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The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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With elective care in the NHS how is patient choice faring?

Filed Under (GP Commissioning, Patient Choice) by Paul on 12-09-2011

Over the next few weeks the Bill will be going through a quiet period, so it’s a worthwhile opportunity to take a different look at some of the highly politicised issues that we discussed last week. Today I thought it would be useful to run through a review that was published in July this year by the Cooperation and Competition Panel concerning how patient choice for any willing provider was actually working.

The analysis is important for two reasons. Firstly because it provides an interesting understanding of what is going on and secondly because the panel is suggesting that, unless there are changes to the practices of commissioners, there will be a case against those commissioners – which they will have to answer.

Their starting point is that,

“We have found that patients, providers and commissioners are still adapting to the opportunities arising from choice and competition in routine elective care. But emerging evidence shows that patients and taxpayers are benefitting from high quality care, greater accessibility and more efficient delivery in services that represent around 15% of PCT expenditure on health care (approximately 12 billion in 2009/10) These benefits can be expected to grow as patients become more aware of their ability to choose, and providers respond to patient expectation by improving services”

So in this very, very specific area of choice for elective surgery there is evidence that choice and competition appears to be improving quality and access for NHS patients.

The report goes on to note

“At the same time during our review we saw many examples of PCTs excessively constraining patients’ ability to choose and providers’ ability to offer routine elective care services. While a number of commissioners appear to be performing well in facilitating patient choice and competition in routine elective care, and successful balancing the tensions that can emerge between this and other objectives, there are significant variations in practice across PCTs.

Given this, the Panels view is that there is a serious risk that unless practices that appear endemic among certain commissioners are addressed, the expected results from the policy of Any Willing Provider, including higher quality services and better value for money, are not going to be realised to their full potential”       

Those of us who work around various parts of the NHS will not be surprised by this finding. The problem for those who developed  such levers for reform as the “Any Willing Provider” policy, is that there will be parts of the NHS that disagree fundamentally with allowing that policy to have any impact.

Government will discover that giving people a right – say the right to choice that they have within the NHS constitution – will work in some parts of the country but not in others.

The report goes on to make it clear that some of the ways in which local commissioners are refusing to implement this policy lie outside of the way in which “Payment by Results” is meant to work. They move away from “a rules based system for paying providers through payment by results and are a return to a system where hospital funding is reliant on historic budgets and the negotiating skill of individual managers.”

Payment by results has been working in parts of the NHS for 8 years now. So it is interesting to read that in some they have returned to the situation before 2003.

The Cooperation and Competition Panel offer both advice and a solution to this set of problems.

They understand that some PCTs are worried about how they can maintain the policy of patient choice without very significant destabilisation of existing NHS providers. But the report notes,

“whilst this argument is frequently advanced . We have not yet seen persuasive evidence of this relationship, and we would expect commissioners to rely on robust evidence of this relationship before putting in place such a restriction. Moreover, to the extent that other regulatory arrangements are in place to protect essential services in the event of provider failure, restrictions on patient choice and competition as a means of ensuring service continuity are more difficult to justify” 

What the Panel are saying here is that NHS providers around the country “got to” commissioners and said if a number of patients choose someone else than us we will have to close down important services. The commissioners believe this and restrict patient choice as a consequence.

The Panel are suggesting that in most cases NHS providers are making this apocalyptic claim without much evidence. In fact they are simply using the threat of apocalypse to stop Mrs Jones from having the opportunity to have her hip replacement carried out by the provider that she wants.

So the Report says,

“In summary, the practices identified in this report which restrict patient choice and competition are, in many cases, likely to be inconsistent with the Principles and Rules because of limited offsetting benefits to patients and taxpayers.”

And this leads to the conclusion that,

“Commissioners imposing restrictions are exposed to challenge under the Principles and Rules and we encourage commissioners to approach the CCP for informal advice.”

This is the sting in the tail. It is a clear warning to commissioners that if they restrict patient choice and are reported to the CCP, the CCP is likely to find that they have breached the rules.

If commissioners maintain this behaviour of limiting patient choice they will find themselves told to stop both the policy and practice.


One Response to “With elective care in the NHS how is patient choice faring?”

  1. If choice is to drive up standards it will have to force poor providers out of business. That is how markets work. Lansley seems to be claiming that no hospitals will close on his watch. The two positions are not compatible.

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