CAIPed crusaders: PCNs on receiving this year’s access payments

In the past year, PCNs have been working to improve access, manage demand and boost patient experience. Under the capacity and access payment scheme, PCNs were tasked with first coming up with a plan supported by 70% of the funding – £172.2m – paid up front.

But the other 30%, a total of £73.8m was conditional and based on the extent to which PCNs had put those plans in place. Integrated care boards (ICBs) are tasked with assessing PCNs for this local capacity and access improvement payment (CAIP) against the plans they signed off.

NHS England set out three areas that PCNs would be expected to deliver against – patient experience of contact, ease of access and demand management, and accuracy of recording in appointment books. ICBs are expected to work with PCNs to monitor improvement in these areas only approving the full 30% if they could show improvements across all of them.

Yet PCNs have reported variation in the level of detail they are being expected to provide and their understanding of what the ICB will be measuring them against. There are concerns in some quarters that ICBs will use the exercise as an opportunity to claw back funds to fill large black holes in their finances.

Dr Douglas Price, clinical director at Burntwood PCN in Staffordshire says: ‘Our capacity and access plan was accepted fairly smoothly when we submitted it. We are still awaiting clarification from ICB about whether they are happy with how we are progressing with our plan.’

They had suggested to the ICB at the start that the 30% incentive payment related to the plan, which accounts for £1.18 per patient for the average PCN, should not be all or nothing but incremental.

‘For example, if we were deemed to have not satisfied the ICB regarding “patient experience of contact” but had done well with ease of access and accuracy of appointment recording, that we would still get some of the payment.’

But he adds: ‘We’re still none the wiser about whether or not we need to hit all targets. So really we are not sure whether we’re likely to get the money.’

One aspect that has complicated the situation has been access to GPAD data for PCN management staff. ‘Although they can view the data the system is flagging that our management staff are not reviewing it or not logging on. We’ve escalated this glitch on several occasions but there has been no progress as yet,’ he adds.

Dr Hussain Gandhi, clinical director of Nottingham City East PCN says they have also had issues with GPAD and it is unclear at this point how that is going to impact achievement.

Submitting their improvement plan was a pretty simple process with the ICB only asking for a few bits of clarification as the ICB tried to align the plans more with what was expected from NHS England, he explains. They have also had a fair bit of detail on how achievement will be measured. It has led them to estimate they may get two thirds of the payment.

‘They have told us that each of the three different areas will account for some of the allocation so we have anticipated we won’t get all of it – probably about 20% based on the criteria we have been given.’

Having enough online consultations at all practices and having enough data back from patient surveys to show improvement is likely to see them missing out on a third of the local CAIP payment, he suspects.

Dr Gandhi also believes there will be variation between ICBs in allocation. ‘I suspect most practices may have a chance to get some of it but with ICB shortfalls I would also anticipate some ICBs may be more strict than others.’

For some, a lack of transparency may be an issue. ‘ICBs should be telling practices what they need to do to achieve this and if they’re not that suggests to me that they’re not planning to give the money to the networks. It would not surprise me given the financial situation in most places if there is clawback.’

Dr Tom Holdsworth, clinical director of Townships 1 PCN in Sheffield says when the capacity and access funding came in there was an understanding that you got 70% up front and then 30% for writing a plan and working towards that but more specific targets had since been introduced.

The criteria set by the ICB has included asking practices to increase the number of appointments per 1,000 patients either up to the average or by 3% from baseline. To achieve 5% friends and family test returns per month of your population and send a certain number of staff on care navigation training. There are also targets around GPAD and online consultations, he adds.

‘The message has been that don’t worry about it too much and if you can show you’ve been trying through the implementation of your plan, then that’s fine. 

‘But we’re in a situation where all systems have big deficits and that introduces significant tension. South Yorkshire ICB repurposed the primary care system development funding – that has gone into filling the acute sector deficit –  so I do have some anxiety about how much pressure is going to come on commissioners.’

Dr Holdsworth also has concerns that these sorts of targets distract from the real focus which should be looking after the local population. ‘If someone can give me a reason why 3% more appointments is good, then fine, but why not 1.8% or 3.6%, it’s an arbitrary target and quite blunt.’

He adds he completely understands that people are frustrated about access and there is potentially transformational work happening in Sheffield around total triage and smoothing out the 8am rush. ‘I worry that there will be real unhappiness if PCNs do not receive payment and it’s clear that different ICBs have taken very different, less stringent approaches.’

In other places, it does appear a more hands off approach has been taken. Dr Nicholas Jackson, clinical director at Selby PCN says: ‘Our ICB [Humber and North Yorkshire], to their credit, have tried to be as flexible and as “light-touch” as they can be with CAIP, so I’m expecting that we will be awarded the full achievement payment.’ 

A PCN clinical director in South East London who didn’t want to be named said they have had quarterly reviews locally to ensure PCNs were on track and would get the full payment. ‘It has been a supportive process and generally light touch, which is great,’ they added.

Agreement to pay the full 30% will be subject to a committee meeting to be held in public with explanation about what has been done. Work has included all practices moving to one online consulting tool, new websites, care navigation training and some work on digital inclusion. They have been using APEX to review appointment data which has been useful since GPAD ‘is still a mess nationally’ which gives automated enhanced access reports for practices to review.

Dr Jackson adds that overall there does need to be recognition that if systems want to increase capacity and access, then new investment is needed, and that therefore withholding funding would in fact be ‘counterproductive’.

But realistically for long-term improvements in capacity, approaches like CAIP are not helpful and do not promote sustainability or a stable workforce, he adds.

‘I would like to see the discretionary/incentivised element of CAIP removed and for PCNs to be given a guaranteed multi-year income,’ he says.

However, the latest communication from NHS England shows it will maintain the CAIP payment in next years’ contract although it will increase flexibility around when the discretionary payment can be made.

He also takes the view that the NHSE obsession with access ‘which is probably to a large extent politically driven’ is the wrong measure to incentivise anyway.

‘If we shifted the focus to continuity of care, which has a much more robust evidence-base behind it, and demonstrable benefits for patients and healthcare systems, I would find it much easier to support – as it is, however, the CAIP is simply a means to an end for me – a mechanism to leverage some income which we can then invest in workforce.’