Incentives for choose and book will be extended for another year as GP practices missed uptake targets.

Last week NHS Employers and the GPs committee of the British Medical Association agreed that the directed enhanced services for access and choose and book would be rolled over unchanged this year, at a cost to primary care trusts of£158m.

The government's target of 90 per cent of GP referrals to be made through choose and book by the end of March this year was missed by every strategic health authority.

But the decision on whether to continue with the DES incentive payments were delayed by a stand-off over GP pay. During the uncertainty, many PCTs have introduced their own incentive as a local enhanced service.

NHS Employers head of primary care contracting Chris Dowse said the absence of a national DES could have jeopardised momentum on choose and book: 'If you offer incentives at a national level you raise standards across the country. There would be some successful local enhanced services, but there would be inconsistencies,' she said.

The DES scheme will supersede local agreements and come out of PCTs' baseline budgets. Where PCTs want to offer extra incentives at their own expense then local enhanced services can be continued, said Ms Dowse.

NHS Alliance general medical services lead Dr David Jenner said delaying the decision had caused chaos: 'PCTs have been put in an impossible situation. They still had targets to meet and many have had to develop and negotiate local enhanced services which will now have to be reviewed. This could lead to conflict with practices,' he said.