Select Committee on Health Memoranda


MEMORANDUM

Memorandum by the Department of Health

Table 1.2.2

HEALTH MODERNISATION FUND

SUMMARY OF NHS EXPENDITURE, ALLOCATION AND MONITORING ARRANGEMENTS


Programme
Amount within the HMF
Apportionment
Monitoring and Reporting Arrangements
Gain

Waiting Lists and Times
£320m
(a)  £260m to tackle waiting allocated in line with health authority weighted capitation targets.

(b)  £50m for centrally funded initiatives (including the National Booked Admissions Programme).

(c) £10m for cancer outpatient waits.
Targets set through Service and Financial Frameworks (SaFFs). Monitored throughout the year.
The main elements of monitoring would be:

—  monthly monitoring of elective activity and inpatient waiting lists against profiles at HA and Trust level;

—  monthly monitoring of the delivery of 18 month guarantee;

—  quarterly monitoring of outpatient activity, waiting times and breast cancer against profiles at HA and Trust level;

—  quarterly monitoring of GP and other referrals; and

—  Continued action by the Waiting List Action Team, Regional Waiting List Task Forces and the National Patients' Access Teams.

Booked admissions pilots will be monitored as part of the project management arrangements for the Booked Admissions Programme (monthly summary reports and more detailed quarterly reports on progress against project plans).

New collection arrangements will be put in place so that performance against the breast cancer target will be able to be monitored quarterly from April 1999 and for all cancers from 2000.
To begin the process of fundamental and sustainable change in the whole culture of waiting in the NHS, shortening waiting times, reducing waiting lists and increasing certainty about when the patient will be treated.

No patient waiting over 18 months.

Average waiting times will fall.

Progress towards the Government's commitment that waiting lists will fall below 1.6 million.

A further expansion of the national booked admissions programme.

Everyone with suspected cancer to be seen within 2 weeks of their GP deciding that they need to be seen and requesting an appointment.

Primary Care
(i) Primary Care Groups (PCGs)
£159m
(a)  £135m for setting up PCGs allocated with HA main allocations;

(b)  £19m for fundholding closure. To go out non-recurrently after allocations; and

(c)  £5m held centrally for other PC initiatives, including beacons.
Monitoring to form part of in-year performance management and annual PCG-HA-RO reporting cycle, including quarterly reporting by PCGs to HAs. 480 PCGs/PCTs operational and working to Annual Accountability agreements from 1 April 1999.

More effective and appropriate commissioning of services for local populations.

Primary Care
(ii) PCGs—IT
£20m
(a)  £10m allocated non-recurrently as in-year cash limited adjustment (equally across all PCGs); and

(b)  £10m, non-recurrently as in-year cash limited addition on the basis of relative need for practice investment.
Monitoring to form part of in-year performance management and annual PCG-HA-RO reporting cycle. All PCGs to have systems in place to cover core requirements for expenditure and activity analysis in 1999-2000. This will enable PCGs to function effectively.

Primary Care
(iii) Improving Primary Care
£82m
(a)  £21m uplift on GMS Cash Limited Budget—pro-rata to GMSCL baselines;

(b)  £61m for primary care infrastructure—£58m to be issued as part of initial cash limits, using weighted capitation formula; (recurrently—pro-rata to monetary distance from target) and £3m to be issued in-year, non-recurrently.
Targets and plans agreed through SaFFs.

Monitoring to form part of in-year performance management and annual PCG-HA-RO reporting cycle.
Improve equity and access to Primary Care by making progress towards a 1 per cent WTE growth in GP numbers by 2002; 500 new practice nurses by 2002; and improvements to 1,000 premises by 2002. These improvements to be targeted in areas of greatest need.

Expansion of the number of Primary Care Act Pilot Schemes to improve flexibility and extend services, particularly for target areas and populations in greatest need.

Primary Care
(iv) PC Act Pilots—preparatory costs
£1m
Held centrally and deployed against proposals for PC Act Pilots. Contract between the HA and pilot presents facility for the former to demonstrate that it has maintained appropriate internal control over funds.

Regional Offices will take an overview of HA performance.
Expansion of the scope of Primary Care Act Pilots to improve flexibility and extend services, particularly for target areas and populations in greatest need.

Primary Care
(v) Out of Hours Development Fund
£4m
(a)  £2m allocated through normal means.

(b)  £2m against assessed needs—to be issued following bidding process by in-year cash limited addition.
Health Authorities to prioritise budgets and support bids from GPs for financial assistance against maintenance and development needs accordingly. Improved access to GPs through increased investment in OOH (some of which to be targeted on geographically isolated areas).

