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General practice is a cornerstone of the UK healthcare system, providing accessible, continuous, and person-centred care while coordinating services across the wider NHS. Historically, it has evolved in response to changing population needs, moving from predominantly acute episodic care towards long-term management of chronic disease, prevention, and holistic patient support. The profession has repeatedly demonstrated adaptability, including the development of multidisciplinary teams and the rapid adoption of remote consultations during the COVID-19 pandemic. Despite this resilience, general practice is now under considerable strain. Rising patient demand, increasing multimorbidity, workforce shortages, and administrative burden have contributed to reduced continuity of care, poorer access, and declining morale among clinicians. The future sustainability of general practice will depend on stronger integration between primary and secondary care, effective use of technology, improved recruitment and retention, and a reduction in bureaucratic burden. A renewed emphasis on proactive and preventive care will be essential if general practice is to continue meeting the evolving health needs of the population.
The United Kingdom (UK) healthcare system is internationally recognised for its organised structure, particularly the longstanding division between primary and secondary care. This divide shapes the way patients access services, how clinicians collaborate, and how resources are allocated. As medical practice evolves with an ageing population, increasing multimorbidity, rapid technological advances, and the emergence of new healthcare grades and professionals, the question arises as to whether this historical division remains fit for purpose. This article explores the origins of the primary-secondary care divide and evaluates its appropriateness within today’s healthcare landscape.
Evolution of health service in the UK
The UK health services have evolved from a fragmented 19th/early 20th century patchwork to a unified national service designed around universality and free access. The structure and governance of the NHS have repeatedly changed over decades, through major reorganisations, reflecting shifting political priorities and efforts to improve efficiency and integration.
Before the establishment of the NHS, general practitioners (GPs) largely worked as independent professionals, and patients usually paid directly for medical care. The National Insurance Act of 1911 altered this arrangement by introducing a salaried service, under which GPs were paid annual fees for each registered insured worker [1,2]. The creation of the NHS in 1948 established healthcare free at the point of delivery for all citizens. This transition was met with mixed reactions among GPs: some feared the loss of professional independence, whereas others welcomed the opportunity to treat patients without the barrier of affordability [3]. The early years of the NHS placed substantial pressure on GP services, contributing to declining morale, variable standards of care, and inadequate consulting environments [4]. In response, the profession undertook a period of self-examination, which contributed to the establishment of the College of General Practitioners to improve standards, education, and research.
General practice continued to evolve both financially and organisationally. One example was the introduction of fundholding, through which GPs were given budgets and became responsible for commissioning some services [3]. Later, Primary Care Trusts (PCTs) were established to oversee, plan, and fund local health services, including prevention and health promotion. In 2013, PCTs were replaced by Clinical Commissioning Groups (CCGs), which have since evolved into Integrated Care Systems (ICSs). These systems bring together hospitals, GPs, community health services, local authorities, and voluntary sector organisations to plan and deliver care collaboratively at a local level.
For decades, the profession demonstrated a remarkable ability to adapt. General practice evolved from a fragmented, largely private model into a publicly funded NHS service, while responding to major demographic, clinical, and organisational changes. More recently, however, this adaptability appears increasingly strained, with growing frustration among patients, GPs, and secondary care clinicians. These pressures suggest that the mechanisms that once supported resilience may no longer be sufficient in the current healthcare environment.
Public frustration
Public dissatisfaction with general practice has become increasingly visible since the mid-2010s and intensified during and after the COVID-19 pandemic. This dissatisfaction reflects a combination of rising demand, workforce pressures, and changes in the delivery of primary care. An ageing population and increasing prevalence of chronic disease, including diabetes and mental health conditions, have significantly increased demand for GP services [5]. When resources fail to keep pace with need, patients experience longer waiting times and greater difficulty securing appointments [6]. A major contributor to this pressure is the shortage of GPs [7], particularly in deprived areas where need is often greatest. This shortage places further strain on the remaining workforce, increasing workload and reducing appointment availability.
The COVID-19 pandemic marked an important turning point in public perceptions of general practice because of the rapid reduction in face-to-face consultations. To maintain services while minimising infection risk, practices shifted towards remote consultations [8]. Although this model enabled continuity of service, many patients perceived remote contact as less personal or less effective, particularly for complex or sensitive problems [9]. Since the pandemic, frustration has remained high because of the backlog of unmet health needs that accumulated during this period [10]. Many patients are now presenting later and with greater complexity, while media coverage has further amplified awareness of difficulties accessing GP care. It is important to recognise that these difficulties are not simply the result of failures within general practice itself. Rather, they reflect wider systemic pressures across the NHS, including funding constraints, workforce shortages, and rising population health needs [5].
These pressures are increasingly evident in acute hospitals. Accident and emergency departments and medical wards are seeing more patients whose needs might previously have been met in the community. Many are older adults living with frailty, multiple long-term conditions, and advanced care plans or ReSPECT documentation that could support management outside hospital. Admissions for falls, dehydration, uncomplicated infections, and mild exacerbations of chronic disease may sometimes be avoidable if proactive community services are available. Such admissions contribute to bed shortages, delays across emergency and inpatient services, increased healthcare costs, and greater exposure to hospital-acquired complications including delirium, infection, and deconditioning.
