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Show me the money

As the latest set of indicators for the next phase of the Impact and Investment Fund are digested, PCNs are getting to grips with how to approach, access and use the funds. Emma Wilkinson reports

The Impact and Investment Fund (IIF) will invest up to £150m in PCNs in this financial year if they achieve what is being asked.

It will be introduced in a phased ‘stepwise’ approach with 19 initial indicators where points can be earned. This will build to a more comprehensive package for 2022/23.

Ultimately the overall goals in the IIF are laudable, say PCNs. But as always, the devil is in the detail. Some of the indicators will be challenging to achieve. Not everyone is starting from the same position. And the current pressures in general practice mean there is little capacity to meet yet more requirements. 

There are also big questions about the data and how PCNs can check their current position against the new requirements. It is envisaged the IIF targets will be ‘a QOF for PCNs’, and therefore a familiar process, but some PCNs have observed that this might mean they become a tick-box exercise instead of delivering meaningful change.

Dr Pramit Patel, chair of the NHS Confederation’s PCN Network, says the IIF will provide significant and badly needed extra investment in primary care. But it must be in ‘a format that is manageable, with targets that are achievable and will lead to improved patient outcomes’, he says.

It is likely that clinical directors (CDs) will find the IIF complex initially, he adds, and in the current climate it will not be easy to find the necessary time and space to manage that.

Beccy Baird (left), senior fellow at The King’s Fund health policy think-tank, said NHS England has paid attention to the fact that delivering the service specifications will be tough at the moment and have reined back the demands.

But even the most upbeat and forward-looking GPs are currently very stressed, she says. On top of increasing patient demand, PCN CDs already have a lot on their shoulders with the supervision and management of the additional roles reimbursement scheme (ARRS) and large vaccination programmes, she adds.

‘And I don’t think enough thought has been paid to the infrastructure to support primary care providers,’ she says. Providers who had a history of working together and had operational support for this before the pandemic now have an advantage. ‘Having that infrastructure for data analytics and all that kind of stuff is really critical,’ she says. ‘Now we’re getting more outliers who aren’t part of these networks,’ she adds. 

Sheinaz Stansfield, a practice manager and director of transformation at Birtley, Oxford Terrace PCN in Gateshead, Tyne and Wear, says her PCN has a very clear structure with delegated areas of work that will help it achieve what’s required, but the PCN has a huge variety in patient population across its three practices. For some, screening is a real challenge; one has nine care homes, another has none.

The PCN has created an action plan for what it will achieve as a group. ‘We never wanted to be in the position where we were having to performance-manage each other. We support each other to do what’s needed.’

PCNs are about strengthening population health and the IIF does fit with this, she says. ‘I really welcome the focus on health inequalities and better outcomes in communities. But I would be lying if I said it wasn’t hard.’ 

Dr Emma Rowley-Conwy (left), clinical director at Streatham PCN, south London, says while the IIF indicators broadly make sense, networks should still take a critical approach. ‘If you’re currently way off a target, will the effort to achieve it be worthwhile? We can probably do around two-thirds of it.’ 

This year will be an interesting exercise that will probably affect how PCNs engage with the IIF in the future, she adds.

Dr Stephanie Mason, joint CD at Holderness Health PCN in the East Riding of Yorkshire, believes its set-up as a single practice PCN has some advantages. Her PCN has started to look at how its priorities and existing projects line up with the IIF.

‘We have clinical leads for different areas and my role is to co-ordinate so we don’t have two people doing the same piece of work,’ she says. ‘A lot is still in the planning phases.’

Some of the indicators will be easier to achieve than others, she adds. ‘Some of them are really challenging. Things like – and we haven’t fully started on it yet – analysing A&E attendance, which will all depend on the quality of data. I’m not sure the outcome will be what they think, which is to dramatically reduce A&E attendance, because that’s been the holy grail we have been seeking for years.’

This indicator is the one that generally seems least welcome. It asks PCNs to analyse and discuss the implications of data on A&E rates for minor conditions with the local ICS and make a plan to reduce unnecessary attendances and admissions.

Dr Tom Rustom, clinical director at Healthy Horley PCN in Surrey, says: ‘It’s like someone has decided we need to reduce A&E [attendances], so let’s stick that in. It seems out of keeping with the rest of it.’

Broadly speaking, his PCN’s approach will be to have accountable people for each of the different areas, with the first step to look at coding and monitoring. There are parts – for example online consultations – where Healthy Horley is confident it is achieving above the threshold, but it will need to invest in admin time to prove it. ‘It’s quite a big exercise in showing we’re doing what we’re already doing,’ he says.

Healthy Horley has also decided to invest in blood pressure checks, which is worth about £10,000. For this, the PCN will need a healthcare assistant and admin support and will buy blood pressure monitoring devices for patients.

