GPs feel pressured to provide ‘take it or leave it’ LES packages to access funding 

Exclusive GPs are being asked to accept large ‘take it or leave it’ packages of optional services to access crucial funding from local enhanced services (LES), Pulse has found. 

Exclusive data obtained by Pulse shows in some ICB areas these offers take up sizeable proportions of the overall LES budget and have absorbed many different services into one package. GPs can either accept every service in the basket, or none of them.

In one ICB area, a large LES ‘basket’ offer takes up almost all total LES funding, with the local LMC unaware of any GP practices turning it down due to the importance of LESs as an income stream. 

This ‘single enhanced offer’ basket offered by Birmingham and Solihull ICB received more than 99% of the entire LES budget last year (£19,289,787 out of £19,471,114).  

Elsewhere in England in 2025/26, similar basket offers made up: 87% of the LES budget in Hertfordshire and West Essex; 75% in Somerset; 64% in Nottingham and Nottinghamshire; and 55% in Devon. 

In Birmingham and Solihull, the LES basket includes phlebotomy, wound care, ECGs, diabetes injectable initiation, medicines optimisation, cancer follow-up and immunisations. 

For this, GP practices receive £11.80 per weighted patient payments during the year, with the threat of remediation or clawback from practices unable to ‘demonstrate compliance’ with ‘access’, ‘continuity’, ‘PHM and inequalities’ and ‘collaboration’ objectives. 

Service specifications for the basket offer seen by Pulse indicate the £11.80 payment has not increased since 2019.  

Birmingham LMC vice-chair Dr Philip Downing told Pulse the LMC was ‘not aware of any GP practice that hasn’t signed up’ to the offer.

‘For us, it is funding the equivalent of almost a couple of doctors’, he said. 

Dr Downing told Pulse: ‘I view it as a suitcase and they try and stuff as much as they can in there, but the suitcase never gets larger – if anything, it gets smaller because of inflation.  

‘A lot of LMCs are unhappy with block contracts because you really don’t know if you’re getting value for money, and they’re stuffing so much in there. We’re stuck now, we’re trapped.’ 

Dr Downing said the ICB also claimed other providers are willing to take the offer – and therefore the funding – if GP practices do not.

He said: ‘They keep threatening us by saying “other providers could do this instead” – for example, some other private provider or the hospitals could come in and do your phlebotomy or wound care. 

‘The real worry we have is also that this money is going to get chewed up into integrated neighbourhood teams. Practices are worried that the “left shift” is going to get funded by these sort of schemes, and therefore it’s us who are funding the left shift.’ 

GPs can choose to perform and claim for LESs as an additional source of income outside the standard GP contract. According to GP finance experts, for many GP practices LESs are there second-largest income stream after the GMS contract, exceeding QOF.

In recent years, many ICBs have replaced individual LESs the basket-style offers, often grouped according to clinical area, local population need, or the preferences of the commissioner. 

Pulse has previously reported on GPs in one LMC area rejecting North East and North Cumbria (NENC) ICB’s ‘clinically incoherent’ medicines basket offer.

Dr Peter Kenworthy, a GP in the LMC area (Gateshead and South Tyneside) that rejected that offer, told Pulse the ‘great big bundle’ of injectable medicines had raised patient safety concerns. 

This basket included amiodarone, ADHD medication, antipsychotics, inclisiran, as well as drugs Dr Kenworthy had ‘never even heard of’. 

He said the ICB told him the single offer was to establish equality across the ICB area’s very large footprint, but he argued it was instead a ‘cost cutting measure’.

‘The ICB knows they could save money, so they have packaged lots of things up into one great big list’, he said. 

In formulating the basket, he said NENC ICB ‘purposely bypassed all the LMCs’ in the area, and they ‘won’t share any of the workings about how they worked out how safe it is’ due to it being ‘commercially sensitive’. 

‘[They said] if we didn’t take it, another private company would, and we’d never get it back. I’ve not seen any private company ever referenced – I just can’t believe that anybody would ever take it on’. 

Responding, a NENC ICB spokesperson told Pulse: ‘Over 96% of practices in our region have signed up to deliver the Medicines LES. Alternative providers have been contracted in the small number of instances where the practices have declined this offer, and the ICB has worked with both practices and new providers to support a safe transfer of care.

‘This LES is worth over £10m across NENC, which represents a significant additional investment of almost £5m this year.

The ICB said the LES had been ‘co-developed with extensive LMC engagement’ which led to ‘a number of material changes to the specification, including removal of depot antipsychotics, refinement of scope, and amendments to address concerns about workload, risk transfer and in-year scope expansion’.

‘Comprehensive clinical information is in place to support practices and prescribers, including shared care agreements. This information is approved by the Northern Treatment Advisory Group, of which the LMC is a core member.’

Pulse has contacted all ICBs mentioned to respond.