How does UK Primary Care Work: insight
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A very condensed overview about: GPs in England
Original 2025 03 29, latest update 2025 06 04 Owen Yang
This post is an ongoingly improving, condensed description of what GPs are. This is aimed to be highly over-simplified, and aimed for the widest audience within and across medical fields, beyond medical fields, and internationally.
Please contact me @0wenyan9 or 0wen.yan9@gmail.com if you have something to say.
GP practices are private contractors under NHS rules
GP practices (or medical centres) are where GPs work. GPs provide primary care services, seeing patients at the frontline and treat if they can, or refer patients to hospitals or other services under NHS contracts. This means GPs generally do not do things that is not paid for by the NHS, or do not do things that are not allowed under the NHS contract. The also implies referrals to the hospital are only made when it is necessary. Practice owners run the GP practice as a business under NHS contracts and rules, but where contracts and rules do not dictate they are otherwise free to operate the practice in their own ways. They can decide how long an appointment is or who has the priority to be seen, as long as these operations jointly fulfil the NHS requirement to take care of the population. GPs largely fall into three categories: owners ('GP partners'), those who are hired to work for the owners ('Salaried GP'), or or those who work odd hours just like replacement teachers in the schools ('Locum GPs').
GP practices are the first contact of all NHS patientsGPs practices are supposed to be the main first contact of each patient in the NHS, although patient can also contact emergency services directly as appropriate. There are other direct-contact services, such as sexual health clinic and abortion services.
Each patient has a named GP or a registered GP practice where they are supposed to make the first contact. Your GP will then assess whether you need to be treated or investigated by the GP, or be referred to the hospital.
Even when the patient is referred to the hospitals, GPs still oversee whatever has happened to a patient across the healthcare system. When someone is referred to the hospital, most of them have an appointment with a consultant specialist, or admitted to the hospital under the care of a consultant specialist, such as a consultant surgeon or a consultant cardiologist. The hospital services feedback to the GP what has happened so that the GP can keep updated and oversee the patient's care across different specialties.
When being referred, a consultant specialist can follow up the patient when they see fit, but can also stop following up and 'discharge' the patient form their service. This means the patient can no longer contact the hospital service directly and has to go through the first contacts, the GPs.
GPs as nanniesThe 'primary care' is not limited to internal medicine, but all ages and problems. This includes gynaecology, musculoskeletal medicine, skin rashes, and mental health. However, most GP practices are only offices, drugs and dressings. If someone takes blood, the blood sample will need to be sent to the hospitals, and the results will require days to come back. An X ray will need to be requested, and wait for days or weeks to see the report. GPs nowadays only see the reports and do not have access to X ray images. In addition of the usual medical care, a significant time is also used for safety, safeguarding, and end-of-life care. Sometimes it can be a bit like nannies, especially when the patient is not keen to their own health but the GPs are under the NHS responsibility to chase patients.
Whats up in the UK primary care 2025 update
2025 06 16 Owen Yang
This is a list in my notebook, a selected list of Whats up in the primary care in 2024/2025. This is supposed to be an inspiration bucket list. Those who are interested need to do their own research to obtain a more accurate picture.
Hormonal replacement therapy, higher progesterone dose for some.
The dose of progesterone should be proportional to oestrogen instead of the fixed dose, with implication to off-license high-dose users. Complicated tables depending on type of oestrogen and type of progesterones.
Link to British Menopause Society Document
Hormonal replacement therapy, use of vaginal oestrogen after having a breast cancer.
Vaginal oestrogen is deemed safe for people with a history of hormone-sensitive breast cancer.
Link to British Menopause Society Document
Hormonal replacement therapy, risk-based algorithm for women with unscheduled bleeding.
Unschedule vaginal bleeding is a sign of endometrial cancer, but is also very common for women starting HRT. Previously women near menopause had a universal management algorithm when they had unscheduled bleeding on HRT. Now there is a new system to treat individuals differently depending on their risk factors.
Link to British Menopause Society Info
Prostate cancer, rise in PSA request..
Since Sir Chris Hoy's diagnosis of prostate cancer at the age of 47, there are increasing requests to get a PSA test. But is the NHS ready to deal with the burden and consequences?
Link to Prostate Cancer UK Info
Men, testosterone deficiency and anabolic steriod use.
The social media has seen the increasing marketing of testosterone deficiency and use of anabolic steroid. They can be two separate issues but sometimes linked. Many young adults test their testosterone for fun, and come to the GP when the level is high or low.
