General practitioner workforce sustainability to maximise effective and equitable patient care: a realist review

Background Global and United Kingdom (UK) primary care face significant General Practitioner (GP) workforce shortages. Worldwide strategies to address this issue include the introduction of additional healthcare professionals and increasing technology utilisation, to reduce GP workload. However, whether these strategies can sustain the GP workforce remains unclear. Our review examines the factors that sustain and enable GPs to flourish. Aim To examine how general practice work and healthcare systems support GP workforce sustainability and effective and equitable patient care. Design & setting A realist review of existing empirical and grey literature. The search strategy encompassed six electronic databases.

Realist synthesis involved (1) finding existing theories, (2) searching for evidence, (3) selecting articles, (4) extracting data, and (5) synthesising evidence/drawing conclusions. Context-Mechanism-Outcome Configurations were developed using extracted data and patient and public involvement/stakeholder suggestions to refine our programme theory.

168 documents were included. Findings underscore the importance of meaningful work and engagement; relationships across individuals, organisations, and communities; and learning and development. We emphasise the need for congruence between GPs’ core values and their work; cumulative-knowledge building; system agility; psychological safety; and direct human connections.

General practice structures, policies, and practices, and the interactions they facilitate, are crucial for the sustainability of the workforce. Collaboration among GPs, the public, and national policymakers is essential for implementing the principles from this review. Future systems should enable personalised care; sustain meaningful work and relationships; facilitate meaning-making; and promote agency, agility, and flexibility to enable GPs to utilise, adapt, and cultivate expertise. How this fits in Global and UK primary care are experiencing a crisis due to GP workforce shortages. Previous UK GP workforce research has emphasised individual-level factors and solutions, including well-being, self-efficacy, training readiness, resilience, and professional identity shifts. This realist review examines the organisational and system-level factors affecting GPs in their work and proposes recommendations to support a sustainable GP workforce and equitable patient care. Competing Interest Statement Elizabeth I Lamb sits on the Royal College of GPs Council as North East England representative. Funding Statement This research is funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR), project no. 593. Elizabeth I Lamb is funded as an NIHR Doctoral Fellow 303014. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability Our CMOC analysis and supporting evidence are available in the online supplement.