Just imagine it’s October 2012 and your left foot is really painful – as in keeping you awake at night. In October 2011 it was your right foot that hurt and your doctor sent you to the local NHS hospital for treatment at its podiatry clinic (for foot health – more than chiropody.)
By October next year, your doctor might well offer you a choice for treatment for your left foot – by your local NHS hospital, by a charity, by a social enterprise group or by a commercial company. Podiatry was one of the services the government wanted put in the fast lane to provide competition to the NHS and choice for the patient by October 2012.
When Health Secretary Andrew Lansley first launched the policy he called it “Any Willing Provider”. It’s now somewhat more reassuringly called “Any Qualified Provider”. We are not re-entering the era of snake-oil salesmen. But we are entering unknown territory.
The timescale is tight. NHS Wiltshire were told late in July that they had to complete consultation by the end of September on the government’s list of eight possible services. So on September 12 they held a Stakeholders’ Assembly – gathering about sixty-five local professionals, councillors, representatives of charities and patient groups and some of the doctors involved in the new commissioning groups to help select the first three or more services.
After much discussion three services came to the top of the list: treatment of neck and back pain (physiotherapy plus), direct access diagnosis (blood tests and more) and memory clinics (for those in the earlier stages of conditions such as alzheimer’s.) As it turned out, podiatry was one of the services least favoured to be part of the first round of setting up competitive providers – so your left foot’s safe with the NHS till well after October 2012.
Two other services – developmental disorders (ADHD and autistic spectrum conditions) and lymphodaema (swelling caused by lymph problems) – may come into the frame once more work has been done on how they could fit with related treatments and how to specify their work.
There are, of course, a great many hoops for any potential rival provider to go through. Are they a credible outfit – with financial stability, appropriate legal status and so on? Will they improve the service to patients? Can they find the right staff? Can they respond to referrals from GPs fast enough? What about training?
One thing is certain: there will be no protection for any kind of provider – government policy focuses primarily on effecting choice. This is a “very explicit political judgment on how to improve the NHS.”
All this will most likely bring added headaches for GPs and their colleagues in the new commissioning groups which will take over the budgets from the primary care trusts. First it will make control of the budgets much more difficult – even precarious. Secondly it may often face GPs with conflicts of interest.
Will they advise patients which treatment to choose when that choice may well affect the commissioning group’s bottom line? We may well see the rise of “patient advisers” attached to surgeries to help patients choose.
Those advisers and the complexity of overseeing and checking the new providers, tracking fragmented sources of cost and keeping clear of the clutches of competition umpires, will all involve a host of backroom jobs – or, as the government likes to call them, bureaucrats. And this at a time when most of the savings from the coalition’s radical NHS restructuring are supposed to come from ‘cutting bureaucracy’.
And no one can foresee precisely how the new commissioning groups will be able to make these services a satisfactory part of continuing and integrated treatment of their patients.
GPs and commissioning groups will be open to scrutiny and public shaming by the competition tsars that want to give non-NHS providers every chance to succeed. This is already happening with the choice of providers for elective surgery (such as hip replacements) – see Marlborough News Online’s earlier story.
There’s evidence already that social enterprises and charities will not get any favours in this process – in fact the risks in size and sustainability they bring to the NHS may doom them.
The social enterprise, not-for-profit group Central Surrey Healthcare (CSH) has been running community health for a large area of Surrey since 2006. Last year David Cameron presented them with the first ever Big Society award – a recognition that CSH’s 770 entrepreneurial nurses, therapists and other community staff have been providing quality care for less money. Even the Cabinet Office said CSH are delivering substantial improvements in quality and efficiency.
But when CSH bid for a new £500milion contract to spread their work to more of Surrey’s patients, Surrey primary care trust decided to hand the contract to Assura Medical Limited (75% owned by Virgin.) It seems the main reason was that CSH could not raise enough money for the necessary surety bond.
Has this decision put money before quality of service? CSH’s own contract comes up for tender in the next twelve months. The fear is the coalition government’s rules will favour another bid from a private, capital-rich company and dish the social enterprise workers.
And bearing in mind the experience of the health workers of Surrey, will charities and social enterprises in Wiltshire be successful when they make smaller scale bids for services under the ‘Any Qualified Provider’ label?