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Context 

In January 2019, a five-year GP contract framework was agreed. This was intended to stabilise general practice, enabling it to become a key delivery vehicle for many of the commitments in the NHS Long Term Plan and to provide a wider range of services to patients. A key development was a voluntary extension to the GP contract, known as a Directed Enhanced Service (DES). This was offered to general practices, typically covering populations of around 30,000 to 50,000 people, that came together as primary care networks (PCNs). This extension was intended to be a mechanism through which a significant proportion of new funding into general practice would be distributed. 

The five-year contract framework has now expired; however, it was not possible to negotiate a new five-year framework due to the potential changes following a general election and the lack of a long-term financial settlement for the NHS. In March 2024, therefore, the Department of Health and Social Care published arrangements for the 2024/25 period. These arrangements were not welcomed by GPs, and as a result, in April, GP leaders at the British Medical Association (BMA) formally entered into a dispute with NHS England over the contract changes. 

This explainer sets out the key elements of the contract arrangements for 2024/25 and potential implications for the wider health system. 

• How is general practice funded? 

Overall funding in the 2024/25 GP contract 

In 2024/25, the government will invest £11.8 billion in the GP contract. This is an increase of £259 (cash terms) million from the previous year and includes: 

• a planning assumption that pay will grow 2% for contractor GPs, salaried GPs and other practice staff 

• a planning assumption of 2% pay growth uplift to the overall Additional Roles Reimbursement Scheme (ARRS) 

• an uplift of 1.68% for inflation in line with the government’s November 2023 GDP deflator 

• an uplift of 0.38% for population growth in line with ONS projections. 

The Doctors and Dentists Review Body, which advises the government on pay for those staff not covered by other pay agreements, recommended an uplift of 6% in July 2024, which was accepted by the government. This means there will be a further backdated uplift of 4% to the 2% pay growth already set out in the contract to make this up to the 6% consolidated uplift recommended for 2024/25. 

Incentive schemes in the 2024/25 contract 

Quality and Outcomes Framework (paid to GP practices) 

The Quality and Outcomes Framework (QOF) is a voluntary programme that individual practices can opt in to in order to receive payments based on meeting specific performance indicators. The framework covers a range of clinical areas, and each area has a range of indicators that equate to a number of QOF points. At the end of the financial year, practices receive an amount of money based on points achieved in the QOF. 

A consultation on incentive schemes undertaken in early 2024 has resulted in some changes. Due to the Covid-19 pandemic, NHS England and NHS Improvement had already announced changes to the QOF. These changes suspended some indicators so that practices could focus on other priorities, such as vaccinations, but still paid practices for the QOF activity to protect their income. This approach has continued, and from April 2024, 32 of the 76 QOF indicators have been suspended, with the income protected so that practices will be awarded QOF payments based on their performance in previous years. The value of a QOF point has also increased, from £213.43 to £220.62. 

The Investment and Impact Fund 

The Investment and Impact Fund (IIF), paid to primary care networks, was introduced initially to help practices manage the additional demands of Covid-19 and was then extended to incentivise practices to meet the goals set by government. The initial indicators included flu vaccinations, learning disability health checks, improving early cancer diagnosis and improving access. In 2024/25, these indicators will be reduced to two: disability health checks and the use of faecal immunochemical testing (FIT) in cancer pathways, and are worth £13 million. The scheme differs from QOF in that it is paid to primary care networks rather than individual practices. 

The Capacity and Access Payment 

There has been a significant focus on improving patient experience of access. The Capacity and Access Payment (CAP) funding was introduced in 2022/23 and is paid to primary care networks. Its aim is to enable PCNs to focus on making improvements to help manage demand and improve patient experience of access. There are two elements to this funding. The first is a national Capacity and Access Support Payment, which is paid to PCNs without conditions and accounts for around 70% of the total CAP budget. The second element is the local Capacity and Access Improvement Payment, which accounts for the remaining 30% of the budget and is paid on an incentive basis to those PCNs making improvements in digital telephony and online triage. Funding from the three retired IIF indicators relating to flu and access will be redirected in the CAP for 2024/25, taking the total available to £292 million, an increase of £46 million. 

