Your life, your choice. By Richard Lewis

11 Sep 08
The NHS is looking at extending the choice of care and treatment to community level. But primary care trusts will have to reconfigure their services in a radical way if patients are to be offered genuine alternatives

12 September 2008

The NHS is looking at extending the choice of care and treatment to community level. But primary care trusts will have to reconfigure their services in a radical way if patients are to be offered genuine alternatives

According to Lord Darzi, author of the latest policy statement from the Department of Health, 'patient choice' will become a defining feature of the NHS in England. The new NHS constitution, which is out for public consultation, has enshrined choice as a fundamental right of all patients. According to the government, choice is not simply a pre-occupation of the middle classes and the educated, as it is often perceived to be, but a concern across the social spectrum. Recent public surveys appear to support this view.

A significant milestone, 'free choice' of hospital care, was reached in April. This was the culmination of a series of initiatives since 2002 to allow patient power to drive up the quality of hospital services and drive down waiting times. Now, any patient referred by their GP can choose any public or private hospital that holds an NHS contract.

However, Lord Darzi's review of the NHS, published earlier this summer, clearly signalled that the choice revolution is to go beyond hospitals to embrace services provided in community settings and patients' homes. This includes general practice services, where the theoretical choice of GP has stubbornly failed to materialise in reality – at least for some patients – as well as the provision of community nursing and other forms of community health services.

The new watchword is 'personalisation': patients should be able to design services around their own particular needs and from the care providers that suit them. This is particularly aimed at the 15 million people with one or more long-term conditions, such as diabetes and heart disease. By 2010, all of these patients will be offered a 'care plan', which will set out what treatments they want as well as where, and from whom, they want to receive them. These care plans will be signed off by the patient to ensure greater control and empowerment.

Choice requires more and better consumer information. The main source of health service advice at the moment, the NHS Choices website, will expand to include more about the services available in the community. A 'patient prospectus' will be launched to inform people about what they can expect in terms of choice and resources.

Last year, the Department of Health published 'Principles and Rules for Competition and Collaboration'. These gave guidance to primary care trusts – the local organisations that are responsible for planning and commissioning NHS care – to establish fair competition between all providers from both the public and private sectors.

Lord Darzi's review makes clear that these rules will now apply to community-based services. PCTs will be responsible for 'market making' in community care; that is, creating more diversity of supply, greater competition and patient choice where this makes sense.

The significance of all of these changes should not be underestimated. Community health services cover a wide range of services. These include the familiar (such as district nursing and health visiting) and the more specialised (such as continence advisers and speech and language therapy). They account for 250,000 professionals, about one in five of all NHS employees, and cost £10bn per year. Currently, most of these services are provided by the primary care trusts, which essentially act as local monopoly suppliers.

But if more choice is to become a reality, new providers must enter the market. Because community health services are largely based around skilled professionals rather than expensive buildings and equipment, this does not seem an unrealistic prospect. Practices of independent nurses and midwives, community groups and private sector companies might all vie to provide an alternative. Pharmacists already have an extensive network of convenient outlets that could easily offer more health services.

However, as well as inviting in new providers, there is also a clear signal that existing PCT provider services will undergo significant change. Lord Darzi's review introduces a right for staff within PCT provider arms to request to transfer to a social enterprise. If the PCT board agrees to the request, it will sign a three-year contract for services with this new organisation (not, apparently, subject to open competition). This length of contract would give a much-welcomed stability of income to any fledgling social enterprise. The main obstacle to transferring NHS staff to non-NHS bodies – access to the NHS pension – has been solved by allowing this pension to be portable.

Other options, such as the 'community foundation trust', are also being developed to speed the separation of PCT commissioning from service provision. Community foundation trusts are a new form of independent public sector body 'owned' by members drawn from the public and staff and overseen by Monitor, the independent regulator.

Choice of community health services is likely to introduce new risks to a part of the health system that has so far largely kept the rigours of the market at arm's length. Revenue for PCT provider arms will no longer be certain and staff employed by PCTs might compete with, or transfer to, a number of different types of organisation, including the new social enterprises, groups of general practices and even hospitals.

