The outline of the 2026/27 contract very much looks as though NHS England is looking to roll out its performance management approach into general practice.

Over the last 20 years the NHS has changed.  In that period it has become much more centralised, with the centre taking a much more active role in establishing what it would term as “grip” across the system.

This involves heavy performance management of any NHS organisation not delivering on finance, activity or access targets.  This has expanded to include a requirement to produce plans (by all, not just “failing” organisations) as to how these targets are going to be achieved, and then heavy performance management of these plans (before delivery has even begun).

Where organisations are deemed to be failing or have an inadequate plan NHS England will “intervene”.  This involves insisting on changes of senior leaders, requiring organisations to use expensive management consultants and “turnaround directors” (at their own cost), along with requiring more information as “assurance” that improvement plans are in place and that the changes are on track.

This approach has not worked.  If anything, overall performance is worse than it was 20 years ago.

One of the huge drawbacks of this approach is that it stifles local innovation.  The constant insistence on the production of a plan does not allow any time for the development of innovation or new ways of working to feature within it.  There is an expectation that organisations will look to what is working elsewhere and use that as a route map to improvement.  But because it allows so little time for organisations to tailor changes to what will work locally they end up having at best a diluted effect.

At the same time, where organisations are investing in developing improvement capability or schemes with longer term benefits, these quickly get culled for the sake of short-term savings or to ensure there is sufficient “focus” on the immediate priorities.  Most areas have seen schemes and enhanced services that will deliver medium term benefits or savings be cut for these reasons.

I have first hand experience of this at work.  I worked as a GP federation leader in pre-CCG days and we were leading the way in the development of general practice led innovations in areas such as pro-active care and delivering multi-agency care models.  But when we became a CCG all that stopped.  The NHS performance management regime ensured all local innovation made way for a focus on cutting costs and short-term improvements in performance targets.

The response by the NHS and the government to the failure of the performance management approach has not been to change it, but rather to increase it.  The (clearly flawed) logic appears to be that if heavy performance management is not working, then it needs to be even heavier.

So far (CCGs aside) general practice has largely been immune from the impact of this NHS way of working.  The independent contractor model provides a degree of protection from it, as the NHS has no direct say as to how practices conduct their business.

But what is increasingly apparent, particularly from the contract for 2026/27, is the NHS’s desire to impose this was of working onto general practice, particularly around access.  The contract changes seem primarily designed to set out a list of minimum standards for the service: patients identified as clinically urgent will be seen on the same day; practices are required to provide an appropriate response to non-urgent patients by the end of the next core hours period; a requirement to use advice and guidance prior to or in place of planned care referrals; online consultation requests must not be capped (etc).

Then alongside this there is a new requirement to engage with support from the ICB if there is “unwarranted variation” in performance.  In other words, a requirement to agree to enter the NHS performance management regime.

This threat will not materialise straight away.  The simple fact of the matter is ICBs do not have the capacity or understanding of general practice to undertake performance management on significant numbers of individual practices (although we may see the start of this).  But come neighbourhood contracts (with GP access consistently featuring heavily as a priority for neighbourhoods), then we could very well expect NHS performance management to fall on these providers, and that in turn to fall on practices.