Annex A
THE DEPARTMENT OF HEALTH POLICY FRAMEWORK
1. The Government has introduced a number
of broad policy initiatives that, taken together, will assist
in delivering high quality, efficient health and social care services.
THE NATIONAL
BEDS INQUIRY
2. The Inquiry recognised the need for a
"whole systems approach" when planning future health
services. Provision of acute hospital services cannot be looked
at in isolation. Acute hospitals need to work in partnership with
local primary, community, intermediate and social services. The
NBI report set out three possible scenarios as a way of focusing
debate. Responses to the consultation confirmed strong support
for "care closer to home", envisaging a major expansion
of intermediate care services. There was also agreement that the
long-term trend of reductions in beds in general, and acute beds
in particular, was not compatible with improving access to care.
INTERMEDIATE CARE
3. The development of intermediate care
services is a critical element in the programme to implement the
Plan, focussing on:
— Preventing avoidable hospital admission.
— Promoting timely discharge; and
— Avoiding premature dependence upon
long-term care.
4. The NHS Plan announced extra investment
of £900 million annually by 2003-04 for intermediate care
and related services to promote independence. Of this, around
£255 million was earmarked specifically for NHS investment
in intermediate care (the first instalment of £26 million
this year). Together with the £150 million made available
recurrently from 2000-01, this will bring earmarked NHS resources
for intermediate care to a total of £405 million by 2003-04.
A substantial component of the £900 million is being provided
to local government, mostly through the Personal Social Services
SSA, for a range of services that link to intermediate care, for
example, through the provision of home care.
5. Intermediate care is a key area for early
implementation in the NSF for Older People. The NSF builds on
intermediate care guidance issued in January 2001 (HSC 2001/001;
LAC (2001)01) and sets out key interventions, evidence base, service
models, performance indicators and milestones.
6. There are many examples of effective,
targeted intermediate care schemes around the country. These provide
an excellent platform upon which to build. Our aim now must be
to ensure that everyone has access to high quality, effective
intermediate care services. We shall be looking to develop a more
targeted approach to the further expansion of intermediate care
services, drawing on the best available evidence. National evaluation
of intermediate care has been commissioned, but the results will
not be known for two-three years. However, we do have evidence
from local, independently conducted evaluations that properly
co-ordinated and targeted intermediate care schemes do have a
significant impact on admissions and discharges. Further guidance
on best practice and successful models is being drawn up and will
be issued to the field.
7. Intermediate care is not a panacea. However,
the Government believes that, with its emphasis on promoting independence,
it can make a significant impact at these points in the care pathway,
and that this approach is a vital part of the strategy to tackle
these issues.
NATIONAL SERVICE
FRAMEWORK FOR
OLDER PEOPLE
8. The NSF, published in March 2001, sets
out new national standards and defines service models across health
and social services drive up the quality of care for older people
whether they live at home, in a care home, or in a hospital or
intermediate care facility. It focuses on:
— rooting out age discrimination;
— providing person-centred care with
older people treated as individuals with respect and dignity;
— promoting older people's health and
independence; and
— ensuring that older people are supported
by newly integrated services with a well co-ordinated, coherent
and cohesive approach to assessing an individual's needs and circumstances
and for commissioning and providing services accordingly.
9. The NSF specifically addresses those
conditions which are particularly significant for older people
and which have not been covered in other NSFs — stroke,
falls and mental health problems associated with older age. Conditions
such as stroke and dementia are not limited to older people, and
the standards and service models will apply to all who need them,
regardless of age.
10. The NSF is a ten-year programme of improvement
supported by local action and national underpinning programmes
for implementation. It sets out a series of milestones and performance
measures to ensure progress. Its implementation will contribute
to the reduction in delayed transfers of care through the development
of whole systems working:
— Standard two (Person centred care)
stresses the need for joint commissioning and provision of health
and social care services and sets out the requirement for a single
assessment process which will improve communications.
— Standard three (Intermediate care)
Sets out the service models for supporting early discharge and
avoiding hospital admission.
