Dear colleague,
Chair’s introduction
Welcome to the May edition of the NEL newsletter. This month’s updates reflect the breadth and intensity of current discussions across North East London. A common theme runs through many of them: general practice is willing to play its part in improving patient care, but this must be done safely, fairly and with proper resourcing.
Your LMCs have been raising concerns with the ICB on a number of important areas, including Advice and Guidance, Same Day Access, MSK pathways, DOAC monitoring, Shared Care, ADHD prescribing and the developing LTC framework. In each case, our focus has been to ensure that changes are
clinically safe, contractually appropriate, adequately funded and not simply a transfer of unfunded work into practices.
We are also working to strengthen LMC representation in system governance, so that general practice is involved earlier in decisions that affect workload, risk and patient access.
Please continue to share your concerns, examples and feedback with us. They are essential in helping your LMCs represent you effectively.
Dr Najib Seedat
Chair, Redbridge LMC
Surviving the 2026-27 GP contract – webinar recording
A recording of the first run of Londonwide LMCs’ webinar is now available on the 2026-27 GP contract guidance page for those people who were unable to attend either session.
You can find out about the effect on London of the contract changes, with our unique patient population and commissioning arrangements, based on the documentation available at the end of April.
Spotlight on policies and guidance
Advice and Guidance and referral pathways
NEL LMCs remain concerned about the direction of travel on Advice and Guidance, Advice and Referral, and Single Point of Access models. While specialist advice can be helpful when used appropriately, we are concerned that these routes are increasingly being used to deflect clinically appropriate referrals back to General Practice, creating delays, additional workload and unclear clinical accountability.
GPCE have update their guidance on A&G, which is clear that A&G and SPoA arrangements should not override a GP’s clinical judgement. Where a GP believes specialist assessment is clinically indicated, they should make this clear in the referral or A&G request and insist that the referral is accepted. NHS England has also confirmed that there is no national target to divert a fixed proportion of referrals away from hospital care, and that specialist advice should include clear next steps and appropriate senior accountability.
Commissioning updates
NEL LTC Proactive Care Quality and Outcome Framework (PCQOF)
LMCs are continuing to be involved in discussions over the NEL Long Term Conditions enhanced service work. The service has three main funding components: clinical delivery (88% of the total budget), MDT funding (3.2% of the total budget) and PCN leadership and management funding (8.8% of the total budget). Although the largest proportion of the funding sits within clinical delivery, LMCs have also provided feedback on expectations attached to MDT and management funding. We have advocated for local determination of how this funding should be utilised and provide some principles to work towards, rather than strict service requirements being imposed by the ICB.
So far, there have been discussions about diabetes, CVD, CKD and AF indicators, reporting requirements, and the need to ensure any targets for the first year are proportionate and deliverable. LMC has advised that the ICB consider the significant variation in the starting point/ current achievement of each borough and the warranted variation between each PCN. We remain concerned that enhanced service changes must be realistic, properly funded and not create additional administrative burden to practices or PCNs without clear value. We recognise that it is imperative that the financial viability of individual practices is maintained, and that the scheme is implemented in a fashion that achieves the underlying objective of reducing health inequalities across North East London.
Local LMCs and the Londonwide team will continue to engage with the ICB through the relevant working group, review the proposed requirements and feedback on whether the expectations are proportionate for practices and PCNs.
Same Day Access specification
NEL LMCs have responded to the draft refreshed Same Day Access specification. While supporting the ambition to improve urgent primary care access, reduce variation, strengthen interoperability and support urgent care flow, we are concerned that the draft does not yet balance ambition with realistic resourcing.
Key issues raised include the need to properly fund telephony, SMS reminders, administration, GP Connect and wider interoperability; address continued variation in SDA hours across boroughs; and ensure reporting and KPIs are proportionate and focused only on what providers can control. We have also asked the ICB to ensure UTCs and EDs are held to account through equivalent contractual expectations, as this is a system model and cannot all fall on general practice to resolve.
SDA pilots in boroughs like Tower Hamlets show the potential value of this model, with high utilisation, strong patient satisfaction and significant reductions in avoidable A&E attendance. However, the tariff has not kept pace with inflation or increasing operational complexity. LMCs and the Londonwide team will continue to press the ICB for a proper tariff review, sustainable interoperability funding, clearer system accountability and a specification that genuinely improves the model rather than simply adding unfunded requirements to PCNs and practices.
MRI communication to patients
We are hearing that practices are often having difficult conversations with patients who are attending for MSK conditions, when they tell them that they are not able to request MRI scans for MSK anymore. LMCs has put together the statement below, that can be shared with patients to explain why this is happening.
