Embedded Bulletin | Edition 24 – How NHS England is reshaping General Practice through contracts, access and neighbourhood health
NHS England's latest changes to GP contracts, patient list validation, neighbourhood health and Advice and Guidance are all pointing towards the same conclusion. General Practice is becoming the operational engine of NHS reform, while simultaneously facing greater financial, contractual and performance pressure.
The most important story this week is not one single policy announcement. It is the way several developments are heading in the same direction.
General Practice is being asked to carry more of the future NHS model, but it is also being managed more tightly through list validation, access performance, Advice and Guidance rules, neighbourhood contracts and financial consequences.
The argument is no longer just about whether care should move closer to home. Most people accept that. The real question is whether the operating deal underneath general practice is becoming stronger or weaker.
At the moment, the answer looks uncomfortable.
The Lead Issue – National Patient List Cleansing Is Not An Admin Exercise
The national patient list cleansing exercise has become one of those issues that looks technical until you understand what it does in practice.
GPonline reported that nearly 350,000 patients had been removed from GP practice lists in what it described as an “aggressive” list cleaning drive, wiping around £45m from practice income.
The BMA has now said more than 300,000 patients have been stripped away from practices as part of NHS England’s national audit of patient lists, warning that the exercise leaves patients without a GP and increases financial pressure on practices.
This is not just about inaccurate lists. Nobody is seriously arguing that list inflation should be ignored. A practice list should be as accurate as possible. Funding should reflect real patients. That part is fair.
The problem is what happens when a national clean-up programme lands inside a service that is already financially tight, workforce constrained and being asked to do more work through neighbourhood care, access improvement, digital front doors, frailty, prevention and the left shift.
For a GP practice, list size is not an abstract number. It affects income, staffing, capacity planning, premises, drawings, partner risk, investment decisions and the willingness to take on additional local service work. When list changes happen quickly and practices believe the process is blunt, the consequence is not just a spreadsheet adjustment. It can destabilise the business model.
That is why the BMA language matters. It is framing the issue as a patient risk and a practice sustainability risk, not simply a technical correction. Pulse has also reported concerns that list cleansing could cost GP practices more than £30,000 on average, while further reporting highlighted local clawback pressures and warnings that some practices may have to close.
The practical test is simple. If patients are genuinely no longer eligible to be registered, lists should be corrected, but if patients are removed inappropriately, or if practices lose significant income before the operational consequences are understood, the system creates a new problem while trying to solve an old one.
This also lands at a difficult moment politically. NHS England’s 2026/27 GP contract changes include £485m additional investment, taking the estimated contract value to £13.863bn, with stated aims around capacity, same day urgent access and patient experience, but practices will judge the deal by what they experience locally, not by the headline investment figure.
Embedded Conversations Podcast – Real discussions about what’s shaping the NHS
In the latest episode of Embedded Conversations, Scott is joined by David Thorne, an experienced NHS leader with more than 45 years in the service, bringing a clear and practical perspective on system change. In this episode, he shares his views on value-based healthcare, outcomes-focused commissioning and the role of data in moving from strategy to delivery.
The Impact On Practice Behaviour Cannot Be Underestimated
If the message to practices is “we are investing in you”, while the local experience is income removal, access performance management, unfunded work transfer and greater contractual pressure, trust will not improve.
The bit people are underestimating is how quickly this affects behaviour. Practices that feel financially exposed become more cautious. They look harder at Local Enhanced Services. They question shared care. They resist unfunded pathway changes. They challenge Advice and Guidance. They become more selective about pilots. They ask, quite reasonably, who is paying for the work.
That matters for everyone working with the NHS. A pharma, medtech or device company may have a clinically sensible offer that supports prevention or care closer to home, but if it requires primary care to absorb work without a funded model, it will hit a wall.
What to watch
- Whether NHS England or ICBs pause, review or soften the list cleansing process where practices report inappropriate removals.
- Whether the financial impact becomes another driver of GP Collective Action.
- Whether ICBs start treating list accuracy, access improvement and neighbourhood delivery as separate issues, or continue pushing all of them through the same stretched primary care infrastructure.
Neighbourhood Health is Becoming Contractual, Not Just Collaborative
The second development to watch is the way neighbourhood health is starting to move from language into contract mechanics.
HSJ reported (£Paywalled) that a first of its kind neighbourhood contract will tie around £1.7m of primary care revenue to A&E attendances from next year. That is a significant shift. It moves neighbourhood working away from warm words about integration and into a much harder question – should GP income be linked to hospital utilisation?
