Martin McShane: Toffee popcorn

Martin McShaneI went to see a film with my son. He bought a packet of toffee popcorn. I love toffee popcorn but it has little nutritional value and in excess would be bad for you, but as it was available I couldn’t resist it!

For some reason the experience came to mind when I read a paper on Any Qualified Provider (AQP).  The principles seem laudable:

  • There are no guarantees of volume or payment and commissioners will only pay for patients treated
  • Patient choice will determine activity levels and providers will be rewarded for attracting more patients by demonstrating high levels of quality, responsiveness, and patient satisfaction
  • Providers will need to meet minimum accreditation criteria e.g. be registered with CQC, be legally and financially sound
  • Providers will only need to be accredited once and will then be free to sign a standard contract with any commissioning body and provide services to their specification
  • This will significantly reduce the burden of procurement on commissioners, promote consistent treatment of providers and reduce the opportunity for dispute

But there are risks identified:

  • AQP increases provider capacity, so robust referral thresholds are needed to ensure that demand for services is appropriate
  • Resource requirements for managing procurements will reduce but resource required to manage contracts may increase

The issue which caught my eye was “appropriate demand for services.” One of the examples given where it was suggested AQP could improve quality of services was physiotherapy. Last year, one of our effectiveness consultants (as I like to call this particular public health doctor) presented an analysis of the effectiveness of physiotherapy to the professional executive committee. We were all somewhat shocked to discover that the evidence is not that great.

Managing demand generated by societal expectation is one of the biggest, if not the biggest, hidden driver of costs in the health system. Coupled with this is the behaviour of professionals. Methods for “giving” patients something at the end of a consultation are popular. Prescriptions, investigations, and treatments give a consultation meaning or, if we are honest, help get the patient out of the room. Changing professional behaviour to manage demand is a holy grail no one has truly cracked. One might conclude that introducing AQP for physiotherapy will generate supply led demand with, in reality, little real effectiveness. 

Perhaps we could coin a new phrase for this sort of commissioning?  Toffee popcorn commissioning – loved by providers and the public, but of no nutritional value in improving health or health care.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.