Investigation: How ICB variation has created a LES lottery

The first piece of a new Pulse investigation looks at the ‘lottery’ experienced by GPs when it comes to local enhanced services funding – which is eroding the foundations of general practice and threatening provision for vital services across England. Harry Hetherington investigates   

‘You could be on the other side of the street from another GP surgery and not be able to offer a service, just because you’re in a different ICB,’ says the Doctors’ Association UK GP spokesperson Dr Steve Taylor. ‘It’s a lottery, depending on which part of the country you’re in – you really don’t know what you can get and what you can’t get.’  

Experts say that the main issue with local enhanced services (LES) is variability – in terms of whether practices across the country are able to offer a specific service, the funding available, and what is expected of practices – despite GP practices being dependent on the services as a crucial form of income. ‘There’s massive variation across the country, but LESs are still worth more, on average, than QOF is,’ says medical accountant Andy Pow.  

Gateshead LMC chair Dr Paul Evans points out that many practices are forced to spend most of their GMS and QOF money on keeping their doors open, paying staff, keeping the gas and electric on, and paying service charges. Indeed, data gathered by the BMA earlier this year found that global sum income meant to cover all expenses for core general practice ‘barely covers’ staffing costs for the average GP practice. ‘In terms of income for partners and the ability to employ extra staff and therefore provide better services to patients, LES money is absolutely critical,’ says Dr Evans. ‘But the discrepancies are a patchwork with seemingly no rhyme or reason. Lottery is a pretty good summary of it.’  

Given that LESs are commissioned at local level, variation is to be expected. Commissioners work out LES offerings with local health needs in mind, and individual GP practices can choose whether to take them up. However, even among areas that offer the same or similar LESs, data obtained by Pulse indicate that the work expected of GPs and the amount they are remunerated for those services, significantly differs by location. 

Compiled by Pulse from Freedom of Information (FOI) requests to ICBs, the data represents the most comprehensive comparison yet of LESs in England, cataloguing more than 1,500 services. Pulse obtained data from 42 ICBs – prior to the mergers and ‘clustering’ of some ICBs this year – including their 2025/26 budgets for each LES they offered to GPs, as well as specification documents detailing how much practices are paid to provide a LES, and the criteria for getting paid.  

In this investigation, Pulse uses exclusive data for three LESs – spirometry, prostate cancer monitoring and ear wax removal – and speaks to GPs and experts to illustrate the national picture, revealing the extent of the LES value for money ‘lottery’ and exploring what happens next for LESs in England. 

Practices ‘operating at a loss’ and ICB threatening clawbacks  

Our analysis found that there is variation not only in the amount GPs are paid to deliver services and what is required of them, but also in when the payments will occur, and crucially to what extent ICBs factor the extra costs to GPs providing the service into their payment offer – meaning that some practices offering LESs, offer them ‘at a loss’. In terms of why practices decide to offer the services at a loss, experts have pointed out that this usually happens because GPs look at optimising clinical care and keep the practice attractive to patients. ‘They have a very loyal relationship with their patients and it is therefore quite difficult to say, “no, we’re not doing something”, when you actually can affect the patient’s care,’ says Mr Pow. ‘Explaining to a patient that I’m going to stop doing this because we’re not getting paid for it is going to be quite difficult for the patient to understand.’

GPs say that some commissioners do not account for hidden and sunk costs involved with providing LESs, meaning that practices risk operating at a loss. ‘Practices end up subsidising services out of core income,’ Birmingham GP Dr Rupeysh Jha told the UK LMCs conference in Belfast earlier this month. ‘It is eroding the foundations of primary care. Services are commissioned, amended, or withdrawn with no meaningful discussion or consultation with LMCs, and no assessment of workload impact on practices.’ 

GPs in Hampshire are paid £52.30 to perform and interpret each spirometry test, and an additional £2,360 per 10,000 patients on their list. ‘At best, it breaks even,’ says Hampshire GP Dr Matt Prendergast. ‘It probably makes a small loss. A lot of these LESs do that. That’s the problem. We’re encouraged to look at all these things and see if they’re worth doing. And then you have a judgment to make over whether you say, “I’m sorry, this doesn’t make any business sense” or “actually, we think we should do this” – and usually the judgement is somewhere in the middle.’ He estimates that it costs his practice in the region of £8,000-£10,000 every two years to run the spirometry service, and his practice cannot claim a payment if a patient does not attend an arranged test. 

