The PCN Investment and Impact Fund Explained

NHS England published a set of guidance last week in relation to the PCN DES.  One specific piece of guidance was detail on how the new Investment and Impact Fund (IIF) is going to work.

The IIF has the feel of one of those initiatives that probably started out as a good idea, but has been watered down so much in the making of it a reality that its impact is likely to be minimal.

For a start, the sums we are talking about pale into insignificance when compared to some of the other funds on offer to PCNs.  An “average” PCN can earn a maximum of £21,534 in this year’s IIF.  Compare that with the c£350,000 (£7.131 per weighted patient (pwp)) the average PCN has received through the Additional Role Reimbursement Scheme, or even the £75,000 (£1.50 pwp) core PCN funding.  These sums require very little effort from the PCN.

PCNs have already received  c£13,500 (£0.27 per weighted patient) for the six months up to the end of September as a Covid “support payment” for the PCN.  The question, then, is whether the £21,534 available between October 1st and March 31st is going to be sufficient to entice PCNs into action, particularly in the context of everything else that is going on.

It depends to some extent on how achievable the targets are.  The scheme is designed like a QOF scheme, but at a PCN rather than practice level.  There are 194 IIF “points” available, each worth £111 each (adjusted for list size and prevalence).  These points are divided across 6 indicators.  For each indicator there are limits outside of which practices either earn zero or the maximum, with a sliding scale applied in between:

Indicator No of points Upper limit Lower Limit £ available
% patients aged 65+ who received a seasonal flu vaccination 72 77% 70% £7,992
%patients on the learning disability register aged 14+ who received an annual learning disability health check 47 80% 49% £5,217
% patients referred to social prescribing 25 0.4% 0.8% £2,775
% patients aged 65+ currently prescribed a non-steroidal anti-inflammatory drug (NSAID) without a gastro-protective medicine 32 30% 43% £3,552
% patients aged 18+ currently prescribed an oral anticoagulant (warfarin or a direct oral anticoagulant) and an antiplatelet without a gastro-protective medicine 6 25% 40% £666
% patients aged 18+ currently prescribed aspirin and another antiplatelet without a gastro-protective medicine 12 25% 42% £1,332

It will be hard for any individual practice to achieve the 75% flu vaccination target, let alone 77%.  It will be even more difficult for a whole PCN to achieve it. A non-guaranteed incentive payment of less than £8,000 is not going to change behaviour.  PCNs may well work very hard to achieve as high a vaccination coverage as possible for their local population, but it will be because they want to protect their local population, not because of the IIF.

Even if a PCN does examine the scheme and thinks the rewards could be worth the effort, there are further barriers to overcome.  To earn any IIF funding, a PCN must first “commit in writing to the commissioner that it will reinvest the total achievement payment into additional workforce and/or primary medical services” (2.15).

I find this astonishing.  The IIF funding is not recurrent (it has to be re-earnt each year) but the cost of any additional staff or service delivery is, so how is this supposed to work as an incentive? Equally, if a PCN invests in extra resources to achieve these targets it does not seem as if they can refund their own outlay with any money earned.

We will have to wait and see how these restrictions are applied in practice (e.g. whether any earned IIF funding can be applied retrospectively, whether it can be used to fund on-costs of additional staff not covered by ARRS funds etc).  Hopefully common sense will prevail.  Either way, it seems that either the policy should be to create incentives and allow PCNs the freedom to innovate to achieve them, and the freedom to use those incentives as it sees fit, or it should abandon any notion of payment for performance (which is what this scheme at its heart is) and stick with fixed payments for expected deliverables.  As it stands, this scheme neither promotes investment nor looks like it will have much impact.

The Growing Influence of PCNs

We are just over a year from the formation of PCNs and, despite the pandemic, their importance and influence is growing.  Could this incarnation of general practice be the one that finally starts to shape the NHS around the needs of local populations?

The voice of general practice has long been sought after.  Right back from the days of GP fundholding, different regimes have tried different ways to enable general practice, the “gatekeepers” of the NHS, to have a bigger say in how the service is organised.

It would seem the main problem, however, is that this has been done throughout any extremely long NHS experiment with the purchaser provider split.  Each attempt so far (fundholding, primary care groups, primary care trusts, practice based commissioning and clinical commissioning groups) has been hampered by the inability of any of these incarnations (or indeed any form of purchasing) to make its mark on the shape of healthcare provision.

As the purchasing model is finally put out of its misery, and CCGs simultaneously reduce in number and influence, the new order is starting to take shape.  Centre stage are Primary Care Networks.

The NHS already knows that merging organisations makes no difference.  Integration is not about the merger of providers.  We used to have merged community and acute providers.   Back then the argument was that resources were being stripped from community services to fund hospital services.  What was needed was to make community services organisations independent in their own right.  We have just come back full circle.

