Contract mandates GPs to work with ICBs to reduce ‘unwarranted variation’

The GP contract in England will be amended from 1 April to mandate GPs to ‘engage’ with ICB performance improvement measures.

Outlining changes in the 2026/27 GP contract, NHS England said practices must work with ICBs in cases of ‘unwarranted variation’, with examples given including on-the-day patient access and patient-to-GP ratios.

In the contract letter published yesterday, NHS England said it will ‘amend the core practice contract to require practices to engage with support from their ICB where unwarranted variation has been identified in contractor performance’.  

This ‘unwarranted variation’ would include ‘where practices are not meeting their requirement to see all clinically urgent patients on the same day or are at risk of contractual breach’, the letter stated.

As Pulse has reported, the contract will be amended to ‘explicitly’ require practices to deal with ‘clinically urgent’ patients on the same day.

In a separate close-of-consultation letter, sent to the BMA on 20 February, NHS England gave further detail on the performance enforcement measures.

The letter said: ‘We will amend the regulations to require practices to engage with support from their ICB where unwarranted variation has been identified in contractor performance, including where practices are not meeting their requirement to see all clinically urgent patients on the same day, or where a practice is at risk of contractual breach.’

The letter also indicated that the measure had come up against resistance from GP representatives.

It said: ‘Stakeholders recognised the value of consistent support arrangements, while also emphasising the need for this to be framed as improvement‑focused rather than punitive. Feedback also highlighted the importance of clarity on unwarranted variation and how ICBs will fulfil their responsibilities in offering support.

‘In response, we are maintaining the proposal while ensuring that supporting guidance will set out clear expectations for both practices and ICBs. Our intention is to promote early, collaborative engagement where challenges arise, helping practices access support in a timely and fair way.’

It added that practices looking to access a new practice-level recruitment scheme that have high patient-to-GP ratios (more than 3,000) would first need to engage with their local ICB to explain the ratio. 

And it noted the need for ‘clarity’ on variation and ICBs’ role in engaging with practices and said it would publish guidance to ‘set out clear expectations for both practices and ICBs’.  

Doctor’s Association UK GP co-lead Dr Steve Taylor said: ‘If it is used as a stick for practices, then that is a real problem, but if there’s a carrot, with a way of fixing it and the resources to help it happen, that could be amazing and probably something that we would have called for. If it came with money and incentives, that would be a good thing.’ 

the room for interpretation in the contractual changes would be ‘restrictive’ for GPs.

With regards to the specific example of patient on-the-day access, he added: ‘It’s hard to know how an ICB will define an urgent request. Given that practices will triage and assess requests and their urgency. This is too vague and sounds restrictive. Without clarity, it is open to interpretation and therefore confusion, both for patients and practice teams.’

‘The contract says GPs should be obviously prioritising urgents, which we have been doing for the last 30 years – so in that sense, it’s not, it’s not new.’ 

Last year, Pulse revealed NHS England had asked ICBs to ‘tackle unwarranted variation’ among GP practices in their area using a ‘GP dashboard’ tool, which has since been rolled out.