Diabetes, two recent drugs that can change the landscape.
Of few new DM drugs, SGLT-2i (gliflozins) and GLP-1 agonists (glutides) are likely to stay, and to expand their effect beyond DM and its complications.
Finerinone, another new drug that is expected to expand its use.
It remains a specialised drug but has made its way as a treatment for chronic kidney disease (CKD). CKD now has ACEI, SGLT-2i, and finerinone as 'active' treatment to prevent its progression.
Mounjaro and an average person's understanding over the NHS system.
Mounjaro (a GLP-1 agonist) is authorised to treat for obesity but under NHS it was only funded for diabetes under strict criteria. Some areas might start to commission its use for obesity under specialist use.
Asthma: new inhaler paradigm. Individuals with asthma used to have a reliever inhaler for symptoms, and a preventer inhaler for preventions. The new guideline has changed so that there will be just one mixed-medication inhaler used for both.
Link to Asthma and Lung UK
Endometriosis, increasing awareness? In 2024 there has been huge social media campaign to encourge women who think they might have endometriosis to seek active investigation and treatment, instead of being treated as this is something women has to endure.
Link to Endometriosis UK
Assisted dying. Isle of Man is on track to implement assised dying. This is also under strong consideration in (other parts of) the UK. People who disagree tend to focus on the declining state of palliative care in the UK.
The everchanging name of the metabolic liver disease.
Since the 2020s there is increasing evidence and funding on this disease, and as of now the correct name is MASLD, Metabolic Dysfunction-Associated Steatotic Liver Disease. There is mixed message on why it is important compared to other conditions but given the large funding and successful campaigns/marketing I think we will soon know more.
Neurodiversity.
Since COVID there is a sharp rise of mental health issues in young persons and adults, and some of them are desparate to get a neurodiversity diagnosis, such as autistic spectrum disorder and ADHD. The system just cannot cope with the demand and many face years of waiting.
The true cost behind a false positive test
2025 06 08 Owen Yang
A common scenario is someone in his 30s or 40s without any symptoms asks for a prostate cancer blood test, known as a PSA test. But there are many other scenarios that may occur in a day-to-day GP consultation.
There is currently no test is good enough for you
For someone with a very low risk of a disease who asks for a diagnostic test that is not offered, most of the time this is not offered simply because there is no test that is good enough to tell the difference between having and not having the disease in a low-risk individual.
A lot of time this is mistakenly simplified by patients or even by doctors as ‘a waste of the NHS money’, but most of the time the cost of the test itself is really not the issue.
False positives in low-risk individuals
Think about this: for a group of people whose risk of a disease is near zero, when they receive an average test for that disease, nearly all the positive tests will be false positives.
If there is a false positive rate of 1% and the risk in that population of 0.01%, then false positive individuals will be 100 times more than the true positive individuals. Therefore, this average test does not need to be a bad test and the risk of the disease does not have to be that low.
A bad statistician can play with the numbers and say a positive test increases the probability of cancer by 100 folds. But there is very few real life implications when the risk is raised from 0.01% to 1%.
This is why for an average test, it is important to only request the test when the risk of the disease is sufficiently high.
The danger of the next steps after a positive test, and who is responsibleA large number of false positives leads to unnecessary further, more confirmatory tests that can lead to complications.
It can be relatively easy for a patient to imagine how a colonoscopy can cause bleeding or bowel perforation, or a CT can cause kidney damage due to the need to inject contrast agents. Sometimes it is difficult for a patient to conceive how MRI can lead to complications. Whilst MRI itself tends not to have a direct complication, it has the power of detecting many things that we cannot interpret, such as cysts, nodules, or shadows that can be common in an average individual. Some of them will be difficult to determine its nature, and in many circumstances they can lead to a biopsy or an invasive procedure that may or may not be related to the original inquiry.
Again if your risk of having that disease is known to be low, most findings on the MRI will be false positives, and more MRIs lead to more unnecessary invasive procedures.
With few exceptions, it is simply difficult to fund research that looks into complications of false positives in very low-risk individuals. It would be very unfortunate for the individual who have low risk but actually have the disease, but if the test is not good enough, it should not be used.
Extended reading (academic papers)[1] Incidental findings in imaging diagnostic tests: a systematic review
[2] Potentially serious incidental findings on brain and body magnetic resonance imaging of apparently asymptomatic adults: systematic review and meta-analysis
Approaching the End of Our Lives: Function Matters
2025 05 06 Owen Yang
When someone approaches the final phase of their life, what matters most is not always the medical diagnosis, but how they are functioning. Whether it is cancer, heart failure, infection, or something else, the actual condition often matters less than the impact it is having on someone’s day-to-day life.
