HM Government Call to Evidence on Open Public Services Right to Choice

HM Government Call to Evidence on Open Public Services Right to Choice The Chartered Society of Physiotherapy response By email: openpublicservices@cabinet-office.x.gsi.gov.uk 1. The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK s 51,000 chartered physiotherapists, physiotherapy students and support workers. 2. Physiotherapy enables people to move and function as well as they can, maximising quality of life, physical and mental health and well-being. Physiotherapists work across sectors and care pathways, providing the bridge between hospital, primary and community care; and alongside AHP colleagues, physiotherapists are central to the delivery of integrated care and keeping patients out of hospital. 3. Physiotherapists work with a wide range of population groups, facilitating early intervention, supporting self management, promoting independence and helping prevent episodes of ill health and disability developing into chronic conditions. 4. Physiotherapy supports people in a wide range of areas including musculoskeletal disorders; many long term conditions, such as stroke, MS and Parkinson s; cardiac and respiratory rehabilitation; children s disabilities; cancer; women s health; continence; mental health; and falls prevention. 5. The CSP welcomes the opportunity to respond to this call for evidence. 6. Our response is focussed on the areas on which we feel we can most effectively contribute to the debate. We would be pleased to supply additional information on any of the points raised in our response at a later stage. Introduction 7. Members of the CSP work in a variety of health care settings, but the majority of our working members, in excess of 25,000 members, are employed by NHS organisations providing NHS services to the public. The CSP and our members therefore have a very strong interest in these proposals. 8. The CSP disagrees with the Government s contention that the only way to improve public services is to ensure that wherever possible they are open to a range of providers competing to offer better services. The CSP strongly 1

supports an NHS which is publicly funded, free at the point of need and in which mainstream NHS services are provided by people employed by the public sector. The CSP believes that collaboration and communication are the best ways to deliver services within the NHS and that an over emphasis on competition between healthcare providers is potentially destructive to patient care. 9. The CSP recognises that both NHS and wider public services need to change over time to meet changing needs. The CSP recognises the valuable role the private and voluntary sectors have played in NHS care by supplementing NHS services in certain areas, such as measures to reduce waiting lists while NHS services are being built up, and delivering services to patients with very specialist needs (such as the specialist cancer services provided by Marie Curie and Macmillan). 10. However we have very strong concerns that the radical extension of competition in the NHS in England poses significant threats to the care of NHS patients. These include: Fragmenting care pathways and therefore reducing the quality of patient outcomes and the patient experience. Destabilising NHS services Reducing the sharing of good practice and innovation Limiting the ability of NHS patients to self-refer to physiotherapy Increasing contracting costs through the administration of plurality of providers Diverting taxpayers money into shareholder profits and director salaries Reducing accountability for the use of public money Reducing staff morale through the downward pressure on terms and conditions of employment. Problems with recruitment and retention of staff with greater use of short term, bank and zero hours contracts due to the unpredictability of demand for services. 11. The Society supports service redesign and innovation aimed at improving patient care but believes that there should be demonstrable evidence that proposed alternative providers of NHS care will deliver better quality patient care than existing providers of these services, before these services are put at risk. 12. The Government has stated that choice will be increased by giving people control over the services they use and cites fair access as one of its key principles. The CSP has strong concerns about inequality in access to services but we do not believe that the Government s proposals will tackle inequality. The NHS provider landscape is complex and becoming more so with the increase in alternative providers. Our concern is that some service users will be better equipped to exercise choice in terms of the resources and knowledge available to them allowing only some patients to access the widest range and most appropriate services for their needs. 13. We support the need for an information revolution to ensure people are aware of the health services available to them and the benefits and side-effects of different courses of treatment. The availability and access to clear, transparent 2

