Why AQP can drive real benefits in primary and secondary care

The any qualified provider initiative promotes the provision of NHS funded services by a range of public and independent health providers in a local area.  

Promoting AQP was thus always going to be a controversial policy for the government. Indeed, AQP has often had a poor press to date. It is frequently portrayed as anti-NHS, destabilising, and a politically motivated vehicle that promotes privatisation. It can thus be construed as the antithesis of integrated and coordinated clinical care. 

However we argue that, on the converse, AQP can be a powerful driver of harmonization between primary and secondary care remits. If commissioned correctly, AQP can encourage hospital based care to focus increasingly on high-end complex investigations and therapies, while at the same time involving both tiers in a patient centred model of care. 

AQP can promote improved community-based, efficient and modernised care that extends the choice and quality of services available for patients. In addition, AQP offers increased cost-effectiveness - since competing for patients generally leads to higher quality and lower costs.

Key factors underlying success include:

• Basing AQP on a clear service specification of what services are to be provided.
• Consistent clinical engagement throughout the process.
• Basing provision around best available evidence.
• Absolute clarity as to the respective role of hospital/secondary based care in the broader context of clinical pathways for individual patients.
• Ensuring public and patient confidence via effective consistent external accreditation.
• Setting price in ways that promote constructive tension in the local health economy, thus stimulating greater pluralism and alternatives to traditional health systems.

Recent trials suggest that AQP may offer particular advantages if used to support local fast-access diagnostic activity. Newly emerging clinical commissioning groups are also likely to look to capitalise upon AQP as a mechanism for driving decentralisation of services away from over-burdened and over-crowded acute hospital settings. 

AQP Principles

Competition is not new to the NHS.  Ever since compulsory competitive tendering was introduced in the 1980s, there have been episodic attempts by commissioners to extend this to health care services itself.  However, these efforts were episodic and largely ineffectual in developing a vibrant, pluralistic supply-side in heath care provision across the UK. 

Little change to the traditional model of provision took place until the introduction of choose and book (C+B) to acute services in 2008. C+B has in practice been tangential to changing the traditional forms of provision across the NHS. Its consumerist approach has also largely failed to address effective clinical prioritisation or decentralisation of services away from hospital.

AQP promises something rather different. Its basic principles are:

• Commissioners establish guidelines and specifications against which potential providers are assessed. This ensures that there is absolute clarity on what services are required.
• Providers are then accredited principally on their ability to meet a range of quality standards, rather than cost.
• Patients and their referring clinicians can decide upon which provider they wish to use. This facilitates patient choice and empowerment.
• Providers are assessed on their ability to meet established quality standards via external accreditation e.g. by the Care Quality Commission, Monitor, etc.
• Providers undertake to continue to meet a range of established criteria and standards, thus ensuring that high standards of service are maintained.

Tendering procedures for AQP are relatively straight-forward. They are focused on assuring commissioners that potential providers have the capacity and ability to deliver the required services, and also can give the necessary guarantees about meeting quality standards.

National Perspectives

AQP is consistent with the political philosophies of the government. That said, its initially bullish approach towards rolling-out the concept nationally (as exemplified in the original version of the Health and Social Care bill) have been modified substantially following the national “listening exercise” earlier in 2011. 

PCT clusters have now been given until 2012 to introduce a very limited range of AQP schemes. The majority of these are expected to be in relatively politically non-contentious areas – mainly community-based services such as podiatry, continence services, adult hearing, wheelchairs, musculo-skeletal, etc. Plans for extending AQP further in 2013 are also mainly in non-acute settings such as Speech and Language Therapy, community chemotherapy, ante-natal education, etc.

AQP providers are expected to be drawn not just from the ranks of current NHS providers, but also from less traditional sources such as social enterprises, voluntary organisations, local authorities, etc. The philosophy is simple – the best providers should be empowered to provide services for the NHS irrespective of their pedigree or ownership structure. Services for patients will still be free at the time of use, and the decision to use them will be for each patient to decide – albeit with NHS commissioners being required to pick up the cost.

Local progress

It is a little premature however to draw any substantive general conclusions about the effectiveness or impact of these new services – not least since their introduction across the country have been opportunistic.

A number of PCTs have however embarked tentatively down the AWP/AQP route (see case study below). New AQP opportunities are now being advertised nationally and locally on a daily basis, and a significant growth in these schemes can be expected.

Case study

Several pilot AQP projects have been carried out in South West Essex over a two-year period, based in primary care settings. 

