On November 23rd 2014 The Observer newspaper quoted the President of the Royal College of General Practitioners as saying: “…doctors are routinely having to work 11 hour days and are making between 40-60 patient contacts a day. We now make 340 million patient consultations a year – 40 million more than five years ago”. The Royal College of GPs also warned that 600 practices might close in the next year due to poor recruitment and retention of staff. The British Medical Association argued that virtually all GPs believed that bureaucracy and ‘box ticking’ had increased, and four in five blame target chasing for reducing contact time with patients. The BMA stated that GP income had dropped by 11% between 2008 and 2014, whilst the cost of running practices had risen by 2% (BMA 2014).

Just over two years later the chair of the British Medical Association’s GP committee repeated these workload figures, saying on Friday 13th January 2017: GPs are now delivering up to 340m consultations a year and can see up to 60 patients a day”. Dr Mark Porter, BMA chair of the Council of the British Medical Association, said (on Tuesday 10th January 2017): “GPs are conducting millions more consultations every year while also facing a recruitment crisis. A recent BMA survey of GPs found that 84 per cent said that workloads are now so unmanageable it is affecting the delivery of safe patient care”. (BMA 2016a). The next day he added: “GPs are unable to keep up with the number of patients coming through the surgery door”.

A large database analysis of consultation rates carried out by Hobbs and colleagues concluded that general practice “could be reaching saturation point”. (Hobbs et al 2016) Beccy Baird, Fellow at The King’s Fund, went further, arguing that The current situation is untenable. The pressures on general practice are now so great that it is at risk of imploding without rapid and radical action”. (Baird 2016)

 

The consequences of implosion would be serious. The author of the Observer article in 2014 concluded that A consequence of overcrowding at GP practices is a huge increase in patients being admitted to hospital wards from accident and emergency departments” (Boffey 2014). On 12/1/17 Stephen Dalton, Chief Executive of the NHS Confederation, joined in to widen the argument: “Pressure on A&E departments is being caused by a lack of funding in primary, community, mental health and social care”. The end of the NHS seemed nigh. According to Martin Roland and Sam Everington in a Leader in the British Medical Journal, “If general practice fails, the whole NHS fails”. (Roland & Everington 2016)

This briefing explores the apparent crisis in general practice, asking if GPs are having more consultations, if the number of general practitioners is going down, if GP earnings are declining and if the NHS is spending less on general practice. To help clarify what is going on in general practice this briefing uses three different understandings of the word ‘crisis’: a common usage as found in dictionaries, Klein’s view of crisis in the NHS as dramaturgy (dramatic composition for political effect) and Gramsci’s concept of organic, system-shaking, crisis.

What is a crisis?

The Oxford English dictionary (OED 2017) gives five meanings of the word ‘crisis’:

  1. A stage in a sequence of events at which the trend of all future events, especially for better or for worse, is determined; (turning point).
  2. A condition of instability or danger leading to a decisive change.
  3. A dramatic emotional or circumstantial upheaval in a person’s life.
  4. The point in the course of a serious disease at which a decisive change occurs, leading either to recovery or to death (or the change itself).
  5. The point in a play or story at which hostile elements are most tensely opposed to each other.

The Cambridge English dictionary (CED 2017) adds: a time of great disagreement, confusion or suffering.

Policy analyst Rudolph Klein notes the apocalyptic prophecies and premature obituaries that are part of the political rhetoric about the NHS, and asks: ”What is it about the NHS that prompts linguistic excess and muddle? And does this dramaturgy matter? (Klein 2015) In Klein’s view crises are normal parts of the bidding and bargaining processes that determine resource allocation within the NHS.

Gramsci’s ‘organic crisis’ occurs when economic contradictions in one part of the social structure have an effect on the whole system. Such crises reflect the weakening of hegemony (the dominant power) and the loosening of ties that had previously bound political actors together (Forgacs 1988).

Is demand for general practice appointments rising?

The Nuffield Trust report “Is general practice in crisis?” concluded that the absence of up-to-date and comprehensive activity data in general practice is a serious problem that reduces planning to guesswork and the debate on pressures within general practice to exchanges of anecdotes (Dyan et al 2014). In contrast to NHS hospitals, which report monthly on how many people are treated, for what conditions, and for how long, levels of activity in general practice remain something of a ‘black box’. There is no national repository or routine public reporting of GP activity data, which makes it difficult to understand what is happening in general practice (Curry 2015).