information will be vital. In order to be able to make effective choices about their care, patients will need to be fully appraised of the range of options open to them, with their benefits and risks. This must include access to senior specialist clinicians where appropriate. It is important to note that many patients will not have the capacity or inclination to exercise choice over their care, and alternative arrangements will need to be in place to support those people to make informed decisions. CSP evidence on the impact of alternative providers on patient choice and care 14. The CSP has been monitoring the effects of the implementation of Any Qualified Provider (AQP) through written feedback provided by members attending a series of workshops for managers and clinical leaders which have been held across England during 2011 and 2012. The written feedback to a series of open questions has been systematically analysed. In addition, the CSP has analysed the service specification from 14 AQP sites. Our response includes an overview of the early findings. 15. There are two distinct competitive commissioning methodologies currently being employed by commissioners of NHS services: Competitive Tendering (CT) and Any Qualified Provider (AQP). Both involve commissioners identifying which services should be delivered through a competitive commissioning model based on local priorities. The CSP has deep concerns about the potential implications of Competitive Tendering and Any Qualified Provider for NHS patients and services. Impact on patient choice 16. The Department of Health s goal for implementing AQP is to enable patients to choose any qualified provider where this will result in better care. Our concern is that such choices will be based on location and price rather than quality. We also have concerns that choice is being limited rather than expanded. A survey by commissioners in North East Essex found that 60% of patients chose their AQP provider based on their GP s recommendation and 30% on the basis of which provider is nearest to where they live. Only 10% of patients were making their own choice of who was the best provider for them. 17. Patients are given a limited amount of information comprising provider name, location and waiting times. As all the AQP specifications set out the expected waiting times, which tend not to vary significantly between providers, the choice is based on name and location only. This raises the question of how patients can make informed, educated choices when so little information is available. 18. Patient choice appears to be compromised in examples highlighted by members in the South East and the Midlands where local GPs have applied to be AQP providers and are referring their patients to their own services. The False Economy website recently carried out a survey of Clinical Commissioning 3

Groups board membership and found at least half of the GPs in the survey, and sometimes all, have personal financial interests in a private or other non-nhs provider. 19. The majority of AQP specifications have excluded the provision of self referral to physiotherapy where they existed previously (whereby patients can refer themselves direct to physiotherapy services without the need to seek a referral from their GP). This is despite overwhelming evidence of positive feedback of self referral from patients and that self referral is both clinically and cost effective (recognised by its inclusion in the QIPP programme). This also demonstrates how patient choice is being limited rather than extended by this policy. 20. The CSP is concerned that, especially in the current tight financial climate, tariff prices will be set too low in some areas, making it impossible for quality providers to compete other than on the basis of loss leading (ie making an initial loss in order to capture market share and future profits). If an array of local prices develop for the same kind of service, local commissioners will inevitably drive prices down to the lowest, accelerating a race to the bottom in terms of both service quality and employment terms and conditions. This is also likely to lead to some providers being forced to withdraw as it becomes economically unviable for them to continue, thus further reducing patient choice. 21. Although AQP is being introduced on a phased basis it is the CSP s understanding that over time local commissioners will lose the discretion to maintain current service delivery arrangements, even where these arrangements are judged to be working well. This seems to contradict the devolvement of decision making down to local level as well as exposing the NHS services even further to European competition law. 22. The CSP s analysis of AQP service specifications has shown that there is a huge variety in the tariff rates. In Berkshire there is no set tariff with a range of different tariffs for a range of different services being accepted giving patients no ability to make an informed choice by comparing like with like services. This structure also clearly raises questions about to what extent cost rather than quality is the overriding factor when choosing providers. 23. Where tariffs have been set out in specifications, rates for the initial patient assessment session have varied from as little as 32.37 to 50. Follow up treatment sessions vary from 16.26 to 38. We have strong concerns about the ability of providers to provide quality services at such low rates. We already know that some NHS providers have opted not to put themselves forward for AQP because they know that they cannot provide a service at the tariff rates. This clearly limits the choices of providers available to patients. 24. Other problems have included non payments for DNAs (Did Not Attends where patients fail to turn up for their appointment) leaving the provider to bear the costs. 4

Impact on quality of care 25. The service specifications for AQP which CSP has reviewed, limit the number of follow up treatments that may be carried out after the initial patient assessment for example 3 or 4 follow up treatments following assessment. Although 3 or 4 follow up treatments will be suitable for many patients, those presenting with more complex conditions will require more than a maximum of 4 follow ups. 26. If the number of follow ups is expressed as an average (rather than a defined limit) that will provide flexibility allowing some patients, where there is clinical need, to be given more than the specified average follow up treatments. Our concern is where the maximum number of follow up treatments is restricted, rather than based on an average, patient care will be compromised with patients having to pay privately for further follow up treatments, or, if they are unable to pay, facing deterioration in their condition, which may be or become chronic, resulting in a longer term reliance on other NHS or social care services. 27. Principia, the social enterprise carrying out practice-based commissioning in the Rushcliffe area of Nottingham, imposed treatment restrictions in January 2011 after a massive overspend in the first year of the scheme, which went live in September 2009. Back and neck pain patients can only receive two sessions of advice and guidance from physiotherapists rather than hands on treatment in a clear attempt to cut costs. Patients already need to have been to see their GP twice six weeks apart in order to get a referral in the first place. This clearly has a negative impact on the recognised benefits that early intervention brings in such clinical cases including an early return to work for patients forced to take sick leave because of their condition. Some patients are having to resort to paying for private physiotherapy treatment in order to receive the quality of care that they need. The CSP submitted a Freedom of Information request to obtain a copy of the confidential review of this service which highlighted the anger of patients and GPs at the restrictions. 28. Other examples of rationing have occurred in North East Essex where patients must have had their symptoms for 6 weeks before they can be referred to physiotherapy and are limited to one referral a year even if their symptoms return or worsen. Similarly in Kent there is an example of patients not being allowed to re-refer within 6 months of treatment. In some areas commissioners have introduced a weekly cap on the number of referrals that GPs can make with the aim of reducing overall referrals to services irrespective of patient/population need. These examples highlight the fact that unmet need will become a growing problem with patients left in pain and with their condition often likely to worsen and become acute. 29. There is anecdotal evidence from some CSP members who report difficulties responding to patients who blame them for the limited service they have received and do not understand that these limitations are the result of restrictions imposed by local commissioners rather than the physiotherapy service itself. There is often reluctance on the part of the patient to complain to the 5

