IPPA | Health care in the United Kingdom

HEALTH CARE IN THE UNITED KINGDOM

CHALLENGES TO PRIVATE PRACTICE IN THE UNITED KINGDOM

Jean Kelly, F.C.S.P

This presentation from the Organisation of Chartered Physiotherapists in Private Practice will outline the Challenges facing Private Practitioners in the UK brought about by Government policy and healthcare funding.

HOW THE OCPPP HAS MANAGED CHANGE

The UK has a mixed healthcare economy - a National Health Service paid for by taxation, which is almost free at the point of delivery and a private healthcare system, paid for by Medical Health Insurance, provided by an employer or by an individual payment directly by patients.

It was a post-war Labour Government that began the National Health Service in 1948. Since that time, and despite tight controls over the costs of healthcare in the National Health Service and private sector, there remains a chronic shortage of funds in both.

Neither public taxation, nor increases in subscription levels within Medical Insurance Companies provide sufficient resources for the demand within healthcare today. This shortage of funds is only one of several reasons for change within the delivery of healthcare services that are common to both the independent and the public sector.

The reasons why this shortage will continue to occur in future are:

the increasing complexity of healthcare today.

he increasing frequency of use of medical health services due to the greater expectations of the public.

The increasing use of technology associated with medical care.
the demographic "time-bomb".

Successive Governments in the UK have tried to deal with these complex issues and as a consequence, healthcare has suffered from being a political football - ideologically governed, repeatedly "modernised" and badly under-funded.

In 1997, a Labour Government was re-elected after a gap of 18 years. This Government quickly gained a reputation for being determined to fulfil its election promises. One promise was to reform the National Health Service.

This Government published three major strategic documents on health that outlined its strategy. They were:

The New NHS - Modern and Dependable - a strategy for delivering integrated care

A Healthier Nation - a Contract for Health - proposals for concerted action in partnership with local organisations to improve living conditions and health

A First Class Service - Quality in the NHS

Each was "consultative" - requesting comments and suggestions from healthcare professionals and administrators.

In a very short space of time, the strategies have been clarified and implemented and "consultation" has been replaced with "control and command".

GOVERNMENT STRATEGY:

The key directions of Government strategy are:

the delivery of integrated healthcare within a Primary Care setting; and

the improvement of the Quality of healthcare and the way in which quality will be defined and monitored.

The impact of the Government's NHS reforms within Primary Care

It is clear that the radical changes currently underway to reform and streamline the National Health Service will impact not just upon our NHS colleagues, but also upon all independent Chartered Physiotherapists. The government has a clear strategy for healthcare as a whole with the aim that the National Health Service should take the lead in providing quality, clinically and cost effective services in a Primary Care setting.

It is in this environment that we practice as independent chartered physiotherapists and we need to respond to two key areas of change within Primary Care:

Increasing Government control over general practitioners

While talking of collaboration and co-operation, the Government has developed a very controlled management structure for GPs and for primary care, which means that General Practitioners no longer have the ability to determine what is best for their patients alone. They must consider the needs of a wider population base and provide services that meet these needs and that deliver health improvement targets established within the national and local Health Improvement Programmes.

An immediate impact of one of these policies is the loss of GP contracts for many OCPPP members as they are prevented from tendering for contracts to deliver physiotherapy services to the NHS within GP practices.

Alteration of existing relationships with GPs

The continuing move of National Health physiotherapy services into the community will partially replace independent services but will also impact upon relationships that until now have been almost exclusively between independent practitioners and GPs.

Even if independent practitioners do not want to undertake contracts for NHS services within Primary Care, we are reliant on GP referral for 60% of our private business.

GPs remain largely the "gatekeepers" of private referral and if these referrals are transferred to new sources available to GPs, it may have serious and long-term consequences on income.

We could take a cynical view of these comprehensive changes and say that they will not take place given the resources that are available. However, the changes are highly structured and controlled. GP autonomy has been largely lost - at least for the time being.

