The partnership model in general practice predates the NHS. Is now the time to change it?

The future of the partnership model in English general practice is uncertain. Partnership predates the formation of the NHS, and keeping it was one of Bevan’s biggest compromises. Always ideologically controversial, for decades partnership was a stable foundation for general practice, and an aspiration for early career GPs. That’s changed. In the past decade, the number of GP partners has fallen dramatically, and relatively few early career GPs now aspire to the role.

The NHS relies on general practice to keep people well, and to manage demand for hospital services. As GP partner numbers have declined, so too has the number of GP surgeries – part of a complex mix of factors resulting in record low public satisfaction with general practice.

The government has signalled its interest in the future of GP partnership, and changed its tone. Branded “a murky opaque business” by the-then Shadow Secretary of State in 2022, in 2024 – now in government – Wes Streeting promised to "consult…engage….listen". Having indicated an intention to use the 2026/27 GP contract as a vehicle for change, he will be mindful of time, and increasingly aware of the complexities involved.

This paper explains what GP partnership is, explores key trends in workforce data and sets out the mix of strengths and challenges associated with the partnership model. It describes a range of alternative business models for general practice, and suggests an approach to tackling the complex mix of questions policy-makers must grapple with to find a route forward.

What is GP partnership?

The GP partnership model is the main legal structure for the delivery of NHS general practice. GP partnerships are independent autonomous businesses, contracting with NHS England – via integrated care boards – to deliver GP services (See Box 1 for types of GP contract). Partners – who are usually medically trained GPs, but may also be practice nurses, practice managers or other invited individuals – operate as self-employed contractors, delivering NHS services to contractual specifications. 

Alongside clinical work, GP partners are business owners. They employ staff – including salaried GPs, practice nurses, admin staff and managers – and manage the finances, estates and administration associated with running a practice. Most GP partnerships are unlimited liability partnerships. This means that while partners are entitled to a potentially unlimited share of business profits, they are also personally responsible for all financial liabilities such as losses and debts.

In keeping with their role as business owners, GP partners take a share of the surplus generated from practice income (so called ‘gain share’). Each partnership has an internal ‘partnership agreement’, setting out terms and conditions within the partnership, including each partner’s share of profits. These are relatively flexible legal structures, allowing agreements to vary between practices to meet the needs of the specific partnership. For example, partners within the same practice may work different amounts (full or part-time), and some partnerships may have a ‘lead partner’ structure, giving one partner a greater share of responsibility and reward.

What’s happening to the number of GP partners?

Historically, GPs aspired to partnership, which was viewed as higher status, better compensated, and more powerful within the profession. This appears to have changed, and the headcount of GP partners has declined significantly in the past decade.

In September 2015 there were 24,491 GP partners in England. Despite efforts to encourage GP partnership – including a time-limited “new to partnership scheme” offering significant financial incentives – the number of GP partners has dropped by almost 25%, to 18,425 in December 2024. Simultaneously, the number of salaried GPs has increased by 81% – from 10,270 in September 2015 to 18,557 in December 2024 (see next chart).

This represents a big change in the proportion of GPs working in partner versus salaried roles over the decade. In 2015, almost 68% of GPs were GP partners. Now, GP partners are a minority of the GP workforce – which has equal proportions of salaried and partner GPs (both 48%), and a small proportion of regular GP locums (3.5%) ¹ (see next chart).

Changing age profile of GP partners

The age profile of GP partners is also changing. Since September 2015, the number of GP partners aged under 40 has fallen by 53%. This is the steepest fall across age groups, but the only age group with growth in partner numbers is the over 60s (see next chart).

Workforce data from NHS Digital tallies with survey data, which has consistently suggested that fewer GP trainees and early career GPs are considering partnership as a career option. This means that the workload and risk of running partnerships are falling on a diminishing number of GPs, who are increasingly approaching retirement age.

How is this affecting GP practices?

As the number of GP partners has fallen, so too has the number of GP surgeries in England – from 7,623 in Sept 2015 to 6,227 in December 2024 (a drop of 18%). Publicly available data does not allow us to disentangle how many of these reflect closures versus mergers, and reporting suggests that some areas are more affected than others. 

Why is this a challenge, and are there opportunities?

The partnership model has underpinned general practice throughout the life of the NHS. Proponents view partnership as cost-effective: GP partners have a strong incentive to run an efficient service, and often work the kind of long hours that would be very expensive to pay for in a salaried model. Partnership also drives tight financial discipline: partners may take personal or business loans to fund investment in their practices – but these are personal (non-NHS) liabilities, and partners can’t run deficit budgets in the same way that NHS trusts can. This offers a degree of financial safeguard for the system.