“NHS North East London Integrated Care Board (NEL ICB) has changed the process for requesting MRI scans for MSK conditions. This means your GP practice can no longer request these MRI scans directly in the usual way. Instead, if an MRI is needed, your GP will refer you to the community MSK service. A senior MSK clinician within that service will assess your symptoms and decide whether an MRI is appropriate, and arrange it if needed. This is an ICB decision and applies across North East London.”
DOAC monitoring – commissioning position and LMC advice
Londonwide LMCs has written to the ICB regarding the ongoing monitoring of DOACs in general practice, following several months of discussion. The ICB has now indicated that it does not intend to commission a dedicated service for DOAC monitoring from general practice. Their position has been that existing mechanisms – such as QOF and the new NEL Long Term Conditions Proactive Care Quality and Outcomes Framework (PCQOF) – provide sufficient financial support for this work.
The LMC does not agree with this position. We have made it clear that:
- QOF is a voluntary incentive scheme and does not create a contractual obligation to deliver DOAC monitoring.
- Any new PCQOF indicators must be properly resourced and commissioned if they generate additional workload.
- DOAC monitoring is not part of core GMS services.
Across North East London, there are approximately 33,000 patients prescribed DOACs, all requiring regular monitoring. This represents a substantial workload and a clear patient safety risk if not properly commissioned and resourced. We have therefore asked the ICB to:
- Develop a locally commissioned service, or
- Provide clear guidance on the appropriate pathway, with secondary care (haematology) as the default for ongoing monitoring and prescribing responsibility where no community service exists
Practices are increasingly asking how to respond. The key principles are:
- You should continue to act in the best interests of patient safety in the short term
- However, practices are not contractually obliged to undertake unfunded DOAC monitoring
- Practices may need to review this work and consider appropriate pathways, including referral to secondary care where no commissioned service is in place
Please speak to your LMC rep, if you have any concerns. We will continue to engage with the ICB and update practices as the situation develops.
Shared Care and Amber drugs
NEL LMCs are concerned about amber drugs and Shared Care arrangements being pushed into general practice without appropriate contracts, funding or agreement. There is particular concern that short training sessions funded by the ICB on specific drugs could be used to imply that GPs are competent and therefore expected to prescribe or monitor drugs that require specialist oversight.
We want to remind practices that Shared Care is not part of the core GMS contract and it is currently unfunded by a local enhanced service in NEL. Shared Care must be genuinely shared, clinically safe, properly resourced and agreed with the profession. Attendance at a training session should not be treated as acceptance of unfunded workload or automatic transfer of responsibility.
According to NHS England responsibility–prescribing–between–primary–secondary–care–v2.pdf : “When decisions are made to transfer clinical and prescribing responsibility for a patient between care settings, it is of the utmost importance that the GP feels clinically competent to prescribe the necessary medicines.”
We will continue to scrutinise emerging Shared Care models across London and advocate to fund this work in NEL.
Proposed NEL ADHD enhanced service
NEL LMCs have written to the ICB raising serious concerns about the proposed new Adult ADHD LES. While we support appropriately funded and clinically safe care closer to home, the current proposal does not appear to describe true Shared Care and does not meet the standards set out in NICE guidance.
The key concern is that the proposal risks transferring adult ADHD prescribing and monitoring from specialist mental health services into general practice without adequate specialist review, Shared Care arrangements, or protection for patients and practices. We also highlighted risks linked to diagnoses and management plans from non-NHS Right to Choose providers, which should be verified by ELFT or NELFT before any transfer to general practice.
We have made clear that ADHD medicines remain Shared Care drugs and require proper Shared Care agreements, clinical competence, and appropriate funding. We have asked the ICB to revise the LES so that it is a genuine Shared Care LES, with NHS specialist provider oversight and verification arrangements. Without these changes, NEL LMCs are unable to endorse the proposal.
The LMC has also highlighted that greater clarity is urgently needed about the pathway for patients diagnosed with ADHD, for whom the registered GP Practice does not accept transfer of care for ongoing management, including ongoing prescribing, monitoring, and annual review in General Practice. We will keep you updated on progress.
NEL Mental health LIS for stable SMI patients on Depot antipsychotics
Londonwide LMC has been attending the NEL SMI mental health LIS working group on behalf of the boroughs that we support. The working group includes the ICB as commissioners and both ELFT and NELT as service providers.
