Classification: Official
Publication reference: PRN00257

To:     

• All GP practices in England
• Primary care network clinical directors   

cc.                       

• Integrated care board (ICB) primary care leads
• ICB chief executives
• Regional directors
• Regional directors of commissioning                                          

Dear colleagues

Changes to the GP Contract in 2023/24

1. We recognise and appreciate the incredibly hard work of general practice during this period of sustained significant pressure. The past few years have demonstrated the dedication of practice and Primary Care Network (PCN) teams in innovating and responding to the needs of their populations. In January 2023 General Practice delivered 30m appointments, an increase of 11% on January 2020, a testament to the incredible work of GP teams.
2. 2023/24 is the final year of the 5-year framework agreement which was set out in Investment and Evolution. Over the course of 2023/24 NHS England will engage with the profession, patients, ICSs, government and key stakeholders, building further on the Fuller Stocktake from May 2022 which set out the next steps towards integrating primary care. In response to feedback from practice teams, GPC England and the Health and Care Select Committee on the Future of Primary Care, in 2023/24 the profession and representative patient groups will be consulted on the Quality and Outcomes Framework (QOF) and its future form.
3. The Chancellor in his Autumn Statement set out a commitment to publish a recovery plan for General Practice access in early 2023. The Delivery Plan for Recovering Access to Primary Care will be published shortly and sets out how practices and PCNs can be supported to improve access during 2023/24 building on the contract changes outlined in this letter and expanded in Annex A.
4. The changes to the GP contract in 2023/24 set out the requirements of General Practice and PCNs with the goal of improving patient experience and satisfaction and we recognise that this will require both time and support to assess, review and implement changes. We intend to provide this support in a number of ways outlined below including freeing up workforce capacity through significant changes to the Impact and Investment Fund (IIF) and through the QOF Quality Improvement (QI) modules. Further support for practices and PCNs will be outlined in the recovery plan.

Access requirements

5. Offer of assessment will be equitable for all modes of access: To ensure consistency in the access that patients can expect, the GP contract will be updated to make clear that patients should be offered an assessment of need, or signposted to an appropriate service, at first contact with the practice. Practices will therefore no longer be able to request that patients contact the practice at a later time. The IIF focus on access will support practices and PCNs working towards achieving this during 2023 recognising the changes that will need to be made.
6. Prospective (future) record access to be offered by 31 October 2023: To make it easier for patients to access their health information online without having to contact their practice, the GP contract will be updated so new health information is available to all patients (unless they have individually decided to opt-out or any exceptions apply) by 31 October 2023 at the latest. This builds on the 1,400 practices that are already automatically offering this access, with 6.5 million patients already able to see their prospective records. NHS England will continue to provide support to practices as more patients gain online access to their records. Support will continue nationally and through commissioners to enable practices to make this offer to all their patients.
7. Mandate use of the cloud based telephony (CBT) national framework: All practices need to be aware, that from the end of 2025, all analogue ISDN and PSTN lines will be removed for use in all home and business settings. From this point, only cloud-based platforms will be supported. Digital telephony (CBT) provides greater functionality for practices and patients. This includes call queueing or call back which provide a better patient experience when the lines are busy as well as management information and data to support practices gain insight and improve their responsiveness further.
8. Background research and pilot studies have demonstrated how challenging it can be to navigate the telephony market for practices and understand the offers. A Better Purchasing Framework (BPF) has been developed by NHS England to provide recommended suppliers and assure value for money. As part of the 2023/24 GP contract changes, practices will be required to procure their telephony solutions only from the framework once their current telephony contracts expire. The Delivery Plan for Recovering Access to Primary Care will describe further support available for practices who indicate they are interested in making this move in 2023/24.

