Santé; the Caisse Nationale d’Assurance Maladie des Travailleurs Salariés; Institut für Qualitätssicherung und Transparenz im Gesundheitswesen; the Dutch Ministry of Health, Welfare and Sport and Radboud University Medical Center; The Norwegian Institute of Public Health; the Swedish Agency for Health and Care Services Analysis (Vårdanalys); the Swiss Federal Office of Public Health; The Health Foundation; and any other country partners.

• The Commonwealth Fund surveyed 13,200 primary care physicians across 11 countries between January and June 2019. This included 1,001 general practitioners (GPs) from the UK. The Health Foundation analysed the data and reports on the findings from a UK perspective.
• In some aspects of care, the UK performs strongly and is an international leader. Almost all UK GPs surveyed use electronic medical records, and use of data to review and improve care is relatively high.
• The survey also highlights areas of major concern for the NHS. Just 6% of UK GPs report feeling ‘extremely’ or ‘very satisfied’ with their workload – the lowest of any country surveyed. Only France has lower overall GP satisfaction with practising medicine. GPs in the UK also report high stress levels, and feel that the quality of care that they and the wider NHS can provide is declining.
• A high proportion of surveyed UK GPs plan to quit or reduce their working hours in the near future. 49% of UK GP respondents plan to reduce their weekly clinical hours in the next 3 years (compared to 10% who plan to increase them).
• UK GPs continue to report shorter appointment lengths than the majority of their international colleagues. Just 5% of UK GPs surveyed feel ‘extremely’ or ‘very satisfied’ with the amount of time they can spend with their patients, significantly lower than the satisfaction reported by GPs in the other 10 countries surveyed.
• Workload pressures are growing across general practice, and UK GPs report that they are doing more of all types of patient consultations (including face-to-face, telephone triage and telephone consulting). Policymakers expect GPs to be offering video and email consultations to patients who want them in the near future, but the survey suggests that this is currently a long way from happening. Only 11% of UK GPs report that their surgeries provide care through video consultation.

The 2019 Commonwealth Fund survey compares perspectives from GPs across 11 high-income countries. The survey asked GPs’ views on their working lives, changes in how they deliver services, and the quality of care they can provide to patients. Analysis of what the survey data means for the United States health system has been published elsewhere. This publication provides UK-focused analysis of the survey data, including several UK-specific questions funded by the Health Foundation.

The previous Commonwealth Fund Survey in 2015 made uncomfortable reading for policymakers. It showed that UK GPs were the most stressed of the 11 countries surveyed, with more than one in five GPs reporting being made ill by the stress of work in the last 12 months.

Since 2015, pressure on general practice in the UK has increased. In all four countries, the population has grown, and across the UK as a whole, the number of GPs (headcount) per person has fallen. In England, investment in primary care declined relative to the rest of the NHS for a decade until 2014/15, according to NHS England, which has now guaranteed real terms funding increases for general practice for the next 5 years. But despite a target (set in 2016 in the General practice forward view) of 5,000 additional GPs by 2020, the number of fully qualified permanent, full-time equivalent GPs has continued to fall (declining by 1.6% between March 2018 and March 2019). Higher GP workload has negatively impacted on GP morale, increasing the likelihood of GPs leaving the profession or reducing hours, and worsening workforce shortages.

While publicly available data on general practice do not permit direct comparisons between the four UK countries, evidence suggests a similar picture of increasing pressure on general practice in Northern Ireland, Scotland and Wales (Box 1).

Pressure on GPs is reflected in patient experiences of care. In England, for example, the percentage of patients reporting a good overall experience of general practice is high but declined from 88% in 2012 to 83% in 2019. These pressures also threaten to undermine broader plans for health system reform.

Although responsibility for health services sits with devolved governments within the UK, GP-led primary care is at the heart of plans for service improvement in all four health systems (Box 2). This includes efforts to increase the number of GPs, develop team-based models of primary care with GPs working alongside other health and care professionals, and closer integration of services between general practice, hospitals, social care and other services.

Against this backdrop, we present our analysis of data from the Commonwealth Fund’s 2019 GP survey – including comparisons with the 2015 survey data where possible.

