ANY WILLING PROVIDER

                             FAQ document for primary care

Key points

       The Any Willing Provider (AWP) model is not new – it has been in place for
       routine elective care since April 2008 („Free Choice‟)
       AWP allows patients to choose, where appropriate, from a range of qualified
       providers who are accredited to provide safe, high quality care and treatment –
       and select the one that best meets their needs. It allows innovative and responsive
       services to grow, benefiting patients and providers alike.
       Under AWP commissioners know that a range of safe, good quality and
       affordable providers are available to which they can refer their patients without
       the cost and effort of competitive tendering.
       AWP is proposed to be extended by 2013/14 to most NHS services, starting with
       some community (and possibly some mental health) services during 2011.
       Engagement has taken place since the Autumn to inform implementation, with
       commissioners, providers, professional groups, and voluntary/patient

1. What does ‘Any Willing Provider mean?

Any Willing Provider‟ is a way of commissioning services that enables patients to choose
any provider that meets the necessary quality standards and price (either a national tariff
or a locally set price).

2. Why are you introducing ‘Any Willing Provider’ now?

AWP is already happening in elective services (“free choice”) and has been successful at
providing real choice for patients. We want to build on this to offer many more patients
greater choice, to allow good quality responsive providers to grow, and to encourage
innovation by making it easier for new providers to offer services. This is especially so in
community and mental health services, where AWP should enable greater participation
by voluntary organisations and social enterprises, which are already demonstrating their
ability to provide good quality, responsive, cost-effective services to individuals and
communities at the margins.

3. Does ‘Any Willing Provider’ mean that commissioners need to competitively
   tender all contracts?

No. Quite the opposite – it avoids the cost and time involved in undertaking a
competitive tender, whilst maximising the potential number of providers from which
patients can choose. The process for AWP is both quicker and less bureaucratic than a
traditional procurement.

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Competitive tendering is a way of selecting a single provider, or a limited number of
providers, to provide a service exclusively. Tendering will be appropriate in some cases,
including where choice of provider would clearly not be appropriate (e.g. for a range of
emergency care services), or to provide complex, integrated packages of care (e.g. for
frail older people with multiple complex conditions), or where commissioners need to
provide income or activity guarantees in order to ensure a guaranteed service. .

4. Can GP practices provide services under the ‘Any Willing Provider’ model?

Yes, provided there are appropriate safeguards to manage any potential conflicts of
interest and ensure that patients have genuine choice and that the way in which services
are specified does not give an unfair advantage to GP practices or to any other provider.
One of the intentions of AWP is to allow all suitable providers of the services to be able
to join the framework provided they meet quality and price requirements; GPs would not
be excluded. The NHS Commissioning Board will be able to issue guidance on simple
safeguards that consortia can introduce to ensure fairness and transparency and avoid any
distortion of competition.

5. So what is changing?

The Health and Social Care Bill does not in itself make any major changes in this area.
The AWP approach has applied for most outpatient referrals for elective care since 2008
under „Free Choice‟. The Government proposes that this approach should be extended to
other types of health services, starting with community (and possibly some mental health)
services from Autumn 2011. The Department of Health is keen to explore with
professional and patient groups how to expand the approach so that it can include most
NHS-funded services by 2013/14.

6. Why does the Government want to extend ‘Any Willing Provider’?

So that patients can choose, where appropriate, from a range of qualified providers who
are accredited to provide safe, high quality care and treatment – and select the one that
best meets their needs. So that commissioners have the confidence of knowing that there
are a range of safe, good-quality and affordable providers to which they can refer their
patients. So that existing good providers that offer innovative and responsive services are
able to grow. So that potential new providers who can meet the standards and prices set
by the NHS can offer services more easily, enabling innovation whilst ensuring that
quality and safety remain paramount.

For example, an independent professionally-led provider on the South Coast has
developed and contracted with its local PCT for an innovative specialist wound care
service which is delivering excellent results, both clinically and in terms of patient
satisfaction, very cost-effectively. AWP would enable patients in neighbouring areas to
benefit from this.

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7. How does this differ from the former Independent Sector Treatment Centre
   (ISTC) programme?

Under the ISTC programme, independent sector providers received 100% volume or
income guarantees. The „Any Willing Provider‟ model is the complete opposite – it does
not involve any volume or income guarantees. Prices for the ISTC programme were
negotiated centrally and varied between providers. The price set for the AWP service will
be the price the NHS wishes to pay, either set locally or through the national Tariff.

The ISTC programme was restricted to independent sector providers. The „Any Willing
Provider‟ model allows the full range of NHS organisations, voluntary organisations,
social enterprises, and independent sector bodies to provide services.

The ISTC was a top-down, centrally-led programme. In contrast, commissioners will be
responsible for implementing AWP.

8. Will AWP lead to privatisation of the NHS?

No. Services will remain free at the point of use, based on need. Patients will be able to
choose who provides their services, based on information about the quality and
accessibility of those services. Providers from all sectors, including NHS trusts,
voluntary organisations, social enterprises and the independent sector will continue to
have a role in providing NHS services.