Drug misuse
£12m
(a)  £11.9m to be distributed on the basis of the existing drug misuse special allocation formula (based on population and need); and

(b)  £0.1m to be held at the centre and spent in updating regional drug misuse databases, which will be used to help monitor the impact of the new money.
Spending will be tracked through Drug Action Team Action Plans and achievement of targets monitored through the drug misuse element of AIDS Control Act reports completed by HAs, updated on regional Drug Misuse Databases. Appropriate training in treatment of drug misusers for Primary Care Teams to be in place.

All HAs to ensure that Primary Care Teams that treat drug misusers have access to specialist support and advice, by the end of the year.

All HAs to have strategies to commission and fund drug prevention activities with vulnerable young children, including: children in care and those excluded from school, young people in contact with the criminal justice system and homeless young people.

Paediatric Intensive Care (PIC)
£5m
Allocated via bids. Primarily concerning the development of capability to provide PIC services from "lead centres" in PIC within each region. But funds may also be used to other purposes eg: improve ability to receive/stabilise critically ill children at DGHs prior to transfer to lead centre, where necessary; increase training for nurses specialising in PIC, or improved retrieval services. There will be an annual review by the National Co-ordinating Group on Paediatric Intensive Care, in liaison with the regional co-ordinators in PIC, to take account of progress, specific achievements and key emerging issues. Regional co-ordinators will require lead centres and other paediatric units to provide details of progress being made and will report on a quarterly basis on the achievement of the targets set. By April 2000, formalised networks will exist between lead centres and specialist centres (eg for burns care), major acute general hospitals associated units within the geographical area, and detailed protocols, to include admission, discharge and retrieval policies covering:

Children with acute respiratory failure; Children with meningococcal/ meningitis/ septicaemia, and those with severe head injuries.

By April 2000, regional offices, health authorities, and hospitals should have fully developed their PIC strategies across the region or area.

Calman/Hine Fund (lung cancer)
£10m
Funds to be held centrally and allocated on the basis of bids. HAs and Trusts will work up project proposals within the Calman/Hine strategy and will be required to produce costed plans demonstrating how the funding will be targeted to assist in the implementation of the lung cancer guidance and achieve the White Paper cancer target in light of the Cancer Waiting Times Audit data. HAs will need to demonstrate in HIMPs that they have plans to take forward implementation of the Calman/Hine framework including achievement of the White Paper cancer target and the ongoing implementation of Calman/Hine including the implementation of cancer site-specific guidance. The plans should take account of the snapshot audit to work up target deliverables. Investment in areas identified in evidence-based guidance or identified as deficient by the cancer waiting times audit will enable funds to be targeted in the most efficient manner and achieve the greatest health gain.

The NHS Executive will be responsible for ensuring that funds made available to HAs are spent as intended and for providing information on planned spending in-year in line with published guidance on the issue of funds from centrally held funds. Where the funds cannot be fully utilised for the purpose intended, underspends will be recycled on lung cancer services within Regions. Any major redistribution's will require further Ministerial approval, smaller reallocations cleared by the national budget holder.

Regional offices will provide spending reports at 6 months after funds being received. These must demonstrate that spending plans are in line with predicted spend and that the target objective will be achieved within the timescale by giving proxy measures of progress. The 12 month report will report on target achievement.
Specific outcome targets from implementation of Calman Hine will be linked to the resourced funding proposals. We expect to see eg:

Speedier access to diagnosis—shorten time from GP referral to first hospital appointment; increase the proportion of lung cancer patients for whom histological information and full staging data available.

Appropriate Management—ensure the existence and adoption of clinical practice protocols; increase the percentage of non small cell lung cancer(NSCLC) patients offered curative radical radiotherapy.

Quality of care—ensure that systems and resources are in place to provide palliative care.

HAZs
£49m
(a)  £40m direct to HAZs on a weighted capitation basis;

(b)  £2.6m to HAZs (equal shares) for development;

(c)  £6m for the HAZ innovations fund; and

(d)  £0.5m for central support/evaluative work.
In working towards targeted improvements in the health of local populations in areas of deprivation, all HAZs must have agreed and be working towards locally developed targets. These are detailed in the implementation plan as part of the proposals for using national funds. These proposals assessed against five national criteria and approved by ROs. Local targets quality assured by an independent researcher. There will be a mix of process and outcome targets to reflect the fact that some Public Health targets will take longer to achieve than the lifetime of the HAZ.

ROs to monitor use of funds against targets detailed in the implementation plan as part of performance management process.

ROs will also monitor use of Innovations Fund monies as part of overall expenditure, when allocation of such monies has been finalised.