The data are presented under three main themes:

1. How GPs view their job.
2. The care GPs provide and how it is changing.
3. How GPs work with other professionals and services.

The results are presented for the UK as a whole, with differences between UK countries highlighted only when they are of particular interest. The final section of this analysis discusses the implications of the results and what they mean for policy in England, though the implications we identify are likely to be broadly relevant across the UK. See Methods below and the Appendix for more details of the data and methods used.

Methods

The 11 countries surveyed were: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States.

13,200 primary care physicians across 11 countries completed the survey, of which 1,001 were from the UK. The survey was completed between January and June 2019. Primary care physicians were recruited through a variety of methods including by post, email, fax, phone and online. In the UK, GPs were asked to complete the survey either online or via phone. The response rate was 26.8%, with 1,001 GPs participating.

There was an international set of 37 questions, and UK GPs were asked an additional set of UK-specific questions, funded by the Health Foundation.

These methods were used in the analysis:

• Weighting: for the 11 country results, data from each country were weighted to ensure the final outcome was representative of GPs in that country based on their demographics (gender, age – and region for the UK) and selected specialty types. See the Appendix for full details.
• Comparison with the 2015 results: few reliable comparisons can be made between the 2015 and 2019 survey results because the wording of most questions and/or responses changed between editions. Where year-on-year comparisons could be made, the statistical significance was calculated for a 95% confidence level, giving a margin of error of 3.5% for the UK.
• Statistical significance: where we report differences between countries these are statistically significant at the 95% level unless otherwise stated.

Further information on methods can be found in the Appendix.

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Overall satisfaction with practising medicine

GP satisfaction in the UK is low compared to other countries. 39% of surveyed UK GPs report feeling ‘extremely or very satisfied’ with practising medicine, compared to an average of 51% for the 10 other countries in the survey (Figure 1). Only France has lower overall GP satisfaction (though the proportion of GPs reporting that they are ‘not at all satisfied’ or only ‘slightly satisfied’ is higher in the UK).

Figure 1: Overall how satisfied are you with practising medicine?

Workload

GP workload includes time spent with patients, but a significant proportion of the work that GPs do happens outside consultations. This includes writing referral letters, managing prescription requests, and liaising with housing authorities, social services, food banks and other services. In this survey, 6% of GPs in the UK report feeling ‘extremely satisfied’ or ‘very satisfied’ with their overall workload – the lowest of any country surveyed.

Time with patients

In addition to overall workload, the survey asks how GPs feel about the amount of time they are able to spend with patients. Only 5% of UK respondents feel ‘extremely satisfied’ or ‘very satisfied’ with the amount of time that they spend with patients – significantly lower than the satisfaction reported by GPs in the other 10 countries surveyed. The UK is also an outlier in terms of short appointments: 86% of GPs in the UK report that average appointments involved less than 15 minutes of face-to-face time with patients – the highest percentage of all countries featured in the survey. 77% of GPs in the UK report that their average appointment length for a routine appointment is 10 minutes or less.

Satisfaction with pay

UK GPs report lower satisfaction with pay than any of their international counterparts. There was some regional variation within the UK: 37% of GPs in Northern Ireland report that they are ‘extremely or very satisfied’ with pay, compared with 25% in England. (33% of GPs in Scotland and 29% in Wales say they are ‘extremely’ or ‘very satisfied’, but the differences are not statistically significant between these and other UK nations.)

Stress levels

High workload and short consultation times are likely factors affecting the number of GPs finding their work stressful. 60% of UK respondents report that they find practising in primary care to be ‘very stressful’ or ‘extremely stressful’ (Figure 2). This is similar to the 59% responding the same way in the 2015 Commonwealth Fund survey, suggesting that little progress has been made in reducing GP stress. Reported stress levels vary across the UK. In England 62% of GPs said they are ‘extremely’ or ‘very’ stressed, compared with 52% in Wales, 48% in Scotland and 43% in Northern Ireland.

Figure 2: How stressful is your job as a GP?

