Month: May 2026

General Medical Services, Primary Medical Services, APMS and the “Undifferentiated GP” Problem

The starting point is probably not the performers list, nor appraisal, but the statutory idea of general medical services.

Under the National Health Service Act 2006, a general medical services contract is a contract under section 84 for the provision of primary medical services. Section 85 then requires a GMS contract to include prescribed primary medical services. Those prescribed services are found principally in the NHS (General Medical Services Contracts) Regulations 2015, especially regulation 17, dealing with “essential services”. Regulation 17 describes essential services in broad patient-facing terms. A contractor must provide services for the management of registered patients and temporary residents who are, or believe themselves to be, ill, terminally ill, or suffering from chronic disease. “Management” includes consultation, examination where appropriate, identifying the need for treatment or investigation, providing treatment or investigation where necessary and appropriate, referral, and liaison with other healthcare professionals.

This is the closest statutory foundation for the idea that NHS general practice is broad, first-contact, generalist work. It is not narrow specialist practice. It is concerned with patients who may present with almost anything, including early, unclear, or non-specific illness. That is where NHSE can plausibly find the conceptual root of “undifferentiated” general practice. But the statute does not itself use the term undifferentiated GP, and it does not define a GP by an obligation to maintain active competence in every possible domain of community general practice. The duty in regulation 17 is framed primarily on the contractor or practice, not on each individual doctor personally. A practice must provide the service. The individual doctor must work safely within competence and within the contractual and governance arrangements of the service.


The performers list legislation then sits on top of this. The NHS (Performers Lists) (England) Regulations 2013 define a “general medical practitioner” as a registered medical practitioner who is either a GP registrar or whose name is included in the GP Register. Regulation 24 says, broadly, that a doctor may not perform primary medical services unless they are a general medical practitioner included in the medical performers list, subject to exceptions. So the performers list does not define a GP by “undifferentiated” scope. It defines eligibility by GP Register status, licence, registration, and inclusion on the list. The work protected by the list is primary medical services.

That matters because primary medical services are wider than GMS. They may be delivered under GMS, PMS, APMS, section 92 arrangements, and other arrangements under Part 4 of the 2006 Act. The performers list regulations expressly recognise this. They define an APMS contract as an arrangement under section 83(2) of the 2006 Act for the provision of primary medical services. They also require the medical performers list to record whether a doctor provides primary medical services under, or pursuant to, an APMS contract.


That is fatal to any simplistic argument that APMS work is somehow not GP work or not primary medical services. A doctor working under an APMS contract may not be providing “general medical services” in the strict contractual sense, because GMS means a section 84 GMS contract. But they may very much be providing NHS primary medical services and, in ordinary clinical language, GP-type work.
This is important for prison doctors. A prison GP working under an APMS contract may have a restricted patient population. For example, they may not treat children, pregnant women, or the full demographic range seen in community general practice. NHSE may label that “differentiated” because the scope is narrower than full community general practice. That label is not wholly irrational. Prison practice is a specialised setting. It has a defined population, particular clinical risks, and areas of GP work that may be absent.

But the legal conclusion does not automatically follow. A prison APMS GP is still capable of providing primary medical services. The question is not whether the doctor is identical to a community GMS GP. The question is whether the doctor is safe, current, and fit to practise within their actual scope, and whether they are performing services of the kind relevant to inclusion on the performers list.
The RCGP and GMC material helps explain the professional background. The RCGP curriculum describes the GP as a generalist, dealing with complexity, uncertainty and risk, and addressing early undifferentiated presentations (which in any case prison GPs have to do). That could be seen to support the idea that undifferentiated work is part of the core identity of general practice at qualification. But it remains curriculum and professional language. It does not by itself create a statutory condition that every doctor on the performers list must personally maintain full undifferentiated community GP scope.