If National Health Service patients are to be provided with guarantees of a quality, clinically and cost effective service based upon evidence of good practice, what reasons would there be for patients to continue to seek private treatment?

The National Health Service is now also the single largest provider of health services to the private sector. If the clients of medical insurance companies are guaranteed high standards of quality within a NHS setting, will the medical insurance companies contract with the National Health Service to provide private services also?

Medical insurance companies that provide for 40% of our income are well aware of the Government's health strategy and the quality initiatives that are in place. They will certainly wish to develop a differential for their clients and will demand a higher level of service from their providers.
If we are to remain as providers to medical insurance companies, private practitioners in the UK must meet that enhanced level of service.

The Government's Quality Agenda

The government intends to tackle the Quality issues in two ways:

by setting, delivering and monitoring SERVICE STANDARDS

by delegating responsibility directly to individual clinicians and professional bodies for SELF-REGULATION

THE SETTING, DELIVERING AND MONITORING OF SERVICE STANDARDS

For the first time in the history of the NHS, the government, working with clinical bodies, will systematically appraise medical interventions before these are introduced into the NHS. Clear authoritative guidelines on clinical and cost effectiveness will be offered to front line clinicians.

The Government has established several bodies and processes to ensure that their quality agenda is addressed. These are:

The National Institute for Clinical Excellence, which will ensure that authoritative national guidance, is available for all health professionals on the latest drugs and technologies.

National Service Frameworks, which will lay down the care that different groups of patients should expect.

Local NHS organisations will be obliged to take on responsibility for Clinical Governance - making sure standards are met.

A process of lifelong learning, to ensure that staff keep their skills continually up to date.

Rigorous standards of professional self-regulation, which are in line with the valid expectations of patients.

The Commission for Health Improvement, which will carry out a rolling programme of spot checks and act as a trouble-shooter to ensure that the highest standards are being met.

A National Performance Framework, which will measure the things that really matter to patients.

A new Annual National Survey of Patient and User Experience will ensure that the voice of the people who depend on the NHS is heard and acted upon.

All these measures will complement and reinforce each other to ensure that high quality care becomes the norm within the NHS.

PROFESSIONAL SELF-REGULATION

The Government's policy for self-regulation is contained within the Health Papers where it states:

"The Government will continue to look to individual health professionals to be responsible for the quality of their own clinical practice. Professional self-regulation must remain an essential element in the delivery of quality patient services. It is crucial that the professional standards developed nationally continue to be responsive to changing service needs and to legitimate public expectations."

Professional Regulation will, in reality, occur in two ways:

Externally, by statutory protection of the title "physiotherapist" enabling only those with recognised standards of training to practise and requiring confirmation that competence to practise is maintained throughout professional life.

Internally, through the Standards of practice and Disciplinary procedures of the Chartered Society of Physiotherapy and its Specific Interest Groups.

PRIVATE MEDICAL INSURANCE STRATEGIES

In the UK, we have not experienced the full introduction of "managed care" as seen in the USA during the early nineties but there have been a number of developments that have impacted on our marketplace.

The marketplace is dominated by two large insurers who share approximately 70% of the medical insurance marketplace. They have diversified their businesses into hospital ownership, private GP practices and referral centres. Their promotional activities have included unlimited free physiotherapy to insured members who are willing to be directed to specific centres for treatment (usually owned by the Insurance company) and price capping when external independent physiotherapists are used.

They have introduced major projects that include the dramatic reduction of the "recognised" consultants that patients can access and a significant reduction in the numbers of hospitals on their "preferred provider" lists.

Changes in the Marketplace

The past year has seen a fine-tuning within the whole healthcare market to ensure that only clinical and cost effective services are delivered.

They can be summarised as:

those encapsulated within the Governments Healthcare reforms;

the implications of gaining protection of the title "Physiotherapist"; and

the developments within our business environment.

The challenges we face as a consequence of these changes are:

to maintain our professional autonomy.

to maintain our income.

to continue to understand and be flexible to the needs of patients.

to anticipate the future and proactively manage our response.

to actively influence the marketplace.

