THE ASSURA GROUP

  Assura invests in primary health care property, by developing and retaining primary care resource centres, GP surgeries, polyclinics and community hospitals for long-term investment, and is also involved in a number of LIFT schemes. We are currently involved in approximately 150 sites around the country and aim to be one of the UK's largest independent healthcare provider organisations by 2010. We are an expanding care provider, seeking to establish for the long term, in those places that most require servicing.

  As a mature and established primary care support service organisation, the Assura Group and its subsidiaries, Assura Property, Assura Medical and Assura Pharmacy, work together to deliver solutions to local primary care needs. We have so far committed more than £500 million to the sector and are on target to invest or commit £750 million of capital on health care by 2009. This significant expansion of premises is entirely in line with the Government's aim of bringing in private capital to improve services, particularly in deprived communities.

EXECUTIVE SUMMARY

  Assura welcomes the Health Select Committee's Inquiry which will examine the extent to which the NHS can help to achieve a reduction in health inequalities, particularly through primary care and public health services. Assura is encouraged by the government's overall ambition to eradicate the post code lottery which exists around the country and to ensure health equality is realized by sustained investment in deprived communities.

  Assura strongly supports the aims of the Government's White Paper "Our Health, Our Care, Our Say" which acknowledges that the private and independent sector can play a vital role in supporting the modernisation of primary care services. In line with the White Paper, Assura also believes that the expertise and investment brought by the private sector can and does play a vital role in tackling health inequalities.

  Throughout the country hundreds of GPs are working with Assura to form provider organisations and deliver community based care closer to their patients. In many deprived communities Assura is offering integrated facilities and support systems which enable GPs to undertake a much wider range of services. Driven by levers including Practice Based Commissioning this is putting power in the hands of clinicians and practitioners who understand the needs of their local community and can drive up standards of care for all. Making these policy drivers work effectively across the country will be central to maximizing the opportunities afforded in primary care.

HEALTH INEQUALITIES

  1.  Our dealings with many of the PCTs around the country have enabled us to build up significant knowledge and expertise in primary care services. The Assura Group therefore believes that access to GP services as well as quality of GP services is key in order to reduce health inequalities. Primary care is of particular importance in deprived areas to reduce these inequalities and Assura was therefore particularly supportive of the publication of "Our Health, Our Care, Our Say" and the renewed emphasis it places on primary health care.

  2.  Continuing reform and modernisation is critically important to ensure that patients gain maximum benefit from the significant funding increases within the NHS and that remaining health inequalities are tackled appropriately. The independent sector can play a vital role in supporting the modernisation of primary care services and we welcome the government's sustained acknowledgement of this. It is vitally important that the government seeks consensus wherever possible on its health service reforms and ensures that the market in primary care continues to grow and mature. The introduction of private providers is a tremendous boon for the NHS in financial terms but also in terms of expertise, competitiveness and service provision.

  3.  Assura has often filled gaps in primary care services in deprived areas through our unique financial and delivery model. If government objectives for primary care in poorer areas are to be realised, the private sector's skills, expertise and funding for facility development is essential. As there remain significant geographical disparities in terms of health outcomes, Assura recognises that the facilities being delivered need to be reflective of the needs of the local community and are provided promptly and with the opportunity for refurbishment and update.

  4.  Cross-subsidy from Assura's three divisions; Assura Property, Assura Medical, and Assura Pharmacy, allows the development of major primary care developments and GP led Polyclinic-type models. It also gives far better value to the taxpayer through improved efficiency savings. 50:50 joint ventures with GPs are formed to enable them to provide out-patient and diagnostic procedures in the community. These advanced facilities help to enable the reconfiguration of secondary care services into primary care in line with patient needs and the wider NHS agenda. This collaborative approach between the GP community and Assura leads to improved utilization of healthcare professionals across a patch and helps support a greater skills mix amongst clinicians within a Practice.

  5.  The Assura model carries the whole risk in developing modern, high quality facilities for primary care by enabling us through our large equity base to speculatively acquire and develop new primary care facilities in areas ahead of a final decision by PCTs on funding. This allows Assura to go into deprived areas that traditionally have not received as much investment whether that is through high land costs or low GP numbers and to develop facilities which support that local community.

  6.  There is a reduced appetite amongst GPs for owning property with the introduction of new contracts for GPs and the focus on larger primary care centres. This reduces the burden of property ownership, allows GPs to focus on service delivery and can unlock capital value in premises in a tax efficient manner. It also means that GPs who were previously tied up in asset management are freed from that responsibility helping ensure a focus on service redesign and improved care pathways for all patients.

  7.  We have found that our modern facilities encourage GPs to relocate into areas they have considered too unfavourable and deprived in the past. It is also clear that modern, technologically advanced primary care facilities—one-stop primary care centres, polyclinics, community hospitals and super surgeries—offering co-location of services are key to providing a patient-led, high quality health service.

