Policies to improve general practice in deprived areas since 1990

Over the past three decades, governments and NHS agencies in England have tried various approaches to tackle the inverse care law in general practice. Table 1 provides a summary of key national policies to improve the provision of general practice in deprived areas between 1990 and 2021. These policies overlap and interrelate, and are shaped by wider policy on NHS reform and spending. For example, policies aiming to reduce inequities in access to general practice in the 2000s were implemented in the context of major increases in NHS spending, and as part of a wider national strategy to reduce regional health inequalities.,,

In this section, we analyse the main national policies introduced since 1990 that explicitly aimed to reduce inequities in the quantity or quality of general practice services in England. We group these policies by their focus, including policies related to changes in:

  • resource allocation
  • commissioning and contracting
  • the GP workforce
  • premises.

For each area, we describe the key policies proposed and delivered, and review available evidence on their implementation and impact.

Table 1: Summary timeline of national policies aiming to improve general practice in deprived areas in England, 1990–2021

Source: Gov.uk; NHS England website; UK Government Web Archive.

Resource allocation

The level of funding available has a major impact on what general practice can deliver. From 1990, successive governments acknowledged that funding for general practice was not evenly distributed. Changes have been made to how overall NHS funding is allocated between areas. But major changes to the allocation of core GP funding – the ‘global sum’ formula – to help reduce inequities have not materialised, despite repeated promises to make the system fairer.

Key policy developments since 1990

Core practice funding

There is a complex mix of funding streams for general practice, but most of the funding comes through the core GP contract (Box 1). The government introduced a major new GP contract in 1990, which increased the proportion of GPs’ income from capitation payments (for each registered patient) and introduced new financial incentives, including for undertaking health promotion activities. The contract also included additional payments for patients living in deprived areas (calculated using the Jarman index, which accounted for several factors, such as patients’ employment and housing). To try to target funding more accurately based on need, government updated the system for calculating deprivation payments in 1999 (and also increased the budget for deprivation payments by 45%).

The next major changes to the GP contract were made in 2004. QoF was introduced to offer financial incentives for improving care (see Box 1), deprivation payments were removed, and a new funding formula – the ‘global sum’ formula, also known as ‘Carr-Hill’ – was introduced to allocate GP funding. The formula was designed to ensure that resources would be directed to practices based on an estimate of their workload and unavoidable costs. Payment was based on the GP patient list size, adjusted to reflect differences in the age and sex of patients, additional patient needs (using the standardised mortality ratio and longstanding illness for patients younger than 65), list turnover, rurality, and the cost of employing staff. There was no specific adjustment for workload associated with practising in areas of socioeconomic deprivation. A ‘minimum practice income guarantee’ was also added to the contract, ensuring that practices’ income would not fall because of the new formula.

Policymakers agreed that the formula would be reviewed after implementation by a Formula Review Group (FRG). The group reported in 2007 and suggested significant changes to the formula. They recommended that the workload adjustment be changed to factor in deprivation, by including an index of multiple deprivation (IMD) score for patients’ electoral ward of residence. They also suggested an adjustment to reflect the extra costs of recruitment and retention to attract GPs in deprived areas. The FRG recognised that their revised formula – if implemented – would lead to ‘significant redistributive effects’ between practices.

Following the review, the BMA general practitioners committee – responsible for GP contract negotiation – asked practices and local medical committees (representative GP committees) to consider whether the FRG recommendations should be introduced. Although most respondents from local committees agreed with the changes, GPs did not. By this point, the 2008 NHS Next Stage Review had repeated the promise to ‘develop a fairer system of funding for GP practices’, but the FRG’s recommendations were not implemented.

A series of subsequent policy papers from national NHS bodies promised that the GP funding formula would be reviewed to make the allocation of resources fairer between areas, including the Five year forward view in 2014.,, In 2016, the General practice forward view contained the most explicit pledge yet to revise Carr-Hill, stating that the formula is ‘out of date and needs to be revised’. NHS England promised a ‘new funding formula’ to ‘better reflect practice workload including deprivation’. 5 years later, the formula has not been updated. The 2016 review of Carr-Hill is not publicly available.

