1.  As the UK's leading business organisation, the CBI speaks for some 240,000 businesses that together employ around a third of the private sector workforce, covering the full spectrum of business interests both by sector and by size. Business has a triple stake in the delivery of an effective health service, as users, funders and increasingly providers of health services. Healthy employees are needed to help businesses compete in the global marketplace; companies generate 27% of yearly tax revenues—some of which is used to pay for the NHS; and many businesses are now directly involved in health provision, including primary care services.

  2.  The CBI believes social equity should be one of the main goals of public service reform, with public service providers from all sectors working together to help achieve it. Health inequalities—for example those to do with age, access, disability or the particular needs of hard-to-reach groups—not only damage social cohesion but also the UK economy.

  3.  The terms of reference for this inquiry are broad; our submission relates mainly to the second point of inquiry: "The committee wishes to address the distribution and quality of GP services and their influence on health inequalities and asks how the Quality and Outcomes Framework (QoF) and practice-based commissioning might be used to improve the quality and distribution of GP services to reduce health inequalities". It draws upon our members' experience in delivering primary care services and our most recent research.

  4.  The inquiry comes at a time of wider reform of the NHS as envisaged by the interim report of Lord Darzi in November and the prime minister's announcement of a new preventative health focus for the NHS and the wider acceptance of the principle of personal budgets for those with chronic conditions. Increasingly, these reform ideas recognise that the NHS must be more innovative and agile if it is to respond effectively to the new health challenges identified by government.

  5.  The following submission makes the case that the best primary care system should offer both equality of access to all patients and equality in terms of the quality of service each patient receives. Competition is the most efficient and effective mechanism for achieving those two goals because it is more likely than a one-size fits all system to create more responsive and personalised services. Competition should work in the patient's interests by challenging providers to respond more effectively to the health needs of all groups, and rewarding those which do so most effectively.

  6.  The QOF and practice-based commissioning are important elements in creating more targeted attention to existing health inequalities, but both must be part of a wider policy of NHS reform that ensures an optimum environment in which competition can be harnessed to help commissioners effectively.

  7.  Our submission suggests:

—  Competition can help the NHS achieve both greater equality of access and quality of service in primary care for all patient groups

—  The policy framework must create a primary care market which delivers effective commissioning that addresses health inequalities and promotes real patient choice

Competition can help the NHS achieve both greater equality of access and quality of service in primary care for all patient groups

  8.  Health inequalities are the result of a complex and wide-ranging network of factors. People who experience material disadvantage, poor housing, lower educational attainment, insecure employment or homelessness are among those more likely to suffer poorer health outcomes and an earlier death compared with the rest of the population.

  9.  This is recognised in the new health inequalities public service agreement, whereby the Department of Health (DH) has a target to reduce inequalities in health outcomes by 10 percent by 2010, as measured by infant mortality and life expectancy at birth. The new operating frameworks by which PCT performance will be measured introduce a welcome benchmark which should stimulate them to look holistically at how they approach different health inequalities.

  10.  Lack of accessibility of primary and GP services is a particular contributory factor to many individuals from hard to reach groups or living in deprived areas feeling unable to access the NHS. The issue of lack of access is two-fold: capacity and location. As the gateway to other NHS services, registering more people with a GP is a pre-requisite for addressing issues around access. But that is problematic. According to Which? one in four surgeries has turned away a new patient; there are also major problems with under-doctoring in many inner city areas, precisely the areas where health inequalities needs effective GP and other primary care services to hand.

  11.  The most basic step in addressing health inequalities is to ensure access to the NHS through its primary care provision. The current system for delivering primary and GP care services—the main point of access to healthcare—has historically not been able to address multiple health inequalities or reflect the fact that different patient and social groups often have differing needs which are not served by a "one size fits all" system. As a result, the lack of flexibility in existing NHS provision can exacerbate, or at least not help address, health inequalities.

  12.  The move to practice-based commissioning (PbC) does give GPs the potential to reshape services more around patient needs—and specific health inequalities, such as for example the health needs of isolated minority ethnic groups in inner cities. But PbC has not taken off universally across the country. The primary care trusts have an important role in ensuring GPs deliver more comprehensive, joined-up packages of care by partnering with secondary, community and social care provider. But there needs to be an overall improvement in commissioning at the GP and PCT level to ensure this happens across the board.

  13.  The best primary care system will offer both equality of access to all patients and equality in terms of the quality of service each patient receives. Accessing a competitive market of providers is the most efficient and effective mechanism for PCTs and GPs to deliver these goals because it works to create more responsive and personalised services, and challenges providers to respond more effectively to the health needs of all groups, as identified by commissioning decisions in the market.

  14.  If patients are able to choose from a range of providers who can offer alternative solutions which best meet their needs (in terms of access, type of treatment, etc) then people are more likely to engage with the NHS earlier and benefit from a preventative focus in healthcare. Informed patients, faced with a choice of providers (and with support from the PCT commissioners) will act as a challenge to providers of primary care to think differently about the services they offer to patients, or to provide new services where there is a clear need.

