October 2010
Care UK Response to the Government’s White Paper.
Equity and Excellence: Liberating the NHS
Care UK is supportive of the proposals set out in the Government’s White Paper “Equity and Excellence: Liberating the NHS”.
We have worked closely with colleagues across the independent sector and the NHS Partners Network (“NHSPN”) to develop detailed responses to each of the elements in the consultation documents where we believe we can add value and insight to the consultation. We feel strongly that it is appropriate for that response to be a collective one representing as broad a view as possible from the sector.
As a broad based health and social care provider we have also given consideration to the provisions of the White Paper for specialist services, notably mental health, and we have worked alongside 8 other leading providers within the Independent Mental Health Services Alliance (“IMHSA”) to produce a coordinated sector response on these provisions.
We would urge the Secretary of State to carefully consider the ideas, alternatives and challenges as set out in those 2 responses.
This document is in 2 parts:
- Summary of Care UK’s response to the principles and major themes of the White Paper, the further detail of which can be found in the NHSPN and IMHSA collective responses.
- Identification of a number of practical examples of how improved, patient focused care solutions are emerging that represent best value for the tax payer and provide genuine choice, but where we feel the White Paper does not go far enough to enable such initiatives to flourish; or where the manner of the White Paper’s implementation may stifle or prevent such initiatives.
1. Care UK’s response to the White Paper
1.1 General principles
Care UK is supportive of the principles set out in the Government’s Health White Paper “Equity and Excellence: Liberating the NHS”.
In particular, we consider that the more direct engagement of GPs in commissioning care will reduce administrative barriers and result in commissioning of more relevant and more ‘patient focused’ care.
However, we feel that many PCTs have made positive progress with commissioning and we are concerned that this momentum may be lost. We are also concerned that many GPs will not have the inclination or capacity to fully participate in commissioning and we believe that in such cases alternatives are required to ensure innovation and service reform. Finally, we are concerned that the NHS will find the extent and pace of the change management programme extremely challenging and we would therefore urge strong leadership and oversight of the change process.
We have worked with the NHSPN to provide additional thinking and constructive challenge to ensure that the changes deliver a health system in the UK that works for patients and delivers real value; to ensure that the implementation of the changes proposed is as effective as possible; and to identify areas where we feel that alternative approaches should be considered.
Care UK is committed to the core principles of the NHS and the provision of patient focused, outcome driven care, free at the point of delivery. Care UK and the independent sector as a whole, is ready to bring investment, imagination and long term commitment to delivering excellent patient care and best value for taxpayers.
1.1 Maintaining Equity of Access
Equity of access is an important principle of the NHS and it is vitally important that planned reforms enhance rather than inhibit this equity. Care UK considers that the transition of commissioning responsibility from PCTs to GP Commissioning Groups will prove to be beneficial to patient care and will drive more relevant and more efficient commissioning.
However, there is undoubtedly a correlation between demographics and GP capacity, capability and inclination to be effective commissioners. GPs located in deprived inner city and rural areas will require far more support – and even leadership -than their colleagues in affluent areas. In Care UK’s experience, many PCTs located in deprived areas are making good encouraging progress with health improvement initiatives and it is vital that this progress is maintained. This need for support and leadership should be carefully considered in the migration to GP commissioning.
1.2 Protecting Patient Choice
We believe that patient choice should lie at the heart of reform and we strongly support the drive for greater clinical involvement in defining the optimum response to the needs of patients and commissioning of care.
As the largest independent provider of health services to the NHS, Care UK has demonstrated over a sustained period and across a range of care pathways the ability of the Independent Sector to assist the NHS to cost effectively deliver choice and reduce waiting times for patients. Most importantly it has demonstrated that the Independent Sector is more than able to deliver best-in-class standards of care, outcomes and levels of customer satisfaction, even from a standing start.
It is worth reflecting that virtually all General Practitioners are also independent small businesses who have been central to the creation of the NHS.
Despite the rhetoric of the BMA, we believe that with continued encouragement from the Government, the majority of GPs will respond positively to alternative providers of health services, especially where these are presented in community environments, focused on better and faster access to high quality, independent and well resourced diagnosis and treatment.