Area-based funding allocations

In addition to the core GP contract, some funding for primary care is included in the overall NHS funding allocations for each local area – currently allocated to clinical commissioning groups (CCGs). In the early years of the NHS, there was little attempt to match local funding to population needs. In the 1970s, government introduced formulae to allocate overall NHS funding more equitably between regions.,, These initially only applied to hospital services but the formula was extended to include primary care in the early 2000s.

Governments in the 1990s pledged to allocate resources more fairly between different parts of the country. In 1996, the Conservative government announced major reforms to primary care, including a promise to tackle ‘long-standing inequities’ in the distribution of resources. The next year, the Labour government announced a new Advisory Committee on Resource Allocation to advise on the distribution of funding for health services between areas (replacing the Resource Allocations Working Group). Soon after, the Acheson review – established by government to assess health inequalities and identify actions to address them – recommended that government improve needs-based weightings to distribute NHS funding more equitably. By 2000, the Labour government pledged to use NHS resource allocation policy to ‘help reduce avoidable health inequalities’.

To help achieve this objective, government introduced a new health inequalities component in the overall NHS resource allocation formula from 2001/02. The formula determined the resources for primary care trusts (PCTs), responsible for commissioning primary care and managing the quality and quantity of local services. An adjustment was initially made to target a proportion of resources to areas with the poorest health. A new formula was then introduced from 2003/04 that contained an adjustment for unmet health need – combined with broader policies and targets to reduce gaps in life expectancy between richer and poorer areas of England (see section on commissioning and contracting). The weighting given to the health inequalities adjustment was originally 15% but was reduced to 10% in 2010.

In 2013, PCTs were replaced by CCGs (which later took on responsibility for commissioning primary care). The funding received by each CCG is determined by several different allocation formulae, covering core services, primary medical services and specialised services. NHS England introduced a new core CCG resource allocation formula from 2014, including a ‘deprivation indicator’.

In 2016/17, a new formula for CCG primary medical care allocations was introduced. This included updated estimates of primary care workload per patient and included IMD scores in the weightings. For each formula, NHS England includes a ‘health inequalities and unmet need’ adjustment – of 15% for primary care, 10% for core services and 5% for specialised services. A review of these adjustments was promised in the NHS Long Term Plan in 2019.

Evidence on policy impact

Core GP funding

The impact of GP funding allocations on practices in more deprived areas has changed over time. Deprivation payments in the 1990s were broadly welcomed by GPs. But there were concerns that payments did not reflect workload, small pockets of deprivation in relatively affluent areas were not recognised, and the system favoured urban over rural practices. Changes to the way deprivation payments were calculated from 1999 redistributed some funding from London to deprived areas of northern England, and succeeded in targeting payments more precisely. Deprivation payments were removed with the introduction of Carr-Hill in 2004.

Evidence suggests that Carr-Hill formula – in place since 2004 – does not adequately adjust for additional workload associated with delivering general practice in areas of high deprivation. This results in inequity of funding distribution across general practice, with practices in more deprived areas losing out., This was recognised by the Carr-Hill formula review group in 2007, which recommended the inclusion of IMD scores in the formula to make the allocations fairer. Levene et al studied the relationship between socioeconomic deprivation scores and practice payments between 2013 and 2017, finding that for each 10% increase in IMD score, practice payments increase by just 0.06%. In 2020, Health Foundation research found that, once weighted for need, practices in the most deprived areas receive around 7% less funding per patient than practices in the most affluent areas. Inequities in funding between surgeries in more and less deprived areas are not reducing over time.

Other general practice income also affects the distribution of resources between areas. The ‘minimum practice income guarantee’, introduced in 2004, redirected some funding to practices in deprived areas, but was phased out from 2014. Recent data suggest practices in more deprived areas tend to receive lower QoF scores, resulting in lower income. Provision of ‘directed enhanced services’ in primary care – which practices can choose to provide in exchange for extra income – is also lower in deprived areas.

Area-based funding allocations

Understanding how changes to overall NHS funding allocations affect equity in general practice is challenging. Area-based allocations cover funding for a vast array of NHS services, not just primary care. Local commissioners make different decisions about how these resources are used in their area. And most funding received by general practices comes directly through the GP contract. Area-based allocation formulae have changed over time, and some areas have remained either ‘over’ or ‘under’-funded compared with their target allocations.

