Any qualified provider: a qualitative case study of one community NHS Trust's response

Abstract

ObjectiveTo examine how those managing and providing community-based musculoskeletal (MSK) services have experienced recent policy allowing patients to choose any provider that meets certain quality standards from the National Health Service (NHS), private or voluntary sector.DesignIntrinsic case study combining qualitative analysis of interviews and field notes.SettingAn NHS Community Trust (the main providers of community health services in the NHS) in England, 2013–2014.ParticipantsNHS Community Trust employees involved in delivering MSK services, including clinical staff and managerial staff in senior and mid-range positions.FindingsManagers (n=4) and clinicians (n=4) working within MSK services understood and experienced the Any Qualified Provider (AQP) policy as involving: (1) a perceived trade-off between quality and cost in its implementation; (2) deskilling of MSK clinicians and erosion of professional values; and (3) a shift away from interprofessional collaboration and dialogue. These ways of making sense of AQP policy were associated with dissatisfaction with market-based health reforms.ConclusionsAQP policy is poorly understood. Clinicians and managers perceive AQP as synonymous with competition and privatisation. From the perspective of clinicians providing MSK services, AQP, and related health policy reforms, tend, paradoxically, to drive down quality standards, supporting reconfiguration of services in which the complex, holistic nature of specialised MSK care may become marginalised by policy concerns about efficiency and cost. Our analysis indicates that the potential of AQP policy to increase quality of care is, at best, equivocal, and that any consideration of how AQP impacts on practice can only be understood by reference to a wider range of health policy reforms.

Influence of commissioning arrangements on implementing and sustaining a complex healthcare intervention (ESCAPE-pain) for osteoarthritis: a qualitative case study

“…Providers do not exist in a vacuum and are influenced by wider sociopolitical issues, policy, market forces and funding regimes [19,[22][23][24]. Performance management regimes, payment J o u r n a l P r e -p r o o f systems and commissioning structures can have a critical impact on the uptake and sustainability of innovations within the NHS, including MSK physiotherapy [20,21,28,47]. NHS MSK providers deliver services through a variety of commissioning models [27], and their ability to implement and sustain interventions is influenced and constrained by the funding models under which they operate.…”

“…The disconnect between providers and commissioners and the impact of different commissioning models on ESCAPE-pain has been observed with other interventions. There have been concerns that the Any Qualified Provider model may potentially erode quality in J o u r n a l P r e -p r o o f the Improving Access to Psychological Therapies programme and MSK services due to shorter treatment and fragmentation of care between providers [20,28]. With the WISE programme, a self-management intervention for long-term conditions, the activity-based funding model in primary care impeded its integration [47].…”

“…The number of organisations involved in providing and commissioning care in England, and the variety of ways that different providers are J o u r n a l P r e -p r o o f reimbursed and given incentives to deliver health care, reinforces this fragmentation and complexity [26]. In England, NHS musculoskeletal (MSK) physiotherapy services are commissioned by clinical commissioning groups (CCGs) [27][28][29]. These clinically-led, statutory NHS bodies are responsible for planning and commissioning local healthcare services [30].…”

“…The MSK landscape is further complicated by different types of commissioning models (e.g. Any Qualified Provider regime, tariff or block contracts), and providers deliver services through a range of prime and subcontractual arrangements [26][27][28][29]. For example, Addicott found one CCG 'managed between 25 and 30 individual provider contracts for musculoskeletal serviceseach commissioned in an isolated fashion, to deliver an isolated part of the pathway' [26].…”

“…Whilst commissioning arrangements have a key impact on shaping the provision of care, there is limited evidence about the influence these have on physiotherapy services and the ability of physiotherapists to implement and sustain evidence-based interventions successfully to improve the quality of care [5,28,31]. The aim of this study was to explore the perspectives of physiotherapists on the influence of commissioning arrangements on the implementation and sustainability of ESCAPE-pain within NHS MSK physiotherapy services in England.…”