Changes to the PCN DES 

When the PCN contract extension was initially introduced, the intention was that primary care networks would eventually be required to deliver seven national service specifications, with two more added for 2021/22. In 2024/25, eight of these service specifications have been replaced by one overarching specification, with enhanced access remaining as a separate specification. The new overarching specification will focus on supporting resilience and care delivery, improving health outcomes, reducing health inequalities and targeting resource to deliver proactive care.

Other changes to the DES include simplifying the requirements for PCN clinical directors and combining the payment for PCN clinical director and PCN leadership and management into core PCN funding in order to provide PCNs with more autonomy in how they are led and managed. 

Workforce 

A central feature of the 2019 GP contract was the Additional Roles Reimbursement Scheme (ARRS), which was introduced as a key part of the government’s manifesto commitment to improve access to general practice. The initial aim of the scheme was to support the recruitment of 20,000 staff into general practice by 2023/24, such as first contact physiotherapists, paramedics and pharmacists. Initially, the scheme provided part-funding for a small number of roles but was then expanded to cover a wide number of different roles, and the number of staff funded under the scheme was increased to 26,000. In 2024/25, the number of roles was expanded further to include enhanced nurses. To date, the scheme has successfully enabled the recruitment of over 34,000 new patient-facing staff.

The 2019 contract framework had a number of initiatives to improve recruitment and retention, such as a ‘new-to-partnership’ incentive payment to encourage GPs to become partners, and a Fellowship Scheme for new GPs and nurses. There are no specific initiatives in the 2024/25 contract, although there is a commitment to explore future schemes. Flexibilities to Performer List Regulations that allow doctors other than GPs to deliver primary care services, with some caveats, which were introduced during Covid-19 will now be made permanent.

In August 2024, the government announced that £82 million of additional fundingfrom the Department of Health and Social care budget would be used to enable changes to the ARRS scheme, which means that in 2024/25 it can be used to recruit newly qualified GPs into the NHS and practices will be reimbursed for their salary costs. However, this changes the nature of the scheme as it had been focused on ‘additional roles’ that broaden the skill mix and range of services available to patients in general practice rather than funding core GP roles. 

What next? 

The previous five-year contract included annual funding increases of just over 2%. However, the current economic climate, marked by high inflation and rising costs, meant that the contract did not keep pace with inflation rates and in combination with rapidly rising demand for services has put significant pressure on practices. 

In March 2024, GPs voted to reject the proposed contract changes due to several concerns. These included insufficient funding, with the overall uplift in the 2024/25 core contract not adequately meeting the demands of inflation, rising utility bills and service charges, and increased workload and bureaucracy, which they felt due drew GPs and nurses away from core services. 

In July 2024, for the first time ever, GP members of the BMA took a vote on collective action, with potential actions including limiting the number of patients seen each day and the way in which they work with secondary care services. The potential impact of collective action on the wider health and care system is difficult to gauge; however, NHS England has modelled some of the potential implications for cost and activity and will be publishing data on the impact. 

With a new government, a new 10-year NHS plan in development, and an upcoming multi-year spending review, it has not yet been confirmed whether a new five-year framework will be negotiated for general practice. However, Wes Streeting, the Secretary of State for Health and Social Care, has written to GPs setting out his intention to ‘reset the relationship’ between GPs and the government and to work with the profession ‘to make the future of general practice sustainable’. This sits within the context of the government’s stated ambition to shift the focus of the NHS into the community through a ‘neighbourhood health service’ and increased investment in primary care. 

For more information on what primary care networks are, how they are funded, and what difference they might make, please see ‘Primary care networks explained’.