Barr and colleagues studied the impact of changes to the NHS resource allocation formula between 2001 and 2011 – a period when policymakers attempted to increase NHS resources for more deprived areas in England. They found that geographical inequalities in mortality from causes amenable to health care declined in absolute terms during the 10-year period – with most of the observed reduction explained by the increase in NHS resources in more deprived areas. This suggests that changes to NHS resource allocation may be an effective mechanism to reduce health inequalities. But it is not clear how far overall attempts to make NHS funding more equitable between regions of England trickle down to general practice.

Since 2010, changes to allocation formulae have affected how resources are distributed between more and less deprived areas. The reduction of the PCT health inequalities adjustment in 2010 directed some funding away from deprived areas. And changes to the core CCG allocation formula in 2014, and the primary care allocation formula in 2016, made each less progressive than its predecessor in terms of distributing funding relative to deprivation.,,

Contracting and commissioning

Alongside changes in how funds are allocated, reforms to GP contracts and commissioning have been used to influence how NHS resources are used to improve primary care. Since 1990, new GP contracts have been introduced by policymakers to give greater flexibility to tailor local services in more deprived or under-doctored areas. And regular reforms to NHS commissioning have included broad aims to reduce inequalities in care quality and outcomes.

Key policy developments since 1990

Contracting

Historically, there was only one nationally negotiated GP contract. Government introduced a wider choice of contracts for GPs in the late 1990s, partly to improve quality of care and allow services to be better tailored to meet local needs, and partly to attract GPs to work in under-served areas by providing more flexible employment options.,

To help do this, the NHS (Primary Care) Act 1997 enabled pilots of new PMS contracts (see Box 1) and created more opportunities for salaried GP posts (an alternative to practising as a self-employed GP partner)., PMS pilots began in 1998 – and initially were mostly in deprived areas., Unlike the national contract, GPs could negotiate PMS contracts locally with their PCTs and test new ways of contracting services. Many PMS pilots made use of a new salaried doctor scheme that reimbursed the costs of salaried posts.,

In 2000, The NHS Plan made existing PMS pilots permanent and promised to expand them, including 200 PMS sites mainly in ‘disadvantaged communities’ by 2004. PMS contracts became a permanent alternative to the GMS contract in 2002. PMS and GMS contracts have become more similar over time. PMS contracts and salaried GPs remain.

The introduction of APMS in 2004 (see Box 1) was a further attempt to use GP contracts to help improve primary care in under-doctored areas., These contracts allowed commissioning organisations to contract with non-NHS bodies (such as commercial providers or social enterprises) to supply primary care services. APMS intended to expand primary care capacity and offer patients more choice of providers and services, particularly targeting populations with ‘high health needs without the services to respond to them’ to ‘tackle longstanding inequities’. Between 2008/09 and 2012/13, 4% of practices held APMS contracts. By 2018/19, 2% of practices were run by alternative contract providers. The 2004 contract reforms also saw the introduction of the GMS contract (see Box 1).

Commissioning

Over the past 30 years, local NHS commissioners have been given responsibilities to purchase some primary care services (see section on resource allocation), manage GP contracts, and improve the quality of primary care. National policy on NHS commissioning has had broad and overlapping aims, including to reduce inequalities in care quality and outcomes.,,,

In 1991, two models of commissioning health services were introduced – the first time there had been a formal split between ‘purchasers’ and ‘providers’ of NHS care. Health authorities were responsible for assessing population health needs and purchasing acute or community services – and gained responsibility for primary care contracting in the mid-1990s. GP fundholding was also introduced, enabling GP practices that signed up to control some of the budget for hospital care for their patients (and receive a share of any savings generated).

Fundholding was abolished by the Labour government in 1999, amid concerns that it was contributing to inequities in care. But the purchaser-provider split was maintained and government introduced new primary care groups (PCGs), responsible for commissioning hospital, community, and primary care services in their area. By 2002, primary care trusts (PCTs) had replaced PCGs, bringing together the functions of health authorities and PCGs.