Changes to Impact and Investment Fund and QOF QI modules

9. The number of indicators in the IIF will be reduced from 36 to five (worth £59 million) and will focus on a small number of key national priorities: two indicators related to flu vaccinations, learning disability health checks, early cancer diagnosis and 2-week access indicator.
10. The remainder of the IIF will now be worth £246 million and will be entirely focused on improving patient experience of contacting their practice and receiving a response with an assessment and/or be seen within the appropriate period (for example same day or within 2 weeks where appropriate, depending on urgency). 70% of the total funding, equating to £172.2 million, will be provided as a monthly payment to PCNs during 2023/24 via the Capacity and Access Support Payment.
11. The remaining 30% of the total funding, equating to £73.8 million, will be assessed against an access improvement plan agreed with the commissioner in quarter 1 of 2023/24. At the end of March 2024 ICBs will assess for demonstrable and evidenced improvements in access for patients and then award funding. ICBs will be provided with guidance to assist in determining the appropriate payment.
12. In 2023/24, all the QOF register indicators points will be awarded to practices, based on 2022/23 outturn once finalised, releasing £97m of funding and reduce the number of indicators in QOF from 74 to 55 (a reduction of 25%). Two new cholesterol indicators (worth 30 points~£36 million) will be added to QOF along with a new overarching mental health indicator. One indicator (AF007) will be retired and replaced with a similar indicator from IIF in 2022/23.
13. This year’s QOF QI modules will focus on workforce wellbeing and optimising demand and capacity in General Practice with an emphasis on using data to analyse potentially avoidable appointments and build on care navigation and use of wider workforce or local services to reduce pressure on General Practice.

Increased flexibility of Additional Roles Reimbursement scheme (ARRS)

14. Recruitment through the Additional Roles Reimbursement scheme (ARRS) has been strong, and as of 31 December 2022 stands at 25,262 additional FTE. PCNs are on track to meet the 26k target for March 2024 over a year early. Staff are providing significant numbers of additional appointments, improving patient access to general practice, and providing personalised, proactive, care for the populations that they serve. To support PCNs to recruit the teams that they need, there are a number of changes to the ARRS, including adding Advanced Clinical Practitioner Nurses to the reimbursable roles, increasing the cap on Advanced Practitioners to three per PCN and removing the caps on Mental Health Practitioners. 
15. During 2023/24 NHS England will review the ARRS to ensure that it is tailored to deliver future ambitions for general practice. Staff employed through the scheme will be considered part of the core general practice cost base beyond 2023/24 as previously confirmed, and PCNs can offer permanent contracts where appropriate. We encourage PCNs to continue to recruit, making full use of their ARRS entitlement.

Immunisations and vaccinations

16. Following feedback from PCNs and GPC England, there will be changes to childhood vaccinations. These include the removal of the vaccination and immunisations repayment mechanism for practice performance below 80% coverage for routine childhood programmes along with changes to the childhood vaccination and immunisation indicators within QOF which will see the lower thresholds reduced to 81% – 89% (dependent on indicator) and the upper thresholds raised to 96%.
17. In recognition of the current workload pressures in general practice, no additional requirements will be added to the PCN service specifications in 2023/24. NHS England will instead publish guidance which will suggest best practice to PCNs.
18. Further details on the 2023/24 changes will be published ahead of April including a revised Network Contract DES specification.  If any changes are required to commissioner allocations, we will adjust this through the regular allocations update process.

Yours sincerely,

Dr Amanda Doyle OBE, MRCGP, National Director Primary Care and Community Services, NHS England.

Annex A – changes to the GP Contract in 2023/24

Changes to the GP Contract Regulations

Access

• To ensure consistency in the access that patients can expect, the GP contract will be updated to make clear that patients should be offered an assessment of need, or signposted to an appropriate service, at first contact with the practice.

Patient access to their medical records

• The GP contract regulations will be amended so that patients have online access to their prospective medical records (unless they have individually decided to opt out or any exceptions apply) by 31 October 2023 at the latest.
• The existing requirements in the GP contract regulations relating to providing online access to historic coded and full records will also be amended so that they are consistent with access to information under the GDPR. Amendment of these existing requirements will also provide clarity on how practices are required to offer, promote and provide online access to patient records.

Supporting Cloud Based Telephony

• Practices will be required to procure their telephony solutions only from the Better Purchasing Framework once their current telephony contracts expire.

Simplification of GP registration requirements

• In order to support the simplification of GP registration requirements, the term ’medical cards’ will be removed from the GP contract regulations.

GP retention scheme

• The four-session cap within the GP retention scheme was lifted during the pandemic and will now be removed permanently. Sessions worked above the cap will be funded by the employing general practice. Any further potential changes to the scheme will be picked up as part of the current review of GP recruitment and retention scheme being led by NHS England.

The Additional Roles Reimbursement Scheme (ARRS)

• In 2023/24 the following changes will be made to the ARRS:

• increasing the cap on Advanced Practitioners from two to three per PCN where the PCN’s list size numbers 99,999 or fewer, and from three to six where the PCN’s list size numbers 100,000 or over.
• 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).
• introducing apprentice Physician Associates (PAs) as a reimbursable role.
• removing all existing recruitment caps on Mental Health Practitioners, and clarifying that they can support some first contact activity.
• amending the Clinical Pharmacist role description to clarify that Clinical Pharmacists can be supervised by Advanced Practice Pharmacists.
• During 2023/24 the ARRS will be reviewed to ensure that it remains fit for purpose and aligned to future ambitions for general practice.