Future career plans

Retaining the existing workforce is an important component of efforts to increase GP numbers across the UK, but data from this survey suggest doing so will be difficult. In 2019, 70% of UK GPs report that they work full time (35 or more hours a week), down from 80% in the 2015 survey. 49% of GPs surveyed plan to reduce their weekly clinical hours in the next 3 years (compared to 10% who plan to increase them). The percentage of UK GPs who plan to retire in the next 3 years has reduced – from 17% in the 2015 survey to 11% in 2019. But the number of GPs planning to change career has risen (15% in 2019 compared to 8% in 2015).

Figure 3 shows that it is not only people aged 55+ who are planning to leave general practice or reduce their clinical hours: 21% of those planning to retire from all work, 81% of those planning to change careers and 74% of those planning to reduce their weekly clinical hours are aged under 55.

Figure 3: In the next 1 to 3 years do you plan to…?

Do GPs think they’re providing good care?

The 2019 survey asked GPs to consider the quality of care they provide to patients. In response to a question only asked to UK GPs, 27% feel that the quality of care they provide to patients in general practice has improved in the last 3 years (either ‘a lot’ or ‘somewhat’). This compares with 31% who feel that the care they provide has worsened.

When asked to consider the overall performance of the NHS, 60% of GPs in the UK state that it is ‘good’ or ‘very good’, while 9% feel that it is ‘poor’ or ‘very poor’. This is similar to Canada (61% believe their health system is good/very good) and New Zealand (62%). Only GPs in the US rate their system lower (Figure 4). Within the UK, GPs in Northern Ireland are particularly likely to hold their health system in low regard – just 39% agreeing that it is ‘good’ or ‘very good’, significantly different from 60% in England. GPs in the UK are also not optimistic about the trajectory of NHS performance. 18% think performance has improved in the past 3 years, while 46% feel it has declined.

Figure 4: How would you rate the overall performance of the health care system in your country?

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Consultation type

As demand for appointments rises, policymakers have been looking for ways to reduce GP workload. This includes using online and digital technology to access primary care services – referred to as ‘digital first primary care’ – which NHS England argues will increase patient convenience and allow practices to better manage their workload. Data from the Commonwealth Fund survey shows how GPs are currently working, how this is changing, and to what extent GPs may be prepared to adopt different ways of working in the future.

A range of consultation types have evolved in recent years – including telephone triage (to identify the type of care required), telephone consultations and e-consultations – in addition to the more traditional face-to-face appointments.

Data from this survey indicate that instead of replacing one consultation type with another (for example, using telephone consulting to deal more efficiently with a problem that might previously have used a face-to-face appointment), GPs in the UK are spending more time on many types of consultation (Figure 5). 44% of UK GPs say that the amount of time they spend doing face-to-face consultations has increased in the last 12 months, compared with the 6% who feel it has reduced. Increases in the amount of time spent doing telephone triage and telephone consultations are even more pronounced. 62% say they spend more time on telephone triage and 71% say they spend more time on telephone consulting.

Figure 5: In the past 12 months, how, if at all, has the amount of time you spend doing the following patient care activities changed?

Newer consultation types – email and video consultation – are either not offered or not increasing as fast. Only 21% of GPs surveyed in the UK currently offer email consultations, and even fewer (just 11%) currently offer video consulting.

Use of information technology within general practice

Information technology, or the use of computerised systems within general practice, comprises a broad set of functions. It includes an electronic medical record (EMR – for electronic prescribing, search and audit functions), systems to allow lab results and hospital correspondence to be received and processed electronically, and systems for alerts to help improve patient safety. It also includes patient-facing services, for example online prescription requests, appointment booking and e-consultations.

In previous surveys by the Commonwealth Fund, UK general practice has tended to be more advanced in the use of information technology than other countries. In 2006, 89% of UK GPs reported routinely using an EMR, rising to 98% by the 2015 Commonwealth Fund Survey. In the 2019 edition, 99% of UK respondents say that they routinely use EMRs. Five other countries surveyed have almost total use of EMRs. In Canada, France, Germany and the United States usage of EMRs is between 86-91%, and in Switzerland coverage is 70%.

Although EMRs are in use across the UK, there is variation in the wider use of information technology within UK general practice. The small number of GPs interviewed for the survey in some countries (see Appendix) means that there is a danger of drawing too much from data, but the variation between some regions is large. For example, 97% of GPs surveyed from London (and 95% for the rest of England) say that patients are able to book appointments online, compared to 45% in Northern Ireland, a statistically significant difference. (In Wales it is 80% and Scotland 64%, both of which are significantly different from Northern Ireland.)