In some cases, GPs have to ‘demonstrate achievement’ before they can access the funding, which creates cash flow issues for practices. The documents for the spirometry LES obtained by Pulse show that some ICBs put clauses in that would allow them to claw back payments, cap funding per patient, and don’t pay practices if patients don’t attend.  

In the Black Country, the ICB service specification threatened to claw back payments from practices if they were performing too many ‘reversible’ tests – measuring how well a patient’s lungs function both with and without medication (inhaler), to see the difference – which practices are paid more for. The ICB said it would ‘audit any practice claims where reversibility claims are high’, warning GPs that ‘this may result in clawback of payments’.  

Experts tell Pulse that this illustrates a trend. Katie Collin, a partner at specialist medical accountancy firm Ramsay Brown, says there has been an ‘attitude change’ from LES commissioners meaning GP providers ‘have to demonstrate what you’re doing for the money’. 

‘We’re seeing a lot more restrictive requirements around how you access the money, and a lot of it is also paid now on achievement,’ she says. ‘Whereas before, you might see a monthly income, now we’re seeing monthly income with a clawback until you demonstrate achievement, or you’ll get 50% of the money and then an achievement payment at the end, which also affects cash flow.’ 

In North West London, GP practices are paid a flat spirometry fee of £84.04 – the highest amount among the data we analysed – but this is expected to cover bronchodilator and post-bronchodilator response tests and FeNO tests, with payments capped at one test per patient per year. GPs say that this cap creates issues when tests are inconclusive, and that absolute caps are unhelpful, sometimes pushing practices to provide them at a loss.

‘There will be some cases where the spirometry tests are done and are inconclusive,’ says Dr Evans, ‘or the patient needs a second go, because maybe the first test has been done when they’ve been rather unwell, and it doesn’t draw any definite conclusions about whether someone has asthma or COPD from that test. I think it’s unhelpful to have that absolute cap. I believe that, if we did permit more than one funded test per year, GPs are not crooks, they wouldn’t simply book patients into unnecessary spirometry just for the heck of it.’ 

Professor Azeem Majeed, a GP and head of the Department of Primary Care and Public Health at Imperial College London, says that spirometry underfunding means that many practices have to choose between absorbing the cost themselves or delay testing for patients. ‘This undermines the ability of GPs to diagnose and manage common respiratory conditions such as COPD in the community,’ he says. ‘We know that early and accurate diagnosis of respiratory disease significantly improves outcomes and quality of life, particularly in deprived communities. A “lottery” of provision therefore exacerbates existing health inequalities.’

‘Significant underfunding’ 

In the past, LESs had ‘the virtue of simplicity’, with predictable income and straightforward calculations, according to one London GP. But the funding has not kept pace with increasing workload and cost pressures. ‘The envelope for funding these services has not increased in 15 years,’ they say. ‘Our costs have gone up, our core funding has not kept pace. The prevalence of many disorders has increased and there is a greater volume of work to be done.’ 

Ms Collin has observed a drop-off in money generated from LESs in the last three years. ‘We’re seeing probably the same level of work expected, but probably in pounds per patient, a lot less income,’ she tells Pulse.  

The results of a survey of 960 GPs run by Pulse indicated there is concern over LES underfunding in general practice, which is threatening provision. More than four in 10 GPs said that their ICB ‘significantly underfunds’ LESs for general practice. Adding respondents who said their commissioner ‘slightly’ underfunded LESs, this figure rose to nearly three-quarters (74%). And 65% of practice managers said LESs were either ‘significantly’ or ‘slightly’ underfunded. 

At their conference in Belfast earlier this month, LMC representatives called on commissioners to properly fund LESs to fully account for the costs of providing the services – including staffing, premises, indemnity costs, and automatic annual uplifts for inflation. ‘For years, local enhanced services have been commissioned on the assumption that general practice can simply absorb the difference between what commissioners want and what they are willing to pay,’ Dr Jha told the conference. ‘But we all know that the truth, when funding doesn’t keep pace with inflation, with staffing costs and indemnity, with premises pressures: it becomes a state cut.’  

Workload shift without compensation  

GPs in areas where ICBs do not offer prostate cancer-related LESs say that this was a key area for workload shift without specific financial compensation. 

‘We don’t have a prostate cancer LES locally, and we have one of the country’s leading prostate cancer treatment centres in our patch,’ says Dr Dave Triska, a GP partner in Surrey. ‘So you can guess what they ask us to do all the time: prostate cancer monitoring. If you look at all the things that hospital asks us to do, that are not in the general practice contract, they equate to about 24% of our throughput.’ And there is no mechanism to push back on this work, he says. ‘It gets to the point where everyone just does it, because trying to address it is almost certainly not going to get anywhere.’  

