The Royal College of Obstetricians and Gynaecologists (RCOG) is not opposed to the concept of competition in the delivery of services in the NHS provided the patient is placed firmly at the centre of care.
Competitive tendering should be introduced gradually and must not damage patient care, safety and education/training.
The RCOG’s reports High Quality Women’s Health Care (2011) and Tomorrow’s Specialist (2012) set out the configuration of women’s health services and include proposals for the workforce and training structures needed to ensure that women have access to the care they need and want. These proposals support the principles of the NHS Constitution.
The RCOG does however have some concerns around how competition will work in the new NHS. The regulations for procurement and competition set out the boundaries for Clinical Commissioning Groups (CCGs) but there is still uncertainty over the obligation on CCGs to put all future contracts out to tender. Unnecessary tendering, particularly when done through legal requirement with no benefit to the patient will create more bureaucracy and increase the financial burden on the taxpayer. Similarly, there is the significant potential for conflicts of interest as the system allows some CCGs to award contracts to themselves.
Competition between the NHS with providers that have commercial interests has the potential to reduce co-operation between the professionals involved in the provision of care. In the case of maternity services, communication flows impact on the continuity of care and information-sharing is vital to the patient being offered appropriate and timely care. Likewise, the silo working which characterised services run by the Independent Sector Treatment Centres (ITSCs), established by the previous government, had a negative effect on the professional experience of doctors in the provision of comprehensive care.
The RCOG reiterates that patient safety must be core in the design, commissioning and delivery of women’s health services. The provision of integrated, high quality care is the lynchpin of safety and the co-location and co-commissioning of acute services for maternity and gynaecology should be the core component of such a strategy.
In order for this system to function, there must be integration between primary with secondary care. This should allow for closer collaboration between GPs, hospital consultants and other healthcare providers in local networks.
The introduction of a free market, including Any Qualified Providers (AQPs) may fragment such services. As an example, there are strong operational links between acute, elective and emergency maternity services with elements of gynaecological care (eg. early pregnancy services). If selected contracts are awarded to AQPs (such as routine care focused on high volume, low cost maternity services for low-risk pregnancies) this will invariably have an impact on the other aspects of women’s health services in the acute sector due to the relative cost pressures of providing safe out-of-hours services.
In the medium to long run, if services are not integrated, the NHS will also end up with higher costs as acute services will have to manage the complications referred to them by routine care delivered by AQPs. True integration will only occur if AQPs have the responsibility to deal with the consequences of complications arising from routine treatment.
Such developments will destabilise services and there are similar questions over the effects of AQP input in medical education and training.
There is therefore still much anxiety over the impact of the competitive tendering in the new NHS. In order to abate the concerns of healthcare professionals and the public, the RCOG would like the Government to:
- Clarify the expectations on the CCGs and the grounds on which they can determine single commissioned provision
- Confirm that CCGs should make decisions only on the basis of quality and clinical need and the requirement to co-locate emergency services
- Clarify the role of Monitor with appropriate guidance
- Ensure adequate time is given to debate these important matters in Parliament.
The RCOG would like the Department of Health to indicate how commissioning arrangements can be made transparent and accountable. There must be a level playing field in the regulation of NHS services and AQPs and both must have equal responsibility the provision of patient care.
The principles of the NHS Constitution, namely those pertaining to treating patients with compassion, dignity and respect, must be enforced in both the NHS and AQPs.
There is also the need to monitor the impact of competition between different providers by measuring outcomes, patient satisfaction and the facilitation of training.
The RCOG believes that the basis for the commissioning of services is to improve outcomes. Providing patient-centred care on the NHS must be the priority for the Government.