Whilst we are already a couple of months into the new financial year, with so much going on it has been hard for everyone to fully get their heads round the changes to the Impact and Investment Fund (IIF) for 2021/22.  This week I summarise those changes and what it means for PCNs and practices.

I wrote last year about the Impact and Investment Fund when it was first introduced.  You will recall for the first six months of last year the funding was protected as a covid fund for PCNs.  The IIF was then launched in October, in the format of a ‘QOF for PCNs’.

PCNs are yet to receive money earned from the IIF for the last six months of 2020/21.  As I understand it once the figures have been collated nationally, and they have established exactly what an “average” PCN comprises of, PCNs will be sent a draft declaration which they will need to confirm as accurate, or appeal to their commissioner if the figures are wrong.  The amount of time it is taking to pull these figures together suggests there may be trouble ahead in getting final agreement on these figures!

Year 2 of the IIF is nonetheless underway.  The scheme works the same way as last year, with minimal changes.  The prescribing indicators have been dropped (I suspect at least in part to do with the challenges of integrating the prescribing database with the information from GP systems).  This year there are three flu vaccination indicators, the social prescribing and annual LD health check indicators remain (with adjusted thresholds), and there is a new one off indicator of “mapping appointment categories to new national categories” which needs to be completed by the 30^th June.

There is £200 available per point (adjusted for list size and prevalence), with 225 points available in total.  The indicators and amounts available for an “average” PCN are below (also see the PCN DES specification Annex D, p103):

The amount available is roughly double what was available for the last six months of last year (£40,500, compared to £21,500 for an average PCN last year).  A key point to note here is that only one third of the £150M set aside for the IIF in the contract for this year has currently been allocated. The plan is to allocate the rest of it to new indicators to be introduced from 1^st October (Covid permitting) with double the value of the existing indicators.  My understanding is these indicators are most likely to be linked to delivery of the new PCN specifications also due to be introduced at that time.

So by the end of the year the IIF is likely to be worth over £120k to the average PCN.  This is due to increase further to £250k by 2023/24.  During this year the IIF will overtake the core funding of £1.50 per head in terms of value to the PCN, and will continue to grow thereafter.

The flu indicators, representing 142 of the 225 points on offer, do not start until September, so at present there is relatively little for PCNs to do, other than to ensure they have effective monitoring and reporting systems in place, to try and get ahead of the social prescribing referral target, and to ensure all practices carry out the appointment mapping exercise.

But this will most likely be the calm before the storm.  The importance of the IIF may be minimal at present, but the values attached to it mean this is likely to change significantly in the second half of the year.  At that point the new indicators alongside the existing flu ones will mean the work really begins.

It has been a difficult week for general practice.  The main source of the problem has been a letter from NHS England that panders to press criticism by mandating practices to “offer face to face appointments” (implying they have not), and to allow patients to choose whether they need to be seen face to face or not (“practices should respect preferences for face to face care unless there are good clinical reasons to the contrary”).

The widespread anger this letter has caused is not difficult to understand.  Many practices have been uncomfortable with virtual appointments for a long time, but the ‘total triage’ model was mandated by NHS England in the first place as a response to the pandemic.  To then be criticised on the front page of the Telegraph for using it is galling.

The workload itself in general practice has risen to unsustainable levels over the last few months, in part fuelled by the additional demand from the new routes of access.  Practices are already offering face to face appointments (the implication they are not is of itself insulting), but what this does is raise patient expectations to expect an appointment with their GP whenever they want one.  It is GP receptionists who often bear the brunt where these expectations meet reality, and in extreme circumstances can result in vandalism of practices.

This government’s biggest success has been the vaccination programme, the delivery of which has largely been down to general practice.  There is no mention of this in the letter, of the amount of additional work this has put upon practices, or even any acknowledgement of the contribution made.  Any lingering hopes that the role of general practice in the vaccination programme would change the public perception of GP practices have been sadly extinguished by this letter.

So where does this leave general practice?  What is the right way to respond?

The first thing to note is that the letter is overtly political.  The government is obsessed with access to GP practices (and has been for the last 10 years) because it understands the link between access to a GP practice (where so many of the NHS consultations take place) and the overall public perception of the NHS.

Equally the media understand this.  So a story that demonstrates there are problems with access to your GP is a story that demonstrates a government is failing in its handling of the NHS.  The Telegraph in particular has been trying to make a story about access to GP practices throughout the pandemic. Like it or not, GP practices are political footballs.

The temptation is of course to get drawn into working out how to influence the national debate.  Should there be a collective work to rule, a refusal to participate in any work beyond the core contract, or some other form of collective action?  The unfortunate reality is that for most of us engaging in the national politics around this is futile.  Clearly there is a role for the BMA and GPC in fighting the corner of general practice, but this needs to be done at a national level.  The worst outcome is to penalise your own patients and population because of national politicking.

For individual practices it is better to focus on those things you can influence, such as supporting staff, promoting thank you letters and the positive comments received, building positive local communications about the work of the practice as well as its role in the vaccination programme, and the impact you are making on local lives.  General practice remains one of the most trusted professions in the land, and local people will listen to you.

The bigger question is to work out how you will tackle the next 5 years.  The workload will continue to grow, patient expectations will continue to accelerate, and the number of GPs remains static.  Practices need a plan, because carrying on doing the same things will simply mean the pressure will get worse.  This will not be the last letter, or the last insult, or the last criticism of general practice.

Of course there is the temptation to simply walk away, and say enough is enough.  But not everyone has that option, and all that will do is make it even harder and more challenging for those left behind.  Even if that is what you want, it is better to leave with a clear plan in place so that those who remain have some hope and confidence in the future.

While the independent contractor model means there is limited protection from national and press assaults such as this one, it also means GP practices are businesses that can choose how they operate and organise themselves.  It is better to focus on what you can control and spend time working out what you can do to meet the challenges ahead.

There will always be national politics, and general practice will be part of this.  At times like this it is frustrating, disappointing and enraging.  However, channelling your energy into those things you can control, strengthening your own local communications, and planning for the future is the best way to respond.