9. Won’t increasing competition disadvantage NHS providers?

Only if they‟re providing poorer quality services which patients and GPs don‟t want to
use. Patients should be able to be treated by those providers best able to meet their needs.
Good quality services with a high reputation will benefit and grow; poorer, less
responsive services will be strongly incentivised to improve.

10. If NHS patients are going to various providers for treatment, including in the
    private sector, how can they be assured that they meet NHS standards of

Patient safety is paramount. Providers will be required to register with the Care Quality
Commission according to the services they provide and irrespective of whether they are
from the public, voluntary or independent sector. They will be required to meet NHS
standards, like any other provider. We will also ensure that patients and GPs readily have
information about the quality of care delivered by providers. This will enable patients to
make informed choices

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11. What are the 'appropriate safeguards' which will ensure that patients have
    genuine choice, and how will these be assured?

Commissioners and the NHS Commissioning Board will be under a duty to promote
choice. It will be for commissioners to ensure that their patients are aware of the choices
available to them. The NHS Commissioning Board will be able to issue guidance to
commissioners and GPs about how to deal with any potential conflicts of interest arising
from direct provision by practices.

12. How will ‘Any Willing Provider’ work in practice?

At its simplest, a potential provider would be accredited to provide a service(s). They
would need to agree and be capable of meeting relevant NHS standards and do so at an
agreed price (either national Tariff or a locally set price) which would be the same price
as for any other provider of such services. Having been accredited, placed on a national
register, and signed a Standard National Contract, they would register with a PCT cluster
or (in future) a GP consortium for payment purposes. They would then be paid a
Tariff/local price for any patients they treated.

13. How will approval of AWP providers work?

The Department aims to issue guidance in March about how the initial implementation of
AWP for community services will work, including how to accredit providers as Any
Willing Providers. This will ensure national consistency in terms of quality and safety
and ensure that a provider who is registered in one locality does not have to go through a
full accreditation process again for that service in another locality. This should maintain
standards, whilst reducing duplication and bureaucracy. We will be working with
commissioners and providers to decide how best to do this. We want to build in sufficient
flexibility for AWP to work in the best interests of patients and fit local needs.

14. What services should commissioners use ‘Any Willing Provider’ for and which
    will be for tendering?

The presumption is that most health services should be subject to AWP by 2013/14. In
the meantime, commissioners should decide which services they wish to introduce AWP
for and which to tender. Guidance is provided in the current „Procurement Guide for
Commissioners of NHS funded healthcare services‟ on the Department‟s website. This
guidance distinguishes between entirely new services (which should be tendered openly);
those encompassed by AWP (AWP accreditation; not tendering); those where the
commissioner is seeking substantial change in specification and/or setting, for example,
shifting services to community or home settings (usually open tendering), and those
situations where there is only one capable provider, e.g. for critical care, A&E (single
tender action); or in circumstances where there is incremental improvement to service
(contract variation).

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For some services, especially those where patients/users have complex and enduring
needs requiring a range of skills and resources, where effective care co-ordination is
crucial and commissioners may want to shift demand risks to providers, an AWP model
may not be the best approach. Commissioners could decide to tender such services to a
prime (single) contractor who is then responsible for co-ordinating care, managing
demand risk (within reasonable limits), and embedding choice of treatment and setting,
perhaps through sub-contracting to other providers, including voluntary organisations.
This is the commissioner‟s choice, based on an analysis of need and local providers. See
also FAQ(3).

15. How is the Department engaging clinicians and patients on such an important

The recent consultation, Greater Choice and Control, sought views on proposals for
offering choice of any healthcare provider. The Department is currently considering the
responses. Since Autumn 2010, the Department has held, and will continue to hold,
workshops and meetings to seek the views of clinicians, providers, commissioners,
voluntary organisations, and staff and professional organisations as to how best to extend
the AWP model. This has included technical, cross cutting themes such as currency
development, IM&T issues, etc, and service- specific issues such as referral protocols,
and quality standards.

16. Does this mean that AWP providers will be able to compete on price and loss-

No. The AWP model operates on the basis that the commissioner sets the price
(developed locally or based on the national tariff) which then applies to all providers
participating in AWP for that service for that commissioner. Patients choose and
providers compete on the basis of quality, not price. The Department is working on
developing example currencies and tariffs for a range of community services, and
guidance for prices to be set locally where there is no published national tariff.

17. Does ‘Any Willing Provider’ prevent commissioners working collaboratively
    with established local providers to improve services?

No. One of the key aims of the reforms is to promote greater collaboration and dialogue
between general practice clinicians and clinicians in provider organisations. Where
services are to be commissioned on an AWP basis, commissioners will need to ensure
that those services (and the associated patient outcomes) are specified in a way that does
not give an unfair advantage to established providers. But this does not preclude working
with a range of local clinicians to design better and more integrated pathways of care. We
expect, as set out in existing DH procurement guidance, that commissioners should
continue to work with a range of providers and practitioners to develop service models
which are innovative, deliverable, and contribute towards improvements in quality and

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18. What incentives are there for local consultants to re-design pathways if under
    ‘Any Willing Provider’ there’s no guarantee that their organisation will secure
    the income?