  15.  The CBI showed in our report Just what the patient ordered in November 2007 that for PCTs which have identified specific health inequalities providers outside the NHS—from all sectors—are offering alternative options that help them respond to patient needs. So where existing GP provision is not able or willing to address such gaps in access, a competitive primary care market would encourage consideration of other solutions. Barking and Dagenham PCT in East London, for example, in response to major problems with access for a population with significant socio-economic disadvantages, worked with a private provider to run a 7,000 patient GP practice and a 100 patient-a-day walk-in centre, both targeted to meet the identified needs of that population. The market worked here in response to a failure of the existing provision to address an issue of equality of access.

The policy framework must create a primary care market which delivers effective commissioning that addresses health inequalities and promotes real patient choice

  16.  If the principles of competition, as outlined above, are to be harnessed in the interests of reducing inequalities, the policy framework needs to be effectively designed to ensure a competitive market works in the interests of all the patients. To do that, health policy must:

—  Promote effective market management by primary care trusts and GPs

—  Develop a commissioning strategy that delivers outcomes which address identified inequalities and promote patient choice

Promote effective market management by primary care trusts and GPs

  17.  The Department of Health's Fairness in primary care initiative to improve access and build capacity in under-doctored areas has encouraged new providers from the social enterprise, voluntary and private sectors to offer services alongside existing GP services in nine PCTs. It should also encourage PCTs to make more use of the alternative provider of medical services (or APMS) contracts, which were designed to deal specifically with some of the root causes of lack of access. These changes, and the current NHS review undertaken by Lord Darzi, can make a significant change to the capacity of local NHS services to recognise and respond to identified inequalities.

  18.  But PCTs and GPs must manage primary care markets to stimulate innovative approaches that specifically address identified inequalities. No market should be designed to offer the same type of service in the same way to the same types of people in every area. This is not to argue for postcode lotteries, but to accept that the inequalities too are not uniform and so require non-uniform solutions. The commissioning power now available to commissioners creates an opportunity to rethink how different services are designed so they can specifically take account of the health inequalities identified in a particular region.

  19.  PCT commissioners should be accountable to ensuring the supply side of the primary healthcare market matches patient needs, particularly of hard-to-reach groups and those lacking access. That will require commissioners to act as effective market makers through an on-going dialogue with all providers—public, private and third sector—and ensure information is made available early enough to providers about the health needs profile within a PCT and the desired outcomes from commissioning. It is through this active engagement with the market that new packages of care can arise which are better suited to addressing persistent inequalities.

  20.  But to ensure the market works in the interests of addressing inequalities, commissioners must also:

—  Remove barriers to entry into the market

As PCTs shift their role from providers to commissioners, it becomes imperative that they have the appropriate commissioning skills if they are to understand local population needs, secure an appropriate supply base to match those needs, and oversee service re-design so there is a more direct link between provision and identified health inequalities. PCTs become the stewards and designers of the market, so they are required to reduce the barriers to entry to new providers who may offer new solutions to existing health inequalities.

Providers need to be reassured that market entry is relatively easy. Contract costs, for example, need to be minimised. But there are also cultural barriers to the primary care market—including ideological concerns about the use of private providers—which must be addressed so that new ideas, along with new providers, can respond to the signals provided by commissioners about the healthcare challenges that exist.

—  Create capacity within the system

The example of the introduction of independent sector treatment centres within the NHS has shown the value of introducing additional capacity into the system. They have been vital in helping meet the government's 18-week waiting time target. Perhaps more significantly, the introduction of new providers into the NHS family has brought new ideas and approaches which the NHS does not always find easy to generate from within.

Fundamental changes to clinical pathways have transformed the fight against infection; the use of mobile units has improved access for patients in remote areas; and new pain management techniques have allowed hip-replacement patients to start physiotherapy earlier, boosting recovery. It is clear from the patient satisfaction levels report in ISTCs that such innovations have made a real positive difference to patients' experience of the NHS. Creating similar new capacity within the primary care market also requires a specific strategy for sustainable market creation.

—  Create a clear mechanism for responding to failure of provision

New providers—and new ideas—will only be encouraged into the primary care market if there is fluidity in that market and evidence that competition has an effect on poor provision. Competition should reward the providers who are evidently better at addressing health inequalities identified by commissioners; this also means a commitment by commissioners to require poor providers which fail to respond to identified inequalities to exit the system. This will require PCTs to improve commissioning skills so that poor provision can be replaced quickly and commissioners have access to the right information to ensure ineffective services are not retained.

—  Promote a level playing field beteen all providers, regardless of the sector in which they operate

The lack of similar treatment between NHS and non-NHS providers is a brake on the functioning of an effective market. Any provider with an unfair advantage in the market means that public spending will be directed away from the most efficient providers, and those providing ineffective services are more likely to remain in place. In particular these include the transfer of NHS pension liabilities; the costs associated with market entry; and the economies of scale affecting the abilities of smaller providers to compete. Similarly, the labour supply needs to be structured to ensure that there is free movement of staff between NHS and non-NHS organisations.