These have employed slightly different models of care for patients requiring cardiological diagnosis and treatment. In one practice, a fully specialist-led service has been implemented, while on another site a GPSI-led (GP with special interest) service has been the preferred choice, given local availability of clinical expertise. In both cases, a one-stop clinical model has been provided.

Both models have been based on the cooperation between GPs in a local cluster and local hospital specialist consultants. This arrangement has provided a number of significant advantages:

• The service is offered in local GP practices - therefore moved to the patients’ doorstep, with greatly improved patient comfort.
• In virtually all cases, the consultation leads directly to outline a complete and individualized care plan by the end of the initial session. This is made possible via immediate availability of the necessary basic diagnostics tools, thus enabling immediate review and clinical interpretations.
• Ongoing cooperation between the Specialist/GPwSI and the GP has been enhanced, and this has enabled action to implement the agreed care plan in an extremely short time span.
• The involvement of a recognized hospital specialist consultant with direct links into the local hospital has been pivotal in avoiding delays, and has also reduced unnecessary test duplications should the patient need to be referred on to secondary care.

Of the 195 patients seen, over 86 per cent completed could be managed satisfactorily within this AQP scheme. 79 per cent of patients were provided with an Echocardiogram, and 66 per cent with ECG. 38 per cent also required other local diagnostic investigation.

Compared to pre-existing referral system, waiting-times have been significantly reduced.  Hospital based waiting times – which often necessitate return trips for patients to complete diagnostic work-up – average around 14 weeks in total before care plans are finalised. For the pilot practices, waiting times overall were between two to three weeks, and care plans are generally immediately available and can be implemented in close conjunction with the patient’s GP.

The pilot schemes have also delivered substantial cost savings. These have averaged between 35 per cent to 55 per cent compared with the costs of a traditional secondary care based service.

Advocates of AQP can point to a number of its potential advantages:

• Improved choice for patients and their referring clinicians.
• A positive stimulus for greater innovation and higher quality standards.
• The comparatively low transaction costs of introducing AQP – in comparison for example with full competitive tendering.
• New entrants and exits to the local health market can be accommodated without due delay.
• Costs are driven down via the need for providers to live within a predetermined financial envelope.
• Public confidence is instilled via external independent accreditation and regulation.

So, if the principle of AQP is so appealing, why has it taken over 60 years of the NHS for it to appear on the policy scene? Four main reasons are suggested. Firstly, any state monopoly such as the NHS tends towards monolithic systems of provision – hence it has only been the greater pluralism resulting from NHS structural changes over the past few years that has enabled AQP to be a realistic policy option.

Secondly, AQP needs to be driven primarily via a strong commissioner. However, many PCTs are only now emerging as effective leaders of the local health economy – which is perhaps ironic since this has coincided with their imminent demise. 

Thirdly, greater diversity does not mean that all providers will have all the same competence, capacity and capability. Many of the new entrants – for example, the voluntary sector - have more to do in order to prove fully that they can “cut the mustard” of providing a comprehensive service for NHS patients.

However, the advent of comprehensive independent regulators such as the CQC now allows for greater public confidence. This in turn creates the environment for much greater diversity of provision at the front-line of health care.

The future of AQP will lie less in the hands of politicians but rather with new clinical commissioning groups. These will be well placed to set the clinical and financial framework necessary to enable AQP to thrive.

CCGs will be able to promote clear specifications for services that ensure that the essential overall coordination of services is not lost – for example, issuing clear indications of what services are only suitable for specialist secondary care, and those which can be managed within AQP.

Hospital and their consultants have thus far been largely isolated from AQP schemes. CCGs will however be able to use their commissioning levers to encourage the secondary care sector to become more directly involved in AQP initiatives in community settings.  Furthermore, foundation trusts will have commercial reasons to increase turnover and – in particular – to capture new referrals that may result from active engagement in AQP schemes.

A key issues for secondary care will be the extent to which they are prepared to enable their senior clinicians to work outside the hospital walls. Historically, the referral systems within the NHS have promoted an inward-looking dynamic – patients needing to see a specialist are expected to travel in to see the “great man”. This is likely to change. Hospital consultants may need to travel out to see patients in more local settings.  Technology advancements will support this change – such as increasingly effective near patient testing systems, as well as instant access to patient records as well as other clinical colleagues via internet links. 

Combined with the new power dynamics offered by clinical commissioning groups, AQP offers substantive opportunities for a much greater range of health providers. The end result may be further move towards a more European-style health care system: greater diversity of supply, more choice for patients and greater pluralism - but within the context of an essentially state-funded health care system.