The Partnership Model

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

Published 07/03/2025. A Summary for LMCs of the Nuffield Trust paper - Author Dr Becks Fisher.

Overview

The future of the GP partnership model (in place before the NHS’s creation) is uncertain. GP partner numbers have fallen, and fewer early career GPs now aspire to the role.  There is a shift towards salaried roles.  The author explores the reasons behind this shift, its implications and alternative business models.

What is GP Partnership?

GP partnerships are independent, autonomous businesses contracted by the NHS (via Integrated Care Boards) to deliver GP services. The GP partnership model is the main legal structure for the delivery of NHS general practice.
Partners are usually GPs but can include other professionals (e.g. practice nurses, practice managers).  They are self-employed, share profits (take a share of the surplus generated from practice income known as “gain share”) and take on unlimited liability (i.e. they are personally responsible for all financial liabilities such as losses and debts).

• GP partners are clinicians and business owners. They employ staff, manage the finance, estates and administration. 
• Each partnership has an internal ‘partnership agreement’, setting out terms and conditions, including each partner’s share of profits. Agreements vary between practices to meet the needs of the specific partnership.
• Types of GP contract:
  • GMS (General Medical Services) – the most common, nationally negotiated between DHSC, NHSE and GPC. 71% practices held GMS contracts in 2024. 
  • PMS (Personal Medical Services) – locally negotiated between commissioner and provider.  Flexibility to tailor provision to local need.
  • APMS (Alternative Provider Medical Services) – open to external providers including independent and community sectors and voluntary organisations. Locally negotiated, flexible. Not generally used by GP partnerships.

Decline in GP Partnerships

• Since 2015:
  • Number of GP partners dropped 25% (from ~24,491 to ~18,425). This is despite the “new to partnership scheme “offering financial incentives.
  • Number of salaried GPs increased to 81% (from ~10,270 to ~18,557).
  • GP partners under the age of 40 decreased by 53%.
• In 2015, 68% of GPs were partners. Now, they are 48%, matched by salaried GPs. Regular GP locums make up 3.5%.  The only age group with growth in partner numbers is the over 60s.

Impact on GP Services

• Fewer GP trainees and early career GPs are considering partnership as a career option (evidenced by workforce data from NHS digital and survey data).
• The risk of running partnerships is falling on fewer GPs who are approaching retirement age.
• Fewer partners correlate with fewer practices: The number of GP surgeries fell by 18% from 2015.  Available data does not tell us which are closures vs mergers.
• This contributes to declining public satisfaction and rising service pressure.

Strengths and Challenges of the Partnership Model

Strengths:

• Cost-effective: Partners have a strong incentive to invest time, money, and effort with personal financial stakes.  Partners can’t run deficit budgets in the same way that NHS trusts can and may take out personal or business loans to fund investment. An equivalent salaried model would be very expensive.  The partnership model provides a degree of financial safeguard for the system.
• Efficiency and Agility: The relatively small size of GP partnerships encourages innovation and rapid adaptation (e.g. they are often early adopters of new technology).
• Continuity: Long-term local presence (compared with salaried GPs) supports continuity of care and a deeper understanding of local need allowing for tailor made local services.

Challenges:

• Criticised as "for-profit”.  Public criticism of a few very high earners following the 2004 GP contract which was lucrative for GP partners. Difficult now to convince Treasury that increasing funding will provide value for money.
• Autonomy can limit system-wide changes and hinder integration.  Commissioners have limited levers to make practice level changes and getting agreement and coordination between practices can be difficult.
• Liability risk and workload discourage new entrants.

Policy Implications and Government  

• Wes Streeting (Secretary of State) has promised a consultative approach for the 2026/27 GP contract.  The government recognises the need to reform.
• The 2019 Partnership Review produced recommendations, but little action was taken. This could be revisited.  Acting on estates, and on the liability structure of partnerships are the key recommendations. Buying partners out of their premises would require significant capital investment (in strained financial times).
• Government know that actively abolishing the partnership model would destabilise service delivery but doing nothing is no longer viable.

