The performance of general practice in the English National Health Service (NHS): an analysis using Starfield's framework for primary care.

ABSTRACT

General practice in the English National Health Service (NHS) is in crisis. In response, politicians are proposing fundamental reform to the way general practice is organized. But ideas for reform are contested, and there are conflicting interpretations of the problems to be addressed. We use Barbara Starfield's "4Cs" framework for high-performing primary care to provide an overall assessment of the current role and performance of general practice in England. We first assessed theoretical alignment between Starfield's framework and the role of general practice in England. We then assessed actual performance using publicly available national data and targeted literature searches. We found close theoretical alignment between Starfield's framework and the model of NHS general practice in England. But, in practice, its model of universal comprehensive care risks being undermined by worsening and inequitable access, while continuity of care is declining. Underlying causes of current challenges in general practice in England appear more closely linked to under-resourcing than the fundamental design of the system. General practice in England must evolve, but wholesale re-organization is likely to damage and distract. Instead, policymakers should focus on adequately resourcing general practice while supporting general practice teams to improve the quality and coordination of local services.

General practice is the foundation of the UK's National Health Service (NHS). But these foundations are creaking. More and more people need care, but there are fewer general practitioners (GPs). Job satisfaction for doctors is falling, and public satisfaction with general practice has plummeted. Politicians are promising major changes to the way general practice is organized, but it's not clear what these changes will be. We wanted to understand whether fundamental changes to the whole model of general practice in England are needed. To do this, we measured the performance of general practice in England against a set of features, widely regarded as defining the characteristics of high-performing primary care systems. We found that, although, in theory, the design of English general practice aligns well with these features, in practice, performance is less good and is getting worse. In particular, people are struggling to access care, and their ability to see the same doctor regularly is declining. There are also unfair differences between population groups. We conclude that the crisis in English general practice has more to do with previous policy decisions and longstanding lack of funding than the fundamental design of NHS general practice. Policymakers should focus on giving the system enough resources and supporting GPs to improve the quality of local services.