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By Nita Kotecha, Senior Manager, Healthcare
The headline figure sounds generous. A £485 million uplift to the GP contract, bringing total investment to just under £13.9 billion. But for the partners and practice managers running GP surgeries in England, the number that matter is not £485 million. It is 1.4%. That is the real-terms growth in contract value once inflation is stripped out, and it arrives alongside the most significant expansion of contractual obligations in a decade.
The 2026/27 contract introduces a mandatory same-day response for all clinically urgent patient requests, makes Advice and Guidance a core contractual requirement with no per-request payment, imposes five new access and demand data metrics, requires practices to share data with the Lung Cancer Screening Programme, and creates new requirements around community pharmacy communication. Each of these changes carries cost. The question practice partners should be asking is not whether the money is welcome, but whether 1.4% real-terms growth covers the obligations that come with it.
We have written separately about how the £292 million practice-level GP Reimbursement Scheme works and what it means for partnership economics. This piece is about the other side of the contract: the obligations it imposes, the costs they create, and whether the funding envelope is sufficient.
What does unlimited same-day access for clinically urgent care actually cost?
The contract now requires practices to provide a same-day response for all clinically urgent patient requests. Practices may not ask patients to contact the practice on another day for urgent matters. Online consultation systems must not cap the number of requests that can be submitted during core hours.
The word "unlimited" does not appear in the contract text, but it is the practical effect. There is no upper bound on the number of urgent requests a practice must respond to on any given day. Clinical urgency is determined by the practice itself, which provides some flexibility, but the obligation to respond same-day is absolute. And as any practice manager will tell you, the gap between clinical urgency and patient-perceived urgency is a daily operational challenge that this contract does nothing to resolve.
NHS England has clarified that a same-day response does not necessarily mean a face-to-face GP appointment. Appropriate action might include a telephone call, a message to the patient explaining next steps, or a request for further information. But each of those responses still requires clinical triage time, admin capacity, and a system capable of processing uncapped demand in real time. For practices already running at capacity, that means either extending hours, adding sessions, or accepting that other work will be displaced.
The cost is not theoretical. An additional two GP sessions per week, assuming 3.5 hours per session and the Reimbursement Scheme’s maximum hourly rate of £90.61, adds roughly £33,000 per year before employer on costs. For a mid-sized practice, the question is whether the contract uplift, which averages approximately £47,000 per practice through the Reimbursement Scheme, leaves any margin once same-day access is properly staffed. In conversations with practice managers over recent weeks, I find that most believe it does not.
Advice and Guidance: the quiet cost transfer
Until April 2026, Advice and Guidance was an optional Enhanced Service. Practices that chose to participate received £20 per request for seeking specialist input before or instead of a planned care referral. The arrangement was voluntary, the income was identifiable, and practices could manage the workload within their existing capacity.
That arrangement is over. A&G is now a mandatory core contractual requirement. The £82 million previously ring fenced for the Enhanced Service has been folded into global sum payments, which means it is no longer visible as a separate income line. Practices that were earning £10,000 to £20,000 per year from A&G requests have lost that identifiable revenue stream. The obligation to provide the service has not only remained but expanded.
"Advice and Guidance volumes have nearly doubled since April 2022. The funding is now fixed. The activity is mandatory. The squeeze is already underway."
NHS England’s Medium Term Planning Framework sets a target of 25% of planned care referrals diverted through A&G by March 2027, across at least ten high-volume specialties. A&G request volumes have nearly doubled between April 2022 and January 2026, and the diversion target will push them higher still. The payment will not follow. This is a rising mandatory workload against a flat funding envelope, and the gap will widen with every quarter.
The medico-legal implications are also unresolved. When a hospital specialist provides written advice through A&G suggesting the GP manage a condition in primary care, clinical responsibility shifts. If a GP acts on specialist advice that turns out to be inappropriate, the accountability framework is unclear. The RCGP has raised this concern repeatedly, and the BMA’s template letters for practices explicitly advise documenting every A&G interaction as a safeguard. Documentation takes time. Time costs money.