Merging or not merging organisations is not what integration is about.  Integration is about doing things differently.  About working in different ways to change the experience and outcomes for local people.  The only chance integration, and integrated care systems, has of making this difference is at the level of the Primary Care Network.

This is really important.  Integrated care systems and integrated care partnerships are dependent on PCNs to be successful.

PCNs may only be just over one year old, but we already have groups of practices almost universally working together to provide care for their local populations.  The work to deliver enhanced care into care homes, and to deliver a social prescribing service, has already begun.  Practices are building relationships with voluntary organisations, local authorities, and care and nursing homes in ways not seen before.

We are less than one month away from PCNs finding ways to deliver structured medication reviews to those who need it most, and to support early cancer diagnosis.  With each new service we will see new relationships form, new ways of delivery develop, and new benefits for patients and local people result.

PCNs are not purely conceptual (the problem with many of the purchasing constructs).  An army of new staff who will actively deliver care are currently being recruited.  PCNs up and down the land are building teams of pharmacists, physiotherapists, physician associates and more.  About 10,000 new staff are being put in place this year to provide the energy and impetus to make this work.  Thousands more are to follow next year, and the year after, and the year after that.

PCNs worry about their voice at the “top table” of integrated care.  But the reality is the power sits with them, because they are the ones who can effect real change.  This power will only grow, as their resources grow and they deliver more.  This really could be the opportunity for general practice to finally make the difference it has been seeking to make for so long.

Do PCNs need a manager?

In the update to this year’s GP contract the increase in funding for additional roles for PCNs from 70% to 100% was heralded in this way:

We have heard that the £1.50/head support for PCNs – worth £72,000 annually for an average PCN – has been deployed to contribute to the 30% funding of additional roles.  Instead it can now be used as needed for development and transformation support.  It equates to a full-time band 8A, and increasing the contribution of Clinical Director time by almost 50%.  We encourage Clinical Directors to use the funding to ensure sufficient support as rapidly as possible”.

A band 8A manager, for those not fully conversant with NHS pay scales, attracts a not insignificant salary of between £45,753 and £51,668.

Some PCNs have taken the plunge and employed a manager.  Others are more reticent.  The relative ease with which the PCN requirements were able to be handled in 2019/20 meant many PCNs decided to return much of the (unused) £1.50 to practices at the end of the year, and in doing so set a precedent that some PCN CDs are now uncomfortable breaking.

Part of the problem of course is that a salary of c£50K for a PCN manager is significantly higher than the salary of the average practice manager.  On the one hand, PCN CDs don’t want to be accused of stealing practice managers from local practices, and on the other it is very hard for a manager with no local knowledge to come in and work effectively across practices.  Especially when the local PMs know exactly how much the incoming PCN manager is being paid…

It is very difficult for an outsider to come in as manager and be effective straight away with a group of practices.  This requires trust, which needs time to build, and the covid restrictions make that all the more difficult right now.  It is hard to build relationships via Zoom.

Do PCNs really need a manager?  Is it worth the investment?

Many PCNs have been able to cope perfectly adequately without one until now.  Unfortunately this is no great indicator that this will be the case in future.  On October 1st three new service specifications kick in for PCNs (care homes, medication reviews and supporting early cancer diagnosis), alongside the requirement for PCNs to offer a social prescribing service.  In addition, the new Investment and Impact fund (think PCN QOF) begins.

In six months’ time four more service specifications will need to be delivered, while at the same time PCNs will take on the responsibility for delivering extended access.

Many PCNs are currently recruiting an average of 10 staff, with another 6 or 7 to be recruited by the start of next year.  These staff will generate work, headaches and challenges (new staff always do), and someone will need to pick up the pieces.

Without a PCN manager, who is going to do all of this work?  This is without mentioning the plethora of system meetings (just say no), the data sharing and patient engagement requirements, and any local initiatives the PCN has committed to.  Is the PCN CD expected to do all of this in 2 or 3 sessions a week?  Or the PCN practice managers in their spare time?  I don’t think so.

If your PCN does not yet have a manager in place, the time has come to bite the bullet and recruit.  From October not having a PCN manager will cost more than having one.  Don’t put it off any longer.  Some practices might not like it, but the sheer scale of work means that PCNs will not be able to function effectively without one from October.

Why Flu Planning is So Difficult this Year

There cant be anyone working in general practice who has not yet been asked what their plans are for the flu season.  But I am not 100% sure those asking always understand why the question is so difficult this year.

We are still very much in the planning stage, as we await the arrival of the first vaccines.  It is difficult to know how well prepared practices are, but what is certain is preparations are much more difficult than in previous years.

In part this is because of national shifting sands on three fronts: the cohorts to be vaccinated; the PPE requirements; and getting hold of the vaccines.