The NHSE low-volume guidance is the most relevant document I found. It concerns doctors on the NHS England Medical Performers List undertaking a low volume of NHS GP clinical work, defined as fewer than 40 sessions per year. It says that fewer than 40 sessions should trigger structured reflection and discussion at appraisal. It asks whether the doctor’s work is general undifferentiated GP work or a more differentiated role. It treats restricted scope as a possible risk factor, especially because loss of a skill set through restricted practice may affect future decisions about scope.

However, the same guidance is careful. It says the 40-session figure is a benchmark, not a pass/fail test. It is a trigger for reflection and discussion. It says doctors doing 40 sessions or more do not need extra reflection purely because of volume, but it does not say doctors doing fewer than 40 must be removed or must complete 40 ordinary community sessions.


The structured reflective template is even more useful. Its stated aim is to allow doctors to demonstrate that they are safe, up to date and fit to practise at what they do, particularly if they have an unusual or restricted scope of practice, or do a low volume of a particular scope of work. That phrase, “at what you do”, is central. It supports reflection on actual scope. It does not support forced reflection on imaginary or unwanted work outside scope.

NHSE can say that full-scope community general practice is broad, generalist and often undifferentiated. It can say that a doctor whose work is restricted, such as a prison APMS GP who does not see children, should reflect on the risks of deskilling and the implications for any future return to unrestricted community GP work. It can require annual appraisal, supporting information, and reflection across the doctor’s whole actual scope of practice.

NHSE does ask for reflection where a doctor’s work is low-volume or restricted in scope, but any such request must be grounded in the doctor’s actual scope of practice and cannot convert full-time specialised/APMS primary medical work into ‘low-volume’ work merely by excluding it from NHSE’s preferred concept of undifferentiated community GP.”

I have not found authority for the proposition that such a doctor must perform 40 sessions of ordinary non-specialised NHSE community general practice. Nor have I found authority for a requirement that the doctor must keep up skills in areas outside their declared and actual scope, such as paediatrics, if they do not treat children. Nor have we found authority for requiring a doctor to create a personal development plan to become “undifferentiated” where their actual work is safely and lawfully differentiated.

The proper distinction is between current scope and future scope.
For current prison APMS work, the doctor should demonstrate fitness, CPD, governance, feedback, significant events, complaints, peer benchmarking, and safe practice within prison primary care. If they do not treat children, they should not pretend to maintain paediatric competence as though they do. They can instead state that paediatrics is outside their current scope.

For future unrestricted community GP work, it is reasonable to acknowledge that a return would require appropriate updating, supervision, induction, refresher work, or staged re-entry. That is a safety position, not a concession of current inadequacy. This is the same for any doctor wishing to change his scope of practice and we would reflect that in our CPD

A GP must:

• engage with annual appraisal
• provide supporting information across their actual scope
• demonstrate they are safe, up to date and fit to practise in what they do
• reflect honestly on significant changes or limits in scope
• not misrepresent competence in areas they do not practise

But they do not to have to:

• accept NHSE’s “undifferentiated” label as a legal category
• treat full-time prison GP work as low-volume GP work
• complete a “low volume” template if the factual premise is wrong
• make a PDP to maintain or regain skills outside their intended scope
• perform 40 sessions of ordinary community general practice if they do not intend to practise ordinary community general practice

The relection can be this

“I have reflected on my actual scope. My current scope is full-time prison/APMS primary medical care. I do not practise unrestricted community general practice and do not currently intend to do so. I therefore maintain competence, CPD, governance and appraisal evidence for my actual scope. If I later wished to move into unrestricted community GP work, I accept that I would need appropriate updating and reflect this in my CPD. I do not accept that I am required to maintain competence in areas outside my current and intended scope.”


Summary

Primary medical services are broad enough to explain how NHSE values undifferentiated generalist capability. But neither GMS law, APMS law, performers list law, nor the low-volume appraisal guidance can impose a freestanding duty on every GP to maintain full undifferentiated community GP practice regardless of actual scope. A prison APMS GP may be differentiated in the descriptive sense, but the lawful appraisal question is whether they are safe, up to date and fit to practise at what they do, and what safeguards would be needed before moving into a broader or unrestricted role.

