"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Saturday, 9 April 2011

Any Qualified Provider

The rather bizarrely titled policy document "Making Quality Your Business: A guide to the right to provide" the government outlines the "Right to Provide (R2P)" and "Any Qualified Provider (AQP)" policies.

The idea behind R2P is:
"the right is to present to your board your proposal for a staff-led enterprise and to seek approval to develop a full business case to test your proposal. If the business plan is then approved, you will be able to set up a staff-led enterprise"
So basically you and your colleagues get together and then demand that you can provide the same work as you are doing now either as a mutual (profit-share) or as a social enterprise (not-for-profit). The board are supposed to say "yes, you can".

Except there are problems. First, this does not apply to existing Foundation Trusts (who the government admit are outside the scope of R2P) and half of hospital trusts are already FTs. Second, they say that even if you present your business plan to the board of an NHS Trust, they may turn you down if they think that it may affect their bid to become a Foundation Trust. If the service you intend to supply is one of the surplus generating services in the trust then, yes, it will affect the trust's application to be an FT: they will need the surplus to be able to show that they have sound financial governance. The last thing they would want to do is allow you any your mates to share that surplus between yourselves as a mutual.

If the board agrees (and there will be political pressure for some to agree), it may not be in the best interest of either the trust or the new organisation. The trust will lose control of the service and will only be able to work through a new layer of management - the new R2P organisation's management. If a trust contracts to several such organisations then there will inevitably be fragmentation of service and collaboration will be threatened. The R2P employees will initially get NHS terms and conditions, but will lose them if they change jobs or get promoted within their organisation. They will also be on a fixed term contract, which means that ultimately they could lose the contract.

The R2P policy appears rather dead in the water. The last government had a similar programme called "Right to Request" for community health services. Out of 152 PCTs the first two waves of "Right to Request" yielded just 29 requests. In the third wave under the current government, another 32 were added to the list. Thus just over a third of community health services took up the option.

The "Any Qualified Provider" policy is presented to us as "patient choice". (The previous name, "Any Willing Provider", was replaced presumably because people thought it sounded too much like privatisation.)

First a provider (and it may be an R2P provider) has to "qualify" to be a provider:
"to show that they can meet the conditions of their licence with CQC and/or Monitor (if necessary), provide safe quality services to the contractual standards set by the NHS Commissioning Board and meet NHS prices – either set nationally or locally"
Then, apparently, patients choose them. But will they? Although AQP is being sold as "patient choice" it is quite clear that they will more likely be "commissioners' choice":
"It will be for commissioners to decide which services are best delivered through an AQP approach or tendering but the presumption will be that for most services patients will have a choice of Any Qualified Provider. Subject to Parliamentary Approval, the NHS Commissioning Board will have a duty to promote patient choice, having agreed its scope with the Secretary of State for Health, introducing AQP and holding consortia to account for delivering choice."
The presumption seems to be rather ambitious. If a commissioner is designing integrated care, an AQP aspect to the care pathway will complicate the process, make the commissioning more bureaucratic and more costly. We are now in an age of financial constraints and a pledge to cut bureaucracy, it seems bizarre to add more cost and red-tape.

Further, the government says:
"Once qualified, providers will register locally with commissioners (PCTs, clusters and consortia) for payment purposes. There will be no volume or payment guarantees for providers – their income will be wholly dependent on patients choosing to use their services."
The block contracts that are mentioned here are common in the NHS and help to keep costs down. A commissioner working under the tight finances of the new McKinsey'ed NHS ("£20bn efficiency savings") a responsibility to break even and no chance of a bail out from government, is likely to offset "patient choice" AQP with being able to keep the balance sheet in the black.

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