Dr Rachel Joyce: Competition, Choice and Transparency are vital for high quality NHS commissioning

Dr Rachel Joyce was Conservative candidate at the 2010 General Election in Harrow West. She is also a doctor and has worked as both a Director of Public Health and a Medical Director in the NHS.

I wasn’t at the Special Representative Meeting at the BMA that called for a change of mind on some of the NHS reforms, but I know a few doctors who were. They were from a wide range of specialties – hospital specialties, GPs, community doctors. Attendees also included many GPs who are in pathfinder GP consortia (ie the first wave). Most GPs in my area have signed up because they care about their patients and they don’t want their surgeries being left behind.

The multitude of motions – which ranged from those that are purely about terms and conditions of service to a few politically motivated motions, to constructive engagement and feedback – represented the multiple roles the BMA has as a professional organisation representing many different specialities, and the complexity of the NHS.

The NHS is one of the largest organisations in the world. It is, I believe, the largest employer on the earth –barring the Chinese Army and the Indian Railways. The structures in place, the accountability arrangements, the regulations and safeguards are not simple, and will still not be simple after the proposed changes. It is therefore a good thing that the BMA voted to continue to engage with the government on the Health Bill, and to lobby on the things that they feel need refining or changing. After all, the Bill has not yet passed, and some of the documents from the Department of Health are still being consulted on.

There were a few key points from the meeting (representing the constructive engagement part of the debate) that I do think are worth paying attention to.

Choice, Competition and Any Willing Provider
There is no doubt that competition can raise standards, and increase productivity. The NHS has suffered from a lack of competition in the past, but has improved significantly in some areas recently. In my view there is much more to be done in terms of choice of GP and in particular intermediate and rehabilitation services (where choice is virtually unheard of), and I believe patients should be able to choose their commissioner.

Full choice of hospital has however been available for some time now in the NHS, including the private sector – as long as they operate a “Choose and Book” system, and they charge NHS tariff rates. Doctors are not unfamiliar with the concept of choice and competition. So why was there an overwhelming vote against the concept of “Any Willing Provider” in the NHS (see vote at 12:05 on this link)? I’m afraid that some of the motivation will have been politically motivated. But those speakers who raised the issue about destabilising local services have a point, which needs to be understood.

Let me give a theoretical example. A local Ear, Nose and Throat service is likely to cover a population of about 500,000. Most of the outpatient services they provide might be provided in the “community” (which usually means anywhere but an NHS hospital) by a private provider at a lower cost than the current tariff, and possibly even closer to some communities. For surgery, most patients will be suitable for day case or overnight care, which again a private provider would be able to compete to provide.

On paper the service might be cheaper (if it is in an arrangement outside of tariff, such as a pre-hospital service), or better in some other respect. Depending on how this service is set up, this might offer more or less choice for patients (as I said before, only hospital services are truly subject to choice).

But the dangers are two-fold: cherry picking of low risk cases such as those described could leave the previous NHS service losing money because it is only left with the high risk and complex cases (including cancers, and patients with other serious illnesses). The private provider also wouldn’t be offering an out of hours service, either. Again, the previous NHS service would be funding an on call service for emergency tracheostomies and the like - vital for an intensive care service - at a financial loss.

If they decide to stop providing these loss-making services, then not only does that threaten patient safety for Ear Nose and Throat cases, and mean patients may have to travel considerably further in an emergency, but it could also impact on the provision of local Intensive Care, A&E, cancer and children’s services. Different hospital specialities are interdependent in a complex way, and a domino effect on local services could result from a poorly thought through commissioning plan.

High quality flexible commissioning subject to transparency and scrutiny
For these reasons, it is vital that commissioning is of high quality, and is based on a strategic plan for a comprehensive range of safe and accessible services to meet the needs of the population. But to ensure safe and effective services, and to avoid a domino effect of closer or safety issues in local services, commissioners may sometimes need to commission some services without being required to use an “Any Willing Provider” model.

Sometimes they may need to agree local deviations from national tariff to keep a service going. Commissioners therefore need to have the freedom and flexibility to make these decisions, and not to be bound by overdone well meaning regulations. This is why the BMA Motion calling for the prime duty of Monitor not to be the promotion of competition, but to ‘maintain and extend a cooperative healthcare system’, was passed. I would argue that commissioning high quality and comprehensive healthcare services within budget should be the prime objective of commissioners, and this should therefore be what Monitor should be addressing.

It is also vital that there will be due scrutiny of GP consortia’s commissioning decisions by local people. Under the current proposals, the Health and Wellbeing Boards will provide some scrutiny and assist with the Joint Strategic Needs Assessment. The Commissioning Boards will also provide some scrutiny. This strategic scrutiny is important, but commissioners’ decision making also needs to be transparent, and they need to be accountable. There are significant potential conflicts of interests by members of GP consortia (a subject I will address in another article), and they will be new and immature organisations. Poor commissioning decisions need to be identified and tackled before they are put into practice.

Strategic scrutiny (as described above) is one thing, but detailed scrutiny and lines of accountability are vital. At present it is unclear if the Chair of GP consortia will be accountable for commissioning decisions. There are also apparently no current requirements for these bodies to hold their meetings in public, or to publish their minutes (which PCTs have to do). The BMA was right to call for the minutes these meetings to be published and subject to public scrutiny, and for clarity in terms of accountability arrangements.