We studied primary care in 6 rich countries – it’s under unprecedented strain everywhere

Primary care – the kind delivered by general practice (GP) clinics – is the backbone of every health system. When it works, we barely notice it.

It keeps people healthy, detects problems early, coordinates care and keeps people out of hospital.

But across many high-income countries, despite very different health systems, primary care is under unprecedented strain.

Our recently published paper presents case studies from the United Kingdom, the Netherlands, Canada, the United States, Australia and New Zealand.

All show governments are leaning on primary care to solve increasingly complex health needs. At the same time, bureaucracies are demanding more documentation, compliance, performance metrics and administrative work.

However, very little new investment is going into the four parts of primary care that matter most:

• continuity: seeing the same health provider over time, rather than pinballing from one specialist to another

• comprehensiveness: getting the whole family’s physical, mental and social health care from one place

• coordination: ensuring all the different people and services involved in a patient’s care work together smoothly, information is shared and roles are clear, so patients don’t fall through the cracks

• first-contact care: being able to get an appointment with a doctor or nurse you know, when you need it.

Ballooning administrative burdens

These are the core functions of effective primary care, and they are what reduce hospital visits. But across many countries, the GP workforce is shrinking or stagnating just as populations are ageing and multi-morbidity is increasing.

Medical graduates are turning away from general practice, citing high workloads, lower pay relative to other specialities, and the emotional weight of increasingly complex care.

Many GPs who stay in practice are reducing their hours, not because they lack commitment, but because the amount of unpaid work required outside of the consulting room makes full-time practice untenable.

Administrative burdens have ballooned. Electronic health-record systems generate endless inbox tasks. As hospitals push chronic care back into the community, GPs absorb more responsibility without receiving the resources to match.

The result is predictable: practices stop enrolling new patients, waiting times blow out, and people who cannot get timely care turn instead to emergency departments.

These alternatives are often far more expensive, lack continuity, and do not offer the long-term relationships that help detect disease early and manage chronic conditions effectively.

Quick wins, long-term losses

Many of the countries facing these problems spend less than 6% of their total health budget on primary care. For example, the US spends 4%, New Zealand 5.4% and Australia 6%. But how the money is allocated is as important as the amount itself.

Funding models in many countries fail to support team-based care – a collaborative, coordinated model of healthcare delivery in which multiple health professionals work together with patients and their families.

Governments often finance new roles – for example, physician assistants – in isolation, without ensuring practices have the infrastructure to integrate them safely and effectively. This creates inefficiencies and fragmentation.

Poorly designed “pay-for-performance” measures can make things worse. So, when funding is linked to disease-specific indicators rather than the core functions of high-quality primary care, clinicians end up spending more time on documentation and less on patients.

Continuity and comprehensiveness, the strongest predictors of better health outcomes, remain largely unmeasured and unrewarded.

The benefits of primary care investment accumulate slowly – fewer hospital admissions, better management of chronic disease, reduced premature mortality. But political cycles reward quick wins. Governments are tempted to fund initiatives that reduce waiting lists in months, not strengthen foundations for decades.

The result is a proliferation of short-term “solutions” that crowd out the long-term reforms primary care actually needs. The system that prevents downstream costs is neglected because its benefits are not immediately visible.

Toward a sustainable health system

Primary care is relationship-based. That continuity – knowing patients, their histories, their families and the context of their lives – is what allows efficient decision-making and prevents unnecessary interventions.

When investment flows into standalone or narrow services instead of strengthening general practice, care becomes episodic. This can result in poor followup and patients bouncing between providers who are working without shared information.

This fragmentation increases costs while reducing quality, even though each individual initiative may look beneficial in isolation. Once the foundation cracks, the entire system becomes more expensive to maintain but less effective.

The solutions are clear, and are strikingly consistent across countries. A whole-of-system approach is needed to:

• set explicit investment targets for primary care

• align funding, workforce planning and service delivery

• invest in true multidisciplinary teams, not piecemeal roles

• prioritise continuity, comprehensiveness, and first-contact access in funding models

• and create long-term accountability structures that survive election cycles.

Countries that have strong primary care systems will spend less overall on health, have better population health outcomes, and enjoy greater equity. Those that neglect primary care pay for it many times over in hospital pressures, workforce burnout and widening inequities.

Strengthening primary care is not just another reform. It is the only path to a sustainable health system. Countries that fail to recognise this are already seeing the consequences.