In this context we strongly welcome the fact that the White Paper sets out a clear agenda for a pluralist market place to develop in which the patient is put first, choice is sacrosanct and clinical expertise sits at the heart of commissioning. However, it is absolutely critical to the success of the proposals that the normal rules of competition apply to all and that a level playing field is created between public and non-public sector providers if that market place is to continue to deliver benefits. Equally importantly, evenhanded regulation needs to recognise the risks of conflicts of interest and ensure that the improved delivery of outcomes is incentivised over activity.
The introduction of the Independent Sector into the NHS has been challenging and has met ideological, cultural and vested interest resistance. Whilst the Independent Sector today is an integral part of the NHS and makes a contribution out of all proportion to the scale on which it is involved, it is important to recognise that this activity remains embryonic and fragile.
For Care UK and other independent providers to continue to bring investment, innovation and consistent delivery to the sector, Government must articulate an enduring commitment to a pluralist market. Moreover, Government policies must ensure the freedom and information that patients need to exercise choice, even handed regulation, non-discrimination in tendering and commissioning, and unrestricted access for any provider meeting NHS standards.
1.3 Learning positive lessons from the past
We strongly support the rights of patients requiring elective surgery to have the choice of local access to prompt, predictable high quality elective surgery that is not subject to delays and postponements arising from the juxtaposition of elective care with 24/7 trauma handling in mainstream hospitals. The Independent Sector Treatment Centre programme is a practical example of how a 100% focus on planned surgery in small, local, specialist units is an efficient, cost effective solution that is popular with patients.
It is a deep frustration however, that having responded positively to previous Governments’ policy and having met or exceeded the targets that were set, the ISTC programme has been criticised to the extent that the benefits have been largely lost from sight. On a local level, even delivery of outstanding performance has not always translated to continuity of tenure for the provider.
In our opinion, much of the criticism of the programme can be traced back to:
- Over-expectation in the early stages, partly from poor forecasting and partly from over optimism about the pace of change. (Patients and referring clinicians had to cope with a double learning curve of patient ‘Choice’ and working with new providers from outside of the NHS.)
- An enduring perception of ISTCs as ‘competitors’ to traditional services, in part a result of the imposition of ‘additionality’ -contractual obligations that prohibited engagement of clinical personnel that were currently or had recently worked for an NHS organisation and which, therefore, led to the exclusive use of non-NHS / non-UK clinicians in many instances. This in turn further inhibited initial contracted utilisation given GPs’ unfamiliarity with these clinicians.
Notwithstanding these constraints, ISTCs have nevertheless achieved much:
- Once mature, centres have achieved and even exceeded desired volume throughputs.
- Capacity gaps have been reduced and waiting times have improved significantly from an average 26 weeks to 18 with ISTC patients typically seen in 2 to 4 weeks.
- Infection rates are extremely low (Over 5 years and tens of thousands of operations Care UK has seen ‘zero’ MRSA cases in its centres).
- Return to theatre rates (fewer repeat operations) and patient outcomes are amongst the best achieved in the NHS.
- Clinical quality is driven through high performance standards and KPI reporting.
- Patient satisfaction rates (as measured independently by the DH) are significantly higher than for the NHS as a whole.
Care UK has also introduced the concept of the ‘one-stop shop’ in its treatment centres. Outreach services are being incorporated alongside clinical services that enable patients to return early and safely to their own homes and receive pre and post-care, thereby improving outcomes and speeding recovery times and return to normal activity and/or work.
Given the commitment of the Independent Sector organisations that have responded positively to NHS service provision to date, it seems reasonable for criticism of the ISTC programme to focus on flaws in the design of the initiative rather than the performance of the providers.
To support the continued attractiveness of the sector to new investment, Care UK is calling for an enduring commitment to the market concept and recognition of the contribution made to date of better outcomes, quality of clinical and patient care as well as catalysing wider NHS provider improvement.
Care UK is extremely encouraged by the intention set out in the White Paper to embed open market structures and regulation in legislation. Moreover, we believe that the creation of an ‘Any Willing Provider’ environment is essential to deliver true patient choice, continue to drive up care standards and prevent waiting times from deteriorating.
However, we are also asking for a commitment from Government in a number of specific areas:
- Ensuring that the responsibility for and method of regulation is common to all providers.