We need to keep up to date with the moves in the total marketplace because our practices cross over both National Health Service and private boundaries.

We know that :

60% of patients seen by independent chartered physiotherapists are referred through their General Practitioners. (GPs in the UK are mostly independent contractors to the NHS, not employees, though it appears that it is the Government's intention that this should change) - the treatments for 2/3 of these patients will be paid for through third party reimbursement such as Medical Insurance schemes.

40% are self-referred.

Alterations to any one of these sources of patients will therefore have significant impact upon the income of any practice.

OCPPP STRATEGY

Back in 1996, OCPPP recognised the need to protect the different sources of patients when it developed its strategic plan. At that time it was agreed that the organisation should proactively undertake activities which would grow the marketplace for members particularly within the non-GP referral segment.

Since 1996 we have been taking a planned approach to achieve the following objectives:

To establish OCPPP as a broad based provider of services with a focus on the provision of high quality treatment and education for patients.

To continue to impact upon the GP referral segment of the market.

To be proactive in the non- GP referral segment.

To influence the medical insurance marketplace.

To actively target the 25-44 age group to develop long term relationships with potential purchasers of our services.

To set and regulate standards using Accreditation as a major differentiating factor.

To form alliances in professional and business environments which will benefit members and patients.

OCPPP ACTIVITIES AND ACHIEVEMENTS

Directly to Government

OCPPP has responded directly to all the Government's Strategic Health documents. A response was also given to a Government Select Committee enquiry into the regulation of private and independent healthcare This response outlined how OCPPP has set, and is monitoring the standard of, practise in independent physiotherapy through Standards for Private Practice, Mandatory CPD, Practice Accreditation, the measurement of Outcomes.

OCPPP believes that it is vital that we maintain our independence in determining how competence is measured - leaving us free of statutory control. OCPPP believes that competence can be demonstrated by linking planned CPD to the measurement of the outcomes of practise. OCPPP therefore intends to develop a portfolio to help members to structure their CPD and will encourage all members to undertake the measurement of the outcomes of their practise using the OCPPP Outcome Measurement process currently in use by Accredited Practices.

We are therefore very keen to share the experience of other IPPA members who have developed valid outcome measurement tools. The sharing of such systems internationally within the profession must lead to an enhancement of professional credibility and status.

The OCPPP Practice Accreditation Scheme contains components which enable independent practitioners - especially those who are in sole practice, to fulfil all the quality requirements the Government has identified for the National Health Service including the involvement of patients' views through patient satisfaction surveys. The Accreditation Scheme has also played a major part in persuading Medical Insurance companies and businesses that OCPPP is a Best Practice Organisation whose members - even as sole practitioners - are managing their physiotherapy service to high standards. It will remain a key strategy of OCPPP to encourage all members to undertake the process.

To Medical Insurance purchasers

The Medical Insurance Marketplace in the UK is extremely competitive and price sensitive - The rationalisation of the Medical Insurance Marketplace continues with increasing analysis of the cost of care episodes. We are extremely fortunate in the UK to be first contact practitioners, with a level of professional autonomy which is the envy of the profession in many parts of the world.

PhysioFirst has worked very hard to establish members as the source of quality independent physiotherapy services provided by Chartered Physiotherapists.

We have undertaken a number of initiatives, this year which have helped Insurers and businesses to recognise that PhysioFirst represents a group of highly qualified professionals who work to best practice principles.

These include informing them of our developing initiatives in:

Mandatory Continuing Professional Development

Practice Accreditation in which both practice and clinical issues are addressed

The measurement of Outcomes - having positive evidence about the outcomes of practice is invaluable. Being able to demonstrate that early treatment means fewer treatments indicates a level of professionalism that is both recognised and admired

Membership information OCPPP undertakes an annual OCPPP database survey, which provides the organisation with the ability to access information about members (e.g. location and services available).