The relatively small size of GP partnerships is credited with offering agility to innovate and flexibility to change quickly (for example, GPs have historically been early adopters of tech in the NHS). And GP partners are more likely than salaried GPs to remain working at the same surgery for longer – creating a basis for continuity of care, and for developing deep understanding of local areas required to tailor services to their needs.

There are also criticisms of the partnership model. Partnership has been ideologically criticised as ‘for-profit’, and the high salaries of some partners publicly critiqued. Particularly in the wake of the 2004 GP contract – which proved lucrative for GP partners – it can be hard to convince officials (and particularly the Treasury) that increasing funding for general practice will provide value for money. The same autonomy that yields innovation and agility at practice-level can also be a double-edged sword for commissioners, who have limited levers to make practice-level change, and may find getting agreement and coordination between local practices difficult.

The government knows that actively abolishing the partnership model would have disastrous consequences for the immediate provision of GP services. But policy-makers will have to decide how actively to bolster it. The 2019 GP Partnership Review produced a set of recommendations, but little action from the-then government. This leaves a ready-made set of suggestions for officials to revisit should they wish to. Acting on estates, and on the liability structure of partnerships are the big-ticket items here (the former is particularly challenging, as buying partners out of their premises would require significant capital investment in strained financial times).

As the number of GP partners has fallen, new business models in general practice have emerged. These can broadly be categorised as scaled-up independent providers, and models involving integration with NHS trusts. Examples of both are profiled in Box 2. 

What are the strengths of different models?

The core of NHS general practice is the idea that patients register at local surgeries, which offer comprehensive care. GPs manage acute illness, are responsible for much preventative care, and control access to non-emergency hospital services. The service is plagued with delivery issues, but the fundamental principles of this operating model are evidence based. There is far less evidence though to suggest what business model(s) can most effectively and efficiently deliver that care. Researchers have identified difficulties even identifying ownership structures of GP surgeries, making rigorous evaluation difficult.

At-scale independent providers make impressive claims of improved work-life balance for staff, efficiencies of scale provisions, and analytical support – but independent evaluation is lacking. One large, nationally funded evaluation sought to understand the impact of vertical integration on patients’ use of health care services and patient experience. It found significant but modest reductions in rates of emergency department use for patients registered at GP surgeries run by acute hospital trusts, but concluded that these were temporary and that there was no impact on overall admissions. Impact on patient experience of care was minimal, and researchers concluded that there is no case for widespread roll-out of the vertical integration approach.

In particular, there is little evidence to help us understand any relationship between ownership model of practices and outcomes for patients. Where research exists, it has tended to look for associations between the size of practice, and patient outcomes. For example, continuity of care is higher in smaller GP practices, and patient satisfaction is lower in larger surgeries. And previous Nuffield Trust analysis found that patients have mixed views about large-scale general practice (some value perceived improvements in access, but others worry about losing continuity of care). But caution should be taken in conflating the business model of general practice with practice size: many of the models described in Box 2 allow for the operation of small neighbourhood GP surgeries, just with different ownership structures.

What next?

Policy-makers are in an unenviable position. The future of the partnership model is a controversial topic among GPs, and interventions will not be universally agreed. Years of squeezed funding have made running practices increasingly unattractive, and increasing funding and improving workforce planning might make partnership more appealing. But the number of partners is falling steadily, and GP surgeries closing is a huge threat to the government’s commitment to improving access to general practice. With no guarantees that this trend will end, the government needs to protect against the real risk that if GP partners no longer wish to hold contracts – and viable alternatives cannot be found – the provision of general practice in local areas will be threatened.

Predecessor governments have ducked the issue – allowing a range of models to emerge and taking some (albeit relatively minimal) steps to attempt to boost partner numbers. Their continued decline makes inaction less viable, and relying on innovative GPs, hospital leaders or the market to determine future models of general practice comes with risks.

This section suggests an approach to thinking about the future of the partnership model.

Start with function

Before any efforts are made to reform or move away from the partnership model, policy-makers must address a fundamental question: what is the purpose of NHS general practice? Answering this – and further questions about what outcomes general practice should achieve and how success should be understood – must be done in collaboration with the profession. This doesn’t need to start from scratch – previous work describes various characteristics of general practice and factors that determine quality, and a range of models – including Starfield’s 4Cs, and Reeves and Byng’s United Model of Generalism – set out core functions. Getting consensus on goals and functions is a vital prerequisite to identifying the range of operational and business models that could deliver those aims.