Shared care: the July escalation
From 1 July 2026, the BMA began asking GP practices across England to refuse new requests from hospitals to transfer prescribing and monitoring responsibilities unless those requests are made under locally agreed pathways that adequately fund the additional workload. These shared care agreements, covering specialist drugs for immune conditions, cardiovascular disease, prostate cancer, osteoporosis and other long-term conditions, have historically been transferred to practices with minimal negotiation and no additional funding.
The BMA’s position is that it is negligent for commissioners to place unresourced additional responsibilities on practices that are already seeing 1.5 million patients every working day. The collective action asks practices to accept only those new agreements where a formal arrangement confirms that specialist support will continue, that the additional workload has been calculated and costed, and that the prescribing and monitoring responsibilities are clinically appropriate for primary care.
For practice owners, the financial question is direct. Each shared care agreement transferred from hospital to practice brings additional prescribing costs (reclaimed, but with cash flow implications), additional monitoring appointments, additional clinical time, and additional liability. Practices that have been absorbing these informally need to quantify what they are carrying and decide whether to continue without formal agreements in place.
The employer NIC question that has not gone away
Layered underneath the contract changes is a cost pressure that predates them. From April 2025, employer National Insurance contributions rose from 13.8% to 15%, and the secondary threshold dropped from £9,100 to £5,000. For GP practices, the impact is substantial. A staff member earning £35,000 now costs approximately £925 more per year to employ. Multiply that across a practice with twenty or thirty staff and the annual cost increase runs into tens of thousands of pounds.
Unlike other NHS organisations, GP practices were explicitly told that the compensation for increased NIC costs would not apply to them. And unlike other small businesses, practices classified as public authorities are excluded from claiming the increased Employment Allowance. The BMA estimated the aggregate cost to practices across England at approximately £180 - £200 million. Whether the 2026/27 contract uplift adequately covers this, on top of everything else it is expected to fund, is a question every practice should be modelling.
The NIC increase and the contract obligations compound each other. Every additional session added to meet same-day access requirements costs more than it would have done eighteen months ago. Every A&G request that requires clinical time is handled by staff who are more expensive to employ. Practices that have not yet modelled the combined effect on their projected drawings are making decisions without the numbers.
The BMA’s escalating response
The profession’s response to the imposed contract has been unequivocal. Almost 17,000 GP members voted, and 99% rejected the changes. The GPC England has moved to escalating collective action, with each month bringing a new phase. In May, practices were asked to cease signing voluntary data-sharing agreements. In June, the action moved to switching off non-contractual medicines optimisation software. From July, the focus shifted to shared care agreements.
The trajectory suggests further escalation is likely. A new wholesale GMS contract has been promised for 2028 onwards, and the government has signalled willingness to consult on reform. But for practices operating under the current contract, the political timeline offers no relief for the current financial year. The obligations are live now, the costs are real now, and the question of whether the funding covers them needs answering now.
Can 1.4 % cover all of this?
The contract asks practices to absorb uncapped same-day urgent demand, mandatory A&G with rising volumes and fixed funding, new data collection and reporting obligations, shared care responsibilities that the profession is actively pushing back against, and higher employer NICs that were never compensated. The funding to cover all of this is a 1.4% real-terms uplift.
For some practices, the maths may work. For many, it will not. The only way to know which category your practice falls into is to model it: map each new obligation against the clinical time and admin resource it requires, cost that resource at current employment rates including the NIC increase, and compare the total against your contract income. If the answer is a shortfall, you need to know now, not at year end.
If your practice needs support with contract cost modelling, our healthcare team can help.
This article has been prepared for information purposes only. Formal professional advice is strongly recommended before making decisions on the topics discussed in this release. No responsibility for any loss to any person acting, or not acting, as a result of this release can be accepted by us, or any person affiliated with us.
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