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Any Willing Provider: still the future

03/08/2010
by Rob Findlay

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?

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