The context for developing a new GP contract

In England, NHS general practice contracts (‘GP contracts’) are held between NHS England and individual general practices, and are managed by the primary care commissioning team in each integrated care board. The contract is updated annually based on negotiations between NHS England and the British Medical Association’s (BMA) General Practitioners Committee (GPC). The current national contract:

• requires each practice to maintain a list of patients
• defines the geographical or population area covered by the practice
• describes essential services the practice must provide for its patients
• sets standards for premises and workforce and requirements for inspection and oversight
• describes expectations for patient and public involvement
• Includes a duty of cooperation with selected other service providers (eg out of hours)
• sets requirements for indemnity, complaints, liability, insurance, clinical governance and contract termination.
• defines terms for incentive schemes and fee for service payments (eg immunisations and the quality and outcomes framework).

There have been four major revisions of the GP contract – the General Medical Services (GMS) contract – since the launch of the NHS in 1948, and two optional alternative contracts – Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS) contracts – have been introduced, along with a range of add-on finanical incentives aiming to better match general practice services to patient and health system needs (see the next article in this series, ‘A short history of the GP contract and its evolution in England’). The most recent revision was in the form of a five-year contract framework for 2019–24 to address the workforce and workload problems in general practice and develop new ways of working for the future in line with the NHS Long Term Plan. This introduced an optional national incentive scheme to stimulate the formation of primary care networks (PCNs), reflecting a policy goal to increase the scale of general practice providers and improve their links with other services.  services.

A specific characteristic of the GMS and PMS contracts is that they can only be held with groups of general practices – typically working as partnerships with unlimited liabilities – not with limited liability companies. The introduction of the APMS contract in 2004 (see the article ‘A short history of the GP contract and its evolution in England’ in this series) changed the legal standing of the contract to allow private limited companies to provide general practice services, moving these contracts from the domain of public law to private commercial law.

Contracts are just one step towards achieving change in general practice services

The challenge for negotiators is to develop a contract that clearly specifies what general practices should provide (see below) and how this will be measured; which offers fair reimbursement for defined activities; and which includes incentives (see below) that will achieve desired changes without perverse incentives for unwanted activities. But this is just one step and is not, in itself, enough to stabilise and transform general practice services.

To achieve meaningful change and the actions or activities that commissioners expect requires a whole range of additional inputs, particularly:

• clinical capacity and management skills to implement the contract
• governance systems, resources (including adequate estates) and the ability to monitor progress and manage deviations from course
• skills at harnessing internal and external resources to support contract delivery and service improvement. 

The need for additional resources and management support for contract implementation is increasingly recognised – as evidenced by the 2023 National General Practice Improvement Programme offering three tiers of transformation support to practices to implement the Delivery Plan for Recovering Access to Primary Care, and the allocation of funds to support implementation of the 2019–24 contract framework and PCN development. However, while setting an important precedent, these resources are currently modest compared with the scale of change needed.

Funding for primary care and payment mechanisms to incentivise change

The Lancet Global Health Commission inquiry into primary care financing argued that both the budget allocation process for primary care from the overall health budget and the incentives created through payment arrangements for providers are critical steps in developing effective services. One of the main recent tensions in GP contract negotiations between NHS England and the GPC reflects a sequential reduction in the proportion of the total NHS budget allocated to general practice from a high of 9.2% in 2019/20, as noted in Fisher (2024). Both the GPC and the Royal College of General Practitioners (RCGP, 2024a; 2024b) have called for a significant increase in the overall percentage of the NHS budget allocated to general practice, including investment in infrastructure, to keep practices financially sustainable and to enable them to deliver contracted services. Indeed, as Gregory (2024) notes, GPs in England are undertaking industrial action and a work to rule in response to receiving only a 1.9% increase in funding for practices in the 2024 GP contract settlement.

In 2022, the Lancet Global Health Commission advocated the use of blended financial incentives to purposively combine a fixed payment per patient (capitation funding) with other payment methods to maximise the beneficial incentives and minimise the perverse incentives associated with each, while ensuring other service delivery objectives, such as improved access, are met. The use of blended payments is already seen in English general practice contracts, which reimburse practices through a combination of:

• a global sum per registered patient, adjusted for selected demographic characteristics
• quality incentive payments
• fees for specific activities
• premises payments
• additional local and nationally determined incentive payments (for more detail see Beech and Baird, 2020).

The most commonly used financial incentives in NHS general practice are: fee-for-service payments for specific activities such as flu jabs, through which practices receive a small payment for every immunisation they deliver; and micro-incentives to carry out specific discrete tasks as set out in the Quality and Outcomes Framework (QOF). In the latter model, the incentive payment is made if an agreed percentage of eligible patients receive a specific assessment or intervention.