PCTs were explicitly tasked with reducing health inequalities., PCTs were required to carry out health equity audits to identify how fairly NHS resources were distributed within their areas and identify actions to address inequalities. To help target resources at the most deprived areas, government identified ‘spearhead’ PCTs in 2004, covering the 20% of areas with the greatest deprivation and ill health. A new funding formula was introduced to direct additional NHS resources to deprived areas (see section on resource allocation).

A mix of area-based policies were also introduced in the late 1990s and 2000s that aimed to improve health and reduce inequalities through changes in how services were planned and delivered.,,,, For example, health action zones were local partnerships for improving health and health equity involving NHS commissioners, providers, local government and others between 1998 and 2003, established in areas of high deprivation or ill health. Schemes varied based on local context but included a focus on improving primary care – including by improving premises and expanding services in deprived areas.

PCTs were abolished under the Health and Social Care Act in 2012. CCGs were created to plan and commission most local services – and inherited responsibility for commissioning primary care over time from NHS England. Among other aims, NHS England and CCGs were intended to reduce inequalities in access to and outcomes of NHS care. Under the latest round of NHS reforms due to be implemented in 2022, CCGs will be replaced by integrated care boards, which are also expected to be key vehicles for reducing inequalities.

Evidence on policy impact

Contracting

Evidence on the effects of the new GP contract models introduced from 1997 onwards is mixed. Most available evidence is from the first wave of PMS pilots, which had some positive effects. The pilot sites were concentrated in deprived areas – particularly in cities.,, The national evaluation found that salaried contracts had resulted in modest but positive improvements in GP recruitment and retention., And the pilots were successful in improving access and quality of care for vulnerable groups.,,, But the mechanisms for improving quality in pilot sites – such as effective management, clear objectives, and flexible professional relationships – were not unique to the PMS model.

The impact of PMS in different areas is also likely to have changed over time. Later PMS pilots were more geographically spread, with fewer placed in deprived areas. By 2004/05, salaried GP posts were more common in more affluent areas. By 2013, NHS England analysis found that there was no relationship between PMS expenditure and deprivation.

Evidence on the impact of APMS contracts is more limited. Analysis of practices in England open from 2008/09 to 2012/13 found that practices holding APMS contracts tended to be in more deprived areas than GMS or PMS practices. But while APMS had more GPs per 1,000 patients, they were found to perform worse on care quality and patient experience.

Commissioning

Overall, evidence suggests that changes to NHS commissioning have not led to reductions in health inequalities,,,, – though regular reorganisations of NHS commissioning systems make evaluation challenging, and evidence of the effect on primary care is more limited.

Evidence suggests that PCTs largely failed to reduce health inequalities, despite explicit efforts to do so by improving commissioning of services. Studies on health action zones also found no clear evidence of an effect on population health and health inequalities., More recent evidence, however, suggests the broader health inequalities strategy that these partnerships and other related policy developments were part of – including directing additional NHS funding to more deprived areas – may have been partially effective in reducing health inequalities in England over time.,,, There is little evidence to suggest that clinical commissioning since 2010 has had a significant impact on inequalities.,

Workforce

Having enough staff is central to delivering good care in general practice, and recruiting and retaining more GPs and other primary care professionals continues to be a policy priority. Since 1990, national policies to address the inverse care law in general practice through more equitable workforce distribution have fallen into two broad groups: changes to central controls on the distribution of GPs, and incentives to attract and retain GPs in certain areas. New working arrangements for GPs (see section on contracting) and funding for new practices (see section on premises) have also been used to attract staff to under-doctored areas.

Key policy developments since 1990

Controls on GP distribution

Central controls on GP distribution have been used for much of the lifetime of the NHS. From 1948 to 2002, the Medical Practices Committee (MPC) was responsible at a national level for the equitable distribution of GPs, refusing applications from doctors wanting to practise in areas with an ‘adequate’ number of GPs., The MPC considered various factors including deprivation in its decisions, and introduced a weighting formula for deprivation in 1998.

