Following the rejection of the Department of Health and Social Care and NHS England GP contract offer by GPCE on 2 February 2023, and despite further lobbying and discussions, no further acceptable offer was made by Government ministers to the profession to enable the negotiating parties – NHSE (on behalf of ministers / the DHSC) and GPCE – to reach agreement. 

After sharing the letter concluding formal discussions with GPCE Officers on Monday 6th March around midday, NHSE proceeded to publish the imposed contractual changes before they were even confirmed to the committee.

These changes come into effect from 1 April 2023.

Background and context

Despite it being a priority for practices, GPs will note that the 2023/24 contract changes do not include any additional investment to urgently counter the damaging impact of soaring inflation on practice costs and staffing expenses. This means nothing to cover astronomically rising energy bills, fair and reasonable cost-of-living staff pay increases, supplies and equipment etc. GPCE believes the contract changes mean the safety of anxious patients and burnt-out staff will continue to be at risk, jeopardising the existence of some community practices and will cause even more GPs and surgery staff to reduce their hours or leave general practice altogether.

This comes at a time when patients need them most.

These contract changes wilfully ignore the reality on the ground. Patients need their practices to have more capacity, to provide better continuity, and for the backlog of unmet care to be rapidly reduced . However, our existing and exhausted GPs and surgery workforce cannot do any more than they already are without additional help. In the context of a service that is under intolerable pressure, simply trying to force practices to do more with unhelpful and unnecessary bureaucratic workload and legislative changes is only going to end in disaster.

GPCE negotiators have worked constructively and collaboratively, engaging in conversations with NHSE, DHSC, the Secretary of State for Health and Social Care and the Minister of State for Primary Care and Public Health over the past 12 months. However, ministers have been unwilling to increase funding beyond that set out within the 2019-24 contract framework or countenance alternative policies that would help to:

• stop contractors from having to reduce their staffing because of rising practice costs and staffing expenses caused by huge inflationary pressures in 2022/23 and beyond.
• urgently arrest the alarming seven-year trend of experienced, qualified GP hours being lost from the NHS, the equivalent of 2,078 fully qualified full-time GPs since 2015.
• reduce unnecessary practice workload, such as the retirement of all QOF and IIF targets, in favour of non-target-based quality improvement modules with existing funding invested directly into the core practice global sum.

The five-year framework concludes at the end of March 2024. NHSE have stated their commitment to working alongside GPCE over the course of 2023/24 on how the GP contract will evolve following the end of the 5-year framework agreement. The Committee will continue to work with the profession to develop a contract position that works for all patients and general practice staff.

Core contract changes and requirements of the imposed GP contract 2023/24

Access requirements 

The GMS Regulations have been updated to clarify that patients should be offered an assessment of need, or signposted to an appropriate service, at first contact with the practice. 

Access to records 

The deadline for full implementation of prospective patient online access to their records will be extended to 31 October. 

Cloud-based telephony 

A requirement will be introduced for practices to procure their telephony solutions only from an NHS framework once their current telephony contracts expire.  

GP registration requirements 

The GMS contract regulations will be amended to remove the reference to the term ’medical cards’ within the registration requirements. 

Funding

‘Investment and Evolution: A five year Framework for GP contract reform’ sets out the expected funding arrangements. It specifies agreed funding to provide pay uplifts in line with predicted inflation (as at April 2019). This year the funding provides for a 2.1% pay uplift for all GPs, practice staff and practice expenses.  

GPC England sought additional funding in line with the current rate of inflation. Despite presenting significant evidence, including findings from a representative survey of practices and a series of case studies highlighting the extreme pressure practices are facing, the case for additional funding was rejected by Government ministers.

Vaccination and Immunisations

Vaccinations and immunisations requirements will be amended to reflect updated JCVI guidance. This includes changes to the Human Papillomavirus (HPV) and Shingles programmes, due to come in form 1 September 2023. Further details of these changes can be found on the BMA V&I page, or the NHSE website. 

Childhood Immunisations 

There will be a number of changes to the childhood V&I programme.  These include: 

• Removal of the V and I repayment mechanism if a practice achieves under 80% coverage 
• Changes to the childhood V & I QOF thresholds, so that lower thresholds are reduced to 81% – 89% (dependent on indicator) and the upper thresholds raised to 96% 
• Clarification of the wording in the SFE that an Item of Service fee will be payable for vaccinations for medical reasons and incomplete or unknown vaccination status (‘evergreen offer’). 

QOF (Quality and outcomes framework)

All disease register indicators will be income protected for the year, with funding paid to practices based on 2022/23 performance monthly once the 2022/23 QOF outturn is finalised. 

