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Gold, incentives and meh

Major report concludes PCTs 'excessively' influence GP referral decisions

The Any Qualified Provider policy will fail to deliver high quality services or better value for money unless commissioners address ‘endemic' failures in the provision of choice, a damning Government report has concluded.

The final report of the Cooperation and Competition Panel (CCP) review into the operation of the Any Willing Provider policy for the provision of routine elective care concluded that PCTs have been ‘restricting choice excessively' through their use of referral management centres and block private contracts.

Unless these practices are addressed, the report found, ‘there is a serious risk that… 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 report identified several practices used by PCTs to ‘influence GP referral decisions' and limit patient choice, including directing GPs to refer patients to or away from certain providers, ‘distorting' the referral process through the use of referral management centres, placing caps on the number of patients a GP can refer or a provider will be paid for treating, block and capped contracts and ‘implicit threats of non-payment'.

These techniques, the Panel ruled where ‘likely to be inconsistent with the Principles and Rules of Cooperation and Competition because of limited offsetting benefits to patients and taxpayers.'

The Panel stopped short of calling for an outright ban of the restricting policies, but ordered PCTs to conduct an immediate review of their practices, and set a number of new recommendations for future GP commissioners (see box).

CCP director Andrew Taylor ‘strongly urged' GP commissioners to heed the guidance and ‘bring themselves into compliance with their obligations around patient choice.'

CCP chair, Lord Carter of Coles, added: ‘Commissioners have a difficult job in the current financial climate, but patients' rights are often being restricted without a valid and visible reason. Crucially, it is the lack of transparency that surrounds certain restrictions on patient choice that is of real concern.'

The Department of Health said it would consider the recommendations carefully.

David Worskett, director of the NHS Partners Network director, which represents non-NHS providers, said the report would mean his members would be more willing to challenge individual cases and begin legal proceedings if commissioners were found to be in breach of the CCP's Principles and Rules.

He added: ‘The [report] endorses the concerns we originally put forward that PCTs were in too many cases adopting practices which unjustifiably restrict patient choice and as a result lead to patients not receiving the best or most timely treatment.'

But David Stout, director of the NHS Confederation's PCT Network, said: ‘The CCP have for the first time provided some clarity in setting out how it would judge such decisions.

‘But commissioners will still be left to decide the right course of action when faced with trade-offs between patient choice and value for money. The suggestion that many current PCT decisions are not justifiable on these grounds is largely unsubstantiated by the detail in the report as the CCP has not investigated specific cases in detail.

‘The report also highlights a number of DH policies such as the market forces factor and ISTC contracts which have made the trade-off between value for money and patient choice more difficult. These should be resolved as a matter of urgency.'

Cooperation and Competition Panel recommendations:

  • Commissioners be required to approve any such restrictions at Board level, and annually publish 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 are required to publish the approach they have adopted to activity planning, 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.

  • That SHAs, and in future the National Commissioning Board, implement oversight arrangements to ensure that commissioners are not restricting patient choice and competition in routine elective care against patients' and taxpayers' interests.

  • That the Department of Health 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.

  • We recommend that the Department of Health 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.

Source: Cooperation and Competition Panel. Review of the operation of ‘any willing provider' for the provision of routine elective care, final report. 28 July 2011

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