However, there are large datasets derived from anonymised GP electronic medical records which give an impression of practice activity and allow some analysis of trends in consultations with general practitioners and practice nurses. Six analyses have been published using three different data sets. Three of these analyses have used the QRESEARCH dataset; two have used CPRD and one ResearchOne. The table below (Table 1) shows the characteristics of these datasets.

Table 1 Sources of data on consultation rates in general practice

Dataset

Source

Time period

Analysed by

QResearch

Version 13 of the database with 30 million person years of observation from 525 practices

Dunnigan’s analysis used 10 million patients from 602 practices

1995/6-2008/9

Hippisley-Cox et al 2007, 2009

Data.Gov.uk 2011

Dunnigan 2014

DeLoitte 2012

CPRD (Clinical Practice Research datalink)

11.3 million patients from 674 practices

2007/8 to 2013/4

Hobbs et al 2016

3.2 million patients in 337 practices in England

2010/11 to 2013/14

Curry, Nuffield Trust, 2015

ResearchOne

30 million individual contacts with patients from 177 practices

2010/11-2014/15

Baird B et al, Kings Fund 2016

Figure 1 combines the data from the Hippisley-Cox/Data.Gov.uk analysis, the Hobbs et al study and the Nuffield Trust report. Data from the King’s Fund analysis are not included here because in their published form they do not consistently provide raw consultation data, only percentage changes. Data obtained by Dunnigan and Deloitte are reported selectively and so are mentioned in the text, where appropriate.

Figure 1 Consultation rates per person year

1995/6 to 2014/5 derived from QRESEARCH (Q), Hobbs et al (CPRD), and Nuffield Trust (Nuff). Rates are shown for all practice clinical staff, for GPs alone and for practice nurses alone.

The longest time span of data comes from the QRESEARCH analysis. Between 1995/6 and 1999/00 GP consultations remain steady or even decline slightly, whilst practice nurse consultations increased, suggesting a period when nurse consultations may have substituted for GP consultations. From 1999/00 to 2008/9 both GP and nurse consultations increased at a steady rate, although the nurse consultation rate rose faster than the GP rate, but from a lower baseline. The increase in the consultation rate did not seem to be influenced by the introduction of the Quality & Outcomes Framework in 2004/5.

After 2009/10 the data becomes more difficult to interpret, perhaps because the three analyses used data from three different sets of practices. The CPRD study (Hobbs et al 2016) does suggest a continued increase in consultations by GPs but also suggests a plateauing out or even reduction in nurse consultations, as does the Nuffield study. If practice nurses are no longer absorbing a growing proportion of extra work, this work will stay with the GPs, who may experience it as a burden.

The King’s Fund analysis reported overall consultation rates as 4.29 in 2010/11 and 4.91 in 2014/5, which are slightly lower than the CPRD findings (2007/8 to 2013/4) but more than the rates derived from the Nuffield analysis.

Mathew Dunnigan used QRESEARCH data to measure the change in GP consultations, which rose by 20% from 145 million in 1996/7 to 175 million in 2008/9. Extrapolating consultations rising at the same rate, he predicted there would be 190 million consultations in 2012/13, 56% of the 340 million claimed by the RCGP. This difference in estimates may be due to the inclusiveness of the DeLoitte analysis used by the RCGP, which projected all consultations (GPs, practice nurses and other clinicians working in general practice) and concluded that there would be 349 million by 2012/3 and 396,656 million by 2016/7. The published DeLoitte analysis assumed that consultations would increase at 3.5% per year, based on past trends. A second analysis was run assuming half this increase in consultation rates, but the findings were not published (DeLoitte 2014).

The consistency of the slopes in the consultation rate graphs might indicate that consultation rates are driven by demographic change, with a high birth rate driving up consultations with the under-fives and population ageing (particularly the growth in the numbers of the oldest old) also increasing consultations. Of course this does not mean that a small increase in demand cannot have a powerful impact on practices that are working at maximum intensity, nor does it exclude consumerist pressures for GP consultations.

