Supplementary evidence by the Department
of Health: Follow up information
QUESTION 8: SMOKING
CESSATION/EDUCATION
The 1998 White Paper "Smoking Kills"
set out an overall strategy on tobacco control including expenditure
of some £50m on health education and up to £60m on cessation
services.
Since "Smoking Kills" the Government
has made first bupropion (Zyban) and more recently all Nicotine
Replacement Therapy products available on NHS prescription and
appropriate increases have been made in the unified budgets to
meet the expected costs of these developments (£32.5m in
2001/02). [2]This
expenditure together with £53m on smoking cessation services
and £42.9m on the education campaign means that we will significantly
exceed the sums committed in "Smoking Kills". This reflects
the need to keep our strategy under constant review
QUESTION 12 &
15: DOCTOR NUMBERS
The Secretary of State offered to provide a
note setting out figures on the number of GPs coming through and
how many in the same timescale are retiring and whether there
is a net gain or loss.
The first point to make is that all targets
set out in the NHS plan represent net increases in the numbers.
They take full account of the numbers expected to leave the profession
due to retirement. The numbers appointed will be sufficient both
to replace those who have left and to secure significant increases.
The figures in Table 1 below show the trends
in GP numbers in recent years. The figures show that we have had
continued net growth in the overall numbers of GPs, despite a
considerable reduction in the number of GP registrar training
places in the early 1990s and despite suggestions that numbers
of retirement were set to rise.
We have now reversed the decline in GP registrar
training places and the increases that we have already seen (an
increase of over 300 since October 1997), are beginning to feed
through. Under the NHS plan, the number of GP registrar training
places is set to increase further, by a further 450, to over 2,100.
Under the NHS plan, the number of GPs (excluding
GP registrars and retainers) will increase by 2000 above the October
1999 baseline. Increases in training places will play a part on
this, but there will also be a number of other measures, including
international recruitment and speeding up appointment of those
who have completed their GP registrar training. The figures take
full account of those leaving the profession, which (including
retirements) account for 3 to 4% of the workforce each year.
Table 1
GENERAL MEDICAL PRACTITIONERS: HEADCOUNT
1990 TO 2000
| 1990 | 1995
| 1996 | 1997 |
1998 | 1999 | 2000
|
| General medical practitioners (1) | 27,523
| 28,869 | 29,116 | 29,389
| 29,697 | 29,987 | 30,252
|
| Unrestricted principals and equivalents (2)
| 25,622 | 26,702 | 26,855
| 27,099 | 27,392 | 27,591
| 27,704 |
| GP registrars | 1,562 | 1,404
| 1,305 | 1,343 | 1,446
| 1,520 | 1,659 |
| GP Retainers | n/a | n/a
| n/a | n/a | n/a
| 972 | 1,117 |
| Other practitioners (3) | 339
| 763 | 956 | 947
| 859 | 876 | 889
|
| | |
| | | |
|
Source: Department of Health publication Statistics
for General Medical Practitioners in England: 1990—2000.
Notes:
(1) Excludes GP Retainers, data on which were first collected
in 1999.
(2) Unrestricted Principals and Equivalents (UPEs) includes
GMC unrestricted Principals, PMS contracted GPs and PMS salaried
GPs.
(3) Other Practitioners include Assistants, Restricted
Principals, Salaried Doctors (para 52) and PMS Other GPs, but
exclude GP retainers.
We do not have details of the specific reasons why GPs left
the workforce and cannot therefore identify which GPs retired
(as opposed to, for example, taking a short career break). However
Table 2 below shows the balance of joiners and leavers (for whatever
reason) for the UPE workforce over the last 10 years.
Table 2
UNRESTRICTED PRINCIPALS & EQUIVALENTS (UPEs): ANALYSIS
OF WORKFORCE AND FLOWS, 1990-91 TO 1999-2000
| England | 1990-91 (1)
| 1991-92 | 1992-93
| 1993-94 | 1994-95
| 1995-96 | 1996-97
| 1997-98 | 1998-99
| 1999-2000 |
| UPEs (2) 25,622 | 25,686 |
25,968 | 26,289 | 26,567
| 26,702 | 26,855 | 27,099
| 27,392 | 27,591 | 27,704
|
| Joiners | 1,496 | 1,453
| 1,351 | 1,326 | 1,384
| 1,337 | 1,302 | 1,333
| 1,229 | 1,203 |
Composed of: new
joiners (not seen before
in a census)
| 1,313 | 1,252 | 1,134
| 1,136 | 1,187 | 1,059
| 1,029 | 1,069 | 967
| 958 |
| re-joiners (appeared in a previous census) |
183 | 201 | 217 |
190 | 197 | 278 |
273 | 264 | 262 |
245 |
| Leavers | 1,432 | 1,171
| 1,030 | 1,048 | 1,249
| 1,184 | 1,058 | 1,040
| 1,030 | 1,090 |
| Change in UPEs | 64 | 282
| 321 | 278 | 135
| 153 | 244 | 293
| 199 | 113 |
| | |
| | | |
| | | |
Source: Department of Health publication Statistics for
General Medical Practitioners in England: 1990-2000.
