Any Qualified Provider - How choice affects commissioners

Any qualified provider is both a threat and an opportunity for practices, says Dr Michael Dixon.

Dr Michael Dixon: 'AQP will be good if local people, local practices and CCGs are collectively involved and signed up to the need for AQP'
Dr Michael Dixon: 'AQP will be good if local people, local practices and CCGs are collectively involved and signed up to the need for AQP'

Any qualified provider (AQP) is a central part of government policy - designed to widen the choice of services available to patients, particularly for community and mental health services. It is, effectively, an extension of the principle whereby patients are able to decide between different hospitals and treatment centres for elective referrals.

It represents both a threat and an opportunity for clinical commissioners and practices.

Why?
The rhetoric is that AQP will enable patients to choose any qualified provider where this will result in better care. The principle is that choice of provider will enable individual patients to get the best service for them, while a system of several providers will, through competition, ratchet up standards more generally.

What?
AQP involves three stages:

  • Would-be providers have to register in order to show that their service is up to standard. This includes registration with the Care Quality Commission and licensing by Monitor. Details on the process for registration will follow in the autumn.
  • Local commissioners - in future clinical commissioning groups (CCGs) - agree terms and conditions with potential providers including local referral thresholds or patient protocols. Price will be determined by national tariff, where there is one, or by local agreement, where not.
  • Then with a list of approved/qualified providers, accepting conditions set by their local clinical commissioners, patients and their GPs can choose from a relevant list. The different providers for each service will be listed in a directory so that the patients and GPs know who is providing what.

PCT clusters - supported by pathfinder CCGs - were told that they should select three or more services for implementation of AQP either from the DoH's list (see box below) or other priorities that they might have. Future areas envisaged as a priority for AQP are areas such as long-term condition self-management support and community chemotherapy.

AQP will become a major means of commissioning alongside more conventional forms of tendering and other services being provided by GP practices as directed enhanced services. Its introduction has been very controversial with some seeing it as the marketisation of the NHS, while others view it as simply an extension of patient choice begun in the Blair/Milburn years. Where are the potentials and pitfalls?

Services for early implementation

In the recent DoH guidance, a number of potential services were proposed for early implementation of this system:

  • Musculoskeletal services for back and neck pain.
  • Adult hearing services in the community.
  • Continence services (adults and children).
  • Diagnostic tests closer to home.
  • Wheelchair services (children).
  • Podiatry services.
  • Venous leg ulcer and wound healing.
  • Primary care psychological therapies (adults).

Potential
It is simpler and less bureaucratic than tendering - which can take over six months and cost well over £100,000 per tender. AQP enables commissioners to offer choice, where individual choice is appropriate and where services could be improved.

It is clearly not right for all services and the imperative should be that CCGs, supported by the views of member GP practices and patients, are able to decide where to useAQP.

Pitfalls

  • The qualification of providers will need to be as simple and unbureaucratic as possible so that smaller providers, for example GP practices, can apply.
  • Clinical commissioners will need to be empowered to ensure that AQP does not increase costs and demand. Commissioners will need to be able to cap costs as well as setting referral thresholds.
  • Local commissioners will need to be sovereign in terms of deciding where AQP should apply as local geography and the range of local current services will be important factors. They will also need to balance the need for local integration and close working partnerships with the need for greater choice of providers.

The future
Like any powerful weapon, AQP can be used to good or bad effect. It will be good if local people, local practices and CCGs are collectively involved and signed up to the need for AQP where greater choice is required.

It will be bad if it becomes a process of commissioning that has to be gone through for its own sake - too reminiscent of the rigid framework of choice originally prescribed by the DoH for elective hospital referrals.

Current orchestration of AQP through PCT clusters - albeit requiring them to touch base with their CCGs - and the didactic requirement that three or more community or mental health services to be provided under AQP should have been identified by this October and implemented by next September are ominous. It looks dangerously like another centrally led and directed market initiative handed down to SHAs to PCT clusters and then to CCGs, which will have to take the necessary action. A centrally directed market is an oxymoron.

AQP presents opportunities and is here to stay. It will only work, however, if it is used as a response to local wishes and needs. Over the next few months CCGs and their leaders will need to assert themselves locally and nationally to ensure that AQP becomes something that is useful for them rather than a central requirement that restricts their ability to commission the right services for their patients.

  • Dr Dixon is a Devon GP and chairman of the NHS Alliance

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