Interview key points
- The transition from AWP to AQP has resulted in an ‘explosion’ in diagnostics
- 600 providers applied to go on the Department of Health’s approved AQP list but only 180 met the quality checks
- Checks included how a service links into local referral protocols, such as referring on red flags
- Small providers, including charities and social enterprises, have dominated the independent providers on the AQP list of approved providers
- Frail elderly with complex problems and end-of-life care would not be appropriate for AQP
- An evaluation is underway to ascertain in two years’ time the effect of AQP on NHS workforce and patients
Any Willing Provider (AWP) was often viewed as the commissioner’s friend under PBC because of its simplicity, but services tended to be small-scale. How are things different under AQP?
You’re right, AWP was often for non-mainstream services, not necessarily those that were a priority for patients.
The biggest difference is scale. We’ve got 180 different providers now providing services for community and mental health and by late spring will be very close to three new services in each former PCT. The biggest difference from a patient perspective is, offering much more convenience. Under AQP there’s been an explosion around high street access to diagnostics – 100 PCTs selected diagnostics to be provided under AQP – so I’m hoping that will make a real difference to patient access and convenience. But most importantly it’s the ‘Q’ bit in AQP – the qualified. So any of those 180 or so providers who’ve been ‘qualified’ have had to meet rigorous quality standards, whereas before (under AWP) it was more of a procurement process without the focus on quality. To be qualified as a provider under AQP, you have to meet normal procurement requirements, you have to be registered if appropriate with the Care Quality Commission but also have a team of clinicians vetting your systems, your approach and so on, to make sure you’re safe and of sufficient quality.
But not all AQP services have to have a CQC registration?
Many don’t. But if they don’t require CQC registration, they’ve had to pass the quality test we’ve set down and will have gone through a series of quality and safety checks, not just the legal ones, to make sure that it’s a good quality for patients.
Who does those quality checks?
They’re currently carried out by centres of qualification excellence, basically a number of PCTs who have assembled around them clinical experts in the area, whether it’s musculoskeletal or diagnostics, to look at the service proposals from each provider.
Under the old system the quality checking was done on a local basis (by PCTs)?
Done on a local basis but with no guarantee of rigour and certainly no consistency. So now if it’s a diagnostics service for lower back pain any provider who has been qualified would have to meet the same quality standards whether they’re in Redruth or Dagenham.
There were headlines last year about the limited number of NHS providers on the AQP list. Can you give us a breakdown of who is on the list?
About 60 per cent who got through the process are actually independent sector providers, which can include charities as well as the bigger corporate providers. Of that 60 per cent who are independent, 80 per cent – so the vast majority – are either social enterprises, voluntary organisations, small businesses or enterprises such as groups of practices and residential care homes. So it’s really been seized by smaller providers as a way of diversifying, offering services that have some synergy with what they’re already currently offering whether they’re a physio, back pain or a care home in terms of some of the services . But 40 per cent of the providers are NHS. Many of the foundation trusts have used it as an opportunity to offer up their services to a wider catchment, offering patient choice and obviously increase their incomes.
And are AQP services still going to be on Choose and Book?
In terms of accessing and making a booking, yes Choose and Book or an equivalent in the future.
What we have produced though, because patients and GPs need to learn to use the new system, is an interactive map which you can access via our website which will tell you what services – ultrasound, DEXA, lower back pain – are available in which area. And then you can draw down and see which providers are providing what in which area. Also, if for example you want to see where a particular provider, such as Specsavers, are offering hearing tests in which part of the country, you can click on Specsavers and see where they’re providing services. Hopefully as AQP becomes more popular and grows over the next few years, then you will see more and more services on that map.
And is the department on track to have three AQP services in each PCT area?