(1) Earliest available data.
(2) Numbers of UPEs at 1 October each year from 1990
to 1999 and 30 September from 2000. Other rows relate to changes
between successive October/September Censuses.
QUESTION 24: CASEMIX
OF TREATMENTS
The table below contains details of 20 or so common procedures
(which, taken together amount to about half of all surgical activity
in the NHS) and the number of each procedure which were carried
out in 1996/97 and 1999/00 (the latest year available).
The table shows that the fastest growing procedures are a
mixture of relatively straightforward (for example cataract removal),
and longer more resource intensive operations such as knee replacements
and PTCAs. What characterises all of these fast growing procedures
is that they are clinically effective; producing real health gains
for patients.
At the other extreme, those procedures which have become
less common since 1996/97 are those which are considered to be
less clinically effective in some cases—for example removal
of teeth in hospital and drainage of the middle ear.
NHS HOSPITALS ENGLAND 1996-97 AND 1999-2000
| 1996-97 | 1999-2000
| Increase between 1996-97 and 1999-2000 |
| | | No | Per cent |
| Colonoscopy | 250,090 | 344,373
| 94,283 | 38 |
| Cataracts | 160,013 | 213,303
| 53,290 | 33 |
| Miscellaneous operations including radiograms chemotherapy
| 728,576 | 950,093 | 221,517
| 30 |
| PTCA | 17,045 | 21,968
| 4,923 | 29 |
| Total prosthetic replacement of knee joint |
24,474 | 29,893 | 5,419
| 22 |
| Endoscopic operations on stomach and intestines
| 479,246 | 536,899 | 57,653
| 12 |
| Investigations and minor operations on joints
| 91,368 | 101,287 | 9,919
| 11 |
| Total hip replacement | 64,505
| 69,600 | 5,095 | 8
|
| Endoscopic operations on bladder | 280,890
| 296,209 | 15,319 | 5
|
| Minor skin operations including minor skin cancers
| 182,464 | 190,548 | 8,084
| 4 |
| Mastectomy | 52,737 | 53,823
| 1,086 | 2 |
| Inguinal hernia | 81,398 |
81,758 | 360 | 0
|
| Operation on cervis uteri | 80,775
| 76,148 | -4,627 | -6
|
| Varicose vein | 54,470 |
49,080 | -5,390 | -10
|
| Removal of teeth | 95,069 |
84,689 | -10,380 | -11
|
| Fallopian tube operations | 139,860
| 119,566 | -20,294 | -15
|
| Hysterectomy | 72,232 | 60,955
| -11,277 | -16 |
| Drainage of middle ear | 74,259
| 61,000 | -13,259 | -18
|
| Tonsillectomy | 75,407 |
61,449 | -13,958 | -19
|
| Other evacuation of contents of uterus |
144,577 | 117,611 | -29,966
| -19 |
| Endoscopic operations on outlet of male bladder
| 55,723 | 39,339 | -16,384
| -29 |
| Curretage of uterus | 87,408
| 43,212 | -44,196 | -51
|
| | |
| |
Notes:
The figures for 1989-90 to 1997-98 are grossed for both coverage
and unknown/invalid clinical data.
But the figures for 1998-99 to 2000-01 have not yet been
adjusted for shortfalls in data.
The above operations are mentioned in any of the four fields
in the HES data set.
The total for all operations is not equal to the sum of the
rows because some operations (episodes) have procedures on more
than one row.
Several endoscopic procedures have dedicated "single"
codes in the OPCS4 classification of operative procedures, but
many others require the prescence of a secondary code to qualify
the reported operative procedure as performed by an endoscopic
approach.
Source: Hospital Episode Statistics (HES), Department.
QUESTION 26: WAITING
LIST MODELLING
Modelling the Reduction of Waiting Times for Hospital Treatment
Introduction
This following note covers:
— The waiting times models
— the assumptions behind the analysis; and
— a measure of the sensitivity around those assumptions.
Our analysis has been done within a worst case framework.
It assumes that new objectives will be met without changing the
way we work and manage waiting lists, which is definitely not
the case. Moreover, the implementation of booking across the NHS
represents a fundamental change to the dynamics of the system.
Scenario
The goal is to deliver a three month maximum wait
for first attendance at an outpatient clinic and a six month
maximum wait for elective inpatient (ordinary and day case)
treatment by 2005.
Waiting Times Models
Two basic models are used: an outpatient and an inpatient
waiting times model. They follow a similar methodology and can
be used in conjunction. Specialty level versions and a day case
and ordinary admission version of the inpatient model are also
used. The models use the way waiting lists and times have behaved
in the past to estimate future results within a given set of parameters,
e.g.