- Ensuring a level playing field that makes for a true market addressing inequality in cost base between public and private providers including: the true cost of pension funding, central services (e.g. IT devt.), arm’s length bodies, the funding of regulation and taxation.*
- Ensuring that GPs (as commissioners of services, as referrers and as a trusted source of information to patients) are required to focus on quality of access, standards of patient care and outcomes; do not discriminate between different types of provider; and that they respect and strengthen patients’ right to choice.
* Many of these issues are borne out by the findings of the recent study by Civitas ‘Refusing Treatment: the NHS and Market Reform which concludes that numerous barriers to fair completion remain to be removed, commissioning skills developed and attitudes changed if the market is to be truly effective.
2. Practical examples of where we believe the White Paper needs to go further.
2.1 Patient Access
Care UK operates a number of Commuter Walk-in Centres as well as GP Practices combined with Walk-in Centres located in deprived and historically under-doctored areas. These have been commissioned mostly through PCTs, though often as a result of national guidance. These types of facility exemplify Government’s commitment to improving the public’s speed and ease of access to primary care services.
The direct benefits of these centres include:
- Improved local access to primary care services for patients away from home for work, study or travel.
- Extended opening hours and no requirement for appointments improving access outside of working hours for the working population and others who cannot easily take time off to visit their regular GP.
- Reduced burden on A&E.
- The opportunity to introduce time and cost efficient one-stop shops.
And there have also been unexpected benefits:
- Certain groups within the population take more readily to the ‘walk-in’ concept than ‘appointment based’ surgeries. These include immigrant communities not accustomed to the traditional family GP system and. young or professional people whose lifestyle is simply better suited to unplanned access.
- Young people appear to more readily use the Walk-in Centres for sexual health when they can access a facility of their own choosing rather than their usual family practice.
Care UK believes there is potential to extend the benefits to many more communities by opening up the market for the operation of new GP Practices combined with Walk-in Centres and, in some cases, Urgent Care Centres.
We fully endorse the focus in the White Paper on access to Urgent Care Centres and would also urge that consideration is given to extending the concept of these centres to cover other care services more typically provided in more expensive hospital settings, thereby reducing the cost of provision of care, reducing the burden on hospitals of certain outpatient services and further enhancing accessibility to primary care services.
It has been shown that up to 70% of A&E admissions resulting from ambulance call-outs could be avoided. We believe that a part of the solution would involve the provision of social care and mental health alternatives to acute hospital A&E departments.
Care UK as an independent provider is almost certainly not alone in its willingness to put forward proposals to provide such services at its own financial risk, subject to gaining confidence in the sustainability of NHS market reforms.
Our proposal is that this consultation would not be complete if it did not lead to a thorough review of the root causes of A&E admissions with providers invited to recommend alternatives to the current arrangements for managing emergency admissions. Care UK would be willing to contribute based on its combined experience of Urgent Care Centres and Minor Injuries management as well as its extensive clinical and non-clinical social care and mental health involvement.
However, the White Paper is unclear how such services would be commissioned in the future and there is genuine concern that it may be unrealistic to rely on GP commissioning to drive such initiatives and provide facilitation.
Already under current arrangements there is real evidence of PCTs starting to move away from alternatives to the traditional GP model, particularly where a part of the benefit is not accrued locally (such as with Commuter Walk-in Centres).
It should also be considered that the funding for such services could be apportioned to a patients’ registered GP to reflect the total cost of care more accurately and to encourage GPs to extend services rather than to further restrict them (for example, in situations where an alternative solution for Out of Hours care is available).
GPs are unlikely to want to fund such initiatives or other competing services and this raises the question of where step-change in the creation of a market and in the creation of choice will come from in this context.
It may be considered that the proposed NHS Commissioning Board would be better placed to take a wider community view of the benefits of commissioning such services.
2.2 Developing more integrated solutions
We believe that there is an increasing need for community based, well equipped health services to provide highly responsive local access for clinical diagnosis, assessment and a range of treatments at integrated, multi-disciplinary centres.
We believe that the proposals within the White Paper should encourage GPs to commission such solutions where they offer the greatest convenience, standards of care and outcomes for their patients. However, due to the inherent uncertainty surrounding speed of take up, the economic analysis of such initiatives is challenging.
