NHS gooroo blog

Posts Tagged ‘pathway’

On Friday the Department of Health updated the Procurement guide for commissioners of NHS-funded services. It is littered with the familiar dreary life-sapping injunctions about OJEU notices, procurement rules, and the need to review, benchmark, and consult with everybody in sight. But in the middle of it all, you can glimpse the future of NHS commissioning: the Any Willing Provider (AWP) model. The guidance says:

AWP may be described as an accreditation process underpinned by a ‘call-off’ contract (ie payment is determined according to patients’ choice of provider). AWP has been defined nationally in its application to routine elective care, but can be adapted locally to facilitate patient choice in other services.

…which of course is virtually identical to the wording in the March 2010 version, and a continuation of the AWP rules that were set back in May 2008. So far, the “Liberative” policy is identical to the “New Labour” one.

As often happens with policy innovations, the AWP model is aimed at routine elective care. Policy-makers don’t like messing with the hot stuff if there is a less-controversial area they can start in. But they did leave the door ajar for AWP to be used in other areas of healthcare as well, if local commissioners want to stick their necks out. And local commissioners should. The language in the guidance may be couched around patient choice, but it works for commissioner choice too and gives GP commissioners much greater flexibility when referring emergencies and electives alike.

The trouble with AWP is that it insists on using the NHS Standard Contract, which itself is still rooted in the old world of planning and performance management. What AWP really needs is a Standard Contract Lite, under which GP practices could refer at tariff or local prices but without needing to go through the laborious processes for agreeing detailed activity tables and performance indicators.

That would bring GP Commissioning closer to the world of the normal small business. A local firm of plumbers does not negotiate and agree lengthy annual contracts with each of its suppliers, specifying guaranteed volumes and bespoke performance standards. Instead it sets up accounts at Travis Perkins, Plumb Center and the rest, and pops in from time to time for pipes, valves and whatever else it needs. If one supplier disappoints on cost or quality, they favour a different one for a while. Minimum performance is taken care of by law, regulation, and standards.

Healthcare is more complex and expensive than plumbing, but in other respects the analogy holds where there is a choice of provider. In this spirit, the Procurement guide says for AWP:

As a minimum, potential providers must demonstrate that:

1) They are registered with CQC (or other relevant body) for that service

2) They agree to the tariff that commissioners are willing to pay

3) They receive no guarantees of volume / payment

So minimum standards are assured, price is fixed, and the activity plan tables in the Standard Contract are redundant. This should make the development of a Standard Contract Lite relatively straightforward; all that is needed is a minimum-content default wording for all the locally-negotiated elements in the contract (which in most cases will simply state “Not used”). Local commissioners could do this themselves, or the Department could save them the trouble by providing default wording for them.

Is that it? When Standard Contract Lites are in place for AWPs, can GPs buy care for their patients just as any small business manages its supplies? Not quite: there is still quite a lot of other baggage to deal with. Can you imagine an average GP being enthused about commissioning, while:

In addition, this guidance requires that commissioners also undertake the following as part of the procurement decision-making process

• Undertake Service reviews to identify areas for improvement and ensure alignment with commissioning strategy (eg QIPP)
• Apply benchmarking to existing services
• Use healthcare market analysis
• Specify relevant service specification, outcomes, KPIs and expected prices
• Engage early with providers, staff and representatives / Trades Unions to asses the potential impact / deliverability of the service
• Engage with service users local communities and other key stakeholders eg Health Overview Scrutiny Committees and successor arrangements …
• Have regard to any sustainable development aspects of the procurement.

This baggage had its place in large-scale bureaucratic commissioning. But it will be unsuited and unnecessary in a more normal marketplace, in which the real commissioners are referring GPs, and the risk of establishing a service lies firmly with the provider. When PCTs are leaving the stage, would they kindly remember to bring all their baggage with them?

Whether they want to be or not, GPs are commissioners. Every time they refer a patient, they are committing resources to them.

But not all GPs see themselves as commissioners. After all, isn’t commissioning a complex process of planning, analysing, monitoring, and contract management? PCTs employ whole departments to do that, so why would a GP want to take it on? And if they did, how could they do it well?

There are plenty of compelling reasons why things would be better if GPs (and other practice clinicians) did take a more active role in commissioning. After all, who else could do the job better? On the commissioning side, only they know the patient well enough and have the skill and knowledge to make the right clinical judgement.

When looking for ways to improve GP commissioning, the debate has tended to focus on incentives or, more narrowly, how money can be used to reward GPs for referring within a budget. But there is more to effective commissioning than just meeting a budget (clinical quality immediately springs to mind). And there is more to raising performance than financial reward; the three main factors being ability, motivation, and opportunity (the “AMO model“). So how can we use this broader approach to develop better GP commissioning?

Let’s start with ability, which is built of things like skill, reasoning and perception. We can’t easily improve all of these (improving skill and reasoning is a challenge), but we can improve perception because it depends on the information available to a GP.

A commissioning GP needs easily-accessible information that is up-to-date, accurate, and specific to their own referrals, so that they can monitor their referral spend and keep on top of it. In the past an information analyst would have been needed to crunch the numbers, but new web-based systems (like Mede) can now deliver digestible information and alerts from the SUS datasets directly to GPs.