HAZs to provide quarterly financial report and six monthly progress report to ROs, who, in conjunction with Regional SSI, will assess their performance.
11 1st wave and 15 2nd wave HAZs in operation from 1 April 1999:

The HAZ initiative is to trail blaze changes in areas of significant deprivation, which have been adversely affected by the internal market. 3 strategic objectives are:

developing new partnerships: HAs, Trusts, primary care working together with LA partners, the voluntary sector and others including the private sector to develop new innovative, person-centred, multi-agency solutions;

addressing health inequalities linking the NHS's contribution to work on regeneration, employment, housing; the determinants of ill health;

reshaping of health services to deliver integrated care, meeting needs of individuals and communities.

Adult Mental Health
£40m
(a)  £14m for Secure beds;

(b)  £5m for Development fund;

(c)  £2m for a beacon service Challenge Fund;

(d)  £9m for 24 hour staffed beds (but with £1m held back for issue during the year);

(e)  £5m for assertive outreach teams; and

(f)  £5m for improving effectiveness.
Targets for (d) to (f) set and monitored through Service and Financial Frameworks.

A High Level Performance Indicator set has been published for health, and proposed for social services. These will be examined nationally alongside the targets set for OPA and for NPG as well as for OHN.

Local indicators of performance will be set by the National Service Framework for mental health, due for publication shortly. Indicators of input (funding), process (expenditure, beds, teams, training, effective drug treatment, etc) and outcome (waiting times, user and carer satisfaction, psychiatric re-admissions, etc) will be collected.

A national implementation group for the NSF and Modernisation Fund will oversee the monitoring and reporting arrangements, and the development of better measures of mental health and social care, including efficiency.
Supporting the Mental Health Strategy through a broad range of measures including those shown below.

Provision of 110 additional secure beds (different levels of security).

Provision of an additional 220 staffed beds, largely in inner city areas.

Six specialised secure commissioning teams established.

16 new community teams trained in assertive outreach.

One social worker in each team per year provided through MISG.

One third of HAs to provide round the clock access to mental health services.

1,000 more users of effective antipsychotic drugs.

Child and Adolescent Mental Health
£10m
To be allocated on the basis of joint HA/LA plans to HAs on a needs basis. CAMHS Implementation group will monitor progress. Quarterly monitoring of progress using centrally collected activity and financial data with RO and Social care regions monitoring local targets.

Annual review process against checklist. HImPs will be expected to show:

baseline expenditure maintained;

joint planning between health and other agencies;

agreed plans with local training consortia to increase training provision;

appropriate recruitment plans for all tiers of provision;

strategy for increasing the availability of in-patient beds for urgent and emergencies;

justification for any capital expenditure.
Improved provision of appropriate, high quality care and treatment for children and young people by building up child and adolescent mental health services in all areas.

Improved staffing levels and training provision at all tiers; and liaison between primary care, specialist CAMHS, social services and other agencies.

National Screening Pilots
£3m
Funding will be held centrally. Expressions of interest have been sought from the NHS for pilot sites. Costed bids assessed against key criteria using an advisory group. Contracts are to be established for each pilot. Two sets of progress monitoring will take place, for performance review and financial data.

Monitoring of performance review will take place by a quarterly steering group for each clinical strand reporting to the NSC.

Monitoring of financial data to take place quarterly/six monthly basis through PHSU and then to the steering group.
A complete evaluation in respect of Chlamydia pilot and the start of evaluations in respect of Antenatal Screening and Colorectal Cancer, both of which will continue into 2000-01. In each case Evaluation will focus on a range of information about three key target issues:

the feasibility of the service;

cost effectiveness; and

Acceptability of the service to the public.

Commission for Health Improvement
£3m (part held back for issue during the year)
To establish the Commission as a non-departmental public body. Initially activity in 1999-2000 will be directly managed and funded from the centre. Depending on the effective date for the Commission's taking on its statutory role and functions, the normal relevant accountability and performance management arrangements for NDPBs will then apply. Establishment of the Commission.

Ensure that CHI has made a start during the year in its role of monitoring effectively the delivery of improved quality standards in the NHS.

Diana Nurses
£2m (UK) £1.4m for England
Funds to be channelled to individual health authorities/trusts in response to proposals. HAs will be expected to monitor the development of teams in the following areas:

their success in improving the quality of life for this group of children and their families;

improvements in the co-ordination and co-operation between agencies and disciplines involved in the care and support of these patients (including questionnaires and surveys).