The data we collect from members annually is vital in providing factual information when OCPPP undertakes promotional activities. We know that independent practitioners allocate an average of 35 minutes for treatments which allows for the quality treatment required by our patients, achieves results and justifies the cost of the care episode. We have been able to utilise this information to promote members' ability to deliver fast, effective physiotherapy services, placing a strong emphasis upon education and the reduction of recurrence and chronicity.

Commitment to education and training through Regional Courses and Conferences

OCPPP has achieved some significant gains this year with one major insurer agreeing only to reimburse patients for physiotherapy treatment by Chartered Physiotherapists, excluding osteopathy and chiropractic - unless those disciplines are undertaken by a registered medical practitioner.

Almost without exception, the major medical Insurance companies currently use the PhysioFirst directory of members as a working list of qualified practitioners they feel able to deal with professionally and in future the medical insurance marketplace is seeking exclusive arrangements with PhysioFirst members for the treatment of their clients. The availability of the OCPPP Membership Directory in electronic form facilitates the referral system between Medical Insurers and OCPPP members.

We continue to seek reduction in the "gatekeeper" role of GPs, promoting Chartered Physiotherapists as first contact practitioners - a fact we take for granted but is surprisingly little known in the marketplace. This important first contact role will be actively promoted to all sectors of the marketplace in 1999.

THE BUSINESS MARKETPLACE- STRATEGIC ALLIANCES

OCPPP has undertaken significant activity within the business marketplace to develop business for members within the non-GP referral sector. These activities have taken place over a number of years and are now maturing to secure a sound non-GP referred business base for PhysioFirst Members.

We have forged alliances and long-term relationships with partners in the business sector.
SmithKline Beecham - Pharmaceutical Company. We have agreed to produce jointly branded educational booklets for patients. The first booklet will be about migraines and headaches. This followed a pilot scheme last year when 100 practices were involved in distributing a number of leaflets within their practices. The feedback from this exercise has been taken into account in developing new leaflets that jointly promote the effective use of physiotherapy in the treatment of headache.

Butterworth Heinemann - Publishers. A formal agreement has been developed between PhysioFirst and Butterworth Heinemann, which will lead to the production of at least one jointly, branded book each year. The books will also contain information about the scope of physiotherapy practice and state the benefits of seeing an independent practitioner. The first book has been written by Jean Oliver and is called "Back in Line" and is available to members at a reduced price.

Boots the Chemist - A National chain of Pharmacy outlets, found in major high street positions. OCPPP as "PhysioFirst" has entered into a pilot arrangement with this national chain of chemists, which will enable the pharmacists within the stores to refer patients directly to PhysioFirst practices.

The initial pilot is being undertaken under a "pain management" banner, that is, patients seeking help at Boots will also be told of how physiotherapy can help their problem. They will be directed to the local PhysioFirst practices. Boots Pharmacy Staff participating in the project have been educated about the range of services available from Chartered Physiotherapists. If successful, the pilot will be introduced nationwide and PhysioFirst and Boots will also develop jointly branded educational material for patients.

British Gas - Major gas supplier within the UK. This initiative involves members talking to British Gas staff in their principal service centres during National Back Pain Week. It was extremely successful and British Gas and OCPPP are looking at ways of extending the service during the year.

Red Arc - This is a nationwide "case management group". They have a team of nurses who carry out assessments for predominately the elderly to see what support/equipment they need to remain living in their own homes. They wish to use OCPPP members exclusively to help with this assessment process. They actively collaborate with Social Services. They aim to cover 1.3 million people by the end of 1999. Their aim is to market their service as an added benefit to members of large organisations such as Building Societies.

