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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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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Health systems in high-income countries face several common challenges, including caring for growing numbers of people with multimorbidity and tackling persistent inequalities in health. International comparisons can help identify opportunities for learning about how to address these challenges, but they should also be treated with some caution. Definitions can vary between countries (for example, what counts as social services), and the data need to be interpreted within the wider historical and policy contexts of the systems being compared.

Nevertheless, surveys like this offer broad signals for policymakers. Overall, the findings present a mixed picture for general practice in the UK. In some aspects of care – particularly compared to countries with weaker primary care systems, like the US, the UK is an international leader. Almost all GPs surveyed in the UK use electronic medical records, and the use of data to review and improve care is relatively high. GPs in the UK are broadly supportive of ambitions to improve integration of services. Yet the survey also highlights several areas of major concern, including low GP satisfaction and high stress levels. GPs are more likely to think that the quality of care that they – and the wider NHS – are able to provide is declining than to feel that it is improving.

The remainder of this discussion focusses on England, where reforms to primary care have been proceeding at pace since the publication of the NHS Long term plan in 2019. The plan promised an additional £4.5bn investment in primary and community care by 2023/24 and offered a vision of neighbouring GPs working together in new PCNs, leading expanded teams of pharmacists, physiotherapists and other allied health professionals. PCNs are expected to offer more preventative care with better links to community, social care and a broad range of other non-medical services. The plan also described ambitions for ‘digital first’ primary care, where all patients would have the right to video consultations by April 2021. The survey data highlight several challenges for these reform efforts in England.

Workforce pressures risk undermining primary care reform

The survey illustrates fragility in the foundations of which PCNs are being built. England has the lowest proportion of GPs feeling satisfied with their workload compared to the other 10 countries, and the second highest ranking of GPs reporting very high or extreme levels of stress. These perceptions are not surprising: the most comprehensive analysis of GP workload to date found that overall workload had increased by 16% between 2007–2014 and will have risen further since. Adjusted for inflation, average income has also declined between 2008 and 2017 for both salaried and partner GPs. Stress caused by high workloads has been a persistent feature of large-scale GP surveys and stress has been linked to burnout and increased concern about patient safety. The survey’s finding of low satisfaction among GPs with the short appointments they can offer patients – and the UK’s ranking as the country with the shortest appointments – will not be helping.

There is a close relationship between these pressures and GP retention. There was a slight drop between the 2015 and 2019 surveys in the proportion of GPs in the UK reporting that they plan to retire in the next 3 years (from 17% to 11%), but nearly half (including younger GPs) plan to reduce their clinical hours. Again, these findings are consistent with other studies. A 2019 study found that 18% of GPs surveyed planned to leave or retire within the next 2 years, and 48.5% planned to do so within the next 5 years. Work intensity and workload were cited as the most common reasons behind their intention to leave.

These challenges are not new. Workload has been climbing steadily in general practice for years. The result is that more GPs are leaving the profession or reducing their hours than are being recruited or increasing their hours. Full-time equivalent GP numbers are falling. And the number of FTE GPs has been falling fastest in the most deprived areas, where health needs are greatest. This is despite a raft of policy measures implemented since 2015 to try to meet a government pledge to recruit an additional 5,000 GPs by 2020. There have also been efforts to try to retain more GPs and to help manage escalating workload – including an improved ‘induction and refresher’ scheme for fully qualified GPs returning to practice after a break, increased funding for general practice, and additional allied health professionals in the primary care workforce.

The 2015 survey showed that GPs in the UK were the most stressed of the 11 countries surveyed. What is most concerning about the 2019 results (see Figure 2) is that high stress levels, low satisfaction with practising medicine and high expressed intention to leave general practice have all persisted despite actions taken to address them. This suggests that current policy approaches are inadequate, insufficient, or both.

Workload is increasing across consultation types

Part of the policy response to challenges in recruiting and retaining GPs has been to try to identify new ways of reducing pressure on GP workloads – including by boosting the use of digital technology in primary care. Use of online consultations and other digital tools is seen by NHS England and other policymakers as potential alternatives to face-to-face appointments.

In this Commonwealth Fund 2019 survey, GPs report spending more time on all main consultation types in general practice (telephone triage, telephone consulting and face-to-face consulting). Any potential substitution effect between consultation types (for example, telephone triage saving the need for face-to-face appointments) appears to be eclipsed by increased demand for services.