So rather than start with blood tests or scans, I often begin by trying to understand a person’s function—what their life is like now, and what it was like just before they became unwell. That context tells me far more about their prognosis, their quality of life, and what kind of care will be most appropriate.
Over time, I have found it helpful to look at four main domains of function. It is not a textbook framework, just something that is made sense to me in practice.
Cognitive Function and Communication
First, I look at how well the person can think and communicate. Are they usually alert and able to hold a conversation? Do they understand what is happening around them? Can they express needs and preferences clearly?
When someone becomes unwell—especially older adults—confusion and delirium are common. But if I know that someone was usually sharp and independent in their thinking, that gives me a sense of how far things have changed. On the other hand, if someone has long-standing dementia or rarely speaks, their baseline expectations and needs may be different.
Mobility and Independence
Second, I think about mobility. Is the person usually up and about? Can they walk unaided, or do they use a stick, frame, or wheelchair? Are they bedbound? Can they manage stairs? Can they move between rooms?
Linked to this is daily independence—can they dress themselves, prepare food, take a shower? Independence in personal care is a key marker of how well someone is managing overall. A sudden change in mobility often signals a major shift in health.
Pain
The third domain is pain. Does the person live with ongoing pain? Where is it? How much does it interfere with their life? Pain is one of those things that quietly but deeply erodes quality of life. It might not show up in blood results, but it tells you a lot about how someone is coping.
Pain is not just about discomfort—it affects sleep, appetite, mood, mobility. It is also one of the things we can do most about, if we know it is there. So I always try to ask.
Breathing
Finally, I consider breathing. Do they get breathless walking around the house? Can they speak in full sentences, or do they get puffed out easily? Is there a background of heart or lung disease that limits them?
Breathing affects everything—from movement to sleep to basic comfort. If someone is living with constant breathlessness, or it is become worse recently, that often signals the body is under strain.
Of course, there are other areas too—things like eating, continence, or sensory loss—but these four are the core ones I return to. Together, they paint a picture of how someone is really doing, beyond test results or diagnoses.
When we are thinking about the end of life, it is these domains—cognition, mobility, pain, and breathing—that guide us. They help us make decisions not just about treatment, but about dignity, comfort, and the kind of care that truly matters in the time someone has left.
Triage in the primary care under the NHS
2025 04 10 Owen Yang
This is a brief overview of what triage is in the UK primary care.
In a nutshell
It is important first to understand the basic background of the UK healthcare system, the NHS. Under the NHS, patients have to register to a general practice as the main contact where they see their doctors. It is free at the point of care and paid by the tax, and therefore the service is available only to the extent that the tax can afford.
Without a triage, patients decide when, who and why they would like to be seen by their healthcare services. This has become difficult because there are just not enough appointments available for the demand. With a triage, therefore, there is a gatekeeper who decides when, who, how, and why patients can be seen or not being seen.
Triage is a fix of a longstanding crisis but it is here to stay
The UK primary care has been in this crisis that too many patients want to see GPs and there are just not enough GP appointments. To have a quick fix of this NHS crisis, since 2023 the NHS has imposed a regulation that (1) all patients need to have easy online access to make requests to their GPs, and (2) these requests need to receive ‘appropriate responses.’ Although there is no time frame for this response, many practices seem to aim for the response on the day of the request. I do feel this way of operation can be problematic but it is what it is.
ABC of a typical triage system
A typical triage system: (A) the frontline triage team
In this triage system, patients are expected to submit their request to an online system by themselves or with help. The requests are reviewed by a triage team who then redirect the request either to the duty doctor, or bypass the duty doctor to other relevant team members such as drug dispensary, medical records, or the reception team.
A typical triage system: (B) the duty doctor
The requests that go to the duty doctor will be reviewed to decide the best action forwards. Some requests, such as just a double check with the doctor to issue a medication, can be bounced back to the frontline triage team for further action according to the duty doctor’s instruction. Other requests that may require a doctor to interact with the patient will be responded to the patients in the form of:
[1] invitation to an appointment with a doctor, a physician associate or a primary care paramedic depending on the complexity, at a time frame decided by the duty doctor;
[2] invitation or suggestion to book an appointment with an appropriate role within the practice or redirection to relevant services in the community, depending on what is available in the practice and in the area (see section C the team below);
[3] a call-back from the duty doctor to the patient to obtain information, or convert to what is essentially a telephone appointment with the duty doctor on the spot;
[4] a text reply to signpost information or give updates, or to request more information from the patient, such as filling in a questionnaire.