Financial incentives for larger-scale transformation in the organisation and delivery of care can be offered through ‘bundled payments’, which combine an up-front payment to cover set-up costs and early work, with a later payment linked to achieving agreed outputs or outcomes. Payment mechanisms may also be linked to risk-sharing agreements in which participating providers receive a share of savings achieved through the contracted services and may or may not be liable for a share of any losses incurred. This approach is used widely in the United States, and less so in England, although a version of it was seen in GP fundholding agreements in the 1990s.

Clarity about what services are being contracted

A key challenge for effective contracting is clearly specifying what services are being contracted. This is particularly difficult in relation to the varied work of general practice. Various characteristics of primary care have been described, as have factors that determine quality in general practice (The Health Foundation, 2014), but its core functions remain poorly specified and the current contract describes services to be delivered according to a mixture of broad generality and detailed task specification (for example, QOF activities).

Drawing on the ‘two axis’ model by Reeves and Byng (2017), we have previously argued that there are four key functions of general practice, which should be delivered as an integrated whole if general practice is to retain its role in managing patients safely and holistically without excessive onward referral to other NHS services. These are:

• standardised routine and preventive work (for example, long-term condition reviews, smears and immunisations)
• rapid assessment of acute illness
• continuity of care and ‘interpretive’ care for people with complex or ongoing illness
• coordination with other services.

Various GP contract clauses and incentive schemes have tried to improve one or other of these functions, to mixed effect. Multiple adjustments to the main GMS and PMS contracts have been introduced to improve access to appointments (GPC, 2024), including funding for out-of-hours appointments and a requirement to offer digital access. However, these initiatives have often been at the expense of continuity of care for patients with complex needs (House of Commons Health Select Committee, 2022). Given the growing body of research evidencing the positive impact of continuity of care on clinical (Pereira Grey and others, 2018) and operational outcomes (Kajaria-Montag and others, 2021), this has implications for quality, safety and patient satisfaction. A national ‘Directed Enhanced Service’ (DES) incentive scheme to develop advanced care plans to reduce unplanned hospital admissions sought to improve care coordination and reduce emergency hospital admissions, but no development support was offered to implement the DES and it was dropped when it failed to reduce admissions. Contracts to disaggregate acute access from other general practice services and provide appointments in stand-alone access hubs in Darzi centres proved expensive and duplicative and the Darzi centres were eventually merged into mainstream general practice services. More recently, contracts and incentive payments have been used to implement the ‘building blocks’ for new models of general practice highlighted in policy documents – for example:

• increasing the use of digital technology through the Delivery Plan for Recovering Access to Primary Care
• promoting multi-professional working through the Additional Roles Reimbursement Scheme (ARRS)
• linking general practice to wider primary care services by navigating patients to  the Pharmacy First initiative.

However, the scale of ambition when introducing these services varies widely between practices.

High-quality data for contract monitoring

Improving the scope and quality of general practice data is essential for effective contracting so that the outcomes agreed for each contracted function of general practice can be reliably measured and monitored . Some activities specified in the GP contract (for example, smears and immunisations) are directly recorded in clinical records, generating a reliable dataset for contract monitoring. Data on other activities – including those incentivised through the QOF – are ideally collected through clinical templates. These generate a reliable dataset, but poor data-entry practice by some clinicians means information may be entered as free-text consultation notes or miscoded, leading to an annual end-of-financial-year work burden of data cleaning and problems with data accuracy. And if outcome measures are to be developed for activities to transform and improve general practice services, data on patient experience will also be needed. This is currently collected through a national survey (the GP Patient Survey), which typically has low response rates from individual practices, and cannot be linked to specific contracted activities, so new approaches to data collection are needed.

Evaluating and improving the quality of general practice data is a central aim of 22 recently announced pilot sites for new models of primary care (Tilley, 2024). In the meantime, NHS Digital manages the collection, analysis and quality assurance of the national GP contract dataset.

Perceived problems with the current contract

Problems with the current contract are seen differently by different stakeholders. Work to develop a new contract that is acceptable to GPs and which fulfils the expectations of politicians, policy-makers and patients will need to reconcile different stakeholder views and address perceived problems.

Politician and policy-maker perspectives on the GP contract

Politicians, policy-makers and senior NHS managers take a whole-system perspective, seeing multiple roles for general practice (in addition to delivering core clinical services), including working with other local services to deliver more preventive care, addressing inequalities and delivering more care in community settings (Fuller, 2022). This vision is particularly evident in policy to develop integrated neighbourhood teams. The contract is a potential mechanism to tie general practices and PCNs into integrated care pathways with hospitals and to build networks with local community providers to extend access, albeit that this adds to an already overwhelming general practice workload. However, some policy-makers see a national GP contract as a barrier to innovation, service transformation and sustained quality improvement (Hewitt, 2023), and argue that local contracts are needed to address local needs (which early PMS contracts were able to do).