— Standard four (General hospital care)
sets out the need for improved discharge planning.
— Standard five (Stroke) contains a
service model for stroke. It is well known that organised stroke
services reduces length of hospital stay.
— Standard six (Falls) Organised services
for falls and fractures is known to reduce length of hospital
stay and can also help prevent admissions.
— Standard seven (Mental Health) Improved
mental health services for older people and in particular better
management of dementia should impact on discharge. Dementia is
often a key factor in difficult discharge.
— Medicines Management. Better management
of medicines will reduce hospital admissions. (Approximately one
in six hospital admissions amongst older people are due to the
side effects of drugs).
— Implementing the cross-cutting themes
of supporting carers and meeting the needs of those from black
and minority ethnic communities will support effective discharge
planning. Embedding the principles of rooting out age discrimination
(Standard one) and promoting user involvement (Standard two) into
services will lead to considerably improved services for older
people.
11. As part of the implementation process,
the Department will shortly be issuing guidance on the Single
Assessment Process for Older People for implementation from April
2002. The Government is committed to a single national assessment
framework and a convergence of local assessment procedures, outputs
and outcomes over time.
12. In addition, new guidance on Fair Access
to Care Services will be issued to councils shortly. This will
provide those with social services responsibilities with a framework
for determining eligibility for adult social care services to
allow a more consistent approach to eligibility and fairer access
to care across the country.
MODELLING—THE
MODELSHIRE II PLANNING
MODEL
13. The Department has developed a local
planning model, known as "modelshire". The original
version was made available to the NHS in February 2001 and an
updated and expanded version in September 2001.
14. Modelshire is an analytical tool designed
to assist health and local authorities, in collaboration with
partner agencies, to produce estimates of their future requirement
for general and acute services and beds and for community and
intermediate care facilities in 2003-04 in order to deliver the
targets in the NHS Plan. The first version was mainly concerned
with planning of acute and intermediate care services. The second
version includes residential care and intensive home care.
15. The Department issued a circular in
February 2001—HSC 2001/03: LAC (2001)4—on Implementing
the NHS Plan: Developing services following the National Beds
Inquiry. The circular required health authorities, in partnership,
to:
— examine their current patterns of
service use;
— consider changes needed to make their
contribution to the NHS Plan objectives of more general and acute
beds and more intermediate care beds and places; and
— submit an action plan to NHS Regional
Offices.
16. The circular invited health authorities
to use modelshire in this process. This meant that all authorities
were expected to use the original version in preparing the plans,
which they submitted last August as part of local modernisation
reviews. Queries received on the updated and expended version
suggest that at least some health and local authorities are now
using the later version.
17. Whereas the original version was produced
mainly for health authorities, the revised version is designed
for use by health and local authorities. There are two similar
versions, one operating on 1999 health authority boundaries and
one on 1999 local authority boundaries. It is possible to run
the model for individual authorities or for user-selected groups
of authorities, with a view to use for strategic health authorities.
18. Health and local authorities are invited
to enter their own data and assumptions and to compare their local
plans and projected requirements with projections for a model
authority. If their plans and projections differ significantly
from the model authority, authorities may want to investigate
the reasons for the differences and review their plans and planning
assumptions.
19. The model is not intended to be prescriptive.
The model authority is presented as the national average and not
as a blueprint for each area. The model is assumed to cover one
per cent of the national population. Authorities are asked to
conduct their own planning using the model as a tool but entering
their own planning assumptions. The model is inevitably a simplification.
It is not possible to represent the complex interactions between
different services in a model that is intended to be fairly straightforward
to use.
20. The model contains national assumptions
for changes in hospital admission rates and lengths of stay and
for levels of intermediate care and community services. These
effectively produce default results for each authority, that is
model output for acute, intermediate and community services on
national assumptions.
MODERNISATION AGENCY
21. The Agency's programmes take a variety
of approaches, but are typified by that of Collaboratives. That
is, to ensure those best practices are shared and spread throughout
the service. It is fundamental that the change programmes are
clinically led and focus on small-scale, incremental change.