commissioners as well as a lack of understanding of the procedures for lodging complaints. 30. Overall, AQP has failed to enhance patients quality of care and, on the contrary, has prevented physiotherapists from carrying out their duty of care to their patients. Physiotherapists have reported that their professional standards have been compromised and that AQP so far has started to have a detrimental effect on the profession. Monitoring quality of care 31. The CSP is also concerned about the sheer numbers of providers that are developing in some areas. In North East Essex there are currently around 20 providers just for back and neck pain services but the intention is to expand this to 60 100 providers. This raises questions about how the commissioners intend to monitor the quality of care being provided in this one care area alone, which will clearly be an enormous task if undertaken properly, and concerns that it will become impossible for commissioners to ensure the quality of such a huge number of providers. In Kent commissioners have established a robust monitoring mechanism requiring monthly performance reports and quarterly face-to-face meetings with all AQP providers. However this is bound to be challenging to sustain as the number of providers grows. Impact on the physiotherapy profession 32. Smaller providers in particular report difficulties in coping with the fluctuating levels of demand caused by the fact that there is no guaranteed volume of work or income. This will inevitably lead to greater reliance on short term, bank and zero hours contracts with the resulting uncertainty and lack of secure employment for staff. This has led to some posts being lost or staff having to reduce their working hours sometimes at little notice. 33. The need to cut costs is likely to lead to a downward spiral in the pay and terms and conditions of employment offered to staff by AQP providers. In most, if not all, AQP situations TUPE will not apply because there is no transfer of a business entity so staff are likely to see a deterioration in their pay, terms and conditions without any protection. 34. Traditionally very few private employers have been prepared to take on the supervision of either students or new graduates, as they consider that the cost of this is too high for their business. AQP specifications are not required to include an obligation on the provider to provide student placements (an essential part of undergraduate training for physiotherapists who are required to complete 1,000 hours of assessed clinical placements in order to qualify). This is despite Government assurances, during the Parliamentary passage of the Health and Social Care Act, that all providers of NHS services must share the responsibility for training and equipping the workforce of the future. The result will be that the 6

NHS will have to take on a disproportionate responsibility for this role with even less funding. 35. There are also fears of a reduction in the number of specialist clinical gradings as well as support for training and development, in response to pressure on AQP employers to cut costs. Again this will only serve to limit the availability of high trained, clinical specialists and therefore further reduce patient choice. Conclusions 36. The current Government policy of opening up public services to competition by extending the numbers of non NHS providers of NHS services, rather than extending patient choice is, in fact, reducing patient choice and the quality of care available. Our evidence supports the CSP s concerns that this policy is: Resulting in rationing of access to physiotherapy services and potentially restricting the number of treatment sessions for patients based on cost rather than patient need. Restricting patients ability to choose by providing only very limited information about providers. Compromising choice by allowing GPs and private sector providers to refer patients to services which they themselves are responsible for providing. Likely to lead to reduced quality of care as the need to keep costs down to enable providers to remain competitive results in compromises being made eg reluctance to employ senior specialist clinicians; less investment in continuing professional development and training Phil Gray Chief Executive The Chartered Society of Physiotherapy 20 June 2012 - ends - For further information on anything contained in this response or any aspect of The Chartered Society of Physiotherapy s work, please contact: Kate Moran Head of Employment Research The Chartered Society of Physiotherapy 14 Bedford Row, London, WC1R 4ED Telephone: 020 7306 6687 Email: morank@csp.org.uk Website: www.csp.org.uk 7