GPs in the UK are using computerised systems for a relatively wide range of tasks compared to GPs in other countries (Table 1). GPs in the UK are the most likely to receive computerised reminders for guideline-based interventions and/or screening tests – 72% say that they do, though this is down from 78% in the 2015 survey. The vast majority of UK GPs (91%) also use computerised systems to send patients reminder notices – for example, for flu vaccines or diabetic checks. The percentage of UK GPs using computerised systems to order and track laboratory results has increased since the 2015 survey (84% in 2019, compared with 72% in 2015). Conversely, 56% receive an alert or prompt to provide patients with test results, down from 65% in 2015.

Table 1: How computerised systems are used in general practice – UK ranking shown in parentheses

Are the following tasks routinely performed in your practice using a computerised system?
	2015	2019
Patients are sent reminder notices when it is time for regular preventive or follow-up care (eg, flu vaccine or HbA1c for diabetic patients)	90% (2nd)	91% (2nd)
All laboratory tests ordered are tracked until results reach clinicians	72% (1st)	84% (2nd)
You receive an alert or prompt to provide patients with test results	65% (1st)	56% (3rd)
You receive a reminder for guideline-based interventions and/or screening tests	78% (1st)	72% (1st)

Note: statistically significant year-on-year changes are indicated in bold.

When directly patient-facing aspects of care are considered, the position of UK GPs relative to other countries is more variable (Table 2). 90% of UK GPs say that they offer online appointment booking – the highest of any country surveyed – and 91% say that they offer online repeat prescription requests. However, only 60% of GPs offer their patients the option to communicate with their practice via email or a secure website regarding a medical question or concern – ranking 7th out of 11 internationally. There is also room for improvement in relation to offering patients the option to view test results online (52%).

Table 2: Online services available to patients

Does your practice offer your patients the option to…
	Yes % (rank)
Communicate with your practice via email or a secure website about a medical question or concern?	60% (7th)
Request appointments online?	90% (1st)
Request refills for prescriptions online?	91% (2nd)
View test results online?	52% (4th)

Use of performance and quality data

Having access to performance data and analysing those data to improve care is an essential function of a high-performing health system. The survey asked GPs how often their practice receives and reviews data on a range of aspects of patient care.

GPs in the UK lead the pack in terms of receiving and reviewing performance data (Table 3). Compared to their international counterparts, UK GPs are more likely to receive and review data on a yearly or quarterly basis on hospital admissions or emergency department use, prescribing practice, patient satisfaction and patient reported outcomes. However, more progress can be made. While the UK ranks first internationally on the use of patient reported outcome measures (PROMs), only 63% of UK GPs state that their practice receives and reviews PROMs on a quarterly or annual basis.

Table 3: Use of quality and performance data by GPs

How often, if at all, does your practice receive and review data on the following aspects of your patients' care?
	Quarterly or annual % (rank)
Clinical outcomes such as percentage of diabetics or asthmatics with good control	89% (2nd)
Patients' hospital admissions or emergency department use	80% (1st)
Prescribing practice (eg use of generic drugs, antibiotics or opioids)	91% (1st)
Surveys of patient satisfaction and experiences with care	79% (1st)
Surveys of patient reported outcome measures (PROMs)	63% (1st)

Communication between GPs and other providers

The survey provides insight into whether some core components of care integration – such as the sharing of patient information to deliver safe care – are happening.

The UK performs well compared to other countries in terms of communication between GPs and acute providers, but there is still room for improvement. Basic communication between specialist and primary care does not always take place – and, when it does, this communication is not always timely. 69% of GPs in the UK say that they ‘usually’ (defined by the survey as 75–100% of the time) receive information from a specialist about changes made to the patient medication or care plan, while 96% say that they ‘usually’ or ‘often’ (defined by the survey as 50–100% of the time) receive this information. Although patients frequently require medication changes after specialist review (and patients may expect GPs to ‘know’ the outcome of their review), only 8% of GPs report that they ‘usually’ receive a report within a week and only 26% ‘usually’ or ‘often’ receive a report within a week (the lowest performance of any country surveyed).