22. The Agency does not have a specific
programme dedicated to delayed transfers of care at the moment,
although much of the Agency's work includes this area. For instance,
IDEA (the Ideal Design of Emergency Access) looks at pathways
into and out of care. It is a multi-agency programme including
Acute, Social Services, Primary Care, NHS Direct, etc. A specific
strand of the programme is looking at mapping the pathway of elderly
people who have fallen into and out of acute care. This will inevitably
look at the issues around discharge and delays to discharge, though
the work on this has not yet been completed and is yet to report.
23. Another relevant Agency programme is
the SMART programme that is constructing care pathways for a number
of specific conditions. All of this work starts from the premise
that discharge can be predicted upon, or prior to, admission,
and can therefore be planned. This allows for the elimination
of one or more stages of the process such as the wait for assessment
after the decision to discharge.
24. Furthermore, the Agency is developing
an organisational development competency framework and self-assessment
toolkit for PCT's to determine areas for their own further organisational
development. The domains include partnership development and securing
service provision amongst others, where delayed transfers of care
will undoubtedly be a focus for their local agreements.
NSF FOR LONG-TERM
CONDITIONS
25. This NSF was announced in February 2001
and will look at the care and treatment of people with long-term
conditions. The intention will be to improve diagnosis, treatment,
care and rehabilitation services for this group of people with
the aim of providing integrated health and social care packages
at home. An anticipated outcome will be that people will spend
less time in acute settings and better, proactive management in
the community should help to reduce relapses and hospital readmission.
Good support from community-based multi-disciplinary teams will
be crucial for this group and this is likely to be a theme reflected
in the NSF.
26. Another important strand will be the
need for community-based health and social care professionals
working in partnership with users who are often expert in the
management of their condition. A lot of work has already been
done on this through the Expert Patient Programme which is looking
at effective management of chronic conditions at home (further
details of this are given at paragraphs 51 to 52 below). The NSF
is likely to reflect the themes in the programme.
PRIMARY CARE
27. In 2000-01 the PCT Primary Care Access
Fund was established. This is intended in the first instance to
support local delivery of fast and convenient access to primary
care services and, in particular, achievement of the NHS Plan
targets access to a GP or other primary care professional. This
Fund, which will total £168 million in 2002-03 may also be
used to support services or schemes which support the development
of intermediate care (for example, rapid response or rehabilitation
teams working in community settings). Alongside this, General
Medical Service Local Development Schemes give PCTs (and PCGs)
flexibility to improve the development and responsiveness of general
medical services, by giving local GPs financial incentives beyond
those set out in the Statement of Fees and Allowances for providing
additional or enhanced services. Such schemes may be used to pay
GPs to provide additional support to older patients, so contributing
to packages of care, which enable more patients to be treated
and supported at home.
28. Personal Medical Services (PMS) pilots
are an opportunity to test different ideas for delivering existing
primary care focusing on local services problems and bringing
about improvements. Health care professionals identify the needs
of the practice population and taking advantage of the flexibility
of PMS, they negotiate a contract with the HA or PCT that best
serves these needs thus addressing delivery, inadequacies of existing
services and inaccessible or inappropriate provision. PMS pilots
generally focus on new approaches to nurses' role and skill mix
within primary and community care; new approaches to addressing
the needs of deprived areas and tackling recruitment issues in
under doctored areas; faster, more convenient and accessible services
for local patients and closer working with social care.
29. PMS plus (PMS+) pilots provide a wider
range of services over and beyond that normally provided through
GMS. GPs, community nurses and other professionals can work together
as a single integrated clinical team, delivering primary and community
health services to provide defined secondary care services within
the primary care setting, subject to local agreement and funding.
PERFORMANCE MANAGEMENT
30. The NHS's performance management at
national, regional and local level has a key role to play in managing
the reduction of the numbers of delayed transfers of care. The
2001-02 Planning and Priorities Guidance made specific reference
to what the NHS is required to do and by when to reduce delayed
transfers of care. Similarly, the social services performance
assessment system ensures councils make their contribution to
this shared agenda and provides additional evidence about their
performance in this area. Both the NHS and social services Performance
Assessment Frameworks include a delayed discharge indicator that
is compared with the national target. This has ensured that the
issue has been given a high profile, that health and social services
are held jointly to account, and already some degree of success
is being achieved.
