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.