The government announced the abolition of the MPC in 2000, citing ‘only partial success’ in ensuring the fair distribution of GPs. In 2002 – when the committee was abolished – responsibility for workforce distribution and GP vacancies transferred to PCTs. Despite the shift towards local control, government still set advisory lower and upper limits for GP recruitment for PCTs between 2002 and 2004 to promote ‘more equitable distribution’. In 2009, the new Medical Education England (later Health Education England) assumed responsibility for national workforce planning, but not explicitly for fair GP distribution.

NHS Plan targets

The NHS Plan promised to recruit 2,000 extra GPs nationally by 2004 and improve primary care supply in deprived areas. To support these aims, government introduced financial incentives under the Golden Hello Scheme in 2001. The scheme gave up to £5,000 to new GPs and returners, with an extra £5,000 available to GPs in deprived or under-doctored areas. From 2002, the payment increased for under-doctored PCTs.

The Primary Care Development Scheme replaced the Golden Hello Scheme in 2005. The scheme aimed to provide extra funding and support to areas with recruitment difficulties, particularly ‘disadvantaged areas with high needs’. Funding could be used to recruit more GPs – and in some cases to ‘improve’ the skill mix in primary care – by offering financial incentives (for individuals or practices) and development opportunities. National funding of £13m per year was allocated initially, subject to a planned review in 2008/09. There is no publicly available information on the scheme beyond 2005.

‘Building the workforce’ since 2015

The NHS Five year forward view in 2014 committed to incentivising GPs to work in ‘under-doctored areas to tackle health inequalities’. The Building the workforce plan for general practice in 2015 then announced a mix of funding and policies to fulfil this commitment.

The plan included funding to encourage former GPs to return to practice in ‘areas of greatest need’. NHS England piloted a Targeted Investment in Recruiting Returning Doctors Scheme in 2016 for practices with vacancies outstanding for a year or more. The pilot funded 50 practices in under-doctored areas to pay a returning GP up to £8,000 in relocation costs and a £2,000 education bursary, provided the GP practised there for 3 years. The scheme was not extended beyond the 1-year pilot.

The 2015 plan also promised targeted incentives for GP trainees. In 2016, NHS England and Health Education England introduced a Targeted Enhanced Recruitment Scheme (TERS). Under TERS, GP specialty trainees receive £20,000 for undertaking their 3-year GP speciality training in ‘hard to recruit’ areas identified by Health Education England – including deprived areas. NHS England has funded more TERS places over time.

Building the workforce committed Health Education England to funding ‘post CCT’ training – further training for qualified GPs who have attained their Certificate of Completion of Training – in hard to recruit areas. This built on a recent pilot for a fellowship programme of additional academic study and practical training for recently qualified GPs., Pilots expanded in 2015/16, and in 2016 NHS England committed to 250 new post CCT fellowships in ‘areas of poorest GP recruitment’. In 2020/21, Health Education England continued funding for a less ‘restrictive’ post CCT fellowship programme. The programme is not just for under-doctored areas but includes ‘Trailblazer’ fellowships – piloted in 2018 – for the most deprived practices and specifically focused on addressing health inequalities.,,

In 2017, NHS England introduced an International GP Recruitment programme for ‘some of the most hard to recruit areas’, to help meet a General practice forward view target to recruit from outside the UK. It provided help with relocation and training for GPs. Pilots aimed to recruit GPs from the European Economic Area to Lincolnshire, Essex, Cumbria, and Humber, Coast and Vale. After the government set a more ambitious target to recruit GPs internationally, NHS England increased funding to expand the programme.

Evidence on policy impact

Evidence on the impact of individual workforce policies on recruitment and retention of GPs in deprived areas is limited and mixed. There is some evidence that central controls on GP distribution between 1948 and 2002 helped match GPs more closely with population need. Goddard et al studied the impact of controls on GP distribution between 1974 and 2006, and found that equity in GP supply increased until 1994, but then decreased – and fell further after the MPC was abolished in 2002. They concluded that controls likely increased overall equity in GP distribution, but – given the range of other factors shaping where GPs work – were not sufficient to stop distribution becoming less equitable. By the time it was abolished, the MPC’s assessment was that it had achieved fairer GP distribution. But government criticised the committee for making decisions subjectively and at too local a level.