We recognise that there has been variability in the commissioning of Mental health LIS across NEL to date, with BHR not having had an existing SMI on Depot LIS in place. Additionally, we recognise that in the areas with a pre-existing LIS, the MDT support available from the CMHT has varied between the boroughs. The LMC is actively working on your behalf to support the development of a NEL-wide LIS which promotes patient safety, reduces inter-borough variation and is funded appropriately. We have highlighted to the commissioners that the boroughs who have not had a historic LIS, as well as those boroughs with a reduced impact of the existing LIS (boroughs served by NELFT), will require a Shared Care approach, rather than transfer of care.
The LMC has also made some initial suggestions about the training for General Practice teams, that will be required to successfully implement this LIS in General Practice.
Compression hosiery requests from secondary care
LMCs have been made aware that some practices are receiving requests from cardiology and vascular services to prescribe compression hosiery without clear product details, and with an expectation that GPs will measure and size patients.
We have clarified with medicines management colleagues that there is currently no commissioned primary care or community pharmacy service in NEL to assess, measure or fit compression hosiery. GPs should not be expected to undertake measuring where they have not been trained or commissioned to do so. Where secondary care recommends compression hosiery, the request should specify the exact product required, including class, length, size and type. If this information is missing, practices should return the request to the requesting secondary care clinician and ask them to provide the required details, including confirmation that the patient has been appropriately measured.
The Drug Tariff permits pharmacy reimbursement for made-to-measure hosiery, including measuring and fitting where appropriately endorsed. However, this does not in itself create a local commissioned pathway or oblige practices to provide this service.
NEL Supplementary Care Home LIS update
We are pleased to let practices know that after a challenge from Londonwide LMCs, the ICB has reviewed the eligibility criteria for the NEL Supplementary Care Home LIS, and agreed that payment will be based on patient registration rather than geographical location of the care homes.
Previously practices and PCNs who looked after residents in care homes located outside the NEL borders, where not deemed eligible for the LIS payments. The ICB has now agreed to pay the Care Home Supplementary Service for patients who are registered with NEL practices but are resident in nursing homes or older people’s care homes located outside borough boundaries (but within the practices catchment area). This arrangement will take effect from 1 April 2026.
Local engagement
MSK single point of access and referral pathways
NEL LMCs are engaging with the development of MSK single point of access arrangements across NEL. Existing arrangements differ by borough, with some areas already operating through a single service while others are being approached by ICB and provides about pathway changes.
We have shared previous correspondence and concerns with the MSK leads. Key issues include referral rejections, waiting times, unclear clinical accountability and concerns that SPoA models must not become barriers to clinically appropriate referral. There was also recognition that some current MSK pathways are not working well and could benefit from genuine improvement.
Each local LMC is meeting with their respective MSK leads to continue local discussions. We will update constituents on developments. If you have concerns about MSK services in NEL please do let us know; please also raise Quality alerts when appropriate.
Representation on the NEL formulary and pathways group
The ICB has agreed that Londonwide LMCs should have representation on the NEL formulary and pathways group. We welcomed this as an important step, as many prescribing and pathway recommendations made by this group directly affect general practice workload, clinical risk and patient expectations.
The group was clear that LMC involvement must happen early, before decisions are finalised and passed through other committees where there is limited opportunity to influence. This is particularly important given recent concerns about DOACs, Shared Care, formulary changes and pathway redesign.
Strengthening LMC influence in system governance
LMCs across NEL have discussed the importance of ensuring strong LMC representation in ICB and system governance structures, particularly as NEL continues to redesign pathways and respond to wider NHS reform, with the ICB’s role focusing on strategic commissioning. Decisions are often made in forums where general practice is either under-represented or consulted too late.
LMCs also discussed the need to work constructively with secondary care and local authority colleagues where there are shared interests, while continuing to challenge models that deflect referrals, increase inappropriate workload transfer to General Practice or reduce patient access.
We are considering how representation should be organised across NEL, including how to cover key meetings, share intelligence back to members and constituents, and ensure borough perspectives are reflected. We would like to hear back from you, if you have any thoughts on how we could strengthen our representation in local system governance.
Constituent engagement
Our NEL LMCs are working to optimise opportunities for engagement with our constituents, whether through newsletters, our website, individual practice meetings, discussions with PCNs or borough-level events, including PLTs. We are keen to listen to practices, to understand their concerns and the challenges they are currently facing – please let us know if you would like a call or a face-to-face visit from a member of your local LMC. Please email ian.williamson@lmc.org.uk for further information.
Please also visit the Londonwide LMC website for a one-stop shop on our support for practices—details of our services, practical resources (including template letters and guidance), and details and updates from our North East London committees, including previous local and NEL newsletters.
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