Changes to the PCN service specifications

• In recognition of the current workload pressures in general practice, no additional requirements will be added to the PCN service specifications in 2023/24. NHS England will instead publish guidance which will suggest best practice to PCNs.

Enhanced Access

• Following feedback from GPC England, NHS England has agreed to review the enhanced access requirements in 2023/24 once PCNs have had the opportunity to operate for several months, and to enable links into the wider conversations on urgent and emergency care.

Investment and Impact Fund (IIF)

• The following changes will be made to the IIF in 2023/24:
  • the number of indicators will be reduced to five to support a small number of key national priorities: flu vaccinations, learning disability health checks, early cancer diagnosis and 2-week access indicator. The value of these indicators will be £59m.
  • the remainder of the IIF will now be worth £246m and will be entirely focused on improving patient experience of contacting their practice and being assessed and/or seen within the appropriate timeframe (for example same day or within 2 weeks where appropriate).
  • 70% of the total funding, equating to £172.2m, will be provided as a monthly payment to PCNs during 2023/24, similar to monthly QOF aspirational payments.
  • the remaining 30% of the total funding, equating to £73.8m, will be assessed against ‘gateway criteria’ at the end of March 2024 by ICBs and paid to PCNs for demonstrable and evidenced improvements in access for patients.
• The Learning Disability Health Checks Indicator will be amended by adding a requirement to record the ethnicity of people with learning disabilities.
• A Personal Care Adjustment (PCA) will be added to the indicator on FIT testing (CAN-02) so that PCNs are not being incentivised to refer for FIT testing when there is rectal bleeding. Additional support will be provided where practices are struggling to access tests. This will involve setting up a national ‘supply chain’ escalation system that any GP practice can contact if local supply issues arise. Additional support is available from the regional cancer alliance to fund FIT kits where needed.

Quality and Outcomes Framework (QOF)

• QOF will be streamlined in 2023/24 by income protecting all register indicators. This will release £97m of funding and reduce the number of indicators in QOF from 74 to 55 (a reduction of 25%). Funding will be 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). The mode of review of DEM004 will also be amended to be determined through shared decision making with the patient.
• Indicator AF007 will be retired and replaced with the indicator below (which was in the IIF as CVD-05 in 2022/23):
  • AF008: Percentage of patients on the QOF Atrial Fibrillation register and with a CHA2DS2- VASc score of 2 or more, who were prescribed a direct-acting oral anticoagulant (DOAC), or, where a DOAC was declined or clinically unsuitable, a Vitamin K antagonist (12 points, LT 70%, UT 95%).
• There will also be a number of other small changes to indicator wordings and values in 2023/24.
• The QOF QI modules in 2023/24 will focus on:
  • workforce and wellbeing
  • optimisation of demand and capacity management in general practice.
• Work will need to be undertaken during 2023/24 to review QOF in its current form with the aim of making it more streamlined and focussed. The profession, patients and the broader system will be consulted to determine the most appropriate form in 2024/25.

Childhood immunisations

• The following changes will be made to childhood vaccinations:
  • the removal of the V & I repayment mechanism, removing the payment clawback for practice performance below 80% coverage across the routine childhood programmes.
  • changes to the childhood V & I QOF indicators.
  • clarification of the wording in the SFE that an Item of Service (IoS) fee will be payable for vaccinations administered for medical reasons and incomplete or unknown vaccination status (‘evergreen offer’) for the programmes outlined in the SFE Part 5 Vaccinations and Immunisation, section 19.
• The changes to the childhood vaccination and immunisation indicators within QOF will see the lower thresholds reduced to 89% (VI001) 86% (VI002) and 81% (VI003) and the upper thresholds raised to 96% [1]. All the points for each indicator will be put into a sliding scale of reward between the lower and upper threshold. Reducing the lower thresholds will decrease the number of practices receiving no payment across the three indicators.
• A new Personalised Care Adjustment will also be introduced for patients who registered at the practice too late (either too late in age, or too late in the financial year) to be vaccinated in accordance with the UK national schedule (or, where they differ, the requirements of the relevant QOF indicator).

Vaccination and Immunisations

• The contract will also be updated to reflect forthcoming changes to the routine vaccination schedule as recommended by the Joint Committee on Vaccinations and Immunisation (JCVI), specifically in relation to Human papillomavirus (HPV), and Shingles.

