The performance of general practice in the English NHS: An analysis using Starfield’s framework for primary care

General practice in the English NHS is in crisis. In response, politicians are proposing fundamental reform to the way general practice is organized. But ideas for reform are contested, and there are conflicting interpretations of the problems to be addressed. We use Barbara Starfield’s ‘4Cs’ framework for high performing primary care to provide an overall assessment of the current role and performance of general practice in England. We first assess theoretical alignment between Starfield’s framework and the role of general practice in England. We then assess actual performance using publicly available national data and targeted literature searches. We find close theoretical alignment between Starfield’s framework and the model of NHS general practice in England. But in practice, its model of universal comprehensive care risks being undermined by worsening and inequitable access, while continuity of care is declining. Underlying causes of current challenges in general practice in England appear more closely linked to under-resourcing than the fundamental design of the system. General practice in England must evolve, but wholesale re-organization is likely to damage and distract. Instead, policymakers should focus on adequately resourcing general practice while supporting general practice teams to improve the quality and coordination of local services.