A GP partner in the West Midlands explains the added risk to patient safety associated with GPs taking on unfunded work. ‘There is a balance to be had between trying to do the best for your patient and, in the longer term, undermining your service by essentially subsidising it. Using the example of PSA, you want to do the best for patients and make things convenient for them and easy to access. But if you end up doing the PSA unfunded, there is not going to be any incentive for that to be commissioned in the future. In the long run, it may be more harmful. Each decision you take, you have to balance those competing demands.’ 

How can GPs push for better value for money when it comes to LESs? 

Many GP practices are ‘clued into’ costs, according to medical accountants. Those with the ability to assess all the costs involved can ensure they make a profit by pushing back on loss-making LES offers. Larger practices will find this easier because they have greater management resources to look at costs in granular detail. At smaller practices, ‘managers are doing everything from HR to finance, running the show’, says Mr Pow. The West Midlands GP partner concurs, saying that his practice won’t go down to that granular level, because that would take too long.  

How can these less well-resourced practices assess the value for money of LESs on offer? Mr Pow says having strong LMC backing can help. He cites Surrey and Sussex LMC as one that is ‘very good’ at pushing back and ‘arguing the point of things’. ‘Sussex has probably got one of the highest areas of paid LESs in the country, and that’s because the LMC there were very strong about arguing costs, whereas other areas haven’t necessarily been as strong. A commissioner is going to offer something, but it’s down to the person accepting it, whether they accept, or push back and say “this is unaffordable”.’ 

The recent UK LMC conference offered examples of how GPs can pressure commissioners for better value for money. With the ear wax LES, Kent LMC demonstrated to its ICB that there was a ‘critical mass’ of GP practices – around 25 to 30% – either actively declining to take up the service or not making claims against the service, in order to secure better funding for this LES. Dr Peter Kenworthy, a GP in the North East, said he had learned a similar lesson. He shared how his ICB had offered a ‘bundle’ of medicines as one large LES, but that when ‘a small number of us’ rejected the offer, this ‘caused the ICB to find more attractive ways of encouraging GPs to provide the LES. ‘Change can happen with enough critical mass,’ he says.  

According to Dr Prendergast several LMCs have encouraged practices to ask themselves whether specific LESs are worth their time, and pushed for conversations about whether they should continue. ‘Just because we’ve always done it, doesn’t mean we should continue to,’ he says.  

Last year, the BMA had asked GPs to serve notice on any underfunded LES work as part of collective action coordinated locally by LMCs, and this led to practices in several areas receiving funding boosts, as well as several ICBs agreeing to undertake full reviews of the LES offering in their area. In Lancashire and Cumbria, the ICB agreed to fund a new expanded medicines optimisation LES and a long-term conditions LES as direct result of collective action, and similarly, Somerset GPs reached an agreement with their ICB for an extra £2m investment to cover services such as ADHD, minor surgery and bariatric surgery monitoring. 

What next? 

It is still not clear what form neighbourhood health services will take, but they are likely to impact LES value for money. NHS England recently revealed that ICBs will be allowed ‘greater flexibility’ to tailor contract arrangements for PCNs to facilitate the creation of neighbourhood services, introducing the ability for ICBs to vary the PCN DES at a local level with the approval of NHS England. There has been speculation that this could mean local services could get delivered and funded through these local variations, rather than a LES, but we will have to wait for more concrete details on neighbourhoods to know if this will be the case.

Ms Collin says the issue of unfunded LESs is an example of the gap that the neighbourhood model should be trying to fill. ‘Before, GPs would say to a patient “you need a PSA test at the hospital”, but the hospital won’t do it, and the GP would say, “well, I’ll just do it for you” and not be paid,’ she says. ‘What should actually happen is the trust saying, “please can our GP practices all deliver this service”, and the funding will come out of the trust and go into GP practices to do that work.’ 

Meanwhile, Mr Pow suggests the variation in LES payments could be addressed by reforming the system. For LESs such as spirometry – where a relatively uncomplicated service nonetheless has large variation in payment depending on the commissioner – it may make more sense to be offered in a standardised ‘national tariff’ instead. ‘For things like spirometry, the price being paid varies massively across the country, but everyone wants the same service, I feel there has to be a national tariff for these things that makes it fair and gives clarity on what people are paying for. You’d have thought some services are fairly universal in what’s required, and perhaps it just got over complicated because we’ve localised everything.’ 

The next piece in our LES LOTTERY investigation, coming later this week, will look at why GPs take on unfunded or underfunded LES.