"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Monday, 10 October 2011

AQP and Commissioning

On the surface AQP (patient choice) and commissioning are antithetical since commissioning is carried out for a population, whereas patient choice is for the individual. However, the two can be combined. The House of Lords constitutional select committee report on the Secretary of State's duties outlines this:

12.  Clause 10 of the Bill amends section 3(1) of the NHS Act 2006. As amended, section 3(1) would provide as follows:
(1)  A clinical commissioning group [CCG] must arrange for the provision of the following to such extent as it considers necessary to meet the reasonable requirements of the persons for whom it has responsibility—
(a)  hospital accommodation,
(b)  other accommodation for the purpose of any service provided under this Act,
(c)  medical, dental, ophthalmic, nursing and ambulance services, 
In the 2006 Act it is the Secretary of State who has this responsibility. If this clause survives into the Act then CCGs will decide "to such extent as it considers necessary to meet the reasonable requirements of the persons for whom it has responsibility" the medical services in the area. That is, the CCG determines which services the NHS will pay for. So when GPs in Haxby offer private procedures to their patients they are merely jumping the gun: this is what it will be like in most areas after the Bill is passed. The CCG determines the services the NHS will pay for and private providers (including GPs themselves if they have a private business) can offer the services that are not paid by the NHS as private services.

The government's policy document Making Quality Your Business: A guide to the right to provide says:

To qualify as an AQP, providers will be subject to a qualification process. They will be required to show that they can meet the conditions of their licence with CQC and/or Monitor (if necessary), provide safe quality services to the contractual standards set by the NHS Commissioning Board and meet NHS prices – either set nationally or locally.
This is where the Q in AQP comes in, once a provider has met the conditions of CQC and Monitor it becomes an AQP. However, CCGs do have some leverage, the same document goes on to say:
Commissioners (PCTs and consortia) can set reasonable additional contractually binding quality standards to meet the needs of particular communities or patient groups. This could include referral protocols and thresholds to manage demand and support integration with local services. Providers will be expected to work within and as part of the local health system.
(Note that this pre-dates the introduction of the term CCG.) This says that CCGs can insist that AQPs meet the specific needs of their population and hence this is is another part of the Q in AQP and is part of the commissioning that the CCGs will do.

Once AQPs have been licenced (and hence meet the criteria of CQC, Monitor and the CCG) they will be put on the list of providers from which the patients can choose:

Commissioners cannot refuse to accept qualified providers once qualified, unless providers fail quality standards, reject the agreed price or refuse to comply with any reasonable, additional, locally set standards.
GPs cannot tell patients which AQP provider to use and they cannot refuse to add an AQP provider to the list of providers patients can choose from, so any talk of GPs "protecting" NHS providers is fanciful because Monitor will force them to add AQPs to the providers list.

The remaining "commissioning" part of CCGs is determining which services the NHS will pay for. This is clause 10 of the Bill and is also described in the Making Quality your Business policy document:

It will be for commissioners to decide which services are best delivered through an AQP approach or tendering but the presumption will be that for most services patients will have a choice of Any Qualified Provider.
This says that the government says that there should be a presumption that most NHS services will be AQP, but note that the commissioners (CCGs) decide which services are provided.

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