Although not explicitly discussed in the arguments around the crisis in general practice (except by the Nuffield Trust), supplier induced demand needs to be considered here. The introduction in 2004/5 of the Quality & Outcomes Framework (QOF) – a system of performance-related pay – encouraged practices to see patients with long term conditions more often to collect the clinical data about their condition needed to qualify for QOF payments. Whilst some of this data could be collected in the normal course of doctor- or nurse-patient contacts, some patients ‘needed’ additional appointments for data collection purposes. This form of doctor-initiated clinical activity could be seen as supplier induced demand, similar to the doctor-led demand seen in specialist care in many countries (Mulley 2009,Peacock & Richardson 2007, Smith 2010).

Supplier induced demand in primary care is a contentious explanation for practice variations (Davis et al 2000) that have been observed amongst GPs in the Netherlands (van den Berg et al 2009, van Dijk et al 2013) and Switzerland (Busato et al 2009) but seemingly not studied in the UK. There are grounds for thinking that supplier-induced demand could occur in UK primary care (Peckham& Gousia 2014), and this needs further exploration, informed by the Nuffield Trust’s review of types of supplier- and supply- induced demand (Rosen 2014).

Are the numbers of general practitioners going down?

Dr Chaand Nagpaul, chair of the BMA’s General Practice committee, said (on Wednesday 11th January 2017): “Policymakers have underestimated the number of GPs required to deliver their promises by almost 2,000. This comes at a time when the NHS is already suffering from a chronic shortage of GPs with one in three practices having unfilled doctor vacancies. There are further serious shortfalls in the number of doctors choosing to train as GPs and senior GPs are choosing to retire early or leave the NHS due to increasing pressures……The government must deliver on much needed extra investment in general practice. This, together with tackling the recruitment and retention crisis, is absolutely crucial to ensure patients can receive the timely, safe care they need.”

The claim about unfilled vacancies came from a survey of “more than” 5,000 GPs in England

(about one in seven of the total) conducted in November 2016 (BMA 2016b)

The number of full-time equivalent GPs in England rose from around 30,000 in 2003 to 36,300 in 2013, equivalent to an increase of 12% per 100,000 population. The bulk of the rise occurred between 2004 and 2006 (Appleby 2014). However, a combination of reduced entry to general practice training programmes, rising levels of part-time working, migration (or drop out) of new GPs and intentions to retire expressed by older GPs point to a significant workforce undersupply, under a wide range of plausible futures (CfWI 2014). The CfWI report concluded that there was a clear risk of a major demand-supply imbalance emerging by 2020 unless there was a significant, sustained and immediate boost to GP training.

The CfWI report argues that the increase in GP training posts needed to balance demand and supply over the medium term (up to 2030) is likely to be around 20%. However, given the significant lead-in time in training new GPs, an affordable and achievable 20% increase in training posts would not be able to address short-term demand pressures and may also be insufficient – on its own – to fully meet expected medium-term demand for GP services. NHS England (together with Health Education England, the RCGP and the BMA) has acknowledged this problem and recruitment to GP training posts was higher in 2016/7 than in 2014/5 (NAO 2017). Actions have been taken to re-attract GPs who have dropped out (‘returners’) and to recruit from other countries.

Is GP income falling?

General practitioners may be principals (independent contractors who earn profits) or salaried (paid by principals to work sessions or be locums). Figure 2 shows the incomes of principal GPs with the commonest form of contract, the General Medical Services contract. Total income per practitioner, practice expenses and individual earnings before tax are shown in real terms (as purchasing power, taking 2012/13 sums as 100 %). Gross income is determined by the NHS, using a complex formula. Expenses include premises, staff and equipment costs and are the investment the practitioner makes to keep the practice running.

