09 August

The Real Impact of the Investment and Impact Fund (IIF)

How can the IIF affect practices and staff?

By Victoria Ashton

This article has come about after long conversations with a wonderful GP I have worked with who is a partner at a large practice in Blackpool. The details of our discussion surrounding the IIF startled me and consequently I felt it was a very relevant topic that many of you working in Primary Care could relate to and will undoubtedly have your own opinions on.

I am aware that there is significantly more to the IIF than what is detailed in this article so please accept this as a brief snapshot of how the IIF can impact practices and their staff.

Networks

Before explaining the basics of the IIF, it’s important to address Networks. Historically funding has always come to the practice directly. Funding was released by NHS England depending on that practices circumstances and needs, however, over the last Circa 3 to 4 years Primary Care Networks (PCNs) have been introduced. A PCN is a group of practices brought together based on their locality. Networks are care focussed as opposed to being management focussed so it’s very much that a network will receive funding according to its location and for example have its recruitment requirements tailored depending on its patient needs.

Some people are very involved with networks, and some are put off by them as they have their traditional commitments like QOF and their usual indicators which are separate from normal patient demand i.e., COVID pressure, growing aged population etc. Consequently, some view this as an extra factor to manage while others view it as a positive opportunity to improve their service.

two jigsaw puzzle pieces joined together

What is the IIF?

To address this, it’s import to recognise Direct Enhanced Services (DES). Practices are familiar with DESs anyway but there is now a Primary Care Network DES and in keeping with that, one specific area is the IIF. This is centred around things like access, and the network DES says the IIF section is specific to being proactive which would all be steps in addition to what practice teams are already doing, however many would agree these are fantastic things to do.

An example of this would be Learning Disability checks which are all contained within QOF and part of what a practice should do anyway by ensuring that all the health needs of vulnerable to high-risk patients are met. This is emphasised again within the IIF so one of the criteria is Learning Disability Assessments. You could argue that this is doing the same work, because if you’re doing the work for QOF, you’d be doing the IIF work anyway.

The difficulty comes when recording the work, you have done for the IIF, despite already recording this for QOF. You would think if doing the same thing it would be recorded in the same way, but it isn’t! Those QOF codes and checks don’t tick the boxes for the IIF, it’s all down to different letters and numbers that need putting into a machine. So, despite doing the work and hitting your QOF target, if you haven’t recorded it correctly for the IIF then it’s as if you haven’t done that work at all and any funding owed for your efforts is lost.

Many might say, well get the codes right and you won’t lose funding. The IIF is a 107-page document, to get this templated and ensure errors are not made you would need to check all the points and all the codes and check it against every single patient which is an admin exercise on an industrial scale! Who has time for that in Primary Care! If a staff member is allocated to do this and taken away from their usual responsibilities, this doesn’t come with any extra funding and so it’s an ongoing vicious circle.

Also, funding criteria can change, and practices are often not informed about this until the change has been implemented, consequently they have no time to prepare and update their processes to ensure everything is recorded correctly and funding isn’t accidently lost. You could be 3 months into the financial year, and somebody might say ‘oh did you not get this email with the new codes you should be using?’ If you haven’t, and you haven’t recorded all the services and care you have provided correctly in that time, that funding is lost!

Naturally, the most logical way to address this would be if the IIF worked in conjunction with QOF with the same codes thus not duplicating work, time and risking unfair financial losses! It almost makes too much sense! It would be understandable if it was a different target but it’s not, it’s literally the same i.e., Patient X has had an annual review.

Other issues with the IIF

The IIF funding is for the Network not the practices, so most people will want to use staff from the network to do the IIF work. Practices can’t afford to spare their own staff members as they have other important jobs to do like seeing patients. If it was the practice pot, they could do what they want with it including recruiting staff. With network funding you have a reduced choice of who you can recruit.

Despite a nationwide need, this doesn’t include Practice nurses or GPs, and up until April 2023 it didn’t include ANPs. So, the staff many practices usually depend on, they can’t have, plus the pay rate is restricted and that funding in nearly every case is inferior to what they would get elsewhere, making recruitment almost impossible.

For example, if you need a prescribing pharmacist, you’re not going to get them on the rate the funding allows, instead you will get relatively junior members of staff recently qualified who need lots of guidance and supervision. An example of this was a Blackpool PCN who had an advert out for a Mental Health worker for 2.5 years, eventually one was recruited. Unfortunately, that person has already handed in their resignation as felt overwhelmed and under supported being new to the role.

Another shocking component of the IIF is the loss of funding on a permanent basis. Despite it being unlikely that you wouldn’t need any of the staff that the IIF enables you to hire, if you didn’t use that funding in a particular year, you will lose it for the following year and so on regardless. So, if your practice needs have changed and you do need that paramedic or you do need that Podiatrist, it’s tough! You didn’t need one last year so you can’t possibly need one now.

Apparently, Network staffing can help. What services and skills do your clinicians have? You might be lacking somebody who can do med reviews and switching inhalers to carbon free as this is greener, so naturally you need more pharmacists. So, as a network you prioritise getting pharmacists as they can support with the IIF to help hit the minimum threshold of say 60%.

However, if practices can’t find this achievable, they just forget the whole thing and consequently lose funding. QOF is measured on how well you’re doing but it’s so difficult to do well with IIF. For example, the IIF implement a policy that all patients must be seen within 2 weeks, great, so then what happens with your 4-to-6-week reviews? It forces practices to become a more acute service dealing with short term needs rather than long term care and preventing patients going to hospital. It’s Just not sustainable. If you can offer them appointments, then at what cost? You may have to cancel other appointments. Unrealistic unachievable IIF targets are contributing the burnout.

What can be done?

Network staff who help with IIF will allocate their time to your practice depending on how many are in the network so if there are five practices with even patient lists, that paramedic will do one day a week at your practice. It would make sense if that Paramedic worked across all five sites each day and for example deal with the home visits across the network, this would be more practical, however some practices have polar-opposite ways of working and so in this eventually its unlikely to work as they might want their allocated one day a week support for just them.

In theory you could have a network hub whereby multiple staff supporting practices with the IIF, work, but everybody would need to agree, and to get this planned and executed is almost impossible as who in Primary Care has time to have these discussions? If this could be implemented, then maybe networks would smash there IIF targets.

In my GPs practice in Blackpool, they are more willing to hire Allied healthcare professionals due to difficulties recruiting GPs in their location. Consequently, they are not GP reliant. They use some of their practice staff to deal with the IIF and if the role they were going to do is simpler like a routine medication review they pass this to their Practice Nurses utilising the unique skills of their team.

Conclusion

While the theory behind the IIF is an honourable one it seems to just duplicate QOF and add an extra burden to practices and their teams. To punish practices by withdrawing funding due to incorrect code recording or not using funding is just adding yet additional pressure to our already strained Primary care services and attributing to low morale and burnout.

Action needs to be taken to address the practicalities of implementing the requirements of the IIF effectively. Working in conjunction with QOF and aligning the recording of actions would help immensely and reduce financial losses for services that have been provided.

Attention also needs to be given to the types of staff who can be recruited through IIF funding and the rates of pay that these staff are offered so that the right person can be found who will stay for the long term and be an invaluable member of the practice and network. Acknowledging that practice needs can change from year to year should also be taken into consideration when providing funding, and not using an allowance one year should not have a negative impact for the following year. Unless some simple measures, and as some might argue far more complex measures can be taken, I fear practices will continue to be unfairly underfunded for the incredibly important work they do.

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