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Should we take a chance on a free market in public health services?

By Georgina Craig and Liz Stafford

Can pharmacy turn the opportunities in the public health White Paper  into commissioned services in store?

Georgina Craig NHS Alliance pharmacy commissioning lead, and Liz Stafford clinical commissioning lead at Rowlands Pharmacy

 

Public health commissioning in a liberated NHS is going to look very different from how it does today. With the publication of “Healthy lives, healthy people”, we know that local authorities will lead on all services defined as delivering prevention rather than cure.

Twelve priority services

  • Health protection
  • Emergency preparedness
  • Recovery from drug dependency
  • Sexual health
  • Immunisation programmes
  • Alcohol prevention
  • Obesity
  • Smoking cessation
  • Nutrition
  • Health checks
  • Screening
  • Child health promotion

A new body, Public Health England, will fund 12 priority services (see Panel right) and elements of the general medical and dental services contracts, including the Quality and Outcomes Framework, immunisation, contraception and dental public health services, from a ring-fenced £4bn budget.

It will have three principal routes of commissioning:

  • Granting the ring-fenced public health budget to local government
  • Asking the NHS commissioning board to commission services, such as screening services and the relevant elements of the GP contract
  • Commissioning or providing services direct, for example, through national purchasing of vaccines, national communication campaigns, or health protection functions currently conducted by the Health Protection Agency


Public Health England will also be able to instruct GP commissioning consortia to commission services on their behalf if appropriate — so the Government is leaving all its options open at this stage.

To see how commissioning will work from now on, we must look at the bigger picture and the drivers that the Government is putting in place to create an internal market.

The most important White Paper in this regard is “Liberating the NHS: greater choice and control”. It makes the bold presumption that people will have “choice of any willing healthcare provider, wherever relevant and choice of treatment and healthcare provider becoming the reality in the vast majority of NHS-funded services by no later than 2013/14”.

So what is “any willing provider” (AWP) and how might it work? The concept has been around for a while. It was first mooted under the previous government, although it never really took off mainly due to the limited number of AWP tariffs and the fact that few primary care trusts embraced it.

Under the new regime, AWP will the norm. One criterion for AWP licensing is likely to be Care Quality Commission registration, which raises questions about whether General Pharmaceutical Council registration will suffice for pharmacy premises. It will then be over to a range of AWPs to compete in the market and attract the public. Then the money will follow the patient.

Most public health services lend themselves to this model. Services with few barriers to market entry will attract new entrants, including the voluntary sector, commercial organisations and primary care contractors as well as local authority and NHS providers themselves.

It is all income

Take smoking cessation, for instance. All you need is accredited training and a consultation facility. It is easy to see how the market might expand. What health or care professional would not offer a service like this as an “add on” to clients they are already seeing for other reasons? It is all income with little marginal cost, and with all NHS trusts having to stand on their own feet financially in the near future, they will be after all the marginal income they can get.

Increased competition will, in turn, drive down the AWP tariff — and so the public health service will provide more interventions for less money and the efficiency gains it desperately needs to make.

Pharmacy’s unique selling point is, of course, that it reaches the people other health care providers cannot. In any AWP world, the bigger the footfall and the more often your customers visit, the better chance you have of signing them up to work with you to improve their health — so the greater your marginal income.

What is more, pharmacy is used to competing in this kind of market. The current dispensing model is AWP by any other name.

New world

So, how should we greet this new world? Should we take our chances and lobby for an open market for public health services? Or should we seek a closed shop and make the best case we can for services to be included in the next iteration of the pharmacy contract?

The last time we tried, it failed miserably and all public health services, except for a bit of brief advice and signposting, were boxed off as enhanced services to be negotiated at local level.

Pharmacy’s default has always been a national approach. It shows no signs of changing. So, what has changed between then and now to strengthen the case for inclusion of core services like smoking cessation in a national framework?

Here are three we could harness, but to make them stick, contractors will need a super glue of evidence:

The first is a reduction in procurement transaction costs through “nationalising” services that have a good track record of delivery through pharmacy. The same argument is valid for GPs. The fly in the ointment is that past experience shows that even when services are nationally commissioned, pharmacy fails to deliver the numbers.

The public health service need look no further than medicines use reviews for the evidence. Wanting fast action on health inequalities, it will be reluctant to tie money up in a national contract with a provider who may not deliver the goods.

The second is that pharmacy services reach more of the right people. This is the “footfall” argument. There is emerging evidence that this holds true for alcohol brief interventions. Figures from PCT audits show pharmacy is identifying and intervening with more people than equivalent GP-based services.

This is compelling. It will have to be for the Government to abandon its AWP mantra of competition and choice. Its likely response: “Well in that case, you will do well out of AWP, so go for it!”

The third is healthy living pharmacies (HLPs). Work from NHS Portsmouth shows that they succeed in delivering more interventions than traditional pharmacy. So in the new world, does that make HLPs a great marketing tool?

 

Could now be the time to do things radically differently? By believing people will choose pharmacy and lobbying for a transparent and fair market and the best AWP tariff possible, while preparing pharmacy contractors to adopt the HLP model and deliver from day one, we are taking a risk.

But in times of unprecedented change, he (or she) who dares win.

Citation: The Pharmaceutical Journal URI: 11050923

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