What’s the difference you might ask? Well, here’s the rub, according to the last edition of Private Eye, there isn’t one!
December’s edition of Private Eye reported a range of concerns about the regulation and governance of Any Qualified Providers (AQPs) in the NHS. The definition of an AQP, offered by the Information Standards Board is a “healthcare provider, either NHS or Non-NHS (Independent Sector Healthcare Provider) that provides NHS funded healthcare services”. The Private Eye report detailed how the primary operative word in the AQP acronym was ‘any’ rather than the more regulatory sounding word ‘qualified’. Furthermore, there appears to be very little consensus about what specifically it is that is qualified about ‘any qualified provider’. Given the background detailed in their brief report, it would appear that there are very few unqualified providers, and that this qualificatory rhetoric functioned more as a sop to processes of competition and marketisation rather than any wider appeal to regulation, governance and patient safety.
Back in April 2011, heralded outcomes of the much lauded NHS Future Forum’s National Listening Exercise were changes to the governance of Clinical Commissioning Groups (CCGs), and a change in definition of health care providers, now to be called ‘Any Qualified Provider’ rather than the previous term, ‘Any Willing Provider”. The difference between the two terms is stark; any willing provider suggests that healthcare will be provided by anyone who can be bothered to turn up, whereas ‘any qualified provider’ suggests rigour, assessment and regulation. It suggests a bar against which suitable providers will be benchmarked, and those who are deemed unsuitable (i.e. unqualified providers) will be invited to march onto the next market town to ply their wares.
The Private Eye report sets out how this is far from the case, (I am conscious I may be accused of over-reliance on a single source for this material, but trust me I have scoured newspapers and websites for additional supporting material, all to no avail). So, at the time of the reforms, there was talk of hundreds of providers being assessed by Monitor (the competition regulator), with those that passed being registered on a “central directory of providers”. But this never happened, according to Private Eye, there is no register of AQP’s held at Monitor. Furthermore, licenses are only granted to organisations that hold contracts in excess of £10million per annum, meaning that any contract less than this amount is largely unchecked. The responsibility for assessing the qualifications of ‘any provider’ falls on the purchasers, i.e. the clinical commissioning group. By necessity, this can lead to discreet local practices becoming established, with no national benchmark, such that CCG A might regard provider Y as qualified, whereas CCG B might not. This scenario is unacceptable within a universal healthcare system predicated in equality of access.
So, if the caveat of qualified providers is a ‘straw man’, this raises the question of what its real purpose might be. Certainly, at the height of the reforms, it was used to assuage concerns about rampant competition, and the associated implications for healthcare practice associated with a drive to create profits (sorry, generate surplus) from the provision of statutory healthcare.
These processes are a fundamental component of moves to invoke models of new professionalism into healthcare provision. They are driven by a need to introduce competition between providers into the provision of healthcare, by developing new models of working. This shift is characterised by a move from licence/training based models of professional accountability, towards competency/performance based models. Similarly, embodied trust, based on reputation and self-regulation, is replaced by external standards of competence. Lastly, this move is also characterised by new models of working.
All of these changes are implemented against a backdrop of a failing service, poorly regulated by self-serving professions that are badly in need of external moderation. In this context, it is hard to raise a moral case against these reforms. Indeed, this is often the political function of things like the Francis Report or the Keogh Review. But this moral legitimacy only holds true if the alternative view holds, and continues to hold, the moral high ground. When ‘any qualified providers’ are trumpeted as being the panacea for a sick service, riddled with inefficiencies and ineffective, even wasteful care, then this can only be a panacea if the alternative providers are, indeed, aptly qualified.
So what does ‘qualified’ mean? On what basis can they be described as ‘qualified? They cannot be shown to be qualified. But they are of course “willing” – in this case, willing to make a profit! And meanwhile our free universal health service, based on need not ability to pay, takes on the look of a ‘free for all’ for carpet baggers and profiteers. The AQP ‘reforms’ are nothing more than the final marketisation of the English NHS, dressed up to look like a quest for quality, effectiveness and safety. To say this, is not to say anything new, but the fact that there is no qualification in ‘any qualified provider’ is particularly damning evidence that there is no legitimacy in these reforms.