  8.  Significant sums of money have been put into deprived communities over the last 10 years but persistent health inequalities remain. This is in many cases due to the fact that whilst the solutions and the services may be in place, they are too often not being accessed. In these areas PCTs must work closely with their Local Authority partners to look at education and health promotion as well as simply waiting for patients to "come to the GP". Progressive primary care centres will play an integral part in delivering this vision and will need to look outwards as well as looking inwards at the services they provide.

  9.  Primary care has rightly been put at the centre of the government's reform agenda with policies such as Practice Based Commissioning, Payment by Results (in respect of tariff unbundling) and Any Willing Provider contributing to this direction of travel.

  10.  Practice Based Commissioning encourages provision of appropriate and convenient services for the patient. In order to address health inequalities it is, therefore, vital to roll out Practice Based Commissioning in a speedy and efficient manner and to ensure effective take up by GPs who are not merely the most entrepreneurial or progressive. Giving GPs more power over resources used by their patients to deliver better care is important to meet specific local needs and thereby reduce health inequalities as is the shift towards "fair-share" budget setting.

  11.  Practice Based Commissioning also allows GP practices to keep a proportion of any "efficiency gains" resulting from more cost-effective ways of treating patients, which can then be ploughed back into developing new services. By working with Assura and offering facilities and services which take the burden off the acute estate these savings can be manifest and when put back into the local health economy represent excellent value for money.

  12.  Without Practice Based Commissioning one of the levers for change would not exist. However, Practice Based Commissioning is merely a lever and is insufficient in itself to improve health outcomes and should not be seen as the end of the process. Using existing service providers appropriately and imaginatively and moving towards "practice based provision" must be the aim of the reform process. This means working alongside as opposed to against clinicians throughout the country, engaging them in their patients' care and providing them with the tools to drive up standards. GP-led schemes such as the Assura Limited Liability Partnership (LLP) model does just this and can be a real vehicle for change.

  13.  The government has thus far pursued an appropriate policy of encouraging the independent sector to enter the market and to compete for services where best value can be demonstrated. Any Willing Provider does this by ensuring that no income guarantee is made and no false monopolies are created. Under Any Willing Provider GPs can offer genuine choice to patients in a locality and the local health economy can become far more efficient. Assura would like to see this policy driven forward across the country with the presently patchy implementation smoothed over to enhance patient choice.

  14.  As with Practice Based Commissioning however, it is vital that those entering the market do so by moving in the same direction as the GP community and not against it. An Assura LLP supports this process and is able to operate where Any Willing Provider criteria is being properly followed. Enforcement of this guidance is crucial in ensuring a rich mix of providers in every area and much greater efficiency.

  15.  Similarly the role of the tariff has been important in driving forward the care closer to home agenda and Assura sees the tariff as having a critical future role in reducing health inequalities. Where the tariff can be used to incentivise new providers to move into an area that has problems with under-capacity it can be a real lever for change.

  16.  We urge the government to ensure that it continues on the road to reform and uses companies like Assura to deliver sustained and increased investment, both in premises expansion but also in service redesign, which is a necessary outcome of the significant increase of NHS expenditure since 1997 and the care closer to home agenda.

RECOMMENDATIONS

  1.  Pactice Based Commissioning has had a very mixed take up throughout the country and Assura's experience of this is that where it has been embraced significant service performance improvements result. Focusing on the 38 most deprived PCTs, the government should offer support to Trusts and GPs in taking advantage of the opportunities afforded by Practice Based Commissioning and to ensure patients in deprived communities benefit from greater choice and improved services close to their homes.

  2.  Ay Willing Provider is not being embraced universally and where it is not choice and improved service design is not being realized. A failure to tackle this problem, which has been generated partly by a lack of understanding and also a lack of prioritization, has meant that providers wanting to enter a market "at risk" are reluctant to do so. The government must pursue this policy fully and ensure that PCTs make Any Willing Provider a core part of their strategic planning.

  3.  The role of the tariff must be looked at and expanded to bring in appropriate providers into deprived communities. As it becomes unbundled the tariff has the potential to act as a lever for reform; being lowered in parts of the country with surplus capacity and increased in areas where there is a dearth of capacity. The government must look urgently at how the tariff should be used over the next five years to improve health outcomes for deprived communities.

  4.  The government must also ensure that throughout this reform process levers for change are being used that work with not against clinicians. Assura has found through many years working in localities throughout the country that this is by far the most effective way to get the most out of the system. Given that inefficiencies tend to be worst in the more deprived communities getting this right and prioritizing this partnership approach will be integral to successfully reducing health inequalities.

CONCLUSION

  Overall we support the Government's aims to reduce health inequalities by expanding, improving and increasing primary care as a majority of patients have their initial contact with the NHS through primary care services. However, Assura feel that there is a need to put an even stronger emphasis on the continuation of Practice Based Commissioning, Any Willing Provider and the role of the tariff and to support PCTs with effective implementation; something that is presently not routinely happening. It must also ensure that even within a competitive marketplace structures are in place to ensure all providers link well with the clinicians who are delivering the service.

  The direction of travel for making this happen has already been set out, however the big challenge for the next five years will be making it happen on the ground and ensuring that those PCTs with the worst health outcomes embrace reform and deliver change.

January 2008