GP commissioners also benefit from support from a real human, and this is where PCTs can provide a bank manager service: challenging overspends, spotting unusual activity on the account, and advising alternative courses of action.

Next: opportunity. To what extent do GPs have the clinical discretion to change referral patterns and adapt to budgetary constraints? The answer has got to be “some discretion”, at least, simply because clinical need is a grey area in which human judgements must be made. Beyond that, we are into the practicalities: are alternative pathways available?

Obviously an available pathway must physically exist as a service. Not only that, but GPs need to be able to refer to it, so there must be a contract in place with the PCT. Also, it is only worth using an alternative pathway if it provides suitable clinical quality (so GPs need the assurance of good clinical governance processes) at a lower cost (so the price needs to be directly comparable with the on-tariff alternative). PCTs can help here by providing pathway management support to make GPs aware of the alternative pathways available and help them weigh their merits.

Finally let’s look at motivation. Certainly money into the GP’s or practice’s bank account is going to motivate, and this can be formulated in more ways than the Fundholding approach of simply allowing practices to “keep the change” if they come in under budget. For instance, one or more budgetary ceilings can be set, and practices awarded a modest percentage of the underspend against each ceiling. Non-financial forms of encouragement include status (a consortium leadership, a new pathway directorship, a thought leader), and simple recognition and praise.

As well as encouraging GP commissioners, the PCT needs to be careful not to discourage them with upsets like frequent rule changes, unfair rewards, or failing to support GPs in disputes with providers.

So we have lots of possibilities for improving GP commissioning: information systems and bank-manager support to improve ability; financial and non-financial rewards to improve motivation; and alternative pathways with attractive contracts and assured quality to improve opportunity.

Would I prescribe any particular combination of all these things? No, because every situation is different, and nobody knows exactly what will work best in each case. It would be much better for PCTs and GPs to invent their own approaches together, trying things out, making mistakes, and constantly improving. Partly because that is a good way to solve a complex problem. But also because the satisfaction of problem solved and a job well done is itself a powerful motivator.

Who can manage the demand for healthcare? GPs can. But who else?

Most of the NHS’s work starts with a referral from a GP. That simple fact leads to GPs being described as the “gatekeepers of the NHS” and asked, one way or another, to take responsibility for managing (i.e. restraining) demand and solving all the NHS’s financial woes.

As financial pressures grow, the calls on GPs to restrain referrals and costs will become louder. But how much should GPs take on? Could the temptations to enrich themselves in unethical ways become too strong? And is there a more interesting way to achieve the same objectives, that involve patients and other players more?

Let’s start from where we are now, with GPs having some limited ability to influence the patient pathway and its cost. What makes it limited? Because referrals are fire-and-forget: when a patient has been referred to a consultant, the consultant “owns” the patient, and the consultant has the discretion to make tertiary referrals, keep the patient in bed, prescribe drugs… in short to spend the commissioner’s money on the patient largely as the consultant sees fit (and often to the advantage of the Trust that employs the consultant).

Certainly there are good clinical reasons for this arrangement. But in no other industry would a customer let its suppliers order work from themselves at the customer’s expense.

GPs do sometimes have powers to interrupt the patient pathway using Prior Approval schemes. These can allow commissioners to withhold payment for work that was not approved in advance, either explicitly or by being part of an approved pathway. But Prior Approval schemes have to be agreed with the provider before they can be written into the contract, and a cash-strapped Trust may not welcome a potential loss of valuable excess bed day payments.

So should GPs be given power over the whole patient pathway from end to end, to interrupt consultant-led care, and pull patients out of acute hospitals for transfer to lower-cost providers? Not so fast. Apart from the good clinical reasons mentioned above, it would generate great resistance and ill-will between GPs and consultants: the very people who most need to work co-operatively together if financial control is to be devolved successfully to the front line. So is this line of thinking all a dead end?

No, wait. We’re forgetting somebody. I don’t mean to be unhelpful, but what about the patient?*

The patient (or, if incapable, the patient’s representative) needs to give informed consent at every step along the pathway. Patients are not usually familiar with all the consultants available, their special interests, or the waiting times, infection risks, and other quality standards at each provider. So they need to be informed by healthcare professionals whose judgement they can trust. That certainly includes their consultant, if they are under a consultant’s care. But it surely also includes their GP, no matter whose care they are under?

Now an answer is starting to emerge. If GPs were more available to inform and advise patients at all stages of the patient pathway, even when they are lying in a hospital bed, then patients could manage their own pathways more effectively. Most would choose lower-intensity care closer to home if they could, which aligns well with the preferences of their GP when finances are also considered. It also neatly blunts the potential for a (hypothetical) unscrupulous GP to make money simply by delaying referral, as the patient would be unlikely to agree, and hospital consultants would be involved in the clinical governance process for reviewing the pathways they are using.

This means more work for GPs, and that would cost money of course. But who could be better placed to judge the merits of that trade-off, than the commissioning GPs themselves? Putting patients in control of their own pathways, with guidance at every step from their GPs, is an idea worth trying.

*(“What about the patient?” is a fun game to play in NHS management meetings. If the discussion starts veering off in a direction you don’t like, lean forward and very earnestly ask “what about the patient?”. It stops the discussion stone dead, everybody takes turns to make politically-correct statements about patients, and nobody will have the courage to get back on-topic. Warning: doesn’t work against practising clinicians.)