The guidance, called Raising the Bar, tells PCTs 'it is essential to take an aggressive approach' and provides a template letter for threatening practices with contract termination.

15 key clauses in the GMS contract have been picked out in the guidance that can be scrutinised and used to declare that practices are in breach of their contracts.

The guidance comes a month after the NHS Confederation called for a new GP contract ‘with stronger contractual levers to deal with unresponsive practices'.

Produced by the DoH's Health Inequalities National Support Team (HINST), it offers PCTs advice on how to improve standards across primary care in England.

Raising the Bar acknowledges that 'many PCTs believe the current GP contract is too vague for [driving up performance].

'However, greater and earlier use of contract breach notices can encourage quality improvements', it says.

It recommends PCTs call upon relevant experts, such as health and safety inspectors or data protection teams, to scrutinise practices' adherence to key contractual clauses.

The document says that ‘appraisal and reviews' should also be used to build a body of evidence against practices.

The report found placing practices in performance ‘league tables' was an effective way to drive up performance in even the best practices.

'70% QOF achievement means 30% failure,' the document states. It backs the use of ‘QOF plus' or locally negotiated 'quality improvement frameworks' to improve standards beyond the remit of the QOF.

PCTs are urged to ‘stretch targets in PMS contracts without extra costs'. ‘Funds can be redistributed once behaviours change,' the guidance adds.