Figure 2 General Medical Services contractor GPs – earnings and expenses, real terms (2012/13 = 100 %) Source: Health and Social Care Information Centre 2014

Between 1971/2 and 1977/8 both gross income and earnings fell as expenses slowly started to increase. After 1977/8 earnings began to increase, but not at the same rate as gross income and expenses. An upturn in gross income and expenses from 1989/90 was followed by an increase in earnings a decade later. The introduction of the Quality & Outcomes Framework (a complex system of performance related pay designed to improve the care of patients with long term conditions) in 2004/5 increased gross income and earnings in that and the subsequent year, whilst expenses plateaued. Gross income and earnings started to decline after 2006/7, whilst expenses rose slightly. Even so, a full-time GP in 2012/3 still earned more (in purchasing power terms) than s/he did in 2003/4.

The decade of investment, from 1989/90 to 1998/9 is noteworthy. General practitioners acted as their business model suggests they should; rising gross income from the NHS was used to invest in premises, staff and equipment at a level above increases in individual earnings. Figure 3 shows the proportion of gross income going into expenses. The proportion drops in 2004/5 and 2005/6 because the substantial increase in gross income with QOF (of around 58%) was converted into a rapid rise in earnings (of about 20%), according to the Public Accounts Committee of the House of Commons (PAC 2008). Nevertheless the overall pattern is of a steady rise in investment in practices.

The sources of practice income following the introduction of QOF are shown in Table 2.

Table 2 Income streams for general practice (BMA 2016)

Income streams

Approximate percentage of practice income

Global sum (including correction factors)

Up to 60%

Quality & Outcome Framework (pay for performance)

Up to 15%

Enhanced services, for example extended opening hours and annual seasonal influenza vaccinations

Up to 15%

NHS England administered funds, for example premises’ reimbursements, locum fees (to reimburse practice costs relating to cover of maternity leave and so forth) and seniority payments

Up to 15%

NHS incentive schemes and private services, for example GP with Special Interest (GPSI) services, preparing insurance certificates, external tribunals

Up to 5%

The investment that occurred in the 1990s allowed general practitioners to maximise income from the QOF performance related pay because they had the staff and systems ready to undertake the work of collating patient-level data about disease management, identifying underperformance and documenting activity.

The Department of Health warned the Treasury to expect spending on general practice to increase from £5.6bn in 2003/4 to £6.9bn in 2005/6, but the actual increase was £7.7bn because more practices hit high targets than the Department of Health expected (NAO 2008). The overspend in the first three years of the new contract was £1.76bn, and because the new contract allowed GPs to stop providing ‘out of hours’ (evening and weekend) services the productivity of general practice fell by 2.5% per year (NAO 2008).

The National Audit Office was blunt about the increase in practice income (NAO 2008) “….in return for higher pay, we have yet to see real increases in productivity. The extra money flowing into practices has largely benefited GP partners rather than rewarding other important members of the practice team”.

The introduction of QOF changed the internal organisation of practices; decision making became concentrated in the hands of a small group within each practice, which monitored and controlled staff behaviour for maximum performance to achieve targets (Grant et al 2009). It also focused energy on numbers not people, so that both general practitioners and practice nurses reported that the person-centredness of consultations and continuity of care were both harmed. Medical conditions that were not included in QOF received less attention, and this relative neglect worsened as time passed. Patient satisfaction with continuity of care began to decline (Gillam et al 2012). Those most dissatisfied with their GP’s accessibility – typically younger adults who are employed – do not attract performance-related funding because they do not have a long term condition whose management is remunerated by QOF.

The introduction of QOF led to a large increase in job satisfaction amongst GPs, and a study using the GP Worklife Survey and QOF data returns from practices (Allen et al 2017) attributed this to the large increase in earnings that GPs experienced for a brief period after 2004/5. The study’s authors concluded that GP job satisfaction was unlikely to be affected by changes in pay for performance as long as earnings remained constant. This did not happen and in 2012 job satisfaction fell to its lowest point for a decade (Hann et al 2013).

There is a sense that GPs are now trapped by performance related pay. Declining gross income requires savings but these cannot be made in expenses because expenses allow practices to maximise their performance related income stream. Earnings have to fall, at least in the short term. Bold practitioners might cut their personal incomes even further to boost expenses (for example by hiring an extra doctor to meet the rising demand for consultations) but there is now less certainty that this investment will increase earnings in the future. The relative shortage of GPs means that a sellers’ market exists for doctors wanted for sessional work, which seems likely to increase expenses and erode GP earnings as hard bargains are driven.

