A leading Oxford GP warns that controversial new contract changes could overwhelm practices with extra investigations and workload, threatening both patient care and referral rights.
General practitioners in England face mounting concerns about the latest imposed contract changes, with leading medics warning that new requirements around specialist referrals could trigger a significant shift of investigative work from hospitals into struggling GP practices. The government’s decision to impose the 2025/26 GP contract without full negotiation has sparked alarm among family doctors who fear the changes prioritise access over the quality and sustainability of primary care.
Dr Helen Salisbury, a GP from Oxford and respected voice in medical policy, has highlighted specific provisions in the contract that medical professionals believe could worsen pressures on already stretched general practice. Writing in the British Medical Journal, Salisbury identifies the contract’s approach to specialist referrals as particularly problematic, noting that GPs fear “a major transfer of work will ensue if specialists require investigations in the community before agreeing to see patients.”
The concern centres on the expanded “advice and guidance” (A&G) service, a new enhanced service worth up to £80 million that comes into effect from April 2025. Under this scheme, GPs are encouraged to seek rapid specialist advice before making formal referrals, with practices receiving a £20 item of service fee per pre-referral request. Whilst the government frames this as supporting patients to receive care in primary and community settings rather than adding to elective waiting lists, GPs worry the system could be exploited to shift diagnostic responsibilities downwards.
The fear is straightforward: consultants may increasingly insist on blood tests, imaging, or other investigations being completed in the community before they will agree to see patients. This would mean GPs effectively becoming gatekeepers not just for appointments, but for specialist-level investigations that many community practices struggle to arrange or access. When capacity is already stretched, such demands could further strain practice resources and delay patient diagnosis.
Alongside the A&G concerns sits another contractual requirement that has alarmed GPs: the mandate that “patients identified as clinically urgent must be dealt with on the same day.” Salisbury argues this creates false dichotomies in clinical decision-making. Not all urgent presentations genuinely require immediate assessment; sometimes an appointment the following day with a doctor who knows the patient well provides better continuity and outcomes than emergency same-day triage by a stranger. The language of “dealing with” patients also troubles clinicians, who worry it frames healthcare as problem-solving rather than care-giving.
The broader concern is that these requirements will force practices to prioritise firefighting acute demand at the expense of preventive care and chronic disease management. Recruiting additional GPs through new contract provisions is welcome, but only if those doctors can provide stability and continuity rather than being swallowed by endless same-day demand. The elective recovery agenda, whilst important for NHS performance, risks being pursued at the cost of the foundational work that prevents crises.
Salisbury also raises a critical professional concern: the new contract potentially conflicts with the General Medical Council’s Good Medical Practice guidance and “Jess’s rule,” both of which require GPs to refer patients when they have reached the limits of their expertise or lack a clear diagnosis. If the advice and guidance system becomes a barrier to referral rather than a support, GPs may find themselves unable to fulfil these professional duties without breaching contract terms.
The imposition of this contract itself reflects fractured relations between government and the profession. For four of the past five years, no agreed contract has been reached, with the government imposing terms unilaterally. This year, the government withdrew from negotiations with the BMA’s GP Committee entirely, instead consulting a wider range of stakeholders and holding only a single meeting with GP representatives. The result has been a contract negotiated without primary care doctors at the table.
The contract does include positive measures: relaxed rules allow primary care networks to employ any qualified GP (not just those newly qualified), and new direct payments to practices for recruiting additional GPs aim to tackle the paradox of GP unemployment despite widespread shortages. However, these improvements, Salisbury argues, risk being negated by workload pressures that make practice unsustainable.
The question now is whether this contract will achieve its stated aims of improving access and supporting elective recovery, or whether it will create new bottlenecks as GPs struggle to absorb investigative work whilst maintaining same-day urgent access and delivering preventive care. The answers will become apparent as practices implement the changes from April 2025.
Source: @bmj_latest
Key Takeaways
- GPs fear the new “advice and guidance” service will push specialist-level investigations into community practice, overwhelming already stretched resources
- A contractual requirement to “deal with” clinically urgent patients same-day may damage continuity of care and force practices away from preventive medicine
- The imposed contract was negotiated without meaningful GP input, reflecting ongoing tensions between government and the profession
- New funding for additional GPs is welcome but risks being undermined if excessive workload makes practices unsustainable
What This Means for Kent Residents
Kent residents should be aware that changes to how GPs manage referrals and urgent appointments could affect access to specialist care. If practices are required to complete more investigations before consultants will see patients, this may add delays for some conditions. However, the ambition to move more care into community settings can benefit patients if practices have the capacity. Kent and Medway NHS Trust and local Integrated Care Boards will play important roles in implementing these changes fairly. Patients concerned about accessing specialist services should speak with their GP practice to understand local arrangements, and report any significant delays to NHS England. The King’s Fund and BMJ continue to monitor how these contract changes affect service delivery across England.
