At the end of July, the CCP published a report on Any Willing Provider policy in routine elective care criticising PCT commissioners for various tactics used to manage demand including restricting patient choice activity caps and minimum waiting times.
The report states that we saw many examples of PCTs excessively constraining patients' ability to choose and provide 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 successfully balancing the tensions that can emerge between this and other objectives there are significant variations in practices across PCTs.
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.
The CCP report also says 'PCTs that constrain patients' ability to choose their routine elective care provider most frequently do so through influencing GP referral decisions and in some cases directing GPs to refer patients to (or away from) certain providers. Patient choice of provider is also being limited or distorted through the referral processes used in a number of Referral Management Centres.
In terms of restrictions on providers' ability or incentive to offer routine elective care this most frequently takes the form of PCTs imposing what are in effect caps on the number of patients a provider can treat or will be paid for treating. The Activity Planning provisions of the Standard Acute Contract are one of the vehicles for imposing these restrictions. The arrangements for paying for routine elective care are also being used by PCTs to control levels of routine elective care at providers and hence patient's ability to choose between providers and providers? ability to compete for patients.
These payment arrangements which include block and capped contracts and implicit threats of non-payment appear in many cases inconsistent with the Code of Conduct for Payment by Results. As such they are also likely to be inconsistent with the Principles and Rules which requires that payment regimes are transparent and fair. More broadly they represent a move away from a rules-based system for paying providers through Payment by Results and a return to a system where hospital funding is reliant on historic budgets and the negotiating skill of individual managers.
The CCP also notes that 'some external factors that are incentivising commissioners to restrict patient choice such as ISTC contracts with minimum income guarantees and the application of the market forces factor to the national tariff.'
It makes the following nine recommendations:
- Commissioners review their existing practices in relation to restrictions on patient choice and competition and take steps to bring themselves into compliance with the Principles and Rules.
- Commissioners be required to approve any such restrictions at Board level and annually publish (e.g. as part of their annual report or statement of commissioning intentions) details of any restrictions on patient choice they have adopted the underlying rationale for the restriction an analysis of its impact and terms of the restriction including the period for which it will operate.
- Commissioners also be required to:
- publish the approach they have adopted to Activity Planning with providers in their locality; and
- when imposing waiting time requirements on providers publish on the home page of their website clear information about the minimum waiting time imposed by the PCT on each provider.
SHAs and in future the NCB implement oversight arrangements to ensure that commissioners are not restricting patient choice and competition in routine elective care against patients? and taxpayers? interests.
The DH :
- requires commissioners to ensure that Referral Management Centres implement the Choose and Book system effectively and share with all local providers the scripts and any other communications used by Referral Management Centre staff when referring patients to a provider for routine elective care; and
- requires commissioners to copy to all local providers any information they supply to GPs concerning providers.
- DH takes action to ensure that SHAs and commissioners are implementing Payment by Results in accordance with the Code of Conduct for Payment by Results and national guidance including ensuring that commissioners publish the details of any locally adopted variations to the national tariff.
- The DH in developing accreditation arrangements for future commissioners requires that commissioners demonstrate to the NCB an understanding of the policies and rules concerning patient choice and competition and a commitment to complying with their obligations under these policies and rules. Compliance with the policies and rules concerning patient choice and competition should also be made a condition of continued accreditation.
- DH reviews the rationale for the Activity Planning provisions in the Standard Acute Contract and if these provisions remain necessary assess whether amendments could be made to make these provisions less susceptible to being used to restrict patient choice and competition.
- DH reviews the way in which the Market Forces Factor is incorporated into the tariff for routine elective care and assesses whether the incentives that the current arrangements create for PCTs to restrict patient choice are outweighed by other considerations.
Click here for the CCP report dated 28 July 2011: Review of the operation of ?Any Willing Provider? for the provision of routine elective care.