Indicative Activity Plans should not apply to minor and urgent eye condition services

Executive summary

Indicative Activity Plans (IAPs) are from April 2026 expected to be used by Integrated Care Boards (ICBs) to control activity and manage financial pressures across NHS services. While IAPs can be appropriate for certain planned or elective services, they are not suitable for enhanced primary eye care, including minor and urgent eye condition services.

These eye care services exist to reduce pressure on GPs, A&E and hospital eye services, and their activity reflects genuine, unplanned clinical demand. Applying IAPs risks restricting access, undermining patient flow, and shifting pressure back onto already overstretched parts of the health system.

The AOP believes that minor and urgent eye care services must be formally excluded from the application of IAPs and related activity‑management mechanisms.

What’s the background?

Indicative Activity Plans (IAPs) are a contract management mechanism used by ICBs through the NHS Standard Contract to forecast and manage the level of activity they expect providers to deliver. They help commissioners plan volumes and costs but do not create a hard contractual limit. If activity exceeds the IAP, commissioners can introduce an Activity Management Plan (AMP), a more interventionist mechanism that may include financial consequences. IAPs apply to all services paid by activity, through urgent and non-elective care. Activity delivered via a block contract is normally exempt.

An IAP is a form of contract management that can be used by commissioners, typically ICBs via the NHS Standard Contract to manage the amount of activity that is performed under a contract. The IAP allows commissioners to plan for the level and potential cost of activity that will be delivered by those they contract with. Providing a greater or lesser amount of activity than the IAP isn’t necessarily a breach of contract. IAPs aren’t included in primary legislation, they are instead derived from a semi-complex structure of other pieces of legislation. This begins with the National Health Service Act 2006 and its subsequent amendments via the Health and Social Care Act 2012 and the Health and Care Act 2022. These provide the power for NHS England to insist upon a standard form of contract when they commission services, this standard form is known as “The NHS Standard Contract”. This contract is used to commission most healthcare services, notable exceptions being the General Medical Services contract (GMS), General Dental Services contract (GDS), General Pharmaceutical Contract (GPS) and the General Ophthalmic Services contract (GOS).

It is within the NHS Standard Contract that IAPs can be found. The NHS Standard Contract runs alongside the NHS Payment Scheme and is supported by ‘Technical Guidance’ issued by NHS England. The NHS Standard Contract is reviewed and following a consultation process, revised each year by NHS England. The 2025/26 NHS Standard Contract strengthened the role of IAPs by saying that they should be in place within three months of the service start date, or by 30 June 2025 for existing contracts.

If the provider and commissioner cannot agree an IAP, it is possible for the commissioner to impose an IAP. The IAP should explain how the new activity volumes has been derived, for example population or demographic growth, or strategic aims of the commissioner. This volume target shouldn’t be simply based upon last year’s data but should look at the population need. IAPs shouldn’t act as a ceiling on activity as they are by definition ‘indicative’, however if actual activity exceeds the IAP the commissioner can move to an Activity Management Plan (AMP). This is a firmer, more interventional tool designed to bring activity within the IAP. An AMP may include financial impacts on providers, for example the commissioner may not pay for additional activity. Commissioners must ensure that they consider how an AMP will impact on equality of access to services, service quality and patient safety, and they must also ensure they follow correct contractual processes with the provider before setting an AMP.

The NHS Standard contract does not explicitly exclude any particular care category. IAPs are applicable for any service paid for on an activity basis. Those paid on block contracts are out of scope as the level of payment is not directly linked to activity.

Non-elective, urgent or emergency care is often funded on a fixed payment (block) contract, therefore is usually excluded from IAPs.

What is happening in eye care? 

There have been reports in the media about the growth in ophthalmology services delivered via independent sector providers (ISPs), specifically cataract surgery. The associated costs attached to this increase in activity, especially in financially constrained times, has attracted the attention of ICBs. However, we believe it is important to draw a distinction between these challenges and the services delivered by primary eye care. In particular, this applies to IAPs against minor and urgent eye care services.

Minor and urgent eye care services are designed to:

• Divert avoidable demand away from A&E departments, which are frequently operating beyond safe capacity
• Reduce pressure on GP appointments by ensuring patients with eye symptoms are assessed by the most appropriate clinician
• Prevent escalation of eye conditions that would otherwise require hospital ophthalmology intervention.

Activity within these services naturally fluctuates with clinical need. Attempts to restrict volume through IAPs risk sending patients back to overstretched acute and primary medical services – creating a false economy and contributing to system inefficiency.

Some have suggested that low level eye presentations could be absorbed by pharmacy or selfcare. However, pharmacy colleagues do not have access to the specialist diagnostic equipment required for safe assessment of many eye conditions, including those that initially present with apparently “simple” symptoms. Optometry practices, equipped with slit lamps, imaging and clinical expertise, are essential to safe triage and assessment.

In addition, in this debate all too often cost and value are used interchangeably – but in our view, while they are related, they are different. We know patients value safe and efficient access to the clinical expertise found within primary eye care. This value means, for example, that elderly or vulnerable adults are provided with reassurance and advice on how to manage an eye condition. While, in empirical terms, that condition may not have been sight threatening, the value of seeing an expert clinician has health and social benefits for the patient.

We believe that minor and urgent eye condition services must be formally excluded from the use of IAPs. This is essential to prevent unintended restrictions on access and safeguard system flow, and we ask DHSC and NHS England to provide explicit national guidance requiring ICBs to exempt these services. Clear national instruction is essential to prevent inconsistent local interpretation and to protect the ability of primary eye care to reduce pressure on GPs and A&E.

Our recommendations

We are calling for clear national action to prevent inappropriate use of IAPs in primary eye care:

1. DHSC and NHS England must issue explicit national guidance 
Guidance should require ICBs to exclude minor and urgent eye condition services from IAPs and Activity Management Plans, recognising their role in system flow and urgent care diversion.  

2. Protect equitable access to primary eye care 

Any activity‑management mechanism that risks restricting access must be avoided. National guidance must ensure consistency across England and prevent variation based on local interpretation.  

3. Recognise the unique clinical value of primary eye care 

NHS England should formally acknowledge that enhanced primary eye care services provide essential urgent and preventive care, supporting hospital ophthalmology, GPs and A&E.  

4. Commissioning frameworks must reflect clinical reality 

Commissioners should be supported to use commissioning models that enable, rather than restrict, the contribution of optometry to urgent and unplanned care.