A further consequence of limited access to general practice is increased pressure on Same Day Emergency Care (SDEC) services. These units often review ambulatory patients with problems such as uncomplicated infections, musculoskeletal pain, palpitations, low-risk chest pain, or uncomplicated deep vein thrombosis, many of whom might traditionally have been assessed in primary care. In practice, patients who are unable to obtain timely GP appointments may be directed to SDEC or to the emergency department, from where they are then redirected to SDEC. This illustrates how pressures in general practice can shift workload into secondary care rather than reduce overall demand.
The way forward
Many analysts agree that one of the central priorities for reforming general practice, and the wider NHS, is to shift more care for older and frail patients from hospital to community settings. The current system remains largely reactive rather than proactive. A more anticipatory model could reduce avoidable admissions, ease pressure on hospital beds, and protect older patients from complications associated with unnecessary hospital stays. One possible approach is to develop regular specialist outreach into general practice and community settings. Older adults often live with multiple long-term conditions that may deteriorate rapidly without close monitoring. Community-based specialist input could support earlier recognition of deterioration, more timely management of complex disease, and shared decision-making between specialists and GPs before hospital admission becomes necessary.
Such outreach could also improve access for patients who struggle to travel to hospital because of frailty, mobility limitations, or transport barriers. When specialists work alongside GPs, district nurses, pharmacists, and other community professionals, more coordinated care plans can be developed, with earlier recognition of deterioration, more appropriate prescribing, and better follow-up. In addition, these models may strengthen the confidence of primary care clinicians through joint clinics, case discussion, and informal education.
Workforce shortages have already prompted innovative responses, including the expansion of roles such as Advanced Clinical Practitioners (ACPs), Advanced Paramedics, and Specialist nurses. These roles combine significant clinical experience with advanced postgraduate training and can contribute to assessment, decision-making, continuity of care, and service development. As a result, they may help improve access, reduce waiting times, and support the management of long-term conditions [11].
Alternative primary care professionals, particularly nurses and pharmacists, have also taken on aspects of work traditionally undertaken by GPs. These developments, driven by workforce pressures, financial constraints, and changing models of care, are now an established part of primary healthcare delivery [12].
Advanced nurses also play an important role as care coordinators within multidisciplinary teams, supporting integrated management of patients with complex needs. Their leadership in quality improvement, infection prevention, and practice organisation further strengthens primary care services. There is an encouraging body of evidence that suggests nurses are not inferior to doctors in terms of quality of clinical care; however, nurses tend to provide more information to patients, give longer consultations, and recall patients more frequently for follow-ups. Overall, patients’ satisfaction was also higher with nurses [13].
Nurse-led preventive services, including smoking cessation, hypertension management, cholesterol reduction, secondary prevention of ischaemic heart disease, and weight management, have also demonstrated benefits when compared with standard care [14-17].
Although these expanded and emerging roles have the potential to strengthen primary care, successful integration depends on addressing several challenges. These include role clarity, regulation, training, supervision, professional acceptance, and patient understanding of the competencies associated with different professional groups.
The current healthcare crisis also necessitates a redefinition of the general practitioner role. Historically, GPs have served as the first point of contact, providing continuous and comprehensive care, using their clinical skills and knowledge as diagnostic and therapeutic tools. While this remains essential and still relevant, it is no longer sufficient on its own. The complexity and volume of modern healthcare demand that GPs diversify and expand their scope to embody leadership in MDTs, integration of digital health tools, proactive population health management, and disease prevention. However, this transition is not without challenges. GPs require adequate training and policy changes to successfully adapt. Investment in primary care infrastructure and workforce development is essential to enable this evolution [18,19].
While the UK General Practice workforce crisis is widely attributed to structural pressures, such as workload, funding, and workforce shortages [20], other contributory factors should not be forgotten. These contributory factors are related to professional motivation and career mindset. There is a growing perception among some clinicians that general practice is chosen not out of intrinsic interest, but as an escape from the intensity of hospital medicine. Lack of intrinsic motivation for general practice leads to many unfavourable consequences, such as lower professional fulfilment leading to burnout, reduced commitment to partnership roles, weakening traditional General practice models, and higher turnover, as doctors seek alternative or more satisfying roles [21].
This mindset should be viewed as a contributory, but not the primary, factor in the current crisis. Additionally, surveys indicate that many trainees prefer flexible or locum roles rather than long-term commitment to General practice partnership. This may reflect a shift in how the profession is perceived, or as a means of achieving work-life balance, or as a default option when other specialities are less accessible. To promote general practice as a career, the way it is perceived by some must change. The process of change should start during medical education, highlighting general practice as a speciality in its own right, with early clinical exposure to its intellectual and relational complexity. GPs’ diagnostic uncertainty, management, continuity of care, and community leadership are all unique skills that strengthen the identity of general practice. Flexible careers as well as reducing workload, bureaucracy, and administrative burden 3 of 5 will also help with recruitment and retention.
The history of general practice in the UK is one of resilience, adaptation, and sustained public value. For decades, GPs responded to major changes in healthcare delivery while maintaining high standards of care and public trust. However, current pressures suggest that general practice has reached a critical point at which historic adaptability alone is no longer enough. The challenges facing the profession do not reflect a failure of general practice itself, but rather the erosion of the conditions that once enabled it to thrive. Rebuilding those conditions through workforce support, better integration, reduced bureaucracy, and meaningful engagement with clinicians will be essential if general practice is to remain sustainable and responsive to future population health needs.
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