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Any Willing Provider

Ahead of the forthcoming briefing on Any Willing Provider (AWP), Frontline looks at what it means for you and your patients.

People have been using 'Choose and Book' for planned operations since 2009. Now the race is on to develop a range of providers for community services, including physiotherapy. But the new model of buying in services for the NHS has a nasty twist in the tail: the contracts will be very different from before.

What's the 'any willing provider' policy about?
It's a different model for buying health services in England, including physiotherapy. The idea is to give patients a free choice of providers, unconstrained by a bureaucratic and expensive tendering process. The government claims that the choices patients make will 'drive up quality through contestibility'.

What is the difference between this and competitive tendering?
Under competitive tendering, the primary care trust (PCT) stated how many treatments or procedures they wanted the provider to give in a year, guaranteeing an income for the lifetime of the contract. With any willing provider (AWP) contracts there is no guaranteed level of work and therefore no guaranteed income for the provider. However, the price per treatment session will be pre-determined, either nationally or locally. An approved provider's name is put on a list and - rather like Choose and Book - the patient will be able to select from a list of approved providers, provided by their GP.

Is it really going to happen?
AWP is on course to come in for community services from this autumn. Planning guidance is due to come out from the Department of Health by the end of this month. The introduction of AWP does not depend on the Health and Social Care Bill currently going through parliament, although the bill reinforces the principles of AWP through its stress on promoting competition.

Will it apply now to the existing PCTs as well as to the new GP consortia?
Yes, and to existing contracts with social enterprise companies. If commissioners decide to opt for AWP rather than tendering, existing contracts will be amended.

Hasn't AWP been happening already in the acute sector since 2006 with Choose and Book?
Yes, but AWP isn't quite the same. Choose and Book gave patients three choices of provider, with only one of them from the independent sector. What's more, it applied to elective, planned surgery, which normally has a defined period of treatment. AWP will apply to chronic conditions, which are unpredictable and not necessarily finite.

Has any physio service gone out to an AWP contract yet?
One physiotherapy service, in Nottinghamshire, has been operating on an AWP basis since 2009. There are currently 10 physio providers on the approved list. One is the NHS. The others include single-handed private providers and a large physio company. It's widely acknowledged that there have been problems with this contract. NHS patients have been limited to just one assessment and one treatment session. And some providers are worried that the volume of treatment is not guaranteed, making it a difficult business model.

What will this mean to me as a physio working in the NHS?
It could mean that your existing NHS service is only one of many providers in your area, and that you'll have to compete with them for 'business'. Other providers could include osteopaths and chiropractors as well as private physiotherapists. They could also include large private healthcare companies, domestic or multinational, such as ATOS, Circle or Allied Health. As an NHS provider, you'd need not only to provide a good service, but to make sure your waiting times weren't too long. If patients prefer to go elsewhere for treatment, reduced throughput could mean that your service is no longer viable, or that your manager has to cut the number of staff providing that service.

What will this mean for my employment rights?
The CSP believes that jobs in the NHS will be less secure and there will be more use of casual, short-term work. If staff move to another provider they will have reduced employment rights. There will be greater pressure on NHS pay, terms and conditions of employment in order to meet local tariffs.

If you lose your job because of AWP, you will not be protected under Transfer of Undertakings (Protection of Employment) Regulations (TUPE). Under the more traditional wholesale transfers of entire groups of staff to non-NHS organisations, you would have been. The uncertainty will mean that managers will find it difficult to decide the numbers of staff they will require in the future. Depending on the tariff set for treating a particular patient condition, some providers, whether NHS or otherwise, might judge that it is not possible to continue to offer a safe, high-quality service and may withdraw from 'the market' altogether. And, in an increasingly competitive market, physios may be less willing to share innovative practice.

How will it affect training for new physios?
The NHS has always provided the bulk of support for students and newly qualified staff. The uncertainty over funding for a service will make it difficult to provide either student placements or junior rotations. Effective workforce planning would become even more problematic.

Are there opportunities to work in one of these bigger providers?
Yes, potentially. However, if you decide to work as a physio in one of the non-NHS providers, you will lose your NHS employment rights and you would have to leave the NHS pension scheme.

What will this mean for me as a physio in the independent sector?
As a single-handed provider you could apply to be on the NHS approved list of providers. To do so you would have to meet set criteria about the quality of care you provided, including a demonstration that your skills were current and that you had up-to-date training. However you would not be given any guaranteed level of income so you would still need to maintain other private work. And you would probably need to monitor the service you provide to ensure you met contract criteria.

Won't this mean better choice for patients?
That's the theory. But the worry is that if the contracts are driven by cost, patients may only receive a limited number of treatment sessions after the initial assessment. The CSP knows of examples where this is already happening. If patients need more treatment, the physio will have to go back to the patient's GP and request approval for them, which also may lead to delays. And while those people who know their way around the system might be able to get a good deal, those disadvantaged by their age, disability or education may not find it easy to make appropriate decisions.

Will AWP save money?
It could, potentially, if the commissioners use the model either to drive costs down, by forcing a low cost for treatment, or to ration care. But if the NHS has to make staff redundant because of AWP, there will be associated redundancy costs. The cost of managing this new system should not be underestimated. A considerable amount of administration costs will be involved in invoicing and collecting fees for services provided. And there will be costs involved in monitoring how effectively these services are run.

So, to sum up, what is the CSP's view?
CSP believes that AWP will create a climate of constant instability and uncertainty. More to the point, for many of our members, there could be the distress of seeing patients receive what could be a worse service 'CSP believes that mainstream NHS services are best delivered by NHS-employed staff,' said Lesley Mercer, director of the Employment Relations and Union Services.

'But we realise that the work to introduce AWP has already started, so we cannot afford not to get engaged.

'We have been taking part in numerous Department of Health meetings to develop the initial guidance that is due to be launched later in March, as well as the infrastructure to support AWP if and when it starts to be rolled out to community services in the autumn.'

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