Imagine if buying a muffin from your local café was like using the NHS. You’ve just met with a dietician. She advised you to eat a low-fat blueberry muffin every morning for the next six weeks. The catch is there’s only one café in your local area where you can get your muffin. Unfortunately, you’ve heard some not-so-good things about it. It seems that they don’t mix the ingredients well, and the muffins tend to be slightly burnt. The muffins will meet your dietary needs for sugar, but you’re not going to enjoy eating them. A friend says there’s a café a little further away from your home that does really good blueberry muffins. But, to your dismay, because the café is in another commissioning area, you won’t be able to go there.
Now turn that idea on its head. Imagine if using NHS maternity services was more like buying a muffin from your local café. Let’s say that you are pregnant. Fortunately for you, in your area, there are several different providers to choose from. You can use NHS Choices to see user reviews on each of them, just the same as using Google Maps to compare nearby cafés. You can talk to your GP and friends about which providers have the friendliest midwives and offer the best antenatal classes. There is even one in the area that keeps a stock of fresh blueberry muffins in its waiting room. You consult with your GP and you make your own decision.
Two years later, you’re pregnant again. Things have changed though, as maternity service providers have been competing with each other over the years. There are now two major maternity service franchises operating in your area – think the healthcare equivalents of Pret and Eat. Additionally, there’s a local independent group of midwives specialising in home births. You’re disappointed that you don’t have quite as many providers to choose from, but talking to your GP and browsing NHS Choices shows the quality of services has improved significantly. Once again, you make your own decision.
At its heart, it is this sort of health care that the government’s ‘Any Qualified Provider’ (AQP) aims to achieve. The policy is at the core of the healthcare reforms that aim to stimulate quality and service improvements through competition.
Under AQP, patients in England will be able to choose from any providers of health care that meet certain standards set by the Care Quality Commission and Monitor, the independent regulator of foundation trusts, which is set to become the sector regulator for health and adult social care in England. Providers could include foundation trusts, not-for-profit organisations and for-profit businesses. All will be subject to the same rigorous quality standards as the NHS currently uses.
AQP could eventually apply to most aspects of NHS care, though the Department of Health (DH) has identified some areas as unsuitable, such as accident and emergency. In maternity services, the DH has said antenatal education and breastfeeding support could be subject to AQP from 2013/14. Beyond this, AQP could be extended to all aspects of maternity services.
The RCM expects that, for the foreseeable future, NHS providers (such as NHS and foundation trusts) will continue to deliver the bulk of maternity services. This is predominantly because of the high capital costs involved in setting up birth units and the challenges in getting insurance against clinical negligence claims. However, we have already seen some private providers applying to become qualified providers of community-based services in limited areas. These organisations face a further challenge of setting up agreements with local hospitals for access to facilities. These organisations will be operating under the current structure of the NHS and before AQP takes effect. AQP will make it easier for such private providers to become part of the NHS in England.
AQP policy is at the heart of the controversy around the government’s healthcare reforms, and is a major concern for the RCM. But what makes it so controversial? The problem, as with many major public service reforms, is that AQP is essentially a big gamble. By creating an open, market-based playing field, the government is leaving the future direction of the NHS up to its patients and providers. Even if the policy and regulatory framework that the government puts in place gets all the incentives and rules right, the eventual outcome remains uncertain.
Whatever happens, AQP will likely result in significant changes to the NHS in England. As a market-based approach, it will rely on competition to not only encourage better performance within organisations but also to close poor-performing providers and allow better performers to take over. NHS employment will probably be less stable as a result.
There is a possibility that AQP will lead to improved outcomes for patients and more efficient services, but it is only a possibility. If patients are less discerning, or providers less scrupulous than the government anticipates, the reforms could seriously undermine the quality and efficiency of health care in England.
On weighing up the pros and cons, the RCM decided earlier this year to oppose AQP and call for the Health and Social Care Bill to be scrapped. Not only do we think that the bill is unnecessary, but we believe that it creates a serious distraction from the need to make £20bn in efficiency savings by 2015. Most crucially, the focus on competition that AQP creates runs directly counter to the ethos of collaboration that is so essential for safe, responsive and high-quality maternity care.
The RCM is far from the only organisation to oppose the bill. We are all waiting with great anticipation to see what the government will do in the face of growing opposition. Pros
► Patients get to make more decisions about their own care
► Providers improve their services in response to competition
► Midwives get a wider range of employers to choose from
► Providers are more accountable to their patients. Cons
► Less integrated care as providers are reluctant to support competitors
► Greater variation of care quality between regions
► Profit-driven providers will drive up costs for the NHS
► Instability (for both patients and staff) as providers are forced to close by competition.
RCM chief executive Cathy Warwick will be on Communities between 14:00 and 16:00 on 3 April to answer your AQP questions live. Just sign up at: http://communities.rcm.org.uk
. If you can’t make this time, don’t worry. You’ll be able to post your questions from 27 March until 10 April in a discussion thread in the midwives group.