This might necessitate a complicated programme of reconfiguration. Some services, such as district nursing, might lend themselves to working alongside family doctors. Other, more specialist, services might need to work across larger populations if they are to be cost-effective and will therefore require a different sort of organisational home.

Community health services also suffer from poorly developed information systems. Unlike hospital care, there has been relatively little investment in analysing what community staff do to the patients they see, nor in creating consistent data sets to compare services and value for money. Some studies have suggested that community care is ripe for stronger management and that large productivity gains are possible.

Better information and new contracting currencies will be essential if an effective market is to be created. The Department of Health has established a programme to support the transformation of community health services and to address these issues. However, the experience of developing 'payment by results' (the tariff system that underpins most hospital funding) suggests that the scale and complexity of this task should not be underestimated.

Lord Darzi's review also introduced two pilot initiatives which, if successful, have the potential to change radically the way that community care is purchased and provided.

The first involves personal budgets, which have proved popular in social care. In 2009, a national pilot scheme will test out personal budgets to cover the health care needs for people with long-term conditions. Patients might have these budgets held on their behalf by a third party, but the more radical option is to allow direct payments for care. Enabling direct control over health expenditure is likely to increase the sense of patient empowerment, and shift some power from professionals to patients.

However, there would be some challenges to implementing this. The budgets are intended to be directed to patients with relatively stable and predictable conditions. Unexpected problems are always possible and budgets could easily be fully spent part way through the year through no fault of the patient. (Of course, it is possible that some patients will choose to spend their budget unwisely.) The government has made a commitment that no patient will be denied treatment as a result of holding (and exhausting) such a budget – this implies that resource management by PCTs might be rather more unpredictable in future.

The second initiative involves pilot 'integrated care organisations' which are loosely modelled on US 'managed care' organisations. ICOs are intended to break down institutional boundaries between community-based and hospital care and between health and social care. These boundaries do not facilitate care that is designed round individuals' needs. Instead, services are often seen to be shaped to suit the care providers more than their patients. Indeed, the NHS scores badly in comparison with many other developed countries in the way that patient care is co-ordinated across different providers. Patients often face duplication (for example, having to repeat diagnostic tests and examinations) or might fall through the gaps in the system and miss out on some elements of care altogether.

ICOs will be alliances of professional staff across community, hospital and social care that take financial and clinical responsibility for providing integrated care. ICOs will build on GP practices and will register patients. Instead of holding many different contracts for each element of care, a PCT will agree a single contract with the ICO in return for a combined budget. It will be up to the ICO to find the best way of delivering good care and clinical outcomes for their population. There will be rewards for those that are successful but, potentially, financial penalties for those that are not.

If these pilots prove successful, ICOs could become common and compete with one another for patients based on the quality and flexibility of the service that they offer.

One group of GPs serving a population of 72,500 around Epsom in Surrey will definitely be bidding for national pilot status. This group has been providing an extended range of services since 1998 under a contract with its PCT. These have included consultant outpatient appointments, x-ray, ultrasound and physiotherapy, as well as a wide range of day surgery in its own dedicated unit at the former Epsom cottage hospital.

Dr Tim Richardson, one of the GPs involved in the project, sees ICOs as an opportunity to take their initiative further: 'As an ICO, our GP group wants to initially take responsibility for all elective treatment for our registered patients, not just some of it as is the case now. This will entail agreeing a fixed contract sum for these services with the PCT, and then managing within it.'

Richardson sees challenges ahead but feels the rewards make such a venture worthwhile: 'Inevitably, ICOs mean taking on more financial risk, but they allow us to offer more integrated services with specialist colleagues, more flexibly, and with greater convenience for patients and real incentives if we are successful. Ultimately we intend to take on total care as an ICO for all our patients's needs.'

Community services have traditionally been a backwater of NHS policy, but this looks set to change. Given that the vast majority of our contact with the NHS is with the wide range of community care providers rather than with hospitals, this change in emphasis might do more to change perceptions of the NHS than many of the reforms that have gone before.

Richard Lewis is a director in Ernst and Young's health advisory practice and a senior associate at the King's Fund

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