A typical triage system: (C) the team
Within practice, there may be appointments with
Practice nurses
Clinical pharmacists
First-care physiotherapists
Healthcare assistants
PCN wellbeing service
First-contact mental health professionals
In the community, there may be redirected to
Pharmacy first / Pharmacists
Minor eye condition service / opticians
Self-referral for mental health therapists, physiotherapists, and other services
Minor injury unit
Call 111 or 999
Why do I end up with JUST a telephone call? My personal advice
This is my personal opinion and may not suit every patient and every practice.
I see so much time wasted because the patients are frustrated when they have to explain the same thing every time to a different duty doctor, and the doctors are frustrated because they do not know this patient's past, and have to ask everything from scratch or read every letter and every note in the past 12 months or even longer.
For everyone’s best interest, the best option is almost always with your usual doctor, even when this means waiting a little bit of time to get your answer or your appointment. If this is something that you could wait for a few days, I would advise that when you make a request, specifically say you prefer to have your usual doctor, Dr. XXX to respond to you in 1 week, or in 2 weeks if you are generous.
If you are seen by another doctor for some reason, please always go back to your usual doctor next time. Do your best to stick to a doctor that you are not unhappy with and only see other doctors at an exceptional basis.
NHS GP registrar self-development ideas
Original 2025 03 27, latest update 2025 04 10 Owen Yang
As far as I know, the tutorial time can be used for (1) tutor talking about a defined topic; (2) registrars asking questions; (3) patients booked in for learning purposes or as work-based assessment; (4) registrar sitting with or discuss with other members of staff to learn their roles.
This post is an ongoingly updated list about less obvious ideas that might be helpful for those who would like to arrange structured activites during their protected learning time, such as tutorials, independent learning, or self-directed learning time.
Tutorial time: see one, do one
It is not uncommon and quite convenient to use tutorial time to be observed by ES and complete assessments. However, I would like to argue that in our GP training, we do not have enough time seeing other doctors, or even our ESs to see patients, and seeing others seeing patients can be equally educational.I suggest you could push for the idea of see one, do one, instead of purely being observed and given comments. When I did my research degree my interest was behavioural psychology, and if I learned anything it would be that words are less useful than we think it is. Unfortunately compared to my home country, the UK, the NHS, and the GP training are more obsessed with words, but this is another argument to make. My point is at least we will learn more by diversifying our learning activity, through not only being observed but alos seeing how other doctors prioritise their values in their consultations. I learned a lot of tricks from my ESs that she does not know she has.
Tutorial time: a walk around the neighbourhood
Many of us work overtime and struggle to finish all admin work on time, and as far as I know most do not have time to see the catchment area that we serve. During one sunny day I boldly suggested to my ES that we can walk around the neighbourhood to see what is out there. She kindly agreed.This is a village-town and I personally feel like to 'show myself around' the neighbourhood and subtly imply that I am a new doctor in the practice. I have a good past of my life being trained in social science and my version of a community work should be purposeless: for me the most efficient way of understanding a community is get the footprint, do the miles, spend the time. No agenda. When there is time, I also tend to entice my fellow GP registrars to come with me to have a walk during the elusive lunch braak.
If your are not a natural social scientist like me, I suggest you can justify your walk by doing some forced activity, such as actively introduce yourself to the shop fronts (it helps if you buy something), or draw a map of the neighbourhood area during or after your walk.
Tip for reflection: I personally think this activity should automatimcally make a strong case for 'population health' in the clinical experience group and 'community orientation' in our capabilities, but unfortunately in my experience ESs and TPDs tend not to trust themselves to interpret this and would like to seek comfort by knowing they fit the descriptors. We will need to strategically reflect this to make it easy for them. So be mindful if you need a reflection from this, and show you have demonstrates understanding of how the characteristics of the local population shapes the provision of care in the setting in which the doctor is working.
Turorial time: listen to recorded remote conversations
Credit to TPD Dr. Jennifer Barnes who shared her idea to my ES.To my understanding all remote consultations are recorded, and your ES (or CS) in the practice is very likely to have access to these recordings. During tutorial times we pulled out either 'interesting' or random consultations, listened to them together, and discussed about it.
This can be used as one of the CAT activities.