Identify operational models that can achieve that function

Clarity on the purpose and the desired outcomes from general practice (including their intersection with other parts of the health service, and evolving plans for ‘neighbourhood health services’) will help policy-makers identify operational models that best serve these aims. A multitude of factors require consideration, including:

• What functions of general practice are best done at what scale? For example, is keeping relatively small GP surgeries within communities desirable? If so, what purpose should these surgeries serve, and what services should be delivered at larger scale (for example, to cover a whole town)?
• What support services best serve the desired functions of general practice, and how should they be provided? For example, should some administrative and data support be provided at a scale greater than individual practices?
• What is the future of existing forms of ‘scale’ general practice, including primary care networks and GP federations. How do these intersect with desired outcomes from general practice?
• To what extent do policy-makers want to create opportunities for services currently delivered by hospitals to be delivered through general practice (for example, moving outpatient or diagnostic services to community or general practice settings)?
• What operational models of general practice best support its integration with acute, community and social services?
• What operational models of general practice best support its evolving workforce (with increasing numbers of allied health professionals and multiprofessional team working)?

Given that a single operational model won’t work everywhere, identifying what works well, in what circumstances and why is important. NHS England are testing a range of interventions aimed at helping general practice narrow gaps between demand and capacity. Learning from these pilots might help identify optimal operating models, as could studying the range of different operating models already used by GP providers across England.

Identify business models that can support operational models to achieve desired functions

Identifying optimal business models, and the GP contract(s) to support them should be a third order question – behind identifying the purpose of general practice and how it will be delivered. Key questions for policy-makers will include:

• Whether to retain the ‘gain share’ element of the partnership model (meaning that GP services are effectively run ‘for profit’)?
• To what extent a desired purpose of new contracts is to create options for salaried employment of GPs by entities other than GP partners?
• Who to allow to be contract holders? For example, should contracts be held by a limited range of providers (such as GP partners, NHS trusts), or open to any willing provider?
• The extent to which local areas – in the form of integrated care boards – should be able to determine business models for general practice in their footprints (versus a greater degree of central control)?

Policy-makers can learn from international examples of GP contracts being used to leverage a range of desired outcomes – including improving quality of care, encouraging multidisciplinary working, and larger-scale delivery of general practice.

Get the enablers right

Stabilising general practice requires reform, and policy-makers will need to strike a careful balance. Unnecessary organisational changes which distract from the task of improving care should be avoided. Replacing partnership where it’s working well – or where people want to be partners – isn’t necessary. Increasing the proportion of NHS funding spent on general practice is a prerequisite for improving the service, and may bolster partner numbers too. But the government needs to plan for the future and actively develop alternatives.

The biggest immediate threat to general practice is its inability to retain FTE GPs. Policy-makers must develop solutions that create sustainable, fulfilling work for existing GP partners and for the growing number of salaried GPs. Retaining support across the profession will be crucial, and GPs must be convinced that new business models will benefit patients and staff, without destabilising areas where the current provision of general practice is working well.

In the short term, a plurality of business models seems likely. Different operating and business models for general practice have different strengths: determining which to optimise for and prioritise is ultimately a political choice. The government will need to decide how radical to be. Evolving current models is an option, but so too is designing new ones. There are options to create new NHS-run organisations – separate from existing hospital or community trusts – to deliver general practice and offer salaried NHS employment to multidisciplinary GP teams.

In the absence of a comprehensive evidence base on the strengths and flaws of various models, the government must also decide how far it wants to go in generating better evidence before committing to specific contract types. Particularly if radical options are chosen, well-designed pilots should be used to rigorously test and evaluate proposed models.

Considering how changes would be implemented is also crucial. Many integrated care systems lack the planning and transformation capacity required to support major change in general practice, let alone if they are given greater responsibility for curating, maintaining and overseeing a mixed market of GP providers locally. Investing in leadership and management capacity within general practice alongside supporting ICSs to develop their commissioning architecture seems wise.

All this may sound daunting. Neat evidence-based solutions don’t exist, and the wider context – of a struggling NHS and a government with little fiscal headroom – is tough. There is little room for misstep, and having the support of GPs is crucial. But workforce numbers speak for themselves: delaying intervention is unlikely to improve outcomes. As the government develops blueprints for the future of the NHS, it should set out principles for its approach to the future of GP partnership, and actively work with GPs to find solutions.