‘The biggest challenge – as it is for the NHS as a whole – is not lack of funding or resource,’ he says. ‘It’s lack of people. Identifying people who are not exhausted and burnt out and want to do more work is the hard bit.’ 

Dr Rustom is very clear that his PCN doesn’t want to just tick boxes. ‘We’re going to set our own priorities that make sense to us and make the national guidance fit that – rather than the other way round. I’m not taking the IIF as a set of specifications but as broadly the direction we want to travel.’

A large part of the IIF is work that is already being done, but for a lot of practices, the two indicators for decarbonising inhalers will be a lot of work, predicts Dr Mason. ‘We have already been doing some work on this so we’re quite lucky. As a goal and aspiration we absolutely should be doing it. Rather, the question is, is now the right time, with all the other challenges we have.’

Her CCG has produced a spreadsheet to show what the indicators mean for practices – hers is rural, coastal and very deprived. ‘There will be conversations about what areas are prioritised,’ she says. ‘And not just for income; we will have to discuss whether we focus on things we can achieve. There is an assumption that all PCNs are the same and they’re really not.’ 

Not having up-to-date figures on the PCN dashboard is causing frustration and preventing PCNs from doing the IIF work, some network leaders warn. Dr Rowley-Conwy says her PCN has repeatedly been promised the figures would be available by now. 

Accuracy of data will be an issue for targets involving online consultations, social prescribing, A&E attendances and care home beds, she explains, because some of it comes from outside general practice and isn’t easily coded. ‘It’s very difficult to understand some of the targets when you haven’t got the data in front of you. Having really good data will be crucial otherwise you’re set up to fail.’

Ms Stansfield agrees: ‘I do worry about the thresholds because we’ve got no way of looking at what we’re achieving. We’re 18 months into PCNs and we still don’t have the dashboard.’

Some PCNs have started to ask for the operational support The King’s Fund said is sorely needed. Dr Rowley-Conwy says PCN directors locally have made the case for a flexible business support unit offering a range of services because everyone needs different things. ‘My nine-and-a-half hours a week is not enough; you could spend that just trying to sort the IIF,’ she adds.

PCNs will also need to have clear discussions about how this money will be reinvested fairly between them, she says. She wants to do more community projects but her GP colleagues are keen to invest in staff and other initiatives that have an immediate and clear impact on capacity.

Those trying to get their heads around the IIF may not yet be thinking about how to invest the money, which has to go back into services, but everyone needs to have those conversations now, Dr Rustom advises.

‘The fairest way is that the money follows the patient. But this leaves struggling practices behind.’ 

He adds: ‘Our LMC advised this is a really important discussion for PCNs to have early, to make sure it’s clear how that money will be divided. Get it written down.’ 

Dr Sayanthan Ganesaratnam, South London’s East Merton PCN clinical lead and NHS Confederation PCN network board London representative, believes that while the current targets are reasonable and phased, the work being done now won’t realistically make an impact for years and PCNs must be empowered to have a strong voice at every level in ICSs in order to achieve change.

‘Over time, all PCNs have the potential to succeed with the IIF. In order to deliver, up-front funding is needed rather than retrospective performance-based funding. 

‘PCNs need to work on the assumption they will receive the funding. The majority of the indicators will take
10 years to make an impact and require collaborative system working. I do think the IIF specifications take this into account. I just hope PCNs are given time to mature and develop so we get the opportunity to see this through.’

First phase of IIF

  • For 2021/22, there are 19 indicators. Six of these started in April and the rest were introduced in October.
  • They are split into three categories – prevention and tackling inequalities, providing high quality care and creating
    a sustainable NHS.
  • For 2021/22, each PCN can earn a maximum of 666 IIF points. Each point is worth £200 adjusted for list size and prevalence.
  • Indicators can either be qualitative (where PCNs can either earn all the points or no points based on meeting all the criteria) or quantitative (based on how many interventions have been delivered in the eligible population and may be measured by numbers, standard or improvement over time).
  • There is an upper and lower threshold for points that a PCN can earn for standard and improvement quantitative indicators. Above these, PCNs get all the points, and below they get zero.
    In between the thresholds they get the points proportional
    to achievement.
  • Exceptions known as personalised care adjustments can be applied, for example if patients are offered a flu vaccination and refuse it.
  • The 2022/23 IIF will be based on improving prevention and tackling health inequalities; supporting better patient outcomes in the community through proactive primary care; supporting improved patient access; delivering better outcomes for patients on medication; and helping create a more sustainable NHS. It will be worth £225m rising to £300m in 2023/24.

More detailed guidance on achieving the indicators can be found from NHS England here