There will also be quarterly monitoring of the establishment of teams by Regional Offices in the first instance, relayed to NHS Executive HQ, with regular monitoring of the training of staff and a six-monthly report on activity and the number of families helped.
The introduction of six or seven teams. These will increase the level and quality of help given to children with life threatening illnesses, leading to more children receiving dedicated support and appropriate treatment nearer to, or in their own homes.

NHS Direct
£54m
Funds are being held centrally and allocated direct to pilot areas on the basis of successful tenders.

(a)  £45m direct to pilot areas for second wave and third waves; and

(b)  £9m for start of third wave publicity and central evaluation.
Pilot sites make monthly returns to NHS Executive, containing standard data on levels of activity and action taken.

Study from Sheffield University looking at impact of service on the NHS; impact of service on quality of care; patients' views; and economic evaluation. Final report by December 1999.
Second and third waves increasing coverage of the population to ensure that National coverage achieved by December 2000.

This will lead to more effective use of NHS resources as we increase the proportion of people redirected to more appropriate course of action; people redirected to more/less resource intensive options; and people helped to look after themselves.

NICE
£10m
Funded as a central budget allocated to Special Health Authority. The NHS Public Health Development Unit will be responsible for performance managing the budget and the NHS Executive will attend board meetings as observers. Expenditure reports will be available on a monthly basis and Audit arrangements will be in line with Standing Financial Instructions for HAs. The SHA will be responsible for managing the budget. In its first year NICE will undertake 15 appraisals, which will lead to clear and authoritative guidance for the NHS on the most significant new and existing interventions.

NICE will in the medium term be commissioning, developing and producing clinical guidelines at a rate of approximately 8 major topics per year and will have established itself as an electronic and telephone gateway to a network of existing NHS clinical standards and associated audit and change protocols and guidance.

Nurse Prescribing
£7m
Funding to HAs on the basis of implementation plans approved by ROs. ROs will provide quarterly monitoring reports advising of progress against implementation plans, so that any problems can be identified as soon as possible, and management action taken to encourage uptake of the training. The first of these reports will reflect the position at the end of June 1999. Half of all suitably qualified nurses will be trained to prescribe from the Nurse Prescribers' Formulary. This will lead to:

better targeted and higher quality prescribing of items in the NPF;

more cost-effective prescribing of those items;

reduced workload for GPs and time saved for nurses; and

increased patient convenience.

Medical and Dental Education Levy

(MADEL)
£41m
£41m through weighted capitation to support medical and dental education programmes. Via the usual MADEL process of profiling and monitoring of budget spend over the year. An investment plan for each deanery must be agreed for the Consultant training and GP Registrar elements before funding commences.

MADEL accountability report Spend on hospital training posts will be monitored through regular reports—significant variance from profile being followed up. Mid-year reports on progress against plan will be obtained for the Consultant training and GP Registrar elements.

Workforce census data will provide contextual data on the impact of funding.
The arrangement of programmes for and the recruitment of 220 Pre-Registration House Officers (PRHOs).

The recruitment of 240 additional trainees into specialist training posts and training programmes developed that meet the requirements of the competent authorities and match educational needs and service strategies. Distribution of trainees amongst specialties will depend on the recommendations from the Specialty Workforce Advisory Group and exact numbers planned would be confirmed early in 1999.

Extension of training programmes for Consultants to provide for approximately one third of consultants by 2001-02.

Plans to improve speciality training management to complement trusts' clinical governance implementation plans will be introduced in 5 per cent of Trusts (rising to 15 per cent by 2001-02).

50 new GP Registrars will be recruited in addition to the development of plans by Deans for managing the training of a total of 1,400 GP Registrars.

Non-Medical Education and training

(NMET)
£66m
Funding allocated to education consortia by a cash limit addition to the designated lead health authorities. The funding and distribution to consortia will be targeted according to local workforce plans and contracts. Education consortia will complete finance and workforce information returns (FWIR) which will set out their workforce plans and consequential resource requirements. The individual consortia workforce plans will be submitted to the Regional Education Development Groups (REDG) for approval.

Regional Offices will agree workforce planning and other objectives (including specific objectives relating to the contribution towards the extra 1,000 places) with education consortia which reflect national priorities and local need. They will monitor consortia's progress quarterly against their objectives and also their expenditure through performance management reports.
The investment will provide an annual increase of 1,000 training places to meet the future forecast shortfall in the nursing workforce and to help improve the quality of patient care;

and the continuing training of the additional 3,660 commissions in the previous three years.

Staff Development
£110m
(a) £10m for recruitment and retention via NMET;

(b) £100m to unified allocations to support pay modernisation and nurse recruitment and retention campaign.
Education consortia will complete returns, which will set out their plans for providing additional EN bursaries, salary support for NHS employees and part-time places. Regional Offices will evaluate these plans.