Alternative methods of increasing investment include merging back-office management functions in larger group practices, or in ‘federations’ of practices, or in merging with hospital Trusts. A super-practice of nearly 200 partners was announced in August 2015 (Matthews-King 2015). Federations allow GPs to lose some autonomy but gain efficiencies and some protection from commercial organisations (like Virgin Health) trying to enter the primary care market (Hawkes 2014). Nine hospitals were given the right to provide GPs services in the 2015 Vanguard programme (Kaffash 2015).

Is the NHS spending less on general practice?

Whilst general practice received a large increase in income after the introduction of QOF, the hospital sector received the larger share of extra funding in the generous years between 2006 and 2010 (Dyan et al 2014). The proportion of NHS spending on general practice, general dental services, opticians and pharmacies fell from 27% of the total budget in 2006/7 to 23% in 2012/3, with general practice receiving around 8.5%. Figure 4 shows the annual percentage change in funding in primary care (including general practice) and secondary care (hospitals and Community Trusts).

Source: Primary Care Trust annual accounts data 2006/7 -2012/13Dyan et al 2014

Comments

Is there really a crisis in general practice, or is the talk of crisis just the way in which NHS practitioners express ‘voice’ (protest, complaint, demands) as an alternative to retiring or resigning (‘exit’) (Hirschman 1970)? Are there several crises, mixed up together? This briefing argues that at a macro-level there does seem to be a turning point in GP organisation approaching – towards larger and more efficient organisational forms – but not a systemic, organic crisis in which the fall of general practice brings down the whole NHS. At the meso-level of the practice GP earnings will stabilise and perhaps begin to rise, and practitioner numbers will increase, although not necessarily quickly. At the micro-level of the individual general practitioner the shifts towards part-time working and salaried employment will continue, perhaps with a sellers’ market for sessional work that could erode earnings. Recruitment of practice nurses may continue to be problematic, given that nursing as a profession is losing more members than it is recruiting. So, given an accumulation of changes at micro-, meso- and macro-levels that will resolve or more likely mitigate some problems, theatricality may become muted, at least for a while. From past experience these changes will occur to a greater extent in the less deprived areas and localities.

A turning point ahead?

The Cambridge English dictionary (CED 2017) definition fits current circumstances. For many GPs this seems to be a time of great disagreement, confusion or suffering. These experiences matter, because general practice suffers from ‘burn out’ – a syndrome of exhaustion, cynicism and decreased effectiveness in work (Shanafelt et al 2017) which reduces patient contact and amplifies the effect of workforce shortages as practitioners shift to part-time working or exit the discipline. Burn out is not a consequence of any of the changes identified by GP politicians, but is rather a background problem (found across the public sector) exacerbated by current circumstances.

The Oxford English dictionary’s definitions also seem to fit. There seems to be a turning point ahead, at least in the aggregation of general practices into much larger bodies. The seemingly decisive changes underway (leading to retirement, emigration, career change for individuals and super-practice and Federation formation for groups) are preceded by a period of (financial and organisational) instability and emotional upheaval. And, judging by the tone of GPs calls for their views to be heard and acted upon, the profession and the NHS are “tensely opposed”. For all that general practices seem to be resilient and able to cope with their changing situation (Fisher et al 2017). Expectations that the emergence of management hierarchies within general practice would provoke resistance in defence of professional collegiality may be unfounded (McDonald et al 2009).

There is certainly a lot of noise, and Klein’s linguistic excess and muddle” are widespread. Professional bodies, the RCGP in particular, claim that the future for general practice is bright, whilst also projecting distress about overwork and declining income. The doomsday scenario is that the NHS will “fail” because general practice “fails”, although it is not clear what failure of either would look like. The analogy being used, perhaps, is that general practice is the foundation upon which specialist medicine is built, a comforting if inaccurate image. Workload projections are presented as facts not guesses, as in the 60 consultations a day claim. When challenged the language is softened to present these hard figures as estimates, suggesting that those pressing the claims of overwork and underpayment do not know to any level of accuracy what GPs are actually doing.

