Making the grade

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As the reforms continue to gather pace, Thoreya Swage outlines the schedule for the introduction of Any Qualified Providers and what they’ll need to do to be selected by the DH.

Successive governments of all colours have tried in recent years to shake up the healthcare system in the UK, with England probably being subject to the greatest number of the changes. A minor but key element of these changes has been various attempts to expand the healthcare market to include the private or independent sector. This widening of the door started in earnest with the deployment of the waiting list initiative in the 1990s by using the spare capacity of independent hospitals to reduce the queues of elective procedures that had built up in the NHS. The baton was then taken up by the heady days of the Independent Sector Treatment Programme with the last administration. Here, the range of work done by private providers expanded to diagnostic procedures and screening programmes, as well as the construction of bespoke independent hospitals to take on more hip, knee and cataract operations from the NHS.

It was at this stage that the concept of choice for patients to go to the healthcare institution they desired for treatment or diagnostic procedures started to take off, with some of those choices being the independent sector. This idea of an ‘any willing provider’ began to take shape, with NHS care being delivered by any appropriate healthcare body so long as it had reached identified quality and safety standards. However, with the recent change of government this initiative began to cool under external political pressure, and this all seemed set to fade
away.

What is a qualified provider?

Despite this opposition the Government has continued to plough on with this policy, calling it this time ‘any qualified provider’. In July of this year, the DH in England issued ‘operational guidance’ to the NHS
providing further details to PCT clusters and the emerging Clinical Commissioning Groups (CCGs) – the renamed GP consortia. This policy has come under the guise of improving the quality of care by widening patient choice for specific services.

The intention is to permit a patient to choose from a list of qualified providers when they require a referral for a specific community or mental health service. An ‘any qualified provider’ (AQP) is a healthcare organisation that meets the quality, prices and contractual obligations for NHS services. This process, as we have already seen, is in place for elective care.

The guidance states that the implementation of AQP will be conducted in phases from April next year. However, some work needs to have been done before that. PCT clusters and their associated Clinical Commissioning Groups need to have already decided (by October) which community or mental health services they wish to identify for the implementation of AQP locally, so that their patients can begin to have access to that care between April and September next year. At least three or more services from the following list drawn up by the DH, in conjunction with patient groups, should have been identified by PCTs and CCGs:

  • Musculo-skeletal services (neck and back pain)
  • Audiology services in the community (adults)
  • Continence care (adults and children)
  • Diagnostic services (e.g. imaging and heart and lung investigations)
  • Wheelchair services (children)
  • Podiatry care
  • Wound healing and management of leg ulcers
  • Primary care psychological therapies (adults).

The guidance also says that PCT clusters and CCGs can choose alternative services for AQP for different priority areas if supported by local patients – for example, as identified through the shadow health and wellbeing boards (the new health and social care joint commissioning boards) – and potential effective gains in quality and access can be made by doing so.

Independent interaction

The principles for the AQP approach are that:

  • Organisations can qualify and register to provide NHS services as long as they meet NHS assurance requirements
  • Referral pathways and protocols set by CCGs must be accepted by the providers wishing to be on the AQP list
  • Patients are offered a choice of services from the list of qualified providers
  • There will be a fixed price based on a national or local tariff, thereby ensuring that the provider is chosen by quality.

A national qualification process for all AQP providers is currently being developed by the DH in order to minimise bureaucracy and reduce transaction costs. The proposed principles for qualification are that providers:

  • Must be registered with the Care Quality Commission (CQC) to demonstrate that they meet the essential standards for quality and safety – or equivalent assurance requirements if providing services not covered by CQC registration
  • Are licensed by Monitor from 2013 so that they are authorised to deliver NHS care
  • Can meet the terms and conditions of the NHS Standard Contract, including having regard for the NHS Constitution, appropriate guidance and legal obligations
  • Deliver care at NHS prices
  • Can meet the service specifications developed by commissioners and comply with referral protocols
  • Agree with the commissioners on any supporting schedules to the NHS Standard Contract, e.g. on activity levels.

More details of the qualification process have been published this autumn.

The providers that have successfully achieved the national qualification process have been listed in a directory, which is now published and available for GPs to refer to.

Lead PCT clusters have produced detailed implementation packs for each service on the AQP list that include service specifications, contract currencies, tariffs and information models.

From April 2012 it is anticipated that AQP arrangements for the services identified above will begin to be implemented, with all CCGs having this in place for their patients by September 2012.

What happens next?

AQP will continue to expand and for 2013/14 a further list of services has been identified by the DH for discussion with commissioners, patient groups and providers. The list is not finalised but will probably
include:

  • Maternity care
  • Speech and language therapy
  • Supporting patients to self manage their long-term conditions
  • Chemotherapy in the community setting and at home
  • Primary care psychological therapies for children and adolescents
  • Wheelchair services (adults).

What’s in it for pharma?

At first glance the initial list of services for the first phase of AQP does not appear to have much impact on the pharmaceutical industry, apart from probably wound care management. However, with the second wave of AQP the scope for involvement widens to chemotherapy services at home and in the community setting. The aim for now should be to plan ahead, and the next phase of AQP and pharma should work on this in a number of areas.

Firstly, a keen eye should be kept on the proposed list of services for 2013/14. Whilst some services have been identified for discussion with NHS stakeholders and patient groups, there may be others added later on which could require input from pharma. Once the service areas have been confirmed, the next step is to identify the providers who have been authorised for AQP. These potential providers need to get up to speed in a number of areas, such as ensuring that they are registered with the CQC, have a better understanding of the standard NHS contract, offer services in keeping with the CCGs requirements and can manage within NHS financial envelopes.

Another aim should be to identify the lead commissioner(s) within the local PCT cluster and associated CCGs to find out what which community or mental health services they are planning to include on their local AQP for the next round. Alternatively, contacting the local shadow health and wellbeing
board, if it is sufficiently developed, may indicate other priority areas for AQP.

Service redesign and, in particular, improving care pathways so that more care can be delivered in the community setting will be a priority. Patient self-management of long-term conditions is one such area where better understanding of medication leading to improved compliance achieves better health outcomes. Pharma can provide an invaluable contribution to improving these outcomes for a range of long-term conditions, such as diabetes, asthma, hypertension and arthritis, by helping patients understand the medication through written and electronic patient information and other mechanisms, such as patient self-management programmes.

Through the identification of potential AQPs the industry can work together with these providers to help them meet the qualification requirements for the scheme – for example, some aspects of CQC registration such as infection control, medicines management and clinical risk management. This will be a chance to raise the profile of effective drug therapies in, for example,
chemotherapy.

Although this initiative seems small in scale it does look set to grow in the future, and further opportunities will present themselves for 2013 and beyond as QAP continues to expand. Pharma needs to begin its homework now to identify new markets for their products with this scheme.

Dr Thoreya Swage was formerly an NHS clinician and a senior manager in various NHS organisations covering acute and primary care. She has expertise in commissioning health services and is currently working for a number of NHS organisations, including DH agencies, to develop a more commercial approach to the commissioning of healthcare.