— growth in GP referrals;
— removals from waiting lists without being seen;
— conversion rate from outpatient waiting list to
inpatient waiting list;
— how patients are seen/admitted from waiting lists;
and
— additional outpatient/inpatient activity.
From the information above, the models then estimate the
size and distribution of the waiting lists at given points in
time. The models attempt to replicate the differing clinical priorities
of patients by assuming that a given proportion of new additions
to waiting lists (different for outpatient and inpatient) will
need to be seen very quickly. Another group of patients will need
to be seen fairly quickly and some will be able to wait. The proportions
that will need to be seen within given intervals are estimated
from historical data.
A very crude simplification of the model is shown below
The amount of activity required to keep the outpatient waiting
list steady is first modelled, after taking account of removals
from the outpatient list. The amount of additional activity required
to reduce long waits is then calculated.
The number of additions to the inpatient waiting list is
calculated by applying the converstion rate from outpatients.
This has stayed fairly constant over the last few years.
We have two different versions of the inpatient model. These
vary in the assumptions they make about removals:
— the "Constant" model assumes
that the risk of removal from the list is constant however long
a patient has been waiting; and
— the "Sutherland" model assumes
that the risk of removal increases with time spent on the list.
The constant model provides a more realistic view of removals
when comparing predicted levels of removal with past trends. Throughout
the modelling of the central scenario, the constant model has
been used.
Assumptions
At each stage of the process, we need to make assumptions
about the behaviour of the system. This is covered below:
Outpatients
We have assumed underlying demand of 3% for outpatient
treatment following GP written referral. This level of demand
is the average level of growth seen since the mid-1990s but around
1% higher than the trend over the last couple of years. Any supply
induced demand could be offset by the impact of referral protocols
and new incentives and levers to be put in place around PCGs.
This has not happened during the waiting list initiative during
the last two years (when waiting times have also been falling),
where referral growth has remained fairly stable. [Research from
CHE at York University suggests that the elasticity between average
waiting time and demand is around—0.2.]
Conversion rates from outpatient attendance to the
inpatient waiting list have remained very stable in the last few
years. [We have assumed that this level will continue in the future.]
However, it is important to consider the case-mix changes
that will occur. As long-wait specialties are tackled, the number
of Decision To Admits (DTAs) for ordinary admission may increase
but the overall conversion rate will remain unchanged.
Inpatients
Long waits in inpatients have been tackled by treating
urgent cases first and then targeting additional activity.
With the reduction in waiting times there should be a corresponding
fall in those removed from the list. Reasons for removal
include that the patient cannot be traced, no longer requires
treatment or has moved away. For each of these reasons a shorter
waiting time will decrease the chances of the event happening.
This has proved a realistic view of removal patterns when comparing
predicted levels with past trends.
Reducing cancellations—pre-condition for booking
A necessary pre-condition to successfully introducing booking
systems for all elective hospital admissions is to reduce the
risk of cancelling elective admissions to almost zero. This can
be achieved through increasing NHS capacity to meet the surges
in need for emergency inpatient treatment. This extra spare capacity
(not surplus) would reduce the risk of cancellations but also
increases the average cost of treatment. There are two capacity
requirements to avoid cancellations: the availability of staffed
beds and operating theatre time.
Simulations of emergency admissions at an acute hospital found
that a mean bed occupancy of 80% kept the risk of cancellations
to almost zero. Occupancy rates for non-urgent elective patients
can be run at a higher level (90%) because their admission can
be planned.
Similar considerations apply in theatres.
QUESTION 43: CARE
STANDARDS IN
INDEPENDENT SECTOR
NURSING HOMES
The Committee requested to see details of the standards in
care homes for the elderly. For information, enclosed are two
copies of the report from March 2001 "Care Homes for the
Elderly—National Minimum Standards" which outlines
these standards.
QUESTION 70: UNDERLYING
DATA TO
SUPPORT "STAR
RATING"
The performance ratings website (www.doh.gov.uk/performanceratings)
contains summary data for each acute trust, as stated by SoS in
the HSC. The website shows, for each Trust, the level achieved
against each indicator as a tick, dash or cross. A table is provided
which shows the range of values covered by these three categories
for each indicator. The website also shows, for each Trust, a
further breakdown of the performance against each of the core
targets and focus areas.
Supporting methodology and threshold levels to determine
the ratings are stored under `Methodology' and/or `Indicators'.
The individual report cards containing further information can
be found by selecting the following options on the website:
(eg) Princess Alexandra Hospital
The underlying data was not provided, although some of it
(such as waiting times) is already in the public domain. We are
making arrangements for the data to be forwarded to the committee
2
£32.5m was included in unified allocations to health authorities
for NRT and Zyban. Between April to August 2001, the net ingredient
cost of NRT/Zyban products prescribed in GP practices which were
dispensed was £11.2m. This figure excludes the costs of NRT
products delivered via other routes other than on prescription.
The decision on how best to spend unified allocations is made
locally, depending on local priorities. Back
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