31. Moreover, it is envisaged that, from
this year, primary care trusts will be measured on how they have
performed against one of their key targets "PCTs/HAs must
ensure, with acute trusts and social services partners, that people
move on from acute settings with the minimum of delay." Poor
performance in this area could affect the star rating a trust
receives. Similarly, the level of delayed discharge will be taken
into account when determining the star ratings received by social
services. We believe this too will raise the importance of this
issue.
32. The Department uses the "Health
and Social Service Performance Review" to monitor quarterly
progress towards implementing the NHS Plan. The HSSPR contains
quarterly information at a national, regional and local level
on delayed transfers of care. This information is monitored closely
and any variation from plan can be detected quickly so that any
remedial action that may be necessary can be taken at an early
stage.
WORKFORCE ISSUES
Social Care
33. Approximately one million people work
in the social care sector in England. Of these staff, 80 per cent
have no relevant professional qualifications. The largest group
amongst professionally qualified staff is qualified social workers.
Social care staff work in a wide range of different roles and
settings, and in both the private, public and voluntary sectors.
Estimates of the proportion of care that is provided by the private
and voluntary sectors vary, but may be in the region of 60 per
cent. The high proportion of care provided by the private and
voluntary sectors is due to an increasing emphasis on local authorities
commissioning services rather than providing them directly.
34. The Government is aware that there are
problems in recruiting social workers and other social care staff
and is taking a leading role in working with employers to tackle
the problems.
35. In March 2001, the Government announced
the introduction of a three-year degree level qualification in
social work to replace the current two-year Diploma courses. This
will be a unique opportunity to transform the status, image and
position of social workers and build on the best of social work
education and training. The degree level qualification will come
into effect in England from September 2003.
36. In addition, on 19 October last year,
the Secretary of State launched a £1.5 million social work
recruitment campaign. The campaign consists of national advertising,
leaflets, posters, local and national PR activity, a help line,
and a website. It has three main aims, to:
— Raise the number of people applying
for social work training by 5,000 by 2004.
— Inform the public about what social
workers actually do; and
— Make existing social workers realise
that their work is valued.
The campaign is going very well. The help line
has so far received over 14,000 calls, and the website has had
over 11,000 visitors.
The NHS
37. The NHS Plan acknowledges that a shortage
of human resources is the biggest constraint faced by the NHS
today and sets out the Government's commitments to increasing
the size of the NHS workforce. By 2004, compared to the number
in 1999, there will be:
— 7,500 more consultants;
— 2,000 more general practitioners;
and
— 6,500 more therapists and other health
professionals.
38. Between September 1999 and September
2000 (figures for 2001 should be available later in February)
there were:
— 1,100 more consultants;
— 6,300 more nurses (Provisional figures
for 2001 published in NHS Emergency Pressures — Making Progress
indicate an increase of 10,000 nurses between September 2000 and
September 2001.);
— 1,440 more therapists and other health
professions.
39. The Government's manifesto before the
last election rolled forward the workforce commitments. By 2005,
over the 2,000 baseline, there will be 10,000 more doctors (GPs
and consultants) and 20,000 more nurses. In the longer term, the
increases in training announced in the NHS Plan will provide for
sustained growth. The Plan announced increases of:
— 5,500 more nurses and midwives being
trained each year by 2004 than there were in 1999;
— 4,450 more therapists and other key
professional staff being trained by 2004;
— 1,000 more specialist registrars
by 2004;
— 450 (since increased to 550) more
GP registrars by 2004; and
— Up to 1,000 more medical school places
by 2005 in addition to the 1,100 that had been announced previously.