The UK performs relatively well for GPs receiving notification when patients access emergency care. Table 4 shows that the majority of GPs ‘usually’ or ‘often’ receive notification when their patients are seen in after-hours care, an emergency department or are admitted to hospital, but – again – this information often has a time lag. Only 23% of surveyed UK GPs report that they receive the information they need to continue managing the patient within 48 hours of discharge. Within the UK, GPs in Scotland appear to have the fastest access to information from hospital specialists after an admission. 53% of GPs surveyed in Scotland say that they receive the information they need to continue to manage the patient within 48 hours of discharge from hospital. This statistically significant difference compares with an average of 20% within 48 hours in England, 18% in Wales, and 9% in Northern Ireland.

Table 4: Communication between GP practices and hospital services

When your patients have been referred to a specialist, how often do you…
	Usually/Often % (rank)
Receive from the specialist information about changes made to the patient medication or care plan?	96% (3rd)
Receive a report with the results of the specialist visit within 1 week of service?	26% (11th)
How often do you receive notifications that your patients have been…
	Usually/Often % (rank)
Seen for after-hours care?	96% (2nd)
Seen in an emergency department?	91% (3rd)
Admitted to a hospital?	86% (3rd)
	Less than 48 hours % (rank)
After your patients have been discharged from the hospital, how long does it take, on average, before you receive the information you need to continue managing the patient, including recommended follow-up care?	23% (7th)

Note: Usually/Often is defined by the survey as 50–100% of the time.

As set out in Box 2, all countries in the UK have embarked on reforms (albeit at different speeds of implementation) in which GPs lead a broader primary care team, including additional health professionals (such as pharmacists and physiotherapists) and non-medical professionals (such as social prescribing link workers). The four countries share an intention to improve connections between general practice and other services, including social care and other sources of non-medical support to address patients’ social needs.

Data from this survey give an indication of the extent to which GPs in the UK are already working with some of the roles being introduced as part of wider teams:

• 73% have at least one pharmacist working on their team.
• 26% have at least one physiotherapist working on their team.
• 13% have at least one physician associate working on their team.

Although the precise job description of these roles may vary across international boundaries, the data suggest that other countries have made more progress in some areas. For example, 96% of GPs in the Netherlands and 97% in Germany report that they already work with physician associates. Learning from their experience may be valuable.

Caring for patients with chronic conditions

Meeting the needs of growing numbers of people living with chronic conditions is one of the biggest challenges facing the NHS. The responsibility for providing much of this care, including new models of coordinated care and disease management, falls on primary care.,

83% of GPs in the UK report that their practice is well prepared to provide care for patients with chronic conditions (Figure 6) – though this still leaves 17% of GP respondents not feeling well prepared to do so.

Relative to their international counterparts, UK GPs report feeling well prepared to provide care for patients with dementia or palliative care needs (59% and 72% respectively). GPs feel that their practices are less prepared to provide care for patients with substance misuse or mental illness (23% and 56% respectively stated that they are well prepared, which is in line with responses from other countries).

Figure 6: How well prepared is your practice to manage care for the following patients?

Integration across primary, secondary and social care

The long-standing ambition in all four UK countries to improve integration between primary care and other kinds of care is supported by UK GPs: 73% chose ‘better integration of primary care with hospitals, mental health, and community-based social services’ as a top priority to improve quality of care and patient access. Only Sweden (76%) has a similar or higher level of support for this.

However, integration of services in practice is challenging. The survey asked about coordination between GPs and ‘social services’, which is likely to mean different things to GPs in different countries. In the UK, this may include adult social care providers, as well as wider services available in the community via a range of voluntary and community sector providers. 61% of respondents from the UK feel that a lack of follow-up from social service organisations about which services patients received or need poses a major challenge in coordinating their patients’ care. Around half feel that major challenges to address include inadequate staffing to make referrals and coordinate care with social service organisations (56%), too much paperwork regarding coordination with social services (50%) and lack of awareness of social service organisations in the community (47%). One in three UK GPs (34%) feel that the lack of referral system or mechanism to make referrals is a major challenge.