See more at https://bulger.co.uk/blogs/?p=266

NHS England: undifferentiated GPs, and revalidation. When policy starts masquerading as regulation

The Problem

GPs are being split into differentiated and undifferentiated camps by NHSE.

NHS England (NHSE) is using its funding of English GP appraisals to lever the GMC appraisal and revalidation process for its own ends. There is no legal framework for the NHSE policy of insiting that GPs remain “undifferentiated”

Many GPs are now going to be labelled low volume workers even when they are working full time, simply because their work is deemed differentiated. Not as NHSE wants, which is for GPs to remain as newly qualified undifferentiated general practictioner, as found working in English street practice.

According to NHSE, GPs can only remain undifferentiated if they do at least 40 sessions in an English general practice as a generalist every year. I wondered if this policy is designed to ease GP shortage should 1000’s of specialising doctors be forced to work back in street practice for their 40 sessions.

NHSE and GMC functions are being mixed up by NHSE, and then is presenting that muddle as if mandated by law or by the GMC.  Policy and guidance is masquerading as regulation.

Also see https://bulger.co.uk/blogs/?p=262

The terms at the heart of the problem

NHSE has introduced (or at least put in operation) the term undifferentiated GP in a way that carries consequences inside appraisal conversations and splits the profession. A differentiated is no longer a proper GP. My GMC R.O. says this has been mandated for many years but I met it for the first time this year (2026). I see that NHS guidance is of 2018 vintage.

In correspondence and discussions, the working definition presented to me is broadly:

  • Undifferentiated: an English general practice generalist doing at least 40 sessions/year of normal non-specialised GP work.
  • Differentiated: a GP working in defined-scope settings (for example, prison GP work, GPwSI/portfolio work, or British Territory work) where NHSE says the work does not count as undifferentiated.
  • Low volume: now used by NHSE in a way that can apply even to full-time doctors if their work is deemed differentiated.

That is an extraordinary shift. Low volume meant low volume. Now it can mean high volume, wrong type.

NHSE argues that all GPs should remain as trained, as generalists in case they return to normal practice. Once on the performers’ list a GP can do anything, including return to street practice without much ado. NHSE considers that a risk. But the same risk applies to specialists changing their scope of work. If we plan to, or change our scope of work we change our CPD accordingly. Nobody need keep up skills they were never need to use. But NHSE insists on it for GPs, and only GPs.

My situation: the new-to-us policy that does not fit with reality

My working pattern has not changed in 15 years. Yet for the first time I have been labelled a low-volume worker. I work part time as an APMS GP in prisons and I also do remote location work. The latter is deliberate as it is one of the few ways left to retain genuinely generalist skills that modern English practice rarely uses (e.g. minor surgery and maternity exposure). In this appraisal year I worked around 135 sessions in prisons and another 45 sessions as undifferentiated-plus GP work in the Falklands, where GMC registration is mandatory, plus a few sessions at my old NHSE practice grouping.   

GMC accepts overseas evidence when a small part of appraisal and 100% where GMC registration is mandatory (Gibraltar and beyond).   NHSE does not accept it, only accepting English time as evidence.

Under the NHSE thinking my work was to be treated as low volume because most of the work was considered differentiated prison work.  The rest was not undertaken in England so would not be counted (despite GMC accepting that evidence).

NHSE seeks that we demonstrate maintenance of skills that are outside our real scope of practice, or else do remedial work listed in our appraisal documentation to become undifferentiated.

Using appraisal and revalidation to enforce local objectives

In communications about this issue, the message was that if a GP does not comply with NHSE undifferentiated expectations the Responsible Officer may find it difficult to recommend revalidation. I cannot see how that can be the case as thr GMC’s core revalidation principle is scope-based: you must be up to date and fit to practise within your scope of practice. It is not a requirement to demonstrate competence in skills you do not do, cannot do, and will not do.  Ii is not a GMC requirement to be undifferentiated. The GMC R.O. could not ‘find it difficult’ when the GP is fulfilling all GMC requirements.