Emerging Alternative Business Models

New business models have emerged as the number of GP partners have fallen.  These are broadly scaled-up independent providers, and models involving integration with NHS trusts.

Independent Providers:

• Super-partnerships – GP practices merge to form a single partnership (e.g. Modality)
• Corporate chains – Commercial companies run GP surgeries often using APMS contracts (e.g. Operose Health)
• GP Federations structured as Community Interest Companies run GMS GP surgeries with “scale “and “back office “support services (e.g., Primary Care Sheffield).

Trust-integrated Models:

• Vertical integration: GP practices run by acute hospitals. Staff are NHS employees (e.g Royal Wolverhampton NHS Trust)
• Horizontal integration: GP practices managed by community trusts ( e.g Hampshire and Isle of Wight Healthcare NHS Foundation Trust).

Evidence and Evaluation Gaps

• Core practice principles are evidence-based, but there is insufficient evidence on what business model can most effectively and efficiently deliver that care. Researchers struggled even to identify ownership structures of GP surgeries.
• Large-scale models claim improved work/life balance for staff, efficiencies of scale provision and analytical support but independent evaluation is lacking. They may improve access but often reduce continuity of care (which is higher in small GP practices).
• Some vertically integrated models show modest, temporary reductions in A&E visits but little effect on overall hospital admissions or patient experience.  Researchers concluded that there is no case for widespread roll-out of the vertical integration approach.
• Caution should be taken in conflating the business model of general practice with practice size: many of the models allow for the operation of small neighbourhood GP surgeries, just with different ownership structures.

What next?

An approach to thinking about the future of the partnership model:

Define the Purpose of General Practice

• Reach consensus through collaboration with the profession on core functions and outcomes (e.g., continuity, access, prevention).
• Use established frameworks (e.g. Starfield’s 4Cs and Reeves and Byng’s United Model of Generalism ) as reference points to set out core functions.

Identify Operational Models

• Determine what functions of general practice should be carried out at scale (e.g. to cover a whole town) and at practice level.
• Clarify roles of Primary Care Networks, Federations, and “neighbourhood health services “.
• Consider what operational models best support integration with acute, community and social services and its evolving multidisciplinary workforce.
• Determine to what extent policymakers want hospitals services to be delivered through general practice.
• Decide what support services best serve the desired functions and what could be provided at scale (e.g. administrative, data support).
• Identify what works well, in what circumstances and why.  Learn from NHSE pilots and operating models already in use across England.

Develop Supporting Business Models

Identify optimal business models, and the GP contract(s) to support them.

• Decide:
  • Whether to retain GP partnership ‘gain share’ incentives.
  • To what extent new contracts should create options for salaried employment by entities other than GP partners.
  • Who can hold contracts (e.g., trusts, private providers, new NHS entities).
  • Level of local vs. national control over contracting.
• Learn from international examples of GP contracts being used to achieve a range of desired outcomes.
• Evolving current models is an option, but so too is designing new ones.  Consider creating new NHS-run organisations to deliver general practice and offer salaried NHS employment to multidisciplinary GP teams.

Get the Enablers Right

• Avoid organisational change that detracts from improving care.  Don’t replace partnership where it’s working well but plan and actively develop alternatives.
• 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.
• Increase the proportion of NHS funding spent on general practice.
• Develop solutions that create sustainable, fulfilling work for existing GP partners and for salaried GPs. The biggest immediate threat to general practice is its inability to retain FTE GPs. 
• Invest in leadership, planning and transformation capacity at the ICS level.
• Pilot and rigorously evaluate new models before full-scale implementation.

Conclusion

Neat evidence-based solutions don’t exist, and the wider context – of a struggling NHS and a government with little fiscal headroom – is tough.  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.