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

BACKGROUND: UK and global primary care face significant GP workforce shortages. Much research focuses on individual-level factors such as wellbeing, resilience, and professional identity; however, less attention has been given to organisational- and system-level influences on GP work and workforce sustainability. AIM: To examine how general practice work and healthcare systems support GP workforce sustainability and effective, equitable patient care. DESIGN AND SETTING: This was a UK-focused realist review of empirical and grey literature. The search strategy encompassed six electronic databases. METHOD: The realist synthesis involved 1) finding existing theories, 2) searching for evidence, 3) selecting articles, 4) extracting data, and 5) synthesising evidence and drawing conclusions. Context-mechanism-outcome configurations were developed using extracted data, alongside input from patient and public contributors and stakeholders to iteratively refine the programme theory. RESULTS: In total, 190 documents were included. Findings highlight the importance of meaningful work and engagement; relationships across individuals, organisations, and communities; and learning and development. Sustaining the GP workforce and delivering effective and equitable patient care require congruence between GPs' core values and their work; cumulative-knowledge building; system agility; psychological safety; and direct human connections. CONCLUSION: Structures, policies, and relational connections within general practice are central for sustaining the GP workforce and enabling effective, equitable patient care. Collaboration among GPs, patients, and policymakers is essential. Future systems should prioritise personalised care, support meaning making, and protect GP autonomy to foster sustained engagement, expertise, and equity in care delivery.