General practice commissioners

General practice commissioners are the interface between the transactional activity of contracting and more developmental activities of ‘commissioning’, supporting practices to deliver the contract in ways that address local population health needs. They have been described by Smith (2024) as ‘the shock absorbers between national policy direction and targets and local priorities’. The assimilation of general practice commissioners, who used to work at borough or clinical commissioning group level, into integrated care boards has made them more distant from the general practices they work with and reduced their capacity to provide commissioning support. And while some of the data that general practice commissioners need for contract monitoring are collected nationally, they must also monitor local data quality and ‘craft proportionate performance measures for practices’ to support the implementation of new services. Smith (2024) notes this as a weakness in current commissioning practice, with important implications for the effectiveness of contracting as a mechanism to change and improve services.

Local commissioners also have to deal with the limitations of general practice ‘estates’, with lack of space a frequent barrier to service developments required in the GP contract. Almost a quarter of general practices work from premises built before the launch of the NHS in 1948, and many more work from buildings that lack space for training and are unsuitable for services delivered by a multi-professional team (Hoddinott, 2024).

And there are significant inequalities in the distribution of general practice services, which the contract has failed to address, despite local efforts by commissioners. This can be partly explained by the funding formula used to set practice budgets – the Carr-Hill formula – which is used to adjust the global (capitation) sum paid per patient for various social demographic factors, but does not adjust for deprivation. This creates structural inequalities in general practice provision, with relatively less funding available to address the additional health needs of deprived populations. Further examples of inequalities in the inputs into general practice services include fewer GPs per head of population (Fisher and others, 2020), fewer ARRS staff working in deprived areas (Beech and others, 2023) and slow uptake of various digital technologies.

Patients as indirect stakeholders in the contract

Patients are indirect stakeholders, as ‘customers’ of the GP contract. While they are unlikely to give direct thought to the contract, they can be assumed to want it to deliver fair and equal access for all to a GP or allied health professional who can safely and effectively meet their needs. Data from the British Social Attitudes survey clearly demonstrate that, from a patient perspective, long waits for appointments are a major problem for general practice, despite repeated attempts to improve access through the contract. And there is mixed evidence on patients’ experience of recent workforce changes in general practice, with some positive accounts (Nicodemo and others, 2024), alongside reports of confusion among patients about who they are seeing in the multi-professional workforce and concerns about unequal access (National Voices, 2023) and a risk of a loss of trust if they are expecting to see a doctor but see another clinician (Paddison and others, 2018). This highlights the need for cautious use of the GP contract as a tool to develop the general practice workforce, and careful implementation of workforce changes in collaboration with patients.

The varied perspectives of GPs on the contract

As contract holders, GPs are a heterogeneous stakeholder group, ranging from those running a traditional small partnership, to executive partners in large multi-site practices, and from members of the BMA’s GPC who negotiate the contract with NHS England on behalf of practices, to general practice leads in integrated care boards who combine clinical practice with the strategic development of services based on population health needs. As such, GP hold a diverse range of views about problems with the current contract.

For GP partners, there are technical risks associated with the contract, which, since 1990, has been held by the general practice partnership rather than by individual practices. In addition to financial risks associated with owning general practice premises, partners also hold medico-legal liability, and personal financial risk associated with being in an unlimited liability partnership (in which the GP partners are personally liable for the practice’s business debts). The fact that the last remaining individual in a partnership holds all the risks and liabilities of the business if all other partners leave was reported to be stopping doctors from becoming general practice partners, jeopardising the future of the partnership model (Department of Health, 2019).

Some GPs see the micro-incentive systems in the contract as de-professionalising and not in the best interests of all patients. In his exploration of general practice, What is a Doctor? A GP’s prescription for the future, Whitaker (2023) argues that QOF incentives undermine professional commitment to negotiate shared treatment decisions in each patient’s best interests. Salisbury (2021) has argued that the contractual requirements to provide e-consultations is increasing the GP workload, often for minor self-limiting problems. Also that allocating patients to multi-professional team members on the basis of specific symptoms results in fragmented and inefficient care, requiring multiple visits for different symptoms and undermining the holistic elements of consultations (Salisbury, 2024). There are also problems with perverse incentives associated with the contract, such as:

• excessive use of exception reporting to meet quality targets
• relative neglect of conditions that are not the focus of incentive payments
• excessive focus on incentivised activities, which distracts from what patients want to discuss
• little incentive to invest in much-needed improvements to premises.

And from a pay and rations perspective, the BMA’s GPC, the RCGP and many GPs see the current year’s contract as underfunded for the services it specifies, putting practices at risk of closure. National data show a fall of 9% in general practice partner drawings in 2022/23, despite higher recorded appointment numbers, although this follows increases in general practice partner drawings of 17% and 8% in the years 2020/21 and 2021/22 respectively. The RCGP highlights the unbounded workload in general practice as a significant problem, noting that with increasing appointment numbers, an underfunded contract may drive GPs to leave the workforce (RCGP, 2023).

Given the above discussion of challenges and perceived problems with the GP contract, there is value in revisiting past contracts and examining international experience of contracting for general practice services to inform the development of a future GP contract for the NHS in England.