Published: 05/02/2004, Volume II4, No. 5891 Page 33

Dominic Conlin outlines the issues raised by last year's London patient choice pilot

When London health communities were consulted on patient choice, it was important that they knew how activity, financial flows and information fitted with routine commissioning. As a first step, primary care trusts were asked to predict, for each of their London providers, how many patients would be waiting for six to eight months at 31 March 2004. Anyone waiting six months (the cut-off point at which they must be offered a choice of service provider) would be counted as a 'tripper'.

This quarterly snapshot prediction provided an annualised tripper estimate. It was assumed that 70 per cent of them would be clinically eligible for the offer of choice and, of those, 30 per cent (for orthopaedics) or 40 per cent (for other specialties) would accept the offer of choice and transfer.

This model allowed the project to calculate by PCT and provider trust the likely number of trippers, the expected number of patients to be offered choice and anticipated acceptance. The cumulative position provided an overall London planning figure.

As a PCT's source of funds is based on its activity baselines, any assumed change in activity flows had to be reflected in an adjustment of routine servicelevel agreements between PCTs and originating trusts. In other words, for every case that the model assumed would transfer to an alternative provider, the source of funds had to be in the right SLA.

The issue of source of funds was key. Guidance used the inpatient target of no-one waiting longer than nine months by March as a lever. Any patient who tripped the six-month deadline between 1 April and 31 December 2003 had to be treated in 2003-04 to ensure they do not breach six months by 31 March.

It was assumed, therefore, that 75 per cent of income and activity under the 2003-04 choice system was already in PCT funding baselines. The linking of this group of patients to this source of funds allowed PCTs the flexibility to support both their routine SLAs and their contribution to choice SLAs in a way that reflected the mechanics of the emerging financial flows guidance.

Over and above the planned demand figure and the calculated source of funds it was agreed to commission an additional 15 per cent, funded by the London choice project, to allow excess capacity for real choice to be exercised. This final calculation provided the anticipated capacity volumes (by PCT and by provider trust) and meant the project could move forward into commissioning discussions on behalf of London PCTs.

In the event, the assumption that 70 per cent of six-month trippers would be choice eligible was overstated, due in particular to a high proportion of hand and back surgery cases.Moreover, waiting-list initiatives in the final quarter of 2002-03 changed the shape of waiting lists across London and produced fewer 'trippers'. In the end, 55 per cent rather than 70 per cent entered the choice system.However, the rate of acceptance - across all specialities - was 65 per cent, significantly in excess of the planned uptake rate.

This brings to the fore one of the challenges of implementation:

how does the NHS account for empty capacity under the new financial flows regime? With fullcost healthcare resource group income moving round the system to the provider that actually undertakes the work, a model that predicts both primary care referral patterns and choice at six months becomes critical.

The evidence suggests that real choice can only be offered if additional capacity is in the system. In turn - unless excess funded activity is in the system - some of this additional capacity will be unused.

The London project has resolved this by introducing a tariff payment of 50 per cent of the HRG against unused/ unfilled choice capacity.When trusts provide a booking schedule which is based on the planning model but only makes up part of that schedule, the project essentially makes a fixed cost payment. As the implications of financial flows ebb across the NHS, this kind of project discretion will not be available, as PCTs' only source of funds sit in their activity baselines and this will be committed in actual activity at full cost.

The introduction of the additional dimensions of choice at six months (and by December 2005 choice at the point of referral) challenges established NHS activity planning assumptions.

Previously, planning assumptions were made on the basis of historic or established patterns and known strategic adjustments. Under choice, unless patients are treated within six months of being added to a waiting list, at least one alternative must be offered. By definition, unless all patients decline the offer of an alternative this will cut across previous assumptions.

As the London patient choice project model has attempted to do, local communities must now make further assumptions about how many patients will take up the choice options and what share of capacity they will plan for each alternative. As ever, the modelling is easy, the risks are all in the real world.

Dominic Conlin is project manager for the London patient choice pilot programme.