Quantum Managed Care (QMC). This organisation provides case management programmes for members of the public who have taken out financial loans which have been backed by an insurance covering sickness or redundancy. The insurance companies want these insurance policies pro-actively managed i.e., when someone has an illness or injury which may prevent them from repaying the loan, they want them rehabilitated as quickly as possible to minimise the cost. Everyone submitting a claim for a medical reason (most often a back injury) will receive a self-help Guide to a Healthy Back free. (This is a jointly branded PhysioFirst Book - normal cost £2.99). Current referrals are 500 per month and it is predicted that there will be 30,000 next year. Many insurance companies such as Cornhill, Eagle Star, Zurich, Preferred Insurance and Prudential, are now also operating in case management marketplace ensuring that they have fast access to appropriate physiotherapy assessment and treatment. OCPPP is working with them all in pilot schemes, promoting the use of PhysioFirst members and introducing new business to members.

Other Insurance Companies. Many insurance -companies such as Cornhill, Eagle Star, Zurich, Preferred Insurance and Prudential, are now also introducing a case management approach ensuring that they have fast access to appropriate physiotherapy assessment and treatment.

Self-Help Bookets. OCPPP collaborated with Posturite UK Ltd to produce a jointly branded booklet called "A Self-Help Guide to a Healthy Back". This booklet is available for members to purchase for patients within their practices and is also being purchased in bulk by some of the case management insurance companies for their clients. This means that the name of PhysioFirst and its members is being publicised into new marketplaces.

PROFESSIONAL CONFLICTS AND COMPETITION

The Chartered Society of Physiotherapy - This has been a very important and pressured year for the CSP which has seen the implementation of the recommendations of both its 2001 Strategic Review and the Government's National Health strategy.

The CSP has a tri-partite role which incorporates the Professional Body, Trades Union and Educational Body. Maintaining a balance between these three functions can be difficult at times and OCPPP works exceedingly hard to ensure that the interests of the private practitioner members of the CSP are represented and that policies, which could adversely affect this membership group, are not made.

Internal competition

The statistics (published recently in Frontline) that only one third of graduating physiotherapists will remain in the National Health Service, is an indication of the intense competition that will arise within the independent sector in the future.

Protection of Title will also bring with it the requirement that the physiotherapy profession accepts "Grandfathers" into the profession. Grandfathers are people who are now earning their living by calling themselves "physiotherapists". They are working within our marketplace and will be given the additional credibility of State Registration and the ability to become "Chartered Physiotherapists" if accepted onto the State Register. This will contribute to the internal competition within the physiotherapy profession.

OTHER PROFESSIONAL CONFLICTS

As in many part of the world, competition is increasing from alternative therapies together with osteopaths and chiropractors. These latter professions have recently gained professional recognition in the UK and are undertaking initiatives to increase their client base. They are well organised, politically active and have a financially sound base from which to run publicity campaigns. We are alert to ways in which these professions sometimes promote themselves at the expense of physiotherapy and ensure that we respond appropriately.

PROFESSIONAL ALLIANCES

The National Association of Primary Care (NAPC) This non political organisation has been established to represent the interests of all primary care organisations and professionals and to establish a forum for understanding individual professional roles to fashion the delivery of healthcare for the foreseeable future. Within the past year we have tried to develop this relationship by:

A needs analysis survey of the GP members of the NAPC

A Satisfaction survey of the same group

Attending meetings of the NAPC

Publishing articles promoting the independent resource of physiotherapists within the NAPC Newsletter

Taking the PhysioFirst stand to NAPC conferences

IPPA - We value our membership of IPPA and believe that it will become an international force for supporting independent practice

National Sports Medicine Institute (NSMI) - This is an organisation which is seeking to regulate Sports medicine institutes through a process of classification. OCPPP has worked closely with them to develop this classification.

Andrew Isaacs Initiative - This work involves collaboration with a legal practice to provide information and support for members who undertake work within a legal framework.

The Society of Radiographers - This is a new collaboration with Radiographers who are entering private practice and who may wish to work jointly with physiotherapists.