HQ will agree with Regional Offices their share of the national target and in turn ROs will agree interim targets and objectives with education consortia and will monitor consortia's progress quarterly against these. Quarterly performance management reports will be provided by ROs to assess progress against national targets.
Contribute to the recruitment of 15,000 additional nurses over the CSR period to help achieve planned increases in activity and changes in health care.

With the £10m investment Trusts will work to recruit 500 EN converters supported by bursaries; meet the salary support costs of 200 NHS employees embarking on nurse pre-registration education; and recruit 200 additional part-time students into pre-registration education.

National patient Survey
£2m
Funds to be issued centrally on the basis of invoices received from the contractors carrying out the survey. The NHS Executive HQ and Regional Offices will monitor the use of the survey results within the NHS and specific milestones will be developed for this purpose. Provision of first national patient survey.

The survey results will be widely publicised and used to ensure that the NHS becomes more responsive through taking direct account of patients' experiences of care in planning and delivering health services.

Public Health
£45m
(a)  £24m to develop public health capacity to support the delivery of the public health strategy in the OHN White Paper, held centrally;

(b)  £10m for Smoking cessation, HAZ lead initiatives;

(c)  £10m for smoking cessation publicity campaigning held centrally; and

(d)  £1m for Mental Health public health initiatives held centrally.
(a)  Details of Fund still to be announced. Variable as to project, but central reporting/monitoring mechanisms being developed to ensure overall progress and consistency.

(b)  HAZs will be required to submit data on numbers of clients seen in new services and numbers who have quit.

(c)  ONS Surveys (GHS, Smoking amongst secondary school children and DH Health Survey already monitor smoking prevalence).

(i)  Quarterly progress reports will be part of the contract.

(ii)  Delivery of the campaign will be monitored through the contract.

(iii)  Evaluation will be built into health education contracts.

(a)  Underpinning OHN and providing seedcorn for new approaches in the area of public health, to harness innovation and to tackle inequalities.

(b) & (c)  Contribute towards a reduction in smoking prevalence.

(c)  Help persuade those currently not smoking (particularly young people) not to start.


Capital
£70m
(a)  £20m for waiting lists;

(b)  £30m for A&E Departments;

(c)  £10m for pathology; and

(d)  £10m for CHD National Service Frameworks.
(a)  Proposals from trusts demonstrate how objectives will be monitored and evaluated during the year. ROs to report progress on all schemes twice yearly, with individual reports on larger schemes.

(i)  Monitoring of spend against plan twice yearly.

(b)  Proposals from trusts demonstrate how objectives will be monitored (incorporating quantified targets) and evaluated during the year. ROs to report progress on all schemes twice yearly, with individual reports on larger schemes.

(i)  Monitoring of spend against plan twice yearly.

(ii)  Service performance link to Charter standard on time to admission and trolley waits.

(c)  A Department-led multi professional group will develop a commissioning framework for pathology services against which performance will be monitored.

(d)  Dependent upon arrangements for distribution of funding following finalisation of NSF.
Investment in modern and reliable facilities and equipment to support sustainable reductions in waiting lists and times and greater certainty about when patients will be treated: Y schemes for modernisation.

Provision of faster and better services for patients in A&E and safer working environment for staff: X schemes for modernisation.

Better quality and more effective delivery of pathology services by reconfiguration with the use of new technology and telemedicine.

IT
£50m
(a)  £40m for GP Net implementation.

(b)  £10m for IM&T change fund.
(a)  NHS Executive will project manage; suppliers will be responsible for delivering the software; any new arrangements with existing Suppliers, and new contract terms are subject to the normal business case approval procedures.

(i)  Local progress reported by HAs to ROs who will report to a National Programme Board on a quarterly basis.

(ii)  Monitoring against rollout plans submitted by suppliers, including spend against plan.

(b)  Based on the proposed standard Local Implementation Strategy Performance Management process.

(i)  Health Authorities will be required to report progress against targets on a quarterly basis in line with agreed targets. Reports will be collected through Regional Offices and collated nationally.
Connection of GP surgeries to NHS net to facilitate access to electronic appointment booking, referrals, lab test and results across the NHS.

All computerised GP surgeries to be connected and using the NHS Net.

Informatics funds will underpin the development of a service to ensure that all local health communities have the capacity to produce a "full" local implementation strategy, involving all local stakeholders, agreed with the Regional Offices by March 2000. This will enable the NHS to implement Information For Health.

Total NHS
£1,175m





 
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