Appraisal is not the place to force doctors to remain undifferentiated. If a commissioner or employer wants a particular service profile, that is a contractual and workforce-planning issue, not something to be smuggled into revalidation.

What the law actually says (England)

1) The performers List law gives NHSE some leverage, but not for this

My R.O. stated that as NHSE is paying for my appraisal it is entitled to make adjustments in line with its policies.

In England, the performers list framework is statutory. The enabling power is in the National Health Service Act 2006, section 91. The current implementing instrument is The National Health Service (Performers Lists) (England) Regulations 2013 (SI 2013/335).

Those regulations require that performers list practitioners participate in an appraisal system established by the Board (NHSE):

That is the legitimate place where NHSE can set process expectations for performers list governance.

2) The Responsible Officer framework

The where you do most work rule sits in the Responsible Officer Regulations, not in GMC registration rules and not in performers list entry rules. See The Medical Profession (Responsible Officers) Regulations 2010, regulation 10 (prescribed connection).

3) Revalidation is anchored in the Medical Act, and the GMC can set guidance, not NHSE

Revalidation is a statutory process under the Medical Act 1983. The GMC may publish guidance on information/evidence required for revalidation under section 29G. The GMC’s 2012 regulations that implement the licence/revalidation machinery are The General Medical Council (Licence to Practise and Revalidation) Regulations 2012 (SI 2012/2685).

In other words: NHSE can create policies for its governance systems. The GMC sets revalidation requirements through its statutory framework and its guidance.

What the GMC itself says about local requirements vs revalidation

This is where the clearest support comes from. Two GMC publications provided to me contain explicit statements that should stop local objectives being imported into revalidation decisions.

GMC, 2017: Update on implementation of Taking Revalidation Forward recommendations

Source: Strategy and Policy Board meeting, 9 February 2017, Agenda item 7. Original GMC link:

https://www.gmc-uk.org/cdn/documents/07—update-on-implementation-of-taking-revalidation-forward-recommendations_pdf-69414753.pdf

‘We are also concerned that there can be confusion between revalidation criteria and local job-related requirements, particularly around mandatory training. We do not consider it acceptable for employers to add management objectives to the evidence required for revalidation. Everyone needs to be clear on what is required for revalidation and what is not’ (page 7).

‘distinguish local initiatives and employment obligations from revalidation requirements in the appraisal process so it is clear to doctors what is necessary for the purposes of revalidation and what is not;’ (page 9)

GMC, 2018: Taking revalidation forward, Working with others to improve revalidation

Source: November 2018. Original GMC link:

https://www.gmc-uk.org/cdn/documents/rev—-taking-revalidation-forward—working-with-others-to-improve-revalidation—dc11687_-76860097.pdf

‘We have made the distinction between GMC requirements and local requirements clearer and emphasised that failure to meet local requirements eg completion of health and safety training shouldn’t influence the revalidation recommendation made about a doctor. (page 7)

These are not my blog opinions. They are explicit statements about the boundary between revalidation requirements and employer or local requirements.

The NHSE reply 

In an NHSE reply to my questions (with my annotations), NHSE accepts some principles in words but then applies a different test in practice. For example:

  • Appraisal should cover the full scope of practice, yes, but NHSE implies that to remain on the performers list the Responsible Officer must be assured the doctor is up to date ‘to work in general practice’, regardless of the doctor’s actual scope.
  • NHSE indicates that if supporting information is primarily overseas, the RO is unlikely to consider it satisfactory, while simultaneously acknowledging exceptions where a UK licence is legally required (which is relevant to various British Overseas Territories)
  • NHSE asserts that the old low volume guidance has been replaced by PLAN 32, If Plan 32 is now the basis, it should be cited clearly and explained.