Care UK has relevant experience and is willing to invest in developing such services on an ‘Any Willing Provider’ basis. However, we would appreciate engagement with progressive GP Commissioning Groups and the NHS Commissioning Board to model and assess the financial viability of such initiatives. We would also seek reassurance that acceptable levels of risk would not be compromised by public sector providers bringing pressure to bear on GPs to use traditional pathways to prop up failing hospital-based services in the event that alternative community-based solutions proved successful.
2.3 Liberating PCT Community Services
Care UK believes that the contribution of Community Health Care Services is vital to an effective health care system. We consider that vertical integration of these provider arms into NHS acute trusts presents a potential conflict of interest given the opportunity for effective community services to reduce levels of hospital based activity, and hence income. Moreover, from a management perspective, community-based service provision is culturally and organisationally very different to managing acute hospitals.
Care UK would be keen to work closely with GP commissioners to provide the leadership that these entities require to help them develop into more responsive providers of high quality services adapted to the needs of the communities they serve and working to reduce hospital admissions and lengths of stay.
2.4 Integrating care to reduce hospital admissions and manage chronic diseases
Care UK absolutely supports the White Paper proposals to make greater use of the social care workforce to manage people’s health needs in their own homes or, where greater levels of nursing are involved, in residential care settings.
PCTs and Local Authorities are currently facing the two-pronged challenge of delivering increasing levels of health and social care services to a growing population of older people -many of whom will have complex needs -whilst also responding to the material cost reduction imperative.
In parallel and to achieve similar objectives, PCTs and LAs are seeking to transform the delivery of health and social care services by giving service users greater choice, say and control over what, when and how services are delivered.
These pressures demand a radical shift in the way health and social care are delivered.
Care UK supports a concept of integrated care that moves the system from the traditional NHS model of reactive ‘inbound’ healthcare to proactive, preventative ‘outbound’ healthcare. In other words: from waiting for problems to occur and then fixing the problem, to understanding what problems might occur and preventing as many of them as possible.
There is strong evidence that integrated care can deliver more effective and higher quality care and significant efficiency savings. The recent McKinsey report estimated that somewhere between £3.5bn and £5.0bn of savings may be available from greater integration of health and social care.
The potential for cost reduction typically focuses on reducing healthcare interactions, notably unnecessary hospital visits (especially A&E admissions) and, to an extent, GP visits, by providing cheaper alternative services to pro-actively manage the health of those people who are most likely to consume healthcare resources.
However, this view would tend to suggest that the savings from integrated care are all to be made within healthcare while much of the cost of improved services is borne by social care. In practice, one of the principle triggers for the need for social care (or escalation towards more intense social care) is hospitalisation and deterioration in health. Therefore, there is a strong likelihood that by providing better services which reduce demands on hospitals, demand for social care services might also be reduced.
Since nobody wants to be hospitalised unnecessarily or to lose their independence, efforts to improve care to the end of reducing demand, also improve the quality of care.
The ability to deliver integrated care services depends on a number of critical competencies. In our view there are four major components:
Accessing savings requires an initial recognition that basic nursing can be carried out somewhere other than in a hospital. Where nursing needs to be continuous, greater integration between health and social care pathways would bring nursing homes and community support more directly and actively into the care pathway with the ultimate objective of returning patients to their own home at the earliest practicable time. This would require coordinated inputs from GPs, Occupational Health Therapists and Community Nurses.
A successful system must start and end with the needs of the patient, have the GP at the heart of the system, and replace activity based incentives (such as keeping people in hospital inappropriately) with outcomes based incentives. These could be based on ‘best practice’ tariffs rather than tariffs based on the ’number of inputs’.
Implicit within this is that social care would need to be incentivised and given responsibility for outcomes.
The GP commissioning model proposed in the White Paper could provide a strong basis for focusing resources and taking out cost. However, Care UK believes that the success of such systems would require far more integrated health and care pathways to reduce inappropriate referrals and removal of boundaries between health and social care (as well as between primary and secondary care), all supported by investment in more proactive information systems.
Care UK would be keen to propose solutions based on the management of cohorts of patients funded through capitated budgets providing chronic case management for the most complex cases, through medicines management for those with more manageable conditions, to maintaining the most marginal cases in patients’ own homes. Such solutions should involve the patients themselves in their own care, with the results of continuous monitoring ‘case managed’ through GPs at the centre of the system.
Contacts:
Care UK wishes to continue to support the consultation. For further information please contact us.