PARTNERSHIP ARRANGEMENTS
UNDER THE
HEALTH ACT,
1999
40. The 1999 Health Act Partnership arrangements
are tools designed to help break down the barriers between services,
removing existing constraints, avoiding duplication, and helping
agencies commission and provide services across boundaries more
effectively. Pooled budgets, lead commissioning and integrated
provision can all be used to provide integrated services for older
people, intermediate care, child and adolescent health, nursing
home places, learning disabilities, mental health and equipment,
as well as interim care arrangements for winter pressures.
41. The Department has so far been notified
of 64 Partnership arrangements to date, amounting to over £800
million. They also form the basis for the development of Care
Trusts, as set out in the NHS Plan and the Health and Social Care
Act, 2001.
CARE TRUSTS
42. Care Trusts will be able to commission
and/or provide for all health-related local authority functions,
including some aspects of housing and education, from a single
organisation. They will be statutory NHS bodies, established by
an application from both partners made to the Secretary of State,
and jointly governed by representatives from the NHS and local
government. Care Trusts form one option for taking forward the
Government's proposals for making the NHS a patient-centred service,
with a single strategic approach applied across health and social
care to the management of the care of individuals. Previous arrangements
had allowed for integrated services but not a single organisational
model.
43. By joining together teams and resources,
Care Trusts will provide a more responsive service, with a "one
stop shop" approach. On the workforce side, joint planning
and budgeting will allow a more efficient use of resources, cross-fertilisation
of ideas and skills, integrated training, and a more rewarding
working environment. The client groups to be covered will be determined
locally, though Care Trusts are likely to focus on mental health
services and older people's services, as these groups tend to
use a complex combination of health and social services, and will
often need a co-ordinated care pathway, for example, following
discharge from hospital.
44. 15 sites are working to develop Care
Trust proposals locally, of which six will be based on an NHS
trust model and nine on a Primary Care Trust (PCT) model. The
first Care Trusts should be set up and functioning between April
2002 and April 2003.
SHIFTING THE
BALANCE OF
POWER
45. Following this initiative, the NHS is
undergoing a radical structural change with the aim of creating
a culture that empowers frontline staff and patients. The structural
changes develop and extend the role of PCTs, create fewer, larger
strategic health authorities and refocus the role of the Department
of Health.
46. By April 2002, responsibility for providing
primary and community health services to their populations, and
securing the provision of acute and specialised services, will
have transferred to PCTs. By 2004, PCTs will be controlling over
75 per cent of NHS funding. PCTs will:
— be led by clinicians and local people;
— be the most local NHS organisation;
— be the cornerstone of the NHS;
— involve local people in decisions
that affect their local health services;
— pass more power to frontline staff;
— be responsible for health improvement
and commissioning services to meet needs of local community;
— build partnerships—including
with local authorities, Strategic Health Authorities & NHS
Trusts.
Their main functions will be:
— assessing the health needs of the
community and preparing plans for health improvement;
— strengthening the public health function
in support of needs assessment and for surveillance;
— community development, health promotion
and education and occupational health services;
— to work as part of Local Strategic
Partnerships to ensure co-ordination of planning and community
engagement;
— responsibility for securing the provision
of a full range of services for their local population;
— responsibility for all family health
service practitioners;
— responsibility for management, development
and integration of all primary care services;
— the integration of health and social
care working with local authorities.
47. Discharge planning needs to commence
before planned admission or immediately upon admission. Where
actual or perceived multiple health and social care needs exist,
it is essential that there is an integrated approach to the assessment,
planning and delivery processes. It is PCT's who have responsibility
for integrating health and social care and will also use Health
Act flexibilities to pool resources where appropriate.
48. PCT's also have responsibility for assessing
the health needs of their local population and securing services
based on those needs. Part of this process will focus on analysing
current care pathways and health outcomes. Where closer integration
and joint working between primary, secondary care and social services
is required, services will be redesigned and commissioned accordingly.
49. PCT's have responsibilities for addressing
inequalities and securing access to consistently high quality
rehabilitation and intermediate care services will continue to
be a priority for them.