There is a logic to this. If neighbourhood teams are designed to support complex patients, reduce deterioration, improve continuity and avoid unnecessary hospital use, then some form of outcome link is understandable. The NHS cannot keep funding activity without asking whether it changes demand, flow or outcomes but linking GP income to A&E attendances is not straightforward.
A&E attendance is influenced by many things general practice does not control, including ambulance behaviour, patient confidence, social care gaps, urgent community response, out of hours provision, NHS 111, local deprivation, mental health access, care home support, hospital discharge quality and public expectation.
So, the question is not whether the metric matters. It does. The question is whether it is fair, controllable and supported by enough investment in the model underneath.
This is where the neighbourhood debate is getting more honest. NHS leaders are now openly acknowledging that neighbourhoods have been made too complicated. GPonline reported comments from an NHS chief warning that neighbourhoods had been “massively overcomplicated” and that disputes over who should run them risk undermining the shift out of hospital.
That is a useful admission. The neighbourhood model will fail if it becomes a governance industry.
The RCGP has also warned that Health Bill legislation should clarify how funding will follow work as services move out of hospital into neighbourhood models. That is exactly the right issue. Work cannot move on a slogan. It needs funding, workforce, accountability and a contract.
The practical read is neighbourhood health is entering its commercial phase. Not commercial in the private sector sense, but commercial in the sense that somebody now has to price the work, define the risk, measure the outcome and decide who carries the consequence if it does not deliver.
That is where many local models will either become real or fall apart.
For industry, this creates opportunity, but only for offers that understand the local deal. “We support neighbourhood health” is not enough. The better question is, which cohort, which pathway, which contract, which metric, which workforce and which cost pressure?
Embedded: How Pharma, MedTech & Device Companies Get Their Innovations Into NHS Pathways - And Keep Them There
My book, Embedded, lifts the lid on how NHS decisions really get made and why so many good ideas fail to gain traction. It gives pharmaceutical, medtech and device teams a practical view of how projects get approved, funded and sustained in the real world. Drawing on my frontline experience as an NHS Management Consultant, it is designed to help readers understand the system from the inside and engage it more effectively.
Advice and Guidance has reached the accountability stage
Advice and Guidance continues to be one of the clearest examples of the gap between a sensible idea and a difficult operating model.
NHS England has now said GPs are not mandated to use A&G and will not be in breach of contract if they make a direct referral instead. This followed questions about whether it was appropriate to mandate A&G while HSSIB is investigating patient safety risks linked to its use.
That clarification changes the tone of the conversation. A&G is no longer simply being pushed as a universal route to manage referrals. It is being pulled back into the territory where it should always have sat, a clinical pathway tool that needs local agreement, patient safety governance and clear accountability.
The RCGP position is also important. It supports Advice and Guidance where it is properly resourced and implemented but says it should not be mandated and that local pathways must be co-designed by primary and secondary care, alongside patients.
That is the right balance. A&G can be excellent. Done well, it gives GPs faster specialist input, avoids unnecessary outpatient appointments, supports better decision making and improves patient experience. Done badly, it becomes referral deflection with extra typing. The difference is pathway design.
The misunderstanding is that A&G reduces demand by default. It does not. It can reduce unnecessary outpatient activity, but it may also increase primary care workload, extend clinical uncertainty, create repeated loops, and leave the GP holding responsibility without the resources to act.
That is why the NHS England clarification is more important than it first appears. It recognises that direct referral remains legitimate. It also signals that local systems cannot simply solve outpatient pressure by closing the front door and calling it transformation.
The practical test for A&G should be:
- Does it improve clinical decision making?
- Does it reduce avoidable appointments without increasing unsafe workload?
- Is responsibility clear when advice is given?
- Does the patient know what happens next?
- Is the pathway simpler after A&G than before it?
For commercial digital tools, referral management platforms and pathway support offers, this is a warning. Activity reduction alone will not be enough. The NHS will increasingly ask what happens to workload, governance and risk.