The survey also suggests that the proportion of GPs using new forms of consultation – video and email – is small. This suggests that it may be difficult to deliver NHS England’s promise to extend the right for all patients to have video consultations by April 2021. Research on GPs’ use of video consultations is limited, but evidence suggests there are many questions to resolve and potential unintended consequences – from whether the WiFi infrastructure exists to allow good quality connections between GPs and patients, to what impact video consultations have on GP workload and the distribution of uptake between patient groups. Some new forms of digital first primary care have been evaluated (but in populations that are unrepresentative of those using general practice), but it remains an open question whether new technology can help with the most urgent challenges facing GPs and their patients.

In other areas, use of technology among UK GPs is advanced. The survey confirms previous findings about the long-established use of IT systems within general practices for electronic health records, sending reminders to patients and clinicians, and for UK patients to book appointments online (even if appointments are in short supply). The IT capacity for hospitals and other health and care providers to communicate promptly with general practice has taken much longer to evolve, and information can be slow in arriving.

Support and evaluation are needed as primary care teams evolve

Delivering on the commitments in the NHS Long term plan requires GPs to work with other health and care professionals in multidisciplinary teams, and connect patients with non-medical services in their community. These are core aspects of the new primary care network contract proposed by NHS England. The aim is to provide more coordinated services, boost preventative care and make the best use of the wider primary care team.

The 2019 survey indicates that GPs are familiar with working with pharmacists, but the number of GPs or practices with experience of working with physician associates and first contact physiotherapists is lower. Providing ways to help PCNs fulfil the potential of these additional roles – for example, through sharing of best practice examples, or guidance from professional bodies such as the Chartered Society of Physiotherapy – will be important.

The new PCN contract also includes funding for general practices to hire social prescribing link workers – and it is hoped that every PCN will hire at least one. Social prescribing is an approach to connecting patients with non-medical services to improve their health – for example, helping patients access support related to address housing or social isolation. While a greater focus on addressing patients’ social needs is welcome, evidence on the impact of social prescribing is limited., Social prescribing can only ‘work’ if services are available in the community to address patients’ non-medical needs. And these interventions come with potential unintended consequences – including medicalising people’s social issues and exacerbating inequalities. Data from this survey suggest that screening for social need in general practice is currently variable. Evaluation is needed to understand what approaches to social prescribing work, for which patients and in what contexts.

Recommendations for policy

These findings highlight several considerations for national policy in England:

• Enable all GPs to offer longer appointment times. This is particularly difficult in the face of rising patient need and falling GP numbers; however, GPs with longer appointment times report greater job satisfaction. Offering longer appointments may paradoxically increase efficiency by improving the quality of care delivered, therefore reducing the need for more frequent shorter appointments. Policymakers hope that the additional roles recruited to PCNs may free up GP time, but it is not yet clear whether this will be the case. In reality, freeing up enough additional capacity to offer longer GP appointments will be challenging without more GPs.
• Do more to understand what would keep GPs in practice – and rapidly implement solutions. This survey suggests that measures tried so far are not turning the tide on GPs’ intentions to reduce their hours or leave practice altogether. Increasing the number of allied health professionals in primary care is not a substitution for GPs. Intensifying efforts to understand what would keep UK GPs in practice will be key to improving retention. This survey demonstrates that GPs in the UK are less likely than their international counterparts to report satisfaction with pay and with workload.
• Improve the speed of communication with hospitals. No single country has optimised use of electronic records, or ‘solved’ the challenge of care coordination. Although the UK performs reasonably well with regard to the sharing of clinical information between practices and hospitals, GPs report that these processes are often too slow. This may have implications for the quality of clinical care GPs can deliver. The UK has ambitious digital first primary care strategies, but must ensure that the basics are in place too.
• Set realistic ambitions for digitally enabled primary care. This survey suggests that most GPs in the UK are a long way from meeting ambitious targets to offer digital services to patients. At a time when GPs are under significant and sustained pressure, policymakers must consider whether the evidence of benefit is sufficient to justify pushing this agenda, and should thoroughly evaluate the impact of digital first models to ensure that they deliver the intended benefits to patients and staff.

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.

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