Human papillomavirus

• JCVI recommended a move from a two-dose schedule to a one dose schedule for the routine adolescent programme up to the age of 25 years. This change will align HPV vaccine doses across age groups, aligning the school’s programme, sexual health and general practice provision, therefore minimising the risk of conflicting or missing doses. This change will not apply to those who are immunocompromised and those known to be HIV positive for whom the three-dose schedule will remain.
• There will be a change from a two-dose to a one-dose HPV programme for those aged 14 to 25 years from 1 September 2023 to align with the school’s programme.
• General practice delivery remains opportunistic or on request. Eligibility remains up to 25 years of age for girls born after 1 September 1991 and boys born after 1 September 2006. This difference is due to the programme for boys being introduced at a later date (2019).
• The IoS payment will continue to be paid at £10.06 per dose administered.
• Further information on the programme change will be provided in due course.

Shingles

• The JCVI advised in 2018 that Shingrix had been shown to be effective and cost-effective, recommending its use in the NHS Shingles Programme for individuals for whom the live Zostavax was contraindicated. This change was implemented in the programme in September 2021.
• In 2019 JCVI recommended the replacement of Zostavax with Shingrix and the expansion of the cohorts in the Shingles Vaccination Programme. JCVI have recognised that there may be more clinical benefit from starting Shingles vaccinations at a lower age, with modelling indicating that a greater number of cases would be prevented with vaccination at 60 years for immunocompetent and 50 years for immunocompromised.
• From 1 September 2023 changes to the Shingles Programme to implement the JCVI recommendations will be as follows:
  • replacement of Zostavax with the 2-dose Shingrix vaccine as Zostavax goes out of production.
  • 2-dose Shingrix vaccine for the current 70-79-year-old cohort with a period of 26 weeks to 52 weeks between doses following the depletion of Zostavax.
  • expansion of the immunocompromised cohort to offer 2-dose Shingrix to individuals aged 50 years and over with a period between doses of 8 weeks to 26 weeks.
  • expansion of the immunocompetent cohort to offer 2-dose Shingrix routinely to individuals aged 60 years and over with a period between doses of 26 weeks to 52 weeks, remaining an opportunistic offer up to and including 79 years of age.
• The expansion of the immunocompetent cohort will be implemented over two five-year stages as follows:
  • first five-year stage (1 September 2023 to 31 August 2028): Shingrix will be offered to those turning 70 and those turning 65 years of age in each of the five years as they become eligible.
  • second five-year stage (1 September 2028 to 31 August 2033): Shingrix will be offered to those turning 65 and those turning 60 years of age in each of the five years as they become eligible.
• Additionally, practice call/recall for the immunocompromised and immunocompetent cohorts as they become eligible for the programme will be implemented from 1 September 2023, as well as catch-up call/recall for the newly eligible immunocompromised 50-69-year-old cohort.
• Shingles can be delivered at any time during the year thus enabling practices to manage timing for when the individual is invited and can also be opportunistically delivered if clinically appropriate when an individual attends the practice for another reason.
• The Shingles GPES extraction will be updated to accommodate these changes.
• Further information on the programme changes and management of the immunocompetent cohort expansion will be provided in due course.

Unchanged programmes

37. The following programmes will continue unchanged for 2023/24:
    • 6-in-1 (DTaP/IPV/Hib/HepB)
    • MenB
    • Rotavirus
    • PCV (infant pneumococcal)
    • Hib/MenC
    • MMR provision to remain unchanged for both the 0-5-year-olds programme and 6 years and over programme
    • 4-in-1 pre-school booster (DtaP/IPV)
    • 3-in-1 booster (td/IPV)
    • Men ACWY (provision for those aged up to 25 years who miss the schools programme)
    • PPV (65-year-olds and 2-64-year olds in defined clinical risk groups)
    • HepB (Babies)
    • Pertussis (pregnant women).

Weight Management Enhanced Service

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

[1] VI001: The percentage of babies who reached 8 months old in the preceding 12 months, who have received at least 3 doses of a diphtheria, tetanus and pertussis containing vaccine before the age of 8 months; VI002: The percentage of children who reached 18 months old in the preceding 12 months, who have received at least 1 dose of MMR between the ages of 12 and 18 months; VI003: The percentage of children who reached 5 years old in the preceding 12 months, who have received a reinforcing dose of DTaP/IPV and at least 2 doses of MMR between the ages of 1 and 5 years.