The evolution of GP contracting: learning from history and other countries

As work on the 2025/26 GP contract progresses, there are huge pressures facing general practice. This series of articles on contracting for general practice services describes the context in which negotiations for contract will take place, highlighting underlying challenges with creating a contract that works for all. The series summarises the history of the GP contract and its variants and provides four international examples of how contracts have been used to bring about change, before providing a set of approaches to contract setting for policy-makers to consider.

Comment series

Published: 24/01/2025

In England, the NHS General Medical Services (GMS) contract and its later variants – the Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS) contracts – set the terms on which general practices provide care to NHS patients.

But since the launch of the NHS in 1948, the general practice contract (‘GP contract’) has been seen as problematic by many of its main stakeholders: the politicians and policy-makers who shape the contribution of general practice to the NHS; the GPs who must deliver services in line with contract requirements; and patients who, as users of general practice services, are indirect stakeholders in the contract.

As work on the 2025/26 GMS contract progresses, the context is challenging. General practices, facing intense financial and workload pressure, need a contract that will enable them to sustain their businesses, manage their workload and provide safe, high-quality care. For politicians, policy-makers, patients and general practice innovators, stabilising the status quo is not enough. The contract is the potential vehicle for wider policy ambitions to: improve access through extended use of digital and other technologies and workforce redesign; embed general practice in an array of integrated services; and increase its role in prevention. The 2019–24 GP contract, with its national incentive scheme to form primary care networks (PCNs), used the contract to drive another key policy ambition: to increase the size of general practice providers.

This linked series of articles on contracting for general practice services (click hyperlinks in list below to jump straight into a specific article):

  • describes the context in which negotiations for the 2025/26 contract will take place, highlighting underlying challenges with creating a contract that works for all its stakeholders and suggesting some principles that should underpin future contracts
  • summarises the history of the GP contract, and its variants, including evalutions of the impact of different iterations of the contract on their stated objectives
  • describes four international examples of how contracts have been used to bring about change and improvement in general practice
  • discusses options for a future contract and presents considerations for those negotiating the contract, which focus on stabilising core general practice services, strengthening the building blocks for resilient future services and introducing optional local contracts for new models of care.

The considerations draw particularly on the international examples, which illustrate options for: contracting with different types of general practice organisation; using a mix of financial incentives; and supporting contract implementation with timely data and intensive operational and change management support. The four international examples are:

The NetherlandsA chronic disease contract with ‘bundled payments’ for general practice care of three common chronic conditions. The contracts are held by large-scale general practice organisations called ‘care groups’ (similar to English general practice federations and PCN alliances), which act as lead contract holders, supporting practices with contract implementation.
Norway  Fee-for-service (FFS) financial incentives to increase consultation activity and investigations undertaken in primary care, illustrating both desired and undesired changes achieved through a new blend of contract incentives.
The USAn ‘Alternative Quality Contract’, combining targeted micro-incentives for care quality and shared savings from reduced use of specialist care, and offering implementation support via coaching, data analysis, peer learning and help with change management.
EstoniaA group practice contract introduced in conjunction with European Union (EU) funding for new premises development. The contract offers higher payments to GPs who form a group practice with a multi-professional skill mix and extended opening hours.

Considerations for developing future GP contracts

Negotiating a new contract or contracts for general practice will be easier if there is a fair financial settlement for primary care, allocated through a funding formula that adjusts for levels of deprivation in general practice catchment areas and addresses the current mismatch between inputs into primary care and population health needs. This would help to set a context in which contracting for general practice can both sustain existing services and support transformation for the future. In addition to this, policy-makers should consider:

  • Consider defining the core functions of general practice through an expert group of professionals, patients, policy-makers and academics and contract for all of these functions as a whole service, linking rapid-access appointments to continuity and care coordination where these are needed.
  • Consider defining the ‘building blocks’ of future models of general practice, the outcomes and datasets through which they can be monitored and the skills and resources needed to introduce them. Examples of building blocks are advanced use of digital, technology and data analytics, and multi-professional teams linking general practices and other providers.
  • Consider developing a new national contract for the core functions of general practice along with basic provision of the building blocks of new models of care.
  • Consider using modular local contracts – with enhanced funding to support transformational change – for the agreed building blocks of future models of care, negotiated between local commissioners and practices or PCNs in response to local needs.
  • Consider trialling experimental modular contracts with large-scale general practice organisations (general practice federations and PCN alliances) with a proven track record of service development and the skills and capacity to support local practices to work in new ways.
  • Consider allowing practices and PCNs with an appetite and capacity for change to choose which building blocks to contract for and how to sequence these in response to local contexts (that is, optional local contracts).
  • Consider introducing a new blend of incentives designed to deliver the building blocks of future practice, rewarding step-wise implementation of changes and allowing practices working from different starting points to implement change at a pace they can manage.
  • Consider national and international evidence about the sustained support that is needed for contract implementation over several years, and build the costs of this into contract prices.
  • Consider whether the development of neighbourhood health services creates an opportunity to contract for general practice in new ways, including new employment models and contracting through large general practice organisations with the scale and capabilities to support transformational change in practices.

Read the first article in the series