Two new cholesterol indicators (worth 30 points~£36m) will be added to QOF along with a new overarching mental health indicator. These will be funded by retiring indicator RA002 (the percentage of patients with rheumatoid arthritis, on the register, who have had a face-to-face review in the preceding 12 months) and reducing the value of DEM004 (annual dementia review). This new indicator does not include the prescription, management, recall, or administration of Inclisiran, which does not form part of core GMS work. ICBs may choose to commission this locally via an LCS, and other requests from secondary care should be passed back.

Indicator AF007 will be retired and replaced with the former IIF indicator CVD-05 (as AF008): 

The Quality Improvement (QI) modules for 2023/24 will focus on workforce wellbeing and optimising demand and capacity. 

There will also be other small changes to indicator wordings and values in 2023/24. 

PCN DES (Primary Care Network Directed Enhanced Service)

Practices are reminded that the PCN DES and all it entails (services, IIF, access requirements etc) are optional.

Practices may decide that they can no longer viably participate in the PCN DES and as such that their patients would be better supported and their practice operated more effectively and safely outside of their PCN, they are able to opt-out during the next opt-out window. The next opt-out period will commence when the contract is updated on 1 April, running until 30 April 2023.

See below for further information about the impact of opting-out of the PCN DES.

Service Specifications

No new requirements will be added into the PCN service specifications.  Instead, some action will be suggested to PCNs as best practice, to be supported via guidance. 

ARRS (Additional Roles Reimbursement Scheme)

There will be a number of changes to the ARRS.  These include: 

1. increasing the cap on Advanced Practitioners from two to three per PCN where the PCN’s list size numbers less than 100,000, and from three to six where the PCN’s list size numbers 100,000 or over 
2. reimbursing PCNs for the time that First Contact Practitioners spend out of practice undertaking education and training to become Advanced Practitioners including Advanced Clinical Practitioner Nurses in the roles eligible for reimbursement as Advanced Practitioners (APs) 
3. introducing apprentice Physician Associates (PAs) as a reimbursable role 
4. removing all existing recruitment caps on Mental Health Practitioners, and clarifying that they are able to support some first contact activity 
5. amending the Clinical Pharmacist role description to clarify that Clinical Pharmacists can be supervised by Advanced Practice Pharmacists. 

NHS England has confirmed that the ARRS will be reviewed during 23/24.  

IIF (Investment and Impact Fund)

The IIF will be reduce from 32 indicators to 5. The remaining indicators will be: 

The funding freed up by this reduction in indicators will be moved into the Capacity and Access fund which will be split into two parts:   

• 70% (approx. £172m) will be paid to PCNs as the continuing Capacity and Access Support Payments, introduced in Autumn 2022.  There are no additional requirements attached to this. 
• 30% (approx. £74 million) will be paid as a ‘Local Capacity and Access Support Payment. This will be paid out based on ICB assessment made using guidance provided by NHS England.  
  
  

Opting out of the PCN DES

Practices have a right, written into the PCN DES Specification, to opt-out of the PCN DES. The next regular opt-out period will be 1 to 30 April 2023, with potential further opt out periods during the year if additional changes to the DES are made. 

Read our guidance on opting out of the DES.

Dispensing

NHS England agreed to review dispensing fee scales as part of the broader changes to the contract in 2024/25. 

GP retention Scheme

The current relaxation of the four-session cap within the GP retention scheme will be made permanent. Any further potential changes to the scheme will be developed as part of the current review of GP recruitment and retention scheme being led by NHS England. 

Weight Management DES

The Weight Management Enhanced Service will continue into 2023/24, retaining the £11.50 referral payment.  

From 1 October 2022, the GMS and PMS regulations were amended to require some GPs to self-declare their earnings. The principles of pay transparency in general practice were agreed between NHSEI and GPC England in 2019 and published in Investment and evolution - a five-year framework for GP contract reform to implement the NHS long term plan.

Read guidance on the pay declaration rules, what it means for you and the BMA's position

Next Steps

GPCE undertook these contract change discussions in good faith with NHSE on behalf of ministers and the DHSC. Despite the evidence presented, Government ministers elected to impose contract changes already rejected as unhelpful and inadequate by GPCE last month.

As we embark on widespread engagement with the profession, GPCE officers and members will discuss potential next steps that may be necessary to bring Government back to the negotiating table. We need to be able to discuss and agree GP contract changes that are actually supportive of practices, halt the rapid decline in services and loss of GP capacity and protect and improve patient care