Since 2015, several policies used targeted funding to try to improve recruitment in deprived areas, but data on their impact are limited. NHS England evaluated the Targeted Investment in Recruiting Returning Doctors Scheme in 2017, before discontinuing it. They found that a minority of practices filled their longstanding vacancies, family ties tended to discourage doctors from relocating, and the relocation package was insufficient to attract GPs to under-doctored areas.

NHS England has expanded the TERS scheme, and all posts were filled in 2020/21.,, But there are no data on the retention of trainees recruited through TERS, and the scheme has been implemented in the context of overall increases in GP trainee numbers, making it hard to assess the contribution of TERS to trainee recruitment and distribution. Trailblazer fellowships have also been extended. In a qualitative study of the seven GPs in the initial pilot, participants were very satisfied and thought that it would make general practice more attractive.

There is also little evidence on the impact of the International GP Recruitment Programme. The Lincolnshire pilot recruited 26 doctors against a target of 25, but it is unclear how far the programme contributed to filling these posts, and whether targets to recruit 75 doctors in Essex and Cumbria were met. Health Education England highlighted in its work on the pilots that some doctors needed more support than practices expected.

General practice workforce distribution since 1990

Another way of thinking about the potential impact of these policies on the GP workforce is to compare changes in the distribution of GPs in relation to deprivation over time. Overall, available data suggest that inequities in the distribution of GPs have persisted over the past three decades – though there have been periods where these differences have narrowed. A lack of comparable data makes it hard to understand long-term trends. But the Department of Health identified low levels of practice staff in deprived areas in the early 1990s. And there is evidence that inequity in GP supply relative to population need grew between 1994 and 2003, despite overall increases in GP numbers.

Between 2009/10 and 2013/14, the pattern reversed, with the most deprived neighbourhoods having the most GPs per need-adjusted patient (see Figure 3). This suggests that policies in the 2000s may have had some success in contributing to a more equitable supply of GPs in England. But improvements do not appear to have lasted: there were consistently fewer GPs per patient in deprived areas than in affluent ones between 2015/16 and 2018/19 (see Figure 4). Data between 2004/05 and 2013/14 (Figure 3) are not directly comparable to data between 2015/16 and 2018/19 (Figure 4), as the way that GPs were counted by NHS Digital changed.

Premises

Having high-quality and accessible buildings can support the delivery of high-quality care. Broadly speaking, national policies on general practice premises either aim to improve (or ‘modernise’) existing premises, or to build new ones. Since 1990, some policies attempted to improve the poor state of the general practice estate, though rarely with the aim of increasing equity. In the late 2000s, building new practices was explicitly used by national policymakers as a route to increase equity. Policymakers hoped that putting new practices in deprived areas would encourage GPs to work there, in turn improving access to primary care.

Key policy developments since 1990

Labour governments introduced several policies on general practice premises in the 2000s. Data collected in 1996 had shown that GP premises were often not fit for purpose. Almost half were based in adapted residential buildings or converted shops. 53% were over 30 years old, and patient access frequently failed to comply with Disability Discrimination Act requirements. The 1996 white paper Primary care, delivering the future stated an intention to ‘enable different options’ for GPs to develop premises based on local needs. This was not targeted at deprived areas, but did result in minor changes – for example, allowing health authorities to give GPs loans to buy themselves out of leases on substandard premises.

The 1998 Spending Review promised to ‘improve the quality of GP premises’, and was followed by public service agreements – government objectives linked to departmental spending – pledging that improvements would be ‘targeted towards areas of deprivation, resulting in improvements to 1,000 premises nationally by 2002’., Department of Health expenditure records show that by the end of the 2000 financial year, 598 practices had received some improvements, with plans in place for a further 559 improvements during 2001. But we do not know whether these improvements were made in deprived areas.

The NHS Plan (2000) contained another raft of policies on GP premises. Investment of ‘up to’ £1bn in primary care premises was promised, with ‘up to’ 3,000 premises substantially refurbished or replaced by 2004, alongside 500 new primary care centres. It was not clear where these additional resources would be targeted, but the plan specified that ‘health centres in the most deprived communities will be modernised’. This commitment was repeated in Tackling health inequalities – a programme for action in 2003, which promised to improve primary care facilities in inner cities and ‘disadvantaged areas’.