The most concerning line is the recurring warning that ROs ‘may find it challenging’ to recommend revalidation based on minimal NHS GP work. That looks like using revalidation as an enforcement mechanism for NHSE workforce objectives, even though the GMC’s own published statements warn against precisely that.

Why would we expect a GP to prove competence in unused skills, remain undifferentiated. A breast surgeon is on the GMC register as a general surgeon,, but nobody expects them to demonstrate in their appraisal that they can perform procedures outside their scope pr practice, for example, inserting a renal stent or forming a colostomy when  those are not part of their actual work. The requirement is to be up to date and safe within scope.

NHSE’s undifferentiated status targets GPs, and only GPs  towards a different standard, retain broad skills irrespective of scope, or be treated as low-volume even when working full time.

Summary

  • Appraisal cannot be used or modified to ensure a GP stays on the performer’s list.  NHSE can run a performers list governance system as it does for major complaints.  But otherwise unless a GP fails to work in an area or is not having appraisals, there is no easy mechanism to remove a GP from the performers’ list.  G.P.s cannot be removed for failure to be undifferentiated.
  • The GMC sets revalidation requirements not the NHSE.
  • Appraisal evidence should reflect actual scope of practice.
  • Local requirements must be separated from revalidation requirements, and failure to meet local requirements cannnot, by itself, drive revalidation recommendations. The GMC has said this explicitly.

If NHSE believes it can require undifferentiated work as a condition of remaining on the performers list, then it should cite the precise statutory basis and define the term in a way that is coherent, fair, and challengeable. If it cannot cite the statutory basis, it should stop presenting policy as if it is law or GMC mandate.

 NHSE does have powers as funds and sets the appraisal format. The critical distinction is that GMC revalidation and NHS England Performers List inclusion are not the same legal test. Revalidation concerns fitness to practise and maintenance of the GMC licence. Performers List inclusion concerns suitability and fitness for purpose to provide NHS primary care services in England. NHSE powers are limited in that regard.

Short answer: NHSE cannot simply turn appraisal into a pass/fail exam on whether a GP accepts being undifferentiated.

They can require participation in an appraisal system. They can also expect the appraisal to cover the doctor’s full scope of practice. But the sanctionable issue is not whether the doctor agrees with NHSE’s terminology. The real legal questions would be:

1. Has the doctor engaged with appraisal/revalidation?
2. Has he provided adequate supporting information across his actual scope of work?
3. Is there evidence that his continued inclusion on the performers list is unsafe, unsuitable, fraudulent, or prejudicial to service efficiency?
4. Has he failed to perform relevant performers-list services for 12 months?

If the doctor says:

I dispute the term ‘differentiated’. My scope is prison GP/remote GP/defined-scope generalist work. I maintain competence, CPD, QI, SEA review, feedback and reflection within that actual scope. I do not accept that revalidation requires me to plan to practise outside my current scope.

That is not, by itself, a disciplinary failure.

The possible NHSE levers are these:

Appraisal outcome: the appraiser may record concerns or unresolved issues, but appraisal itself should not be a pass/fail process.
Responsible Officer recommendation: the RO might try and claim, or be trold by NHSE there is insufficient information and seek deferral. That is the practical pressure point that NHSE is attempting to use.
Performers list conditions: NHSE could try to impose conditions, but only on proper statutory grounds, mainly efficiency/fraud prevention, with notice, reasons, representations and appeal rights.
Removal from performers list: possible only under statutory grounds, such as unsuitability, efficiency case, fraud, loss of registration/licence/GP register status, or failure to demonstrate relevant services in the previous 12 months. It is not lawful simply because the doctor refuses to adopt NHSE’s preferred workforce ideology.
Suspension: only where necessary for patient/public protection or public interest, usually pending investigation/removal/conditions. A mere disagreement about “differentiated” status would be a weak basis.

So the key distinction is:

NHSE may ask the doctor to reflect on scope.
NHSE may not lawfully require false reflection or compel a plan to practise outside actual scope as a condition of revalidation, unless it can identify a clear legal basis.

