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Worst among equals

Worst among equals

As Pulse publishes its major comparison of conditions in general practice across the world, editor Jaimie Kaffash reveals why UK GPs are in the deepest merde

It is an achievement of sorts. The UK Government has outflanked its counterparts abroad in making general practice worse than anywhere else. GPs here have lower morale, lower satisfaction with pay, shorter appointment times and are more likely to leave the profession.

A devil’s advocate might point out that UK GP pay compares well with international peers, average working hours are no more strenuous than in many other countries and the average number of patient contacts a week is roughly the same as elsewhere. Are UK GPs simply more vocal than their overseas counterparts? 

But scratch beneath the surface and things become clearer. In the UK, a week’s worth of hours and patient contacts is often compressed into three days, and pay is better because there are fewer people to share the funding pie. The intensity of their appointments is also higher, dealing as they do with patients who would be seen by specialists in other countries. 

In England, the GP contract is set for an overhaul next year and I’m not alone in having called for fresh thinking. And there have been radical suggestions: a salaried service, co-payments and payment by activity, among others. 

But researching models across high-income countries, it was clear to me that no one model stood out. Each way of organising general practice had its good and bad points. 

The one magic bullet, of course, is a greater number of GPs. This improves morale, workload, consultation lengths and everything else bar pay. But as I have argued before, this seems like a bit of a lazy suggestion. All countries are struggling with GP recruitment and I almost feel sympathy for the Government’s forlorn pledges to conjure up a load of new GPs. Higher numbers of GPs are as much a consequence of a strong profession as a cause.

But another solution lies within ministers’ power – although it’s one they may not want to hear. GPs and general practice thrive when they have the right social infrastructure around them. For me, this might be the main reason UK general practice is worst among equals. 

Underfunding isn’t the only consequence for general practice of the brutal austerity imposed on the UK over the past 13 years. Even if GP funding had kept pace with inflation, I am not sure it would have prevented crisis (although it would certainly have mitigated the problems).

So much of GPs’ time is now spent filling gaps elsewhere in the system, most obviously in secondary care. UK GPs have always had more responsibility than international counterparts when dealing with specialist conditions. But the trickle of workload from secondary care is now a flood, and reported plans to expand advice and guidance may drown many GPs. 

GPs are also the fallback option for the people let down by the UK’s neglected social and care services. Contrary to media  coverage, they are the one group of professionals who are always accessible.  

Yes, there are other countries with low spending on public services. But the UK is almost unique among them in having universal free healthcare (which, if it is not clear, I’d be loathe to give up). 

I’ve said this before, but UK GPs are victims of their own success. Accessible, knowledgeable enough to manage long-term conditions and able to provide unlimited free care for £100 per patient. But unless they can focus on their core skills instead of acting as a general safety net, no change in funding structure will lift morale.

Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at



Please note, only GPs are permitted to add comments to articles

David OHagan 5 October, 2023 1:25 pm

The social and commercial determinants of health have all worsened over the last 10 years. See Marmot reports after 10 years, and local marmot reports more recently.
The same factors which increase ill health remove access to professionals from most people.
These factors then make job loss, housing trouble, crime, lack of transport into medical problems such as back pain, and depression. Even heart disease and cancer are actively created by an approach to austerity which aggravates social conditions for the majority of people.

The ‘solutions’ offered at present, such as scapegoating of ‘others’, whether by race, gender, religion, or birth country further worsen health problems. This occurs in a variety of proven mechanisms.

We are currently all worse off as a result of social and economic effects used in an illiterate and ignorant manner with no sense of responsibility.

Bad government is making a poor worldwide situation worse for the poorest in our society,
and that makes things worse for us as GPs, not least because we see the destruction and know that ‘they’ don’t care.

Decorum Est 5 October, 2023 4:30 pm

Well said David OHagen.

Keith M Laycock 6 October, 2023 7:40 pm

A self-fulfilling, self-imposed prophesy?

The elephant in the room: – “A week’s worth of hours and patient contacts is often compressed into 3 days” – how can that not be be stressful.

3 days of work and 4 days of ‘leisure’???????

Catherine Jenson 9 October, 2023 9:22 am

GPs need to ‘become’ specialists and get a specialist contract. The consultant contract specifies every clinical session must have an accompanying admin session. How do I know this? As a medical director for community services, we employ consultants and I have been doing their job planning for years.
In the olden days when we didn’t have electronic records/summaries, there might have been an argument for specialists needing more time to write their letters, and conversely, little need for GPs to do so, since (historically) noone expected a GP letter to be comprehensive and in any case, most patients with longterm conditions remained ‘under’ secondary care with no GP involvement. These days, it is GPs who need more admin time than consultants, since we are the coordinators of the ‘one stop’ approach beloved by commissioners to pin down secondary care costs, transferring almost all work back to primary care. We are the ones who keep the electronic summaries coded and up to date and manage 99% of prescribing. We are the ones with budgets for prescribing who have to control costs (ask any consultant you know if they have one and you will get a blank stare!). We are (generally) the ones explaining to patients what their letters mean and why they have been put on new medications by secondary care. We are the ones used by secondary care to plug all the gaps caused by endless waiting lists- ‘see your GP’ being the standard retort. As long as the patient continues to wait and/or is discharged, the consultant has no clinical responsibility- it is all sitting with the GP. On top of all that, we are now managing ARRS staff as well as PCNs. Little wonder the majority of GP principals can’t wait to retire.