Anuj Chathley is a GP with an extended role in medical and surgical dermatology working in Grimsby.
Earlier this year, we were in discussions with our local Integrated Care Board (ICB) regarding the review of our minor surgery and joint injection Locally Enhanced Service (LES). Following a review of costings, it became clear that we were providing the service at a financial loss.
The ICB informed us that they were not undertaking any local reviews of the costings because a national Directed Enhanced Service (DES) for minor surgery and joint injections was about to be announced. Naturally, we hoped that this new national framework would recognise the concerns raised by many GPs over the years (that the true cost of running such services far exceeds the current tariff) and that it would at last bring some real-world alignment between funding and delivery.
Then the national DES was released.
The new tariffs were £43.54 for joint injections and £87.08 for excisions.
At first glance, these figures seemed unreasonably low. I tried to find how they were derived but found no transparent costing methodology. Out of curiosity, I looked up previous tariffs for comparable services. What I discovered made me feel utterly devalued.
I repeat that again: these tariffs are identical to what GPs were being paid 20 years ago.
These figures were almost identical to those paid to GPs nearly two decades ago. No adjustment for inflation. No recognition of increased premises costs, staff wages, accreditation requirements, equipment, or indemnity. No reflection of the rising complexity of care.
I repeat that again: these tariffs are identical to what GPs were being paid 20 years ago.
A wider pattern of undervaluation
This isn’t just about fish and chips, it’s about how general practice is being systematically undervalued.
The Minor Surgery DES framework is intended to allow practices to deliver minor procedures safely in the community, sparing hospital resources and improving access. However, the new DES tariffs represent an almost 30% cut for injections and a 22% cut for excisions compared to the previous local rates used in many ICBs.²
In one region, the Leicester, Leicestershire & Rutland (LLR) LMC calculated that practices were subsidising the NHS by £21.78 per injection and £42.90 per excision under the previous rates.³ The new national figures simply perpetuate that loss.
Despite the rhetoric of “integrated care”, this DES shows little evidence of collaboration or transparency in its creation. The process behind the tariff calculation is opaque, and there was no meaningful consultation with frontline providers.
The British Medical Association (BMA) has repeatedly emphasised that enhanced and directed services must be properly costed and negotiated, yet many of these schemes have not been inflation-adjusted for over a decade.⁴ By comparison, secondary care contracts and private suppliers within the NHS routinely receive annual inflationary uplifts through the NHS Payment Scheme.
The economics don’t add up
Running a minor surgery service in primary care is not a trivial undertaking. It requires:
- appropriately trained and accredited clinicians,
- aseptic facilities and sterilisation processes compliant with infection control standards,
- resuscitation equipment, audit systems, and data reporting,
- and increasingly, external regulation and inspection.
All of these have become costlier year on year. Even indemnity, while now centrally supported, still brings training, governance, and documentation costs.
The absurdity of this comparison highlights a dangerous reality: while other sectors adapt to inflation and rising costs, general practice has been economically immobilised.
Consequences for care
If these tariffs persist, many practices will withdraw from the service, not out of unwillingness but out of financial necessity. Pulse recently reported that LMCs are advising practices to “stop subsidising minor surgery”, warning that current rates make it unsustainable.³
The likely outcome is reduced access to community minor surgery and an increased flow of referrals into secondary care… where the same procedures cost several times more.6 The system therefore saves nothing; it simply shifts cost and inconvenience from one part of the NHS to another.
These are basic business principles… the same principles that keep every other supplier, from laboratories to fish friers, afloat.
Historically, studies have shown that minor surgery in general practice is both safe and cost-effective compared with hospital provision.7 Yet unless the economics reflect the true cost, the service will quietly vanish… not through lack of skill or demand… but through chronic underfunding.
A constructive way forward
If NHS England wishes to sustain community-based procedures, several principles must be embedded into all DES and LES frameworks:
- Transparent costing based on actual delivery costs (staff, premises, consumables, and governance).
- Annual indexation to inflation and pay growth.
- Mandatory consultation with provider representatives before any tariff changes.
- National minimum tariffs to avoid postcode inequity.
- Regular review cycles to ensure tariffs evolve with clinical and economic reality.
These are basic business principles… the same principles that keep every other supplier, from laboratories to fish friers, afloat.
Conclusion
The minor surgery DES should have been an opportunity to reset the relationship between NHS England and primary care, to recognise that well-resourced GP services save the system money and deliver care closer to home. Instead, it has become a case study in undervaluation.
When the price of a portion of fish and chips has tripled in 20 years but the tariff for a joint injection remains static, something has gone seriously wrong with how we value general practice.
If we continue to treat GP services as a fixed-cost commodity in an inflationary world, we will lose them. And when that happens, the cost to the NHS… and to patients… will be far greater than the price of a bag of chips.
References
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BBC News. Fish and chips for 20p? The menu frozen in time. BBC News; 2025 Jun 29. Available from: https://www.bbc.co.uk/news/articles/c0r1jnn7pd8o
[accessed 30/1/26], see also: https://www.nfff.co.uk/cost-of-a-chippy-tea-soars-as-energy-bills-batter-britains-favourite-takeaway/ [accessed 29.1.26], https://metro.co.uk/2025/11/29/much-favourite-items-cost-1995-vs-2025-a-price-comparison-24921536/ [accessed 29.1.26]
- NHS England. Primary Medical Services (Directed Enhanced Services) Directions 2025. London: Department of Health and Social Care, 2025.
- Colivicchi A. GPs told to stop ‘subsidising’ minor surgery as part of collective action. Pulse, 19 Dec 2024.
- BMA. Enhanced services GP practices can seek funding for. British Medical Association, 2024.
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BBC News. Chippy apologises for prices as fish costs surge. BBC News; 2025 Apr 6 [cited 2026 Jan 31]. Available from: https://www.bbc.co.uk/news/articles/cx2w4lqz73no [accessed 29.1.26]
- Lakasing E. Restricting minor surgery in general practice: another example of financial short-termism. Br J Gen Pract. 2010 May;60(574):385-6. doi: 10.3399/bjgp10X502029. PMID: 20423602; PMCID: PMC2858548.
- Pockney P et al. The cost-effectiveness of minor surgery in general practice: a prospective comparison with hospital practice. J Public Health 2004; 26 (3): 264–70.
Featured Photo by Meelan Bawjee on Unsplash