Integration with other non-medical services

Linking patients with a much broader set of services that impact on their health, such as housing or other kinds of social support, is seen as an increasingly important function of general practice. Doing this requires GPs to be aware of the non-medical needs that their patients might be experiencing, which may be achieved through some sort of screening process. This survey indicates that the screening of patients in UK general practice for social needs is variable (Figure 7). Compared to other countries, the UK performs highly for screening patients for problems with housing, domestic violence and social isolation or loneliness, but poorly for screening financial security and transport needs.

In all countries, the survey results suggest that many patients are not being assessed for social needs related to their health. The percentages in Figure 7 show the proportion of respondents from each country stating that they screen for each need usually, often or sometimes, which translates as 25% or greater of the time. Even when percentages are high, there are likely to be many patients that are not being screened for these social needs. The survey did not ask GPs what happens after patients are screened for social needs and how that information is used.

Figure 7: The proportion of respondents who screen or assess for each specified social need usually, often or sometimes

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General practice in the UK has many strengths – chief among them, its roots in a universal health care system which is free at the point of delivery, and the longstanding relationships built up with families and communities that are essential to good care. Compared to some of the countries included in this study, general practice in the UK performs well in several key areas.

However, data from the survey should add to the growing chorus of alarm bells for policymakers. After a decade of austerity in NHS funding and cuts in wider services that impact on health, general practice in the UK has never looked more vulnerable. Policies to improve and reform primary care services – including PCNs – must reflect the context in which they will be implemented. Solutions to pressures in general practice that rely on the existing GP workforce doing more are likely to misfire.

