Any willing provider contracts - Opening up the healthcare market

GP commissioners must give contracts to accreditated willing providers, explains Dr Shane Gordon.

Dr Shane Gordon: 'Competition is seen as an imp­ortant way to drive up the quality, responsiveness and efficiency of health services' (Photograph: P Starr)
Dr Shane Gordon: 'Competition is seen as an imp­ortant way to drive up the quality, responsiveness and efficiency of health services' (Photograph: P Starr)

The Health Bill confirms the government's intention, as stated in last year's Liberating the NHS White Paper, to 'increase ... choice of any provider significantly' for patients.

The DoH wants to make rapid progress with this goal. Competition is seen as an important way to drive up the quality, responsiveness and efficiency of health services.

There are many potential routes to increase competition in the provision of services (see box, below). One that has received special attention is the any willing provider (AWP) model, perhaps because it is seen as less challenging than the long drawn out and formal process of tendering for NHS contracts.

There will be strong enforcement of the principle of commissioning in a competitive marketplace.

MORE COMPETITION
Options to increase competition
  • Contract variation.
  • AWP.
  • Restricted tender.
  • Open tender.
  • Direct payments (patient-held budgets).
Early targets for AWP
  • Community services.
  • Mental health.
  • Long-term conditions.
  • Maternity.
  • Diagnostic services.
AWP timetable
  • Consultation ended 14 January 2010.
  • Guidance by spring 2011.
  • First mandatory AWP provision, possibly by late 2011.
  • Most services to be AWP contracts by 2013/14.

Competition Commission
The Health Bill is progressing through parliament and, as matters stood when this article went to press, the health watchdog Monitor will be able to refer markets for health services to the Competition Commission where it can demonstrate that a restriction on competition is against the public interest.

The Competition Commission will then be obliged to investigate and can impose 'remedies' to enforce competition.

GP consortia will be held to account for their role.

The AWP model has been around for more than two years but has been used sparingly by PCTs.

One major change this year is the transition of contracts for the extended choice network to an AWP model. These are the independent sector hospitals providing choice of elective treatments through Choose and Book.

Several other services were specifically mentioned in the White Paper consultation as likely targets for the AWP treatment (see box, below). The DoH's ambition is to implement this model for the majority of services by 2013/14.

Regulation of AWP providers will be by registration with the Care Quality Commission for the clinical aspects of care and with Monitor for the assurance of financial robustness.

Local accreditation
There are some concerns, however, that there are significant challenges in the widespread use of the AWP model.

One of these is with local versus national accreditation of services. There is a desire to avoid excluding smaller providers, such as voluntary sector organisations, new start-ups and even GP providers from this new market.

The idea for preventing exclusion is that by enabling them to be accredited nationally, AWP providers will then be able to offer their services anywhere in England. Against this are two main concerns: due diligence and a provider's capacity across multiple geographic areas.

With due diligence, local commissioners will almost certainly wish to assure themselves of the fitness of the new providers to deliver these services.

This is similar to the situation with the framework for external support (FESC) created to support World Class Commissioning. This involved an intensive national accreditation for providers but the reality was that few, if any, PCTs used this as the sole test for their providers. Many of them appointed support partners outside of this framework.

While a provider may deliver excellent services in one area, this does not guarantee its ability to operate on a much larger scale. Even if they have the capacity, this does not ensure that they will deliver the same high quality level in each area.

ANY WILLING PROVIDER CONTRACTS

AWP defined
This is a currently local approval process for providers for the purpose of driving up competition within a range of services rather than for them. So a variety of providers could be offering the same service in different locations. The idea is that primary care and other providers offer a routine elective service.

No tendering, no income guarantee
Providers do not go through the tendering process.

As the service is not a monopoly there may already be local providers. AWP contracts do not contain a guaranteed level of activity. Providers are given permission to supply services to their population without any promises on income.

Minimum quality criteria
PCTs (GP consortia when PCTs are abolished) can only award contracts to willing providers who can show that they meet the minimum quality criteria as per Care Quality Commission guidance.

More choice locally
The service the provider contracts to provide is added to the Choose and Book choice menu. With routine elective procedures for which a tendering process is not required and to promote free choice of provider for patients, commissioners should not stop AWPs from supplying accredited services that are delivered in an alternative setting.

Variant of AWP contract
At present, where commissioners wish to offer patients a choice of provider for services other than routine elective care, a variant on the model may be used. This is an any willing PCT-accredited provider (AWPP) contract under which accreditation and key terms and condition, such as non-tariff prices, may be decided locally.

Partial and whole pathways
Another troublesome aspect is partial versus whole pathways for patients. Some willing providers may only want to offer services for part of a pathway of care, for example, physiotherapy or wound care.

While this might be attractive from a patient or even a commissioner perspective, it may present difficulties when trying to hold providers to account for outcomes reflecting the performance of the entire pathway.

There are many anecdotal accounts of providers finding the interface with other providers in the market difficult, particularly when handing over patients along a care pathway.

To address this there are specific provisions in the Health Bill for Monitor to prevent providers discriminating between other providers when offering services to them.

One option would be to commission a single 'prime contractor' who is then responsible for the provision of all services and choices within an entire pathway of care.

This may be easier with elective case rather than for long-term conditions, where primary care input becomes much more critical.

Many of the services targeted for AWP status have considerable potential to uncover unmet need. For example, mental health services for mild and moderate symptoms have long been under-provided. Creating an AWP market for these services might easily lead to additional cost pressures.

Setting a tariff payment for many AWP services might be tricky - particularly for long-term conditions where care will be ongoing throughout a patient's life and the level of need in each year may be difficult to judge.

So-called 'year of care' tariffs may be created to give a single payment to a provider for all the likely eventualities a patient might encounter during the next year.

Providers failing and 'market churn' are other areas of concern. If willing providers enter an existing market for the provision of health services they might be successful in diverting some of the demand away from the existing providers.

This might result in the existing services becoming uneconomical and the traditional provider (NHS trust, foundation trust or community services provider) withdrawing the service affected.

Potential gaps in services
However, if the new provider subsequently decides that an area of service is no longer profitable, perhaps due to changes in tariff or quality regulations, they might withdraw from the market altogether, potentially leaving a gap in services, which is difficult to fill.

For example, Dr. Elizabeth Bradley from the Yale University School of Public Health cites examples of health economies in the US where up to 50 per cent of providers may cease trading in any given year.


Diagnostic services are an early target for willing providers (Photograph: SPL)

Then there is contract management complexity to consider. The AWP model may increase choice for patients, but it also increases the complexity of contract monitoring for commissioners.

Each provider must be monitored on the quality of the services provided. This may include the thresholds for acceptance of referrals, clinical outcomes, patient experience and clinical safety of the services.

In addition, there will be the usual billing and payment processes multiplied by the number of providers. This extra transactional overhead costs may strain the limited running cost allowance within which GP commissioners are expected to deliver their functions.

So while AWP contracts present an exciting opportunity to break the stranglehold of monopoly providers within local health economies, there are potential pitfalls that must be overcome to avoid creating more problems than we as GP commissioners solve.

  • Dr Gordon is a GP in Essex and national co-lead of the NHS Alliance's GP commissioning federation

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