50. The nursing strategy, "Making a
Difference," highlights how nurses within primary and secondary
care can strengthen their contribution towards meeting local health
and health care needs. In partnership with other disciplines they
are developing new roles and ways of working centred on the patient
and their individual needs. Models of intermediate care and "hospital
at home" are demonstrating that unnecessary hospital admissions
can be prevented and discharges planned in a timely and integrated
way.
EXPERT PATIENTS
PROGRAMME
51. The Government is committed to helping
everyone enjoy more years of healthy active life, as set out in
the Saving Lives: Our Healthier Nation White Paper and The NHS
Plan. This includes those who live with chronic medical conditions.
An Expert Patients Task Force was set up in late 1999 under the
Chief Medical Officer to design a new programme that would bring
together the valuable work of patient and clinical organisations
in developing self-management initiatives. These have been shown
to improve outcomes in chronic illness. The outcome of this work
and the recommendations are set out in a report — The Expert
Patient — A New Approach to Chronic Disease Management for
the 21st Century — published on 14th September. This heralds
the Expert Patients Programme that between 2001 to 2007 will provide
self-management training through the mainstream NHS.
52. Approximately 17.5 million adults in
Great Britain live with a chronic disease and older people are
particularly affected: up to three-quarters of over-75 year olds.
The Expert Patients Programme will:
— build on the expertise of the world
leader in this field, Professor Kate Lorig of Stanford University,
California;
— draw on the expertise of patients'
organisations in the United Kingdom;
— be integral to all local NHS Services
through PCTs;
— involve partnership between NHS and
patient organisations;
— be piloted from 2002-04; and
— be mainstreamed in the NHS between
2004-07.
TECHNOLOGICAL INNOVATION
AND INFORMATION
53. The Department's Information Management
and Technology Strategy is supporting the availability of shared
Electronic Health Records to assist the continuity of care across
different health sectors both in terms of agreed care pathways,
and through access to individual patient records.
54. Telemedicine was part of the vision
of the NHS Plan, and formed part of the Government's Information
Management and Technology Strategy for the NHS, Information for
Health, and its update Building the Information Core. In response
to those documents, local health communities were required to
produce local implementation strategies describing their plans
for delivering the NHS Plan vision. This of course included statements
on their plans for telemedicine, and earlier in 2001 local strategies
were reviewed. There is, at present, very considerable variation,
depending on the resources, priorities and imagination of local
health communities, but broadly speaking it was encouraging to
see that there was a generally fairly positive attitude and recognition
of the potential for telemedicine.
55. Telemedicine is one of the components
of the Electronic Patient Record (EPR) programme, which forms
a core element of the strategy, and a number of sites are looking
at ways of integrating telemedicine into their EPR development.
The Department is also funding a number of Information and Communication
Technologies demonstrators that include telemedicine projects.
Reports on the results of these are due in March of 2002, which
will be a good moment to take stock. There is also the work on
pathology modernisation going forward, and again, a number of
projects include telemedicine aspects.
56. In conjunction with the British Library
the Department has set up the Telemedicine Information Service
(www.tis.bl.uk) to act as a repository for NHS telemedicine initiatives.
We will be reviewing this to see how effective it is, and how
we can make better use of it to help NHS managers and clinicians
better aware of what can be achieved.
57. A key issue with telemedicine and telecare
is not the technology, which is in fact relatively straightforward,
but the implications for clinical practice and the organisation
of workflow processes to deliver healthcare. Re-engineering of
health care services needs to be the focus for change, rather
than telemedicine as such.
58. While many of the current Telemedicine
projects are about links between health care establishments (eg
Minor Injuries Unit connected to A&E specialist centre), there
are also many potential applications for home monitoring, which
should make it easier for patients to be at home rather than in
hospital.
59. Although not often considered as being
telemedicine or telecare applications, the highly successful NHS
Direct and NHS Direct Online programmes are good examples of using
information technology to deliver healthcare and health information
which use the existing communications infrastructure. Their greatest
impact has been in the way citizens and patients interact with
the service. Major strategic projects such as EPR and Direct Bookings
(both of which have telemedicine aspects) are also drivers for
looking at the business processes within the NHS and developing
the NHS telecommunications infrastructure.
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