It’s going really well and I’m very confident we will be on track to have around three services in each old PCT cluster and I think that gives a good foundation for going forward, not least because although we said you can choose from a list of eight services nationally identified as patient priorities, many PCTs chose to go ‘off the menu’ and identify priorities for them and their patients particularly around diagnostic services. So there’s been a much wider range of services and we’ve seen a completely unexpected opening up of access to diagnostics. Going forward, it’s absolutely for individual CCGs to decide which if any services they want to use choice of AQP for, which ones they actually want to tender for, where they want to just roll over the contract with the local FT. It’s entirely for them to choose how, and where, and when they use choice and competition for their patients. There is no set menu from April 1 this year. We’ve got the original three in each area in place and then it’s entirely down to CCGs how and when they build on that.
Some CCGs have amended their constitutions so they can use AQP as they feel is most appropriate locally. Could that be open to challenge?
I think it depends on the grounds for which they’re doing it. So if for example under the previous regime we introduced choice for lower back pain, musculoskeletal services on a AQP basis and in future the CCG said the best thing in future that would meet our patients interests would be a totally integrated musculoskeletal service, then it would be entirely appropriate then to say at the end of the contract, we’re going to move that AQP service into a totally integrated service because that’s better for patients. That’s why we’ve got to have decisions made locally. There will be some services that are actually poor quality, unresponsive to patients, where CCGs will want to use choice of AQP to drive improvement but there are other ones where for frail elderly people with multiple complex problems or end-of- life care you patently wouldn’t use AQP for different parts of the pathway, you’d go out and tender for a completely integrated service. That could be under a prime contractor who could be a NHS foundation trust or a major charity like Marie Curie or Macmillan. But we’re not going to storm (CCGs) and say you must do AQP or you must tender. You actually need to go through a rational process and decide what’s best for your patients and then use choice or competition appropriately.
There seems to be a feast and famine of services on the list – a number of services for cardiology I believe, for example, but none for respiratory. Why is this?
I don’t think it’s feast and famine, I think it’s people looking at what their local priorities are and whether choice of AQP for a tightly-defined service works or not. So if you take COPD as an example then some of the best COPD services I’ve seen are totally integrated between primary and secondary care. If you’re looking for that type of service then my view would be go out and tender for an integrated service, you wouldn’t look to use AQP for little bits of pieces of diagnostics and so on. It wouldn’t make any sense. Likewise for end-of-life care I would be strongly resistant to anyone who suggested using AQP for end of life care because you want an integrated service and part of the problem with NHS end-of-life care currently is that actually it’s the opposite, it’s not integrated so you wouldn’t want to fragment it further. I would strongly support any commissioner who wanted to secure a totally integrated service.
What lessons were picked up in the AQP drive that PCTs undertook?
A key issue for commissioners to decide is where does it make sense to introduce choice of AQP. So for something like lower back pain, it can often be very difficult to get quick treatment because of the NHS waiting times and the process you go through with that can really hinder people in terms of sustaining employment, dealing with pain. The patient might know they need rapid access to physio but are faced having to go through a convoluted process, with the risk they won’t get to see the physio who treated them before.
So there’s hearing, DEXA and even anti-coag therapy (that are suitable for AQP) because you want to reduce the barriers to make it as likely as possible that patients will comply. For other services for frail elderly people, end-of-life care you wouldn’t want to actually have choice of AQP because of the importance of effectively coordinating care.
But what you could do for end-of-life care or for a long-term condition within that overall contract for coordinated care is use some element of choice of AQP so that patients/users can choose settings that are more convenient to them but within the context of properly coordinated care.
So after asking which and why need to work through the implications – how going to make sure the right thresholds are in place and also equally if there are complications, because there could be in lower back pain, that your providers know what are the red flags in terms of spinal carcinoma and if that’s picked up whether it’s a NHS hospital or a physiotherapy practice that patient is referred back very quickly.
And is that action on red flags built into the current quality process?
Absolutely. There are three stages to approving providers: the routine checks eg CQC registered, then there’s looking at the clinical quality standards but the third stage which is equally important is the local PCT, and in the future CCGs, making sure that there’s a complete match between what’s the accepted referral protocol and what the provider will be offering, making sure the provider knows what are the local red flags in something like lower back pain. But that’s very much the duty of the local commissioner to make sure that that pathway will work locally.
