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.

This week NHS England has written to practices and PCNs outlining the changes to the 2026/27 contract.  It is the first time a contract has been produced without any attempt at negotiation with the service.  Instead we have what one presumes will be the first in an annual cycle of contract impositions by the NHS on general practice.

The purpose of this article is not to summarise all the changes that will be made for next year.  It is rather to highlight one specific extremely worrying shift that has taken place within the contract.

This is not (as you might expect) the halving in growth funding practices will receive this year compared to last.  Rather it is that last year practices were invited to take part in a new enhanced service for advice and guidance, through which practices could claim a £20 item of service for pre-referral requests.  But this year the enhanced service has been scrapped and participation made mandatory via the core contract.

Enhanced services have long been a route through which the NHS has been able to introduce new ways of working into general practice.  They work because it puts the onus on the NHS to provide sufficient funding for the new way of working to be affordable for practices.  If insufficient funding is provided then practices will not sign up to the enhanced service, requiring the centre to make further changes to the scheme such as an increase in payment.

There are many practices who considered the £20 item of service payment within the enhanced service and decided that it was insufficient for the amount of work involved, and as such declined to participate.  The work involved in making the request, chasing and understanding the response, potentially recalling the patient and sometimes having to undertake complex further investigations before agreeing a way forward is undoubtedly significant, and it is not a surprise that many deemed £20 as insufficient.

The decision practices were having to make was whether they could absorb this work within their fixed costs (i.e. existing staff levels) and therefore use any money generated to support other costs, or whether the staff were already acting at capacity and that more workload could not be absorbed. The funding may have been insufficient, but at least practices had a choice.

According to NHS England, over 99% practices signed up the DES.  But signing up simply meant practices had the option to claim for any advice and guidance requests they made.  Where there was significantly more variation between practices was in the amount of advice and guidance referrals actually made.

The mechanism NHS England has decided to use to address this variation is not to improve the terms of the DES or make it more attractive, but instead to include it in the core contract and make it mandatory.  The decision-making opportunity for practices as to whether this work makes financial sense has been withdrawn.

We have not seen the wording around this, and are unlikely to before the end of March, but it is hard to envisage it resulting in anything other than a requirement of additional work on practices.  It seems likely that the principle of payment for activity will be replaced by a block payment to include all activity (despite NHSE CEO Jim Mackey describing block contracts as “evil” last year).

To say the funding is now included in core when the overall growth level is half of that provided in the previous year is essentially saying that practices now have to absorb this workload.  And this workload could easily just grow and grow as more and more pathways are put in place.

In previous years this would have been picked up in the negotiation, and some way of coming to a compromise worked out.  But without a negotiation it has just been added to the increasingly unreasonable list of requirements that contractors are now mandated to undertake.

Will practices simply accept this?  Is it okay for NHS England to make unreasonable changes to the contract and simply impose them?  Will there be a reaction, a response?  I hope so, because if there is not I fear for the future of the service, as it sets a precedent that will allow NHS England to make whatever changes it wants to the core contract without regard for the impact on practices.  If NHS England can continue unchecked in this way the independent contractor model of general practice will soon become completely unsustainable.

Dr Katie Bramall, Chair of the GPC, recently referred to the “vacuum” of neighbourhoods.  This certainly struck a chord.  Why is it that the flagship policy of the NHS 10-year plan has become such a dead zone?

There is undoubtedly huge frustration within general practice with neighbourhoods.  It is hard to understand exactly what they are and how they fit into the NHS infrastructure, and they are serving to create high levels of uncertainty without (so far) offering anything of benefit.

Neighbourhoods arrived along with the Labour government, as it proclaimed the NHS was to become a “Neighbourhood Health Service”.  Was that just a catchphrase, a play on letters? When the 10-year health plan arrived it seemed not, as new single and multi-neighbourhood provider contracts were also announced that would put meat on the bones.

This was followed up by the announcement of the National Neighbourhood Health Implementation Programme, but following the initial scramble to participate in this there has been virtual radio silence, both from the programme itself and on neighbourhoods more widely.

The medium term planning guidance in October promised information both on neighbourhoods and on the new neighbourhood contracts in November.  But now here we are in February and according to the GPC we should not expect anything before April.  Does this mean the contracts may not actually materialise?

Some fuel was poured on this particular fire by Robert McCartney at Hempsons, who noted a change to the NHS standard contract which in effect means that the multi-neighbourhood provider contract can be implemented via a variation to an NHS Standard Contract.  This would already limit its availability to NHS providers and the (small number of) GP federations that hold an NHS Standard Contract (which doesn’t bode well for general practice).

But this is the problem.  In the absence of any direct information about neighbourhoods (what they are, what they are supposed to achieve, how they will be funded etc etc) then all we are left with are rumours and whispers that just create anxiety.

One particular such concern is what neighbourhoods will mean for PCNs.  Could they mean that general practice will lose control of PCN funding (a move that could effectively bankrupt the majority of practices)?  Will the PCN DES, and maybe even other enhanced services, become swallowed up into neighbourhoods and neighbourhood contracts?  What does all this mean for practice autonomy?

Will neighbourhoods even be funded?  The track record so far on that front is not great.  PCNs in many areas are being exhorted to pursue neighbourhood pilots, without any real funding or clarity on what success would look like.  At present this is the most tangible reality of what neighbourhoods actually are, and so they increasingly feel like just another commissioner driven drain on resources.

It is not just about the funding and the contracts.  The vision of what neighbourhoods are and what they are supposed to achieve in the new NHS is being lost (if it ever existed).  The bold proclamations of the NHS Plan have not been followed up.  This is why neighbourhoods feel like a vacuum, because they are (at present) a concept that sucks attention, resources and focus without giving anything, not even hope for the future, in return.