First, clinicians have a professional duty to serve their patients' interests. Secondly, a
provider able to deliver such a pathway would be well-placed, under an AWP model of
commissioning, to receive substantial volumes of referrals and the associated income if
they were providing a good service, because more patients are likely to choose them for
their care or treatment.

19. Could working with local clinicians to design a complex pathway, with different
    elements supplied by different parts of the hospital (or even other providers),
    might this be construed as anti-competitive.?

No, it shouldn't be, as long as the requirements in the specification are reasonable and
justifiable and not discriminatory, and the commissioner has offered the opportunity to
engage not just to the local dominant provider. It would then be for other providers to
adapt to meet the necessary requirements. This issue is covered in the current PCT
Procurement Guide, so it‟s not a 'Bill issue'.

20. What if one of the original providers can only do what they are being asked to
    do as part of a broader contract?

The commissioner would need to decide what was fair within the procurement rules to be
set by the NHS Commissioning Board (or until then the current PCT Procurement
Guide), and seek advice from the NHS Commissioning Board (or, for 2011/12, the SHA)
if needed.

21. Does ‘Any Willing Provider’ make it more difficult to deliver integrated care?

No. The Department wants to work with the NHS and professional and patient groups
how to extend the AWP model so that it can also be used to commission more integrated
packages of care. GPs will retain their current role in helping patients navigate the
system, including advising patients around continuity of care. Further, if there are
continuity of care or integration issues, GP commissioners will be able to address these
with providers directly. Where the AWP model is used, providers will have a contractual
obligation to co-operate so that patient care is safe, transfers are co-ordinated properly,
and patient experience is good.

In other cases, particularly where continuity is very important or where patients require
integrated health and social care support, it will be more appropriate to use a tendering
approach to identify a single provider (or small number of providers). This could involve
tendering for a lead contractor that takes overall responsibility for providing integrated
care, but involves other providers in delivering different elements of that care whilst
offering patients appropriate choice at identified parts of the pathway See also FAQ (3).
The Department is not looking to impose a „one size fits all‟ approach. We wish to

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explore with clinicians and patients how to design the best approach for different types of


22. Where the AWP model isn’t suitable, will commissioners be caught by European
    procurement law? Does this mean having to competitively tender above a
    certain threshold?

The Health and Social Care Bill doesn‟t change these requirements. NHS commissioners
are already required to comply with competition law and procurement best practice. The
requirements are currently set out in „The Procurement Guide for Commissioners of
NHS-funded Services‟ (the „Procurement Guide‟), available from the DH website.
Commissioners must adhere to general rules about transparency and fairness and, where
the service is valued at greater than £10,000 over the life of the contract, they must use
NHS „Supply2Health‟ to advertise the opportunity. In future, these requirements would
be set out in regulations to ensure clear and transparent rules and to avoid inconsistency
between consortia.

23. Does this prevent commissioners working collaboratively with an established
    local provider to identify how to improve services?

No. Once a contract is in place, it is an essential part of a good commissioner-provider
relationship that the two work together to identify continuously how to improve services,
where necessary agreeing variations to the contract. .

24. The Health and Social Care Bill includes new provisions to prohibit anti-
    competitive behaviour by commissioners? What do these mean?

The Bill includes a broad duty on NHS commissioners to undertake their functions in
ways that do not distort competition. It will be for the Secretary of State to set out in
regulations the more detailed provisions that underpin this broad duty. The NHS
Commissioning Board will be able to issue guidance to help consortia ensure that they
are able to demonstrate compliance with these provisions. If a provider considered that a
commissioner had behaved anti-competitively, it would be expected to seek to resolve the
matter with the Board in the first instance. If necessary, a provider could refer the matter
to the economic regulator, but we would not expect this to be a frequent occurrence.

Whilst there will not be a legal duty on commissioners to promote competition (as
distinct from patient choice), they will be expected to ensure that there is sufficient
competition to offer meaningful patient choice and ensure that sufficient providers or
appropriate quality and cost-effectiveness are available to meet the needs of their
patients. This is where access to skills such as health market analysis will be important.

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25. Will there be restrictions on advertising and promotions by providers of NHS-
    funded services?

Yes. These exist already in the Promotion Code for NHS services. Providers are required
to comply with its provisions under the terms of the Standard NHS Contracts. The Code
will need to be updated in due course, but remains in force.

26. Does decommissioning a service from a provider mean that the commissioner
   must pay the redundancy costs of those staff employed by that provider?

No. Commissioners are not liable for a provider‟s redundancy costs unless they have
agreed so voluntarily and in advance through some form of risk-share agreement.
Commissioners should always take legal advice before considering whether to enter into
any such agreement.

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