The vehicle for delivering these plans was a new public-private partnership – NHS local improvement finance trust (LIFT) – launched by the Department of Health in 2000. LIFT was a mechanism for funding new NHS estate. It aimed to address longstanding underinvestment in primary care facilities in England, and – by doing so – ‘help resolve GP recruitment and retention problems’. Each project would combine funding from the Department of Health with matched funding from PCTs, local authorities, and others. A larger tranche of money – 60% of the total – would come from a private sector partner. PCTs would be responsible for selecting sites for LIFT funding and GPs would occupy the buildings as tenants.

By 2004, the NHS reported that 42 LIFT projects were underway, and that ‘most’ projects were in deprived areas. A new aim – of 54 NHS LIFT projects by 2008 – was set. A 2005 report from the National Audit Office said that progress had been significantly slower than anticipated, largely due to hesitancy from GPs. In 2014, 314 projects had been developed across England using LIFT funding (though these were not exclusively in general practice).

More targeted policies to improve primary care facilities were introduced in the late 2000s. Fairness in Primary Care Procurement was introduced in 2006. It aimed to improve primary care in the least well-doctored PCTs, which would receive national support to procure new primary care services. Ten PCTs participated in Fairness in Primary Care Procurement, with most securing a single new practice., In 2008, the scheme was extended to all PCTs under the Equitable Access to Primary Medical Care (EAPMC) programme. Government invested £250m between 2008 and 2011 to deliver two aims: opening 100 new practices in the 25% of PCTs with the ‘poorest provision’, and developing a new GP-led health centre in an easily accessible location in every PCT. Each GP-led health centre needed to offer walk-in services, including for non-registered patients, and longer opening hours. EAPMC led to the procurement of 113 new premises in 50 PCTs, before funding was withdrawn in 2011.

More recently, a mix of national policies considered how to improve primary care premises in England – including the General practice forward view in 2016, the Naylor Report in 2017, and NHS England’s general practice premises policy review in 2019. But none of these policies focused on reducing inequalities or improving premises in more deprived areas.

Evidence on policy impact

Evidence on the impact of overall attempts to improve GP premises in different areas is limited. Evaluations of these schemes often focus on pounds spent and buildings produced. But little detail is provided on where improvements were made or practices were built, and how this relates to the socioeconomic characteristics of an area. Even then, new buildings themselves do not necessarily mean better access and quality of care.

NHS LIFT appears to have had some success in enabling new NHS services to be built in areas of high deprivation. By 2013, 40% of all LIFT investments had been made in the 10% most deprived areas, and almost 90% of LIFT projects were in areas of above average health needs. But progress in building new practices was slower than intended, and attracting GPs to move into LIFT buildings proved more challenging than expected. It is difficult to assess the impact of these developments on the provision, use or quality of primary care services.

More targeted policies appear to have had some positive effects. The EAPMC scheme led to fewer practices being built than originally intended – 113 in total. But opening new practices appeared to drive an increase in the number of GPs working in more deprived areas. As a result, Asaria et al conclude that EAPMC partly contributed to a reduction in socioeconomic inequality in GP supply in England from 2006/07 to 2011/12. Socioeconomic inequality in GP distribution increased again after the programme wound down in 2011/12.

EAPMC may have also had unintended effects. In addition to funding for new practices in targeted areas, every PCT was required to develop a new GP-led health centre. The health centres built under the scheme were more likely to be placed in areas of high deprivation (28% of GP-led walk-in centres were in the 10% most deprived areas, compared with 1% in the least deprived 10%). But some NHS leaders worried that the services were poorly targeted. And some commissioners felt that walk-in centres may have created inequity in access because they were mostly used by people living close by, rather than by groups from areas of high deprivation with significant health needs.

* NHS England. Targeted Investment in Recruiting Returning Doctors Scheme: Interim Review. May 2017. Unpublished.

† NHS England and NHS Improvement. International GP Recruitment Lessons Learned workshop summary. April 2021. Unpublished.

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