THE SELF-REFERRAL MARKETPLACE

Many of the initiatives identified above have been undertaken in order to reach patients directly. The three key activities we will undertake are :

informing the market of the availability of the PhysioFirst source of independent physiotherapists

promoting the scope and quality of practice available

promoting PhysioFirst members as direct contact practitioners

OCPPP's Communication network

If we are to continue to be successful we must build a membership which is united in providing a strong lobby. To achieve this we must have an effective two-way communication system.
OCPPP currently communicates with members through Regional Newsletters, Update, our National Newsletter, In Touch a quarterly Journal, Regional Meetings and Conferences. Together they provide a fast and effective method of communication for OCPPP members, providing information about the latest developments in our marketplace and of the ways in which OCPPP is responding, together with keeping members informed about important issues relating to their practices.

OCPPP Web Site

OCPPP is keeping up to date with the latest technology and has developed its own PhysioFirst Web Site. It has the potential to become a site with many links - some specifically to members and some to external organisations, nationally and internationally. We are examining ways of producing a membership directory together with links to members' own pages for those who wish to participate. We will look at ways of producing information about PhysioFirst as a best practice organisation of Chartered Physiotherapists in independent practice.
Some pages will be accessed by members only and some by the general public - providing an up to date information service.

We have also produced a template on disk, which can be personalised for individual practices, which will have 2 hyperlinks to the OCPPP site.
OCPPP exists for its members and providing support for members is enshrined in our Constitution.

Many of our activities have both an external and internal focus and we rely on both paid staff and a voluntary OCPPP Committee to undertake the work involved in achieving our objectives.

OCPPP ACTIVITY STRUCTURE (Chart)

OCPPP Administrative Support

OCPPP has its own premises, technologically up to date office and three full time and two part time staff.
We do not believe that it would have been possible to achieve our current position without a dedicated resource of staff to support such a complex, proactive organisation.

To maintain the current level of activity and services for members will almost certainly demand an increase in this resource in future.

Success has been built by detailed analysis of the marketplace, strategic planning and careful, planned implementation of the activities necessary to grow our market and support members.

The benefit of having the professional support of a business focussed General Secretary cannot be understated.

OCPPP's FUTURE PLANS

This year will see the start of a planned programme of Public Relations and Marketing activity for PhysioFirst which will be specifically targeted to each of the different segments of the marketplace that we need to impact upon. Professional help will be used as appropriate.

Three years ago OCPPP recognised that its title was not "user-friendly" in any marketplace. The title "Organisation of Chartered Physiotherapists in Private Practice" was not easy to use or understand.

Key to our success has been the development and use of our "brand name" PHYSIOFIRST. It encapsulates all we are aiming for - that physiotherapy should become the first choice as a therapy, and that PhysioFirst therapists are first choice in the independent sector.

This trading name has become well known in the marketplace as a source of Best Practice chartered physiotherapists.

The activities of OCPPP require support and collaboration from members to ensure that there is "brand ownership" of the OCPPP Trading name "PhysioFirst". To be successful, the public relations campaign needs ALL members to present a united front in using the name "PhysioFirst" in association with their practice identity - so that throughout the country there are 3000 "PhysioFirst " centres.

OCPPP recognises that it needs to address and successfully deal with the following questions if we are to remain a dynamic, much needed source of physiotherapy in the independent sector.

How clinically and cost effective are our services?

What is the evidence base of our practice?

The principal areas of focus for the PhysioFirst PRO campaign will therefore be Membership differentiation through:

Clinical credibility.

Quality in all areas of service provision.

Fast access through First contact status.

Public Relations and Marketing activities will be planned and implemented to achieve:

consolidation and Expansion of the Marketplace. Consolidation and expansion of the marketplace will remain a key activity for OCPPP now and in the future. Consolidation of our known sources of income and expansion into new areas which will protect income for members facing increased competition;

differentiation of the services of independent practitioners;

through planned and focused PRO Activities presenting PhysioFirst and its members as a Best Practice organisation; and

the continual development of membership services and support. Helping members to understand marketplace changes and resolving problems associated with those changes.

We are looking forward to learning from the "challenging" experiences of other IPPA member organisations and are very happy to share our own experiences in more depth with members if they feel it would be helpful.

International Private Practitioners Association Interim Proceedings, May 1999

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