How will AQP look in the future? Will smaller providers tag on to bigger ones?
I don’t know. It’s very difficult to forecast because we’re saying to commissioners ‘you choose’.
AQP could grow very rapidly or very slowly. In terms of the types of services we’ve seen a really unanticipated explosion around diagnostic services. If patients see that as beneficial, it impacts on waiting times and access then many CCGs may decide to explore diagnostics.
So it depends on the choices CCGs make and whether patients see real benefits, which is why we’re putting in place an evaluation not just of the process stuff, the qualification but what’s the impact in two years’ time on patients, NHS systems, workforce and so on. It is difficult to tell. The only evidence we’ve got is from the implementation of free choice of elective care where we saw an ‘s –shaped curve’ – a slow start as providers came on stream, patients and GPs learned how to use the system, became comfortable with it and then we saw after about 18 months saw a rapid growth. My prediction would be we won’t see much uptake during the course of the next year as patients get to use it, see the benefits, talk to their neighbours and that growth will come as people learn to use the system.
Longer term, in terms of types of providers, I think foundation trusts will increasingly adapt to the system in terms of the services they offer, particularly those that provide services on the back of the transforming community services programme so the NHS will always stay a major player.
For some AQP services there’s a national tariff, for others there isn’t – how cumbersome is it to develop local prices?
We’ve helped develop approaches to local (pricing) policy and have now got over 30 different types of services being offered somewhere under AQP that means we’ve got 30 sets of prices that can be adapted and used. To ensure that experience is not lost we’ve shared all the information on quality specifications and prices with every commissioning support unit (CSU). So CCGs can go to their CSU who will have the specification on the shelf on local pricing and pull it off, so they’re not having to reinvent the wheel.
But you could end up with a situation where a CCG is paying X amount in one area and a neighbouring CCG has got a different cheaper local tariff going. Won’t the CCG with the higher tariff send its patients to the AQP provider in the neighbouring area?
No because under choice of AQP it’s the patients deciding. The price is fixed within the catchment for that provider so under a different contract you can’t have price competition, any provider gets paid the same. Clearly there are variations in price in the NHS, in terms of market forces factor. My expectation over the next two or three years is commissioners will get better at pricing and in some cases initially they might have marginally overpaid and in others marginally underpaid and so not got the number of providers they needed locally and they’ll review and adjust that. AQP is quite a good safe’ish way of getting to know about pricing.
So a CCG (in your example above) wouldn’t make a saving. What the CCG would do if they’ve got any sense, is go back and renegotiate their contract. But the problem is, you don’t know whether the CCG that’s paying less is paying less because they’re getting very good value or whether it’s set a tariff which is unsustainable and will drive down quality.
It could be the other CCG needs to increase its price. So we need to do this evaluation which looks at what prices have been set and what quality standards are right so CSUs help CCGs come up with sensible well-pitched prices which don’t overpay but ensure the quality is right and if they need to adjust it, they adjust it. It’s no different to national tariff where introducing best practice tariffs and seeing successive changes to price.
What advice would you have for CCGs going forward with AQP?
AQP is one of a number of commissioning tools available to you to improve quality and access. It’s not one size fits all. It will work for certain services in certain circumstances but depends on your priorities and your circumstances so need to think through quite carefully, what is the problem I’m trying to solve ? Is it amenable to choice and competition? If it is, there is a choice of competition in the market – AQP all the way to tendering for a large completely integrated service. Monitor and the Commissioning Board fairly soon will be publishing a choice and competition framework to help commissioners work through those types of issues and will publish tools to form part of the kit commissioners can use in doing that. But fundamentally need to know what problem you’re trying to solve, why doing what you’re doing and be quite sophisticated in deciding do I go for AQP, various forms of tendering or extend contract with my existing provider and use contractual mechanisms to drive up quality. The advice is think before you leap in.