Matthew Dunnigan is right to say that “exaggerated estimates of GP consultation rates may discourage GP recruitment” (Dunnigan 2014) but Klein’s dramaturgy is a necessary part of the clamour for resources within the NHS, and not escapable. Because industrial action is difficult for independent contractors, for whom withdrawal of labour is a breach of contract, voice and exit are two of the few protest options available. Others include restricting services – pushing away demands for consultations, for example – and increasing referrals to specialists, both of which appear to be happening, and both of which can be initiated without a formal declaration of a trade dispute.

Gramsci’s ‘organic crisis’ occurs when economic contradictions in part of the social structure have an effect on the whole system, so the ‘GPs fail, NHS fails’ argument, if substantiated, would suggest a transformational organic crisis is brewing. There seems little evidence to support this perception, which fits better with the theatricality noted by Klein. Accident and Emergency departments are struggling with (mainly) older people with multiple and complex medical conditions, the group most likely to get extra attention through QOF, and not with younger adults unable to get an appointment with their GP. The journalist’s conclusion that a consequence of overcrowding at GP practices is a huge increase in patients being admitted to hospital wards from accident and emergency departments” (Boffey 2014) does not make sense.

What is to be done?

Four problems stand out from this complex picture; recruitment and retention of GPs, reducing pay-for-performance elements of practice work, increasing the proportion of the NHS budget devoted to general practice, and the need to shine light into the black box of general practice activity.

The recruitment and retention problem is arguably the most important one to solve, but possibly the easiest given there are multiple methods for enlarging the medical and nursing workforces. At the moment the numbers of GPs are stable or growing slowly, but there is a risk of a substantial mismatch in supply of and demand for general practitioners within a few years. Multiple initiatives are already underway to encourage new entrants to the disciple, stave off early retirements and encourage returners.

Practice expenses – salaried doctors, nursing and other staff, equipment and premises – have held steady or risen slightly because GPs have accepted a reduction in earnings. This is unavoidable, because expenses need to be high to maintain practice income, especially the pay-for-performance funding streams. Not surprisingly declining earnings lead to a decline in morale and job satisfaction, but this is not a problem confined to general practice – most employed people have experienced a reduction in real incomes since 2008 (Dyan et al 2014).

Some of the ‘demand’ may be induced by the pay-for-performance elements of GP work, making it difficult for practitioners to control workloads without losing income. One way to reduce some workload pressure would be to end some pay-for-performance tasks – especially the ones with meagre scientific justification, like Health Checks or over 75 checks – and re-route the money attached to them into core funding. There was a precedent for this, in the 2012/3 reduction in QOF targets without loss of income, and the GP contract agreed in 2017 does re-route some funding and reduce GP expenses slightly. Whether GPs would favour investment of this income in their practice or in a Federation, or opt to increase personal earnings, remains to be seen.

Disparity in the funding of generalist and specialist medicine is a long-standing structural problem of the NHS. The General Practice Forward View published in 2016 plans to increase the proportion of the NHS budget spent on general practice to over 10% in 2020 (compared with under 8.5% in 2014/15) largely by expanding the practice workforce substantially (Everington & Roland 2016). The balance between generalism and specialism may change as general practices move into new organisations shared with specialists, either because general practitioners will become employees of Trusts or because GP Federations will hire some specialists.

The NHS needs a system for capturing GP activity in detail and on a large scale, to allow more sensitive workforce planning and to avoid political debates that are based on anecdote, guesswork and highly selected data. Existing databases built on anonymised GP clinical records all have limitations but nevertheless can provide useful information and insights, as the QResearch data demonstrates; no new data capture system is needed, at least in the short term (i.e. up to 2030). Clarification is usually resisted, so challenges to the data are likely.

Conclusions

The sense of crisis should abate given the actions taken in the last two years to remedy some of the problems described in this briefing, but existential anxiety will persist as general practitioners consider their possible futures as sub-contractors to the NHS, with variable incomes and organisational pressures to collectivise. Some doctors may be pleased to abandon their independent contractor status and become salaried employees of super-practices, Federations or Trusts, even if their income is substantially less than that of their GP principals. Salaried status for general practitioners, once a fringe idea, is now debated in the British Medical Journal (Majeed & Buckman 2016). Dramaturgy awaits the turning point.

Steve Iliffe,  June 2017

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