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 1^st and March 31^st 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:

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.

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.