For many patients, general practice is still defined by the visible parts of care: appointments, prescriptions and consultations. Yet increasingly, much of the work happening within primary care sits outside the consultation itself.  

Across practices, workload is changing shape. The challenge is no longer only the number of patients being seen each day, but the growing amount of operational coordination, administrative reconciliation and system navigation behind the scenes. In many cases, practices are managing work generated elsewhere in the system, often without additional time, resource or visibility.  

One of the clearest examples is the growing complexity around referrals and Advice & Guidance pathways. What was originally intended to support collaboration between primary and secondary care is increasingly reshaping how practices navigate referrals, specialist input and patient follow-up.  

Recent NHS updates around the continued expansion of Specialist Advice and Single Point of Access models through the NHS e-Referral Service highlight how referral pathways are becoming more interconnected operationally, but also more administratively complex for practices managing care across multiple services. 

At the same time, digital access has fundamentally changed the shape of demand. Online consultation platforms and app-based access have improved convenience for many patients, but they have also altered how and when practices receive requests for care. Concerns around Amazon-style GP access driving unsustainable demand reflect a growing tension between improving responsiveness and maintaining manageable workload within already stretched systems. 

Alongside this sits a growing layer of governance complexity. Whether practices are managing ADHD shared care agreements, navigating evolving obesity treatment pathways or responding to changing metabolic health guidance, there is a risk that it becomes unclear where ultimate responsibility lies in the system.  

This is not solely a clinical pressure. GPs and wider practice teams are acting not only as clinicians, but also as coordinators, interpreters and risk-holders within fragmented systems.  

The cumulative effect of this hidden workload is difficult to quantify. The RCGP has previously highlighted the scale of “avoidable workload” generated elsewhere in the system, including significant administrative and coordination pressures that often sit behind day-to-day consultations.  

Yet this hidden work is becoming central to how modern general practice functions.  

Many of these pressures are also shaping the programme for Best Practice Birmingham 2026, particularly discussions around referral redesign, digital-first care, workforce sustainability and operational resilience. The themes emerging across this year’s programme reflect the realities practices are navigating every day.