The safest wording for the doctor is not “I refuse to engage”, but:

I have engaged fully. I have reflected on the issue. I dispute the label ‘differentiated’ as being imprecise and potentially misleading. My professional duty is to remain competent, up to date and safe within my actual scope of practice. I do not consider it appropriate, safe, or consistent with GMC scope-based revalidation principles to create a development plan aimed at practising beyond my current scope unless and until I intend to undertake such work.

That preserves engagement while refusing the trap.

All I got the RCGP team so far is ‘The RCGP supports GPs to continue to work as GPs, whether that is providing core general practice services, or GPs with extended roles or other portfolios, and we shall continue to do so’

 

Here is the NHSE reply to my Qs in black NHSE response in blue and my secondary comment in green.  “SRT” is the RCGP designed form low-volume worker 40 sessions or less in total form. “NPL”: National Performers List.
 
1. GPs working in prisons are providing primary care. These sessions should be counted as such; they are APMS performers’ list work – We request completion of the SRT to assess how you keep your skills up to date, as prison work is not considered undifferentiated GP work. (They ignore Shetland or Falklands, but GMC does not)  
2.      For revalidation, GPs must demonstrate they are safe and up to date within their scope of work. There is no GMC requirement to maintain all undifferentiated skills. – As you are on the NPL, the RO must be assured that you remain up to date to work in the general practice. (What is NPL got to do with GMC appraisal?  Once appraised you cannot be removed from the performers list)
3.      The GMC does not require NHS-only work; a GP may work entirely in private practice and still revalidate. – To maintain your position on the NPL, you must continue to work in General Practice. (That is a bit vague, the RO told me it has to be English street NHS general practice)
4.  Non-NHS work is not excluded from appraisal. – Your appraisal should cover the full scope of your practice. (Quite: appraisal is about SCOPE of practice, not more)
5.      Overseas work is not excluded from appraisal evidence, provided it does not form the substantive part of that evidence. –  Overseas work may be included in your appraisal evidence, provided it does not constitute the substantive portion of that evidence. If your supporting information is primarily from overseas practice, the RO is unlikely to consider it satisfactory appraisal. Supporting information should be from UK practice, except in exceptional circumstances, such as a legislative requirement to hold a UK licence in another country (e.g., Gibraltar). that means all British Overseas territories, Isle of Man, to Falklands.  But yet NHSE won’t accept these hours worked calling them “undifferentiated”)

6.       Low-volume worker guidance applies when a GP undertakes 40 sessions or fewer within their scope of work. – This has now been replaced with PLAN 32. Anyone undertaking only one session cannot be removed from the NPL administratively. However, ROs may find it challenging to make a revalidation recommendation based on minimal NHS GP work. Hence, our appraisers continue to request completion of the SRT if fewer than 40 sessions have been undertaken, and we will advise doctors accordingly based on the provided information. (I could not find any reference to all this in Plan 32)
7.The definition of low volume is not based on the scope of primary care practice undertaken. – please see above.
 
You see in (6) “Anyone undertaking only one session cannot be removed from the NPL administratively”   So there is no mechanism for NHSE to remove someone if they do one day’s work in England (and have an appraisal anywhere; appraisal is UK wide).  I could work in England one day, have an appraisal privately or in Scotland (I am on the list there as well) and NHS could not remove me from the performer’s list, so the stipulation that a doctor must remain undifferentiated cannot be enforced.
  
PS.  As it happens, I am not keen on GPs specialising.  I think it frustrates patients and it creates the need for multiple appointments.  Appraisal is NOT the place to attempt to force GPs to remain “undifferentiated”.  That is a contractual issue.  Yet we all drift into a defined scope of practice. We differentiate ourselves.  
    
Pps: NHSE dissolution will not help on jot.  NHS reorganisations are a game of musical chairs and names changes; functions do not change, and we get to see a nice new logo.
 
 
 
 

 

 

References (key links)