2026 GP contract amendments: key changes for practices under GMS and PMS

The draft National Health Service (General Medical Services Contracts and Personal Medical Services Agreements) (Amendment) Regulations 2026 introduce a series of contractual changes that, while appearing incremental, will have a big impact on how GP practices operate day-to-day going forward.

Several provisions mark a shift from guidance-based systems towards more formalised, enforceable obligations. In particular, referral pathways, performance management powers, and patient interaction requirements now carry clearer contractual weight.

Referral pathways: from guidance to obligation

Perhaps the most significant change is the introduction of a formal requirement to comply with referral pathways. Under Schedule 3 paragraph 11C:

“The contractor must, where clinically appropriate, comply with any relevant referral pathways notified under paragraph (1), prior to referring a patient for services under the Act.”

Referral pathways explicitly include Advice and Guidance (A&G) arrangements and may be both nationally defined and “locally determined”.

This raises several practical issues. It is not yet clear who will determine local pathways. This is likely to sit with Integrated Care Boards (ICBs) but could involve individual NHS trusts receiving referrals. Practices operating across multiple trust footprints may therefore need to navigate different pathways for similar referrals. Whilst this may not be new to them the consequences of failing to do so are now more serious from a contractual perspective.

It’s important to note that these pathways are no longer optional tools to assist clinical decision-making; they are contractually binding requirements. The key qualification is that compliance is required only “where clinically appropriate”. This introduces an important safeguard. In practice, clinical judgement will remain central, and any challenge to non-compliance is likely to hinge on whether a reasonable clinician would have followed the pathway in those circumstances—mirroring established negligence-style tests.

However, it is likely that pathways themselves will increasingly define what is considered “clinically appropriate”, for example by setting thresholds, referral criteria or exclusion categories. This reinforces the importance of practices actively engaging in how local pathways are developed.

A shift in mindset and operational procedures for practices

Taken together, these changes mean that referral pathways—and A&G processes more broadly—must now be treated as core contractual documents, not simply operational guidance.

Practices will need to:

• Understand and monitor applicable local and national pathways
• Ensure clinicians are aware of when and how pathways apply
• Incorporate pathway compliance into governance and audit processes

This represents a clear shift in mindset. Failure to follow a pathway is no longer just a missed opportunity for system efficiency. It could, in certain circumstances, amount to a contractual breach.

Performance management

Another key development is the introduction of a general duty to co-operate with performance management:

Contractors must co-operate with NHS England, “in so far as is reasonable”, in relation to performance review and improvement activity.

Historically, commissioners have had powers to inspect and investigate but limited intermediate options for addressing concerns. The primary route for enforcement has been through formal breach or remedial notices.

This new provision effectively fills that gap. It allows for a more graduated approach to performance management, enabling NHS England or more appropriately ICBs to request co-operation with support or improvement programmes, and to undertake performance reviews without immediately escalating to formal contractual sanctions.

This could create an increased level of oversight, but it may actually help resolve issues earlier by offering a clearer, less confrontational route to improvement.

One key question still hasn’t been answered: what standards or measures will these reviews be based on? Until that’s clearer, there’s likely to be ongoing uncertainty about what “good” performance looks like and when action will be taken.

Patient choice and prescribing responsibilities

A more practical change relates to pharmaceutical services. Contractors must now actively consult patients on their choice of dispenser for each new prescription:

“The contractor must consult the patient… as to their choice of dispenser.”

This formalises what has often been treated as informal practice. Critically:

• Prescribers cannot assume an existing nominated pharmacy remains valid
• The obligation rests with the contractor, not just individual clinicians
• Systems and processes will be needed to ensure compliance across all prescribers, including PCN staff

This is a low-risk change in principle, but one that could easily be overlooked in practice.

Digital access, data and responsiveness

The amendments also strengthen patient access and system transparency requirements:

• Online consultation tools must not limit the number of requests during core hours
• Contractors must make relevant data available to NHS England, which may represent a shift towards data extraction models to replace the previous submission based requirements
• Practices must not ask patients to contact the practice on another day and must respond to non-urgent matters by the end of the next working day

These changes reinforce expectations around accessibility and responsiveness, while also raising familiar data protection and operational capacity considerations.

Other notable changes

Additional updates include:

• A new obligation to provide information for NHS staff surveys which is inline with other NHS services and has been used in the past in some APMS contracts
• Alignment of sub-contracting procedures between PMS and GMS contracts
• New requirements relating to Directory of Services communication details

The 2026 amendments do not introduce wholesale structural reform, but they do strengthen the contractual framework underpinning GP services.

The most important theme is the shift from guidance to enforceable obligation, particularly in relation to referral pathways and performance management.

Practices should act now to review local pathways, update internal processes, and ensure clinicians understand the contractual implications of their day-to-day decisions.

Contact us

Our primary care specialists regularly advise on contract changes, performance management and pathway compliance. If you would like tailored advice on how these developments affect your practice, please contact the Hempsons team.