THE last few years have been a time of considerable change for general practitioners in England. In 2004, general practitioners negotiated a new contract with the United Kingdom's National Health Service (NHS). In came a new pay-for-performance scheme (the Quality and Outcomes Framework), along with the option of opting out of after-hours primary care (which many general practitioners chose to do). General practitioners' pay increased and job satisfaction improved. However, rather than then entering a period of stability, general practitioners subsequently found themselves facing even more changes in their working practices. Workload has increased, new responsibilities for commissioning health services have been given to general practitioners, and their income has fallen.

These recent changes have resulted in the morale of general practitioners in England falling and in increased difficulty in recruiting general practitioners in some parts of the country. Changes in general practitioners' working practices have been further compounded by the devolution of powers for the provision of health care to local governments in Wales, Scotland, and Northern Ireland. These have resulted in the NHS in England beginning to look different in its structure to the NHS in the other 3 countries in the United Kingdom.

At the heart of the low morale of general practitioners lie the twin problems of reduced income and rising workloads. The pay of NHS general practitioners peaked in the 2005/2006 financial year and has fallen in each subsequent year. The most recent statistics for general practitioners' pay (for the 2012/2013 financial year) show that on average, pay is around 25% lower in real terms than at its peak in 2005/2006. Anecdotal reports from general practitioners suggest that pay has fallen in 2013/2014 and will fall further in 2015/2016 and that this is threatening the financial viability of some general practices. During the period 1997-2009, government spending on the NHS increased by an average of 8.0% per year. In the subsequent period between 2009 and 2012, NHS spending increased by only 1.6% per year, well below the rate of inflation in the NHS. With the UK government still struggling to bring down its budgetary deficit, it is unlikely that the NHS will see large increases in spending in the next few years. Hence, general practitioners will continue to face a government that wants them to do more but without giving them significant additional resources.

At the same time as their pay has decreased, general practitioners have seen their workload and their range of responsibilities increase. In April 2013, the previous organizations that commissioned local health services, primary care trusts, were abolished and these functions transferred to newly created general practitioner-led clinical commissioning groups. General practitioners found themselves taking on the additional tasks associated with commissioning local health services in addition to their other work. Clinical commissioning groups have already begun to try to apply pressure to limit the growth in general practitioners' prescribing costs and their use of specialist care in an attempt to control the growth of spending on health services.

General practitioners in England have also seen increases in other areas of their workload. In a survey conducted by the Royal College of General Practitioners in 2013, more than 80% of general practitioners reported that they had insufficient resources to provide high-quality patient care and around half reported they had to cut back on the services they provide to their patients; more than 70% predicted that access to primary care services would worsen further in the future. Consultation rates in primary care have increased, and consultations have also become more complex. The population of England continues to age, and the number of older people with multimorbidity and complex health needs has increased. These patients make large use of specialist services, and the NHS is keen to try to manage them as far as possible in ambulatory care settings. This has led to the introduction of new initiatives to improve their management in primary care. This includes an "Admissions Avoidance Scheme" in which around 2% of patients on general practitioners' lists are invited for a review and a care plan agreed with them that offers them enhanced support in primary care.

The UK government is also proposing to improve access to primary care outside of normal opening hours. All residents of England have access to free after-hours NHS primary care (defined as that occurring outside the hours of 8 AM to 6.30 PM Monday to Friday). This care is usually provided either through a commercial provider of after-hours primary care or by general practitioners working together in a cooperative. There is also access to a telephone advice line (NHS 111). However, despite the provision of these community-based services, attendances at hospital emergency departments continue to rise, putting these departments under considerable strain. There is also dissatisfaction from people in employment about appointments not being made available at more convenient times such as during evenings and weekends.

The government's response has been to propose that general practitioners provide access to routine appointments for longer periods, floating the idea of a 7-day-per-week, 8 AM to 8 PM, primary care service. The UK government has also proposed giving general practitioners a greater role in after-hours care. Unsurprisingly, neither proposal has been popular with general practitioners, with complaints from them about the costs of providing routine appointments for extended hours and the impact of longer working hours-including working at "unsocial times"-on general practitioners with family commitments (a high proportion of general practitioners in England are women).

Both the British Medical Association and the Royal College of General Practitioners have launched public campaigns to increase NHS investment in general practice and improve the morale and working conditions of general practitioners. Thus far, however, these campaigns have had little positive impact. The future for general practitioners in the United Kingdom therefore looks highly uncertain. There is now increased pressure for general practitioners to give up their independent practice model of working and instead to become salaried employees either of the NHS or of large commercial health care providers. There is also increased pressure for individual general practices to come together in "general practice federations." These in theory would also lead individual general practices to share some tasks and therefore reduce the administrative and contractual burdens on practices. However, there is no guarantee that changes in the employment model of general practitioners or practices merging into larger organizations will improve working conditions for general practitioners. Such changes would also mean that general practitioners would lose much of the freedom and flexibility in their work that they currently have. General practitioners in the United Kingdom therefore face an uncertain future and one in which workload and funding pressures may begin to undermine the strong role that primary care has traditionally played in the England's NHS.

England; health policy; National Health Service; primary care