The season started with a message that 50-64 year olds are to receive the flu vaccine this year.  This was then changed to a message that this will only happen later in the season, if vaccine supplies allow.  So now we have a vocal cohort of individuals contacting practices demanding a vaccine that practices won’t be paid to administer, and confusion across practices as to exactly what they are supposed to be doing.

Initially the PPE requirements were a face mask for every session, with new gloves and apron to be worn for each patient.  Once forward thinking practices, PCNs and GP federations had dutifully mass purchased the required equipment, the guidance was changed so that only sessional face masks are now required.  And who knows whether it will change again in future.

As for vaccine supplies, no one knows how that is supposed to work.  Because practices generally order vaccines a year in advance, the orders placed are for the normally expected amounts.  This would be 50-55% of a practice’s usual cohort, which means practices are well short of the 75% needed to achieve the target, even before this year’s additional cohorts are added on.

Anyone who has tried to order additional supplies will know all remaining vaccine stocks are being purchased centrally.  What we don’t know is how any central supply will work in practice, and how these vaccines will be distributed to practices.  But given the recent experience of central purchasing and distribution of PPE, it is not surprising there is little confidence amongst practices that this will work well.

However, these are not even the biggest challenges practices face in developing their flu plans.  Traditional systems of flu delivery (bringing in large numbers of patients over a weekend or two) simply will not work this year.

The social distancing requirements mean that patients need to be given more specific appointment times, and the usual method of “stacking” multiple patients at once cannot be used.  The high DNA rates that can usually be offset using this method will have a significant impact.  Practices will also need additional staff to ensure social distancing standards are adhered to and manage any queues that form.

At the same time, the social distancing and PPE requirements mean that clinicians will be able to vaccinate far less patients per session.  I have seen the overall impact of this estimated at a vaccination rate of one patient every six or even eight minutes, compared to one roughly every two minutes in previous years.

What this means is that practices can see less patients in a session, but with higher staff costs.  The net impact has been estimated as meaning that the costs of vaccination will rise by between £6 and £9 per patient.  This of course calls into question whether practices can even carry out the vaccinations this year for the fee that is being offered (which currently remains unchanged from previous years).

This is why flu planning is so difficult this year.  I am not sure the system fully yet understands the extent of the challenge this creates for general practice, but I suspect when we move from the planning to the delivery phase these challenges will become much more evident.

Start Recruiting 2021/22 Additional Roles Now

We have all been struggling to get our heads around the Additional Role Reimbursement Scheme (ARRS) for PCNs, and in particular how to make most of the opportunity it creates.

Significant changes were made to the ARRS in the 2020/21 GP contract (in particular the increase in reimbursement from 70% to 100%, and widening the number of available roles to 10).  However, the impact of these changes were somewhat lost initially, as a result of uncertainty as to whether PCNs were going to sign up to the revised DES and, of course, the emergence of coronavirus.

But now PCNs are moving forward as quickly as they can with their recruitment plans.

The problem is, despite an apparent enthusiasm nationally for each PCN to use all of its ARRS fund to be used, the rules seem to conspire against this happening.  PCNs can only be reimbursed up to a maximum monthly reimbursable amount, which means funds can only be used once the new staff are actually in post.

In order to spend all of the money PCNs would have needed their new staff to be in post on the 1st April.  But given at that point most practices had not even signed up to the DES, not to mention the distractions posed by the small matter of a pandemic, it is not surprising that for many PCNs staff are only being recruited now.

It seems likely (and entirely reasonable, given the PCN DES specifications only start on the 1st October) that the majority of the new PCN roles will probably not be in post until October.  And if the PCN staff do not start until October this means somewhere in the region of half the available ARRS money will not be spent.

How then can PCNs ensure they make the most of the available ARRS fund for this year?

The best way is for PCNs to start their recruitment to their 2021/22 roles now.  PCNs can use the underspend against this year’s roles to pay for additional months of next year’s roles.

The “average” PCN has £344k available for additional roles this year.  This goes up by nearly 75% to £597k next year.  Even a PCN that is on track to spend as much as 70% of its funds this year could still afford to have all of its roles for next year start in the middle of November this year, and remain within budget this year and next.

This means, taking into account the need for notice periods and the delays these cause to recruitment, PCNs who want to maximise the use of their allocation would be wise to start their recruitment for next year now.

One caveat of course is that paramedics and mental health practitioners cannot be employed until April 2021.  These roles will be popular, so even for these it is worth considering starting the recruitment process at the end of October/early November so that they are recruited and ready to go on April 1st 2021.

Even for those PCNs who did manage to get ahead of the curve and are not looking at much of an in year underspend, it is still worth being ready for early recruitment to next year’s roles.  It is highly likely your neighbouring PCNs will have an underspend (because the majority will), and the rules are that any underspend in an area should be offered in the first instance to the neighbouring PCNs, rather than being lost to general practice.

PCN recruitment may have got off to a slow start this year, but I suspect this wont be the same in the years to come as savvy PCNs get started well before the next year begins!

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