Develop a commissioning strategy that delivers outcomes which address identified inequalities and promote patient choice

  21.  Effective commissioning, as the inquiry terms recognise, is crucial to addressing health inequalities in a more sustained way, ensuring the NHS becomes much more responsive to patients affected by them. The focus for PCTs on needs analysis, procurement and contract management should help create a more direct link between local needs and measured outcomes. The creation of specific "levers" in this system, including the implementation of "competition principles" is a welcome measure, as it recognises that the most effective commissioning solutions cannot be delivered by the existing NHS structure alone.

  22.  The changes introduced by the government are the right way forward towards creating a responsive system and are welcomed by the CBI and its members. However, if inequalities are to be addressed effectively, the government must ensure that the reforms it has put in place are implemented fully so that the expertise of all providers is brought to bear to assist PCTs in addressing health inequalities.

  23.  The inquiry terms ask how best the Quality Outcomes Framework (QOF) and practice-based commissioning can be made to ensure GPs address health inequalities. We would argue that to for these change to be most effective, the following emphases must be considered:

—  The QOF could be tailored around addressing health inequalities rather than just outputs

—  Practice-based commissioning should improve data capture and dissemination

—  The money should increasingly follow the patient.

  24.  The Quality Outcomes Framework (QOF) could be tailored around addressing health inequalities rather than just outputs. The introduction of the QOF into the new GP contracts aims to reward practices which deliver high-quality services to all their patients. It is evident that since its introduction that GPs are doing more to address long-term conditions like coronary heart disease. But we think the QOF mechanism as currently structured is still too focused on outputs from primary care delivery, and is insufficiently focused on outcomes relating to health inequalities. An overly prescriptive QOF will do little to encourage innovative approaches to tackling pre-existing inequality issues.

  25.  Practice-based commissioning (PbC) should improve data capture and dissemination. PbC has the potential to encourage GPs to offer more specialist surgeries in their practice, such as diabetes care or dermatology, or focus on tailored education and prevention programmes with key groups around alcohol dependency or obesity. It should be used to encourage GPs to link up with secondary, community and social care providers to offer more concerted programmes that address existing health inequalities. But at the moment, PbC is not working effectively enough to address health inequalities because too many GPs are failing to share the data they have early enough with all providers, which is a necessary precondition for those providers to work with GPs to develop solutions to address inequalities.

  26.  Empowered patients with real choice are more likely to seek to engage with the NHS if they can see that the service on offer is right for their needs. Patients should be allowed to choose from any willing provider that meets NHS tariff costs and quality standards.

  27.  Good data must be at the heart of making choice within this market work in the interests of patients. Informed patients drive change. It is only when PCTs have good broad data about health needs that an appropriate strategy can designed in response.

  28.  The partnership between Birmingham North East primary care trust and its OwnHealth scheme is a good example of how effective data gathering helped shaped a redesign of the system to address the particular needs of a hard-to-reach group. OwnHealth is a personalised programme of personalised healthcare support to help people manage long-term condition such as cardio-vascular disease and diabetes. In Birmingham, 27% of people have a long-standing limiting illness which contributes to an evident gap in outcomes; OwnHealth is also designed to respond to the fact that delivery to ethnic minority groups is itself another recognised inequality that was not addressed effectively by existing provision.

  29.  Working with Pfizer Health Solutions, the system creates personalised health plans in line with national guidelines, and new software is used to provide decision support and capture data on progress. The PCT provides clinical support, patient identification and stratification, and it is a crucial part of the programme that patients facing health inequalities are part of the solution and encouraged to have control over their own health goals. So far, over 700 patients have managed to reduce their blood pressure using this system, reducing numbers of GP admissions and referrals. The cost per patient is £500, but with the cost of going into hospital being £2,500, the cost benefits of this approach are evident.

  30.  This is a positive example of how intelligent commissioning can create a solution tailored to address specific health inequalities identified by the data measured by a PCT. It also demonstrates the importance in any approach to addressing inequality of access of ensuring that the solution is accessible.

  31.  But too many PCTs are demonstrably not collating sufficient data about their local health needs sufficient to develop an effective response; it is also the case that too often, data which would help providers to develop effective solutions is not shared effectively with them by PCTs. It is also clear from our members' experience that far too many GPs do not know how to effectively use the data available to them.

  32.  As well as basing commissioning decisions on transparent and wide-ranging data, it is also crucial that primary care trusts can ensure all patient groups can easily access information not only about NHS services and their rights within them, but also about specific personal and public health issues. PCTs should be looking at a more creative use of technology to ensure hard-to-reach groups can access information they need; this could be through touch screens (like in job centres) placed in surgeries, pharmacies, libraries, supermarkets and benefits offices.

  33.  The money should increasingly follow the patient. The success of individual care budgets in social care indicates that people benefit from having the choice of a range of different providers offering alternative packages of care, allowing them to opt in to the package best suited to their needs. Those GPs or primary care providers who are the most successful at addressing identified health inequalities—demonstrated by increases in patient numbers or increased access by target patient groups—should be funded to reward successful service innovation that addresses issues of access.

Public Services Directorate

January 2008