1. Doty MM, Tikkanen R, Shah A, Schneider EC. Primary Care Physicians’ Role In Coordinating Medical And Health-Related Social Needs In Eleven Countries: Results from a 2019 survey of primary care physicians in eleven high-income countries about their ability to coordinate patients’ medical care and with social service providers. Health Affairs. 2019; 10.1377/hlthaff. 2019.01088.
2. Martin S, Davies E, Gershlick B. Under Pressure: What the Commonwealth Fund’s 2015 international survey of general practitioners means for the UK. The Health Foundation; 2016.
3. Office for National Statistics. Overview of the UK population: August 2019. ONS; 2019.
4. Palmer, B. Is the number of GPs falling across the UK? [blog]. Nuffield Trust; 2019 (www.nuffieldtrust.org.uk/news-item/is-the-number-of-gps-falling-across-the-uk).
5. NHS England. The NHS Long Term Plan 2019. NHS; 2019 (www.longtermplan.nhs.uk/).
6. Buchan J, Gershlick B, Charlesworth A and Seccombe I. Falling short: the NHS workforce challenge. The Health Foundation; 2019.
7. Owen K, Hopkins T, Shortland T, Dale J. GP retention in the UK: a worsening crisis. Findings from a cross-sectional survey. BMJ Open. 2019; 9(2):e026048.
8. Royal College of General Practitioners Northern Ireland. Support, Sustain, Renew: a vision for general practice in Northern Ireland. RCGPNI; 2019.
9. Royal College of General Practitioners Scotland. From the Frontline: The changing landscape of Scottish general practice. RCGPS; 2019.
10. Information Services Division. Primary Care Workforce Survey Scotland 2017. NHS National Services Scotland; 2018.
11. Royal College of General Practitioners Wales. Transforming general practice: Building a profession fit for the future. RCGPW; 2018.
12. Statistics for Wales. GPs in Wales, as at 30 September 2018. Welsh Government; 2018 (https://gov.wales/sites/default/files/statistics-and-research/2019-03/general-medical-practitioners-as-at-30-september-2018-354_0.pdf).
13. Ipsos MORI. GP patient survey 2019. NHS England; 2019 (https://gp-patient.co.uk/about).
14. Department of Health Northern Ireland. Health and Wellbeing 2026: Delivering together. DoHNI; 2016
15. Department of Health Northern Ireland. Health and Wellbeing 2026: Delivering together. Progress report May 2019. DoHNI; 2019.
16. Scottish Government. Healthier Scotland: Health and Social Care Delivery Plan, December 2016. Scottish Government; 2016.
17. Burgess L. Primary Care in Scotland (SPICe Briefing paper). The Scottish Parliament; 2019.
18. National Primary Care Board. Strategic Programme for Primary Care. Welsh Government; 2018.
19. Welsh Government. A Healthier Wales: Our Plan for Health and Social Care. Welsh Government; 2019.
20. NHS England and the British Medical Association. Investment and evolution: A five-year framework for GP contract reform to implement The NHS Long Term Plan 2019.
21. The Commonwealth Fund. 2006 International Health Policy Survey of Primary Care Physicians. The Commonwealth Fund; 2006 (www.commonwealthfund.org/publications/surveys/2006/nov/2006-international-health-policy-survey-primary-care-physicians).
22. Stafford M, Steventon A, Thorlby R, Fisher R, Turton C, Deeny S. Briefing: Understanding the health care needs of people with multiple health conditions. The Health Foundation; 2018.
23. Salisbury C, Man M-S, Bower P, Guthrie B, Chaplin K, Gaunt DM, et al. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. The Lancet. 2018; 392(10141):41–50.
24. Reynolds R, Dennis S, Hasan I, Slewa J, Chen W, Tian D, et al. A systematic review of chronic disease management interventions in primary care. BMC Family Practice. 2018; 19(1):11.
25. Hobbs FR, Bankhead C, Mukhtar T, Stevens S, Perera-Salazar R, Holt T, et al. Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007–14. The Lancet. 2016; 387(10035):2323–30.
26. Atkins R, Gibson J, Sutton M, Spooner S, Checkland K. Trends in GP incomes in England, 2008–2017: a retrospective analysis of repeated postal surveys. British Journal of General Practice. 2020; 70(690):e64–e70.
27. Gibson J, Sutton M, Spooner S, Checkland K. Ninth National GP Worklife Survey. Policy Research Unit in Commissioning and the Healthcare System; 2017 (http://blogs.lshtm.ac.uk/prucomm/files/2018/05/Ninth-National-GP-Worklife-Survey.pdf).
28. Hall LH, Johnson J, Watt I, O’Connor DB. Association of GP wellbeing and burnout with patient safety in UK primary care: a cross-sectional survey. British Journal of General Practice. 2019: bjgp19X702713.
29. Bostock N. GP workforce falling 50% faster in deprived areas, official data show GPonline; 23 May 2018 (www.gponline.com/gp-workforce-falling-50-faster-deprived-areas-official-data-show/article/1465701).
30. NHS England. General Practice Forward View April 2016. NHS England; 2016.
31. Hammersley V, Donaghy E, Parker R, McNeilly H, Atherton H, Bikker A, et al. Comparing the content and quality of video, telephone, and face-to-face consultations: a non-randomised, quasi-experimental, exploratory study in UK primary care. British Journal of General Practice. 2019; 69(686):e595-e604.
32. Ipsos MORI and York Health Economics Consortium with Salisbury, C. Evaluation of Babylon GP at hand. NHS Hammersmith and Fulham CCG and NHS England; 2019.
33. Clarke G, Keith J, Steventon A. The current Babylon GP at Hand model will not work for everyone [blog]. The Health Foundation; 2019 (www.health.org.uk/news-and-comment/blogs/the-current-babylon-gp-at-hand-model-will-not-work-for-everyone).
34. Drinkwater C, Wildman J, Moffatt S. Social prescribing. BMJ. 2019; 364:l1285.
35. Bickerdike L, Booth A, Wilson PM, Farley K, Wright K. Social prescribing: less rhetoric and more reality. A systematic review of the evidence. BMJ Open. 2017; 7(4):e013384.
36. Gottlieb LM, Wing H, Adler NE. A systematic review of interventions on patients’ social and economic needs. American Journal of Preventive Medicine. 2017; 53(5):719-29.
37. Alderwick HA, Gottlieb LM, Fichtenberg CM, Adler NE. Social prescribing in the US and England: emerging interventions to address patients’ social needs. American Journal of Preventive Medicine. 2018; 54(5):715-8.
38. De Marchis EH, Alderwick H, Gottlieb LM. Do patients want help addressing social risks? Journal of the American Board of Family Medicine. Forthcoming.