Worth watching
- The new NHS Oversight Framework
NHS England has published the 2026/27 Oversight Framework, covering how it will oversee ICBs, NHS trusts and foundation trusts. The important point is not just the framework itself, but the direction it signals; more consistent assessment, more visibility of performance and more pressure on systems to demonstrate grip. - GP access performance management
Pulse reported that more than 100 GP practices in the South East were performance managed by NHS England to improve access and reduce variation, as part of a programme described as laying foundations for neighbourhood working. This is worth watching because access, variation and neighbourhood delivery are starting to blur into one management agenda. - ICB clustering and mergers
The continued push toward ICB clustering and merger discussions matters because market access routes are shifting again. Fewer, larger commissioning footprints may improve consistency, but they may also make local decision making slower and more financially controlled.
What this means in practice
- General Practice will become more selective about new work. If the funding, governance and workload are vague, the answer will increasingly be no.
- Neighbourhood health needs a contract, not just a committee. The serious local models will define cohorts, money, workforce, outcomes and risk.
- A&G must be treated as pathway redesign, not referral suppression. If it creates hidden workload, it will lose clinical support.
- ICBs need to understand the business model of general practice. You cannot build the future NHS on a delivery platform you are accidentally weakening.
- Industry needs to stop selling alignment and start showing adoptability. The question is no longer “does this fit policy?” It is “does this make the pathway easier to run?”
Reform is Happening Locally
What I keep coming back to is the NHS is not short of ideas for moving care closer to home. It is short of credible operating models.
The next phase will be decided less by national language and more by local mechanics. Who funds the work? Who carries the risk? Who owns the patient? Who has the workforce? Who gets measured? Who loses income if the model fails?
That is where the real reform is now happening.
As ever, I would be interested in different local views, especially from practices, ICBs and partners trying to make these models work in real life.
Sources
General Practice finance, lists and access
- GPonline: Aggressive list-cleaning drive strips 350,000 patients from GP practices
- Pulse: NHS England patient list cleansing costs GP practices over £30k on average, LMC warns
- Pulse: BMA demands urgent discussions with Government over NHSE list cleansing drive
- GPonline: GP funding siphoned off at unprecedented scale by patient removals, warns BMA
- Pulse: GP practices facing £6m clawback from ICB may have to close, leaders warn
- Pulse: Over 100 GP practices performance managed by NHS England to improve access
Neighbourhood health and contracting
- HSJ: First neighbourhood contract links GP income to A&E attendances
- GPonline: Neighbourhoods massively overcomplicated, says NHS chief
- GPonline: Health Bill should define how funding will follow work in neighbourhood shift, warns RCGP
- Pulse: Trusts likely to run general practice under neighbourhood model, BMA warns
- Pulse PCN: Neighbourhood health centres to be approved by summer amid unaffordable estate upgrade requests
Advice and Guidance
Oversight and system management
The Embedded Seminar – The room where NHS strategy gets translated into action
The Embedded Seminar brings together operational NHS leaders and senior industry teams for a sharp, practical day focused on what is really shaping delivery, decision-making and market access across the system. It is built to go beyond theory, giving delegates the kind of insight, context and straight talking discussion that is rarely available from the outside. For anyone trying to understand what is changing in the NHS and how to respond, it is a high-value day in the right room.
£499.00
Individual Ticket
£499 + VAT
Need A Team Ticket with 10% off? (minimum three delegates) – Contact Us
Attendance is capped at 70 delegates. Venue: Royal College of General Practitioners, London NW1 2FB | 30 September 2026 | 09:00–16:30 This limit is intentional. The purpose of the day is informed discussion at a senior level, not passive listening in a large auditorium. A smaller room has been chosen to allow proper exchange, constructive challenge and a rich learning experience. Once those places are taken, registration will close.
If you would prefer to pay by invoice, simply add your place to the cart and select “Pay by invoice” at checkout. We will then email your invoice with payment details.
Get the next Embedded Bulletin straight to your inbox
If you want to stay close to the issues shaping NHS delivery, market access and decision-making, sign up to receive email updates when the next Embedded Bulletin is published. Stay in front of the competition and get practical insight on what is changing, what matters and what to watch next.
Sign up to our newsletter
Turn Strategy into Progress. Faster.
Scott McKenzie helps pharmaceutical, medtech and device companies cut through NHS complexity and get their offers in front of the right decision-makers. In 2023, he helped launch 53 new NHS projects – and added another 28 in 2024. Behind those numbers is a system-level understanding of what actually gets approved, funded and sustained.
He’s also the author of the groundbreaking book Embedded – a practical, insider’s guide to landing projects with the NHS and making them stick.
His newly launched coaching and mentorship membership programme is built for results: combining NHS insider insight, proven engagement strategies and warm introductions to the people who hold the pen on purchasing decisions.