Select Committee on Health Minutes of Evidence

Letter from the Rt Hon Alan Milburn MP, Secretary of State for Health, to the Chairman of the Committee

  At my attendance before the Committee on 12 June, I undertook to respond to some of the points raised by the Committee in writing. Together with this information detailed below, I attach, at annex A, a response to the separate points raised in your follow up letter of 17 June.

  I shall take the points the order in which they arose in the session.


  For questions 36 and 37 I undertook to write and confirm the achievement of a number of targets for which the achievement date is this year. In particular, the Committee asked how many heart operations had been carried out to 31 March this year in order to clarify whether "the 2002 target of 3,000 extra heart operations by 1 April 2002" had been met.

  The National Service Framework (NSF) for coronary heart disease (March 2000) set an immediate priority that by April 2002, the total number of revascularisation procedures (over the 1999-2000 baseline) would increase by 3,000. The NHS Plan of July 2000 provided increased funding so that this target could be achieved ahead of time. In addition, a further target was set that at least a further 3,000 operations were performed by 2003. Revascularisation procedures are either coronary artery bypass grafts (CABG) or percutaneous transluminal coronary angioplasty (PCTA). As you will see from the figures below, both of these targets have been met early. An estimated 49,295 revascularisations took place in 2001-02 compared with the 1999-2000 baseline of 40,983.



















  Source: Hospital Episode Statistics (HES), Department of Health

  *estimated figures, full HES data for 2001-02 will be published later in the year.

  In addition, the Committee questioned whether the target of 100 rapid access chest pain clinics by April has been met. The NSF for CHD, did indeed set an immediate priority that by April 2002 100 rapid access chest pain clinics should be established. I can confirm that this target has been met, as by the end of March 2002, 172 such clinics were confirmed open.

  On a separate point that arose during my response to the matter of targets that were set for achievement in the coming year, I stated that 27 per cent of GPs had transferred to PMS Contracts. At the time I expressed some uncertainty about this figure and undertook to inform the Committee if I was mistaken. I would therefore like to take this opportunity to inform the Committee that a fourth wave of PMS began in April 2002 with wave 4b planned for October. The latest figures for wave 4a show that there are around 380 pilots comprising 1,320 GPs. This brings the total number of pilots to over 1,700 and 6,750 GP s and comprises 22 per cent of all unrestricted principals and equivalents. These pilots are focusing on tackling social exclusion problems, meeting the needs of deprived communities and improving patient access to services. The 27 per cent figure should therefore have been 22 per cent, and I should be grateful if you would make this correction in a footnote to the transcript when you publish it.


  In response to Question 127, I undertook to provide you with information on the progress of IT procurement in the South West. The South West procurement is a region-wide collaboration to procure electronic patient records across most of the South West. The procurement process being used differs from traditional approaches in the following ways:

    —  there would be one region-wide process to select a shortlist of "prime" suppliers;

    —  each health community would then work together to select from that list of prime suppliers their chosen partner; and

    —  the project would be supported by a single project office, co-ordinating work across the region, thereby providing a source of expertise and reducing duplication of effort across the consortia.

  The process itself has been very successful. One of the most striking aspects is the level of clinical involvement and support, which has led to the formation of two "super-consortia" rather than the eight separate consortia originally envisaged.

  It is true that the project has not yet signed contracts (although the consortia hope to do so this year). The main delaying factor has been the uncertainty over future funding (an issue which should be addressed by the recent settlement for the NHS). However, in terms of the critical success factors of community-wide working, clinical engagement and the streamlined process for selecting prime service providers, the South West project has already proved valuable. The lessons learned from this project are already helping to shape the Birmingham project, and a similar community wide approach in Berkshire and Buckinghamshire.

  With the advent of the new National Programme for IT in the NHS, officials are examining as a matter or urgency, ways in which the South West procurement could fit with that programme. They will be reporting to Ministers in the very near future.


  As promised in response to question 131 I am pleased to enclose the figures on delayed discharges, which show that the numbers have fallen steadily since 1997.

Definition and Data

  A delayed transfer of care (or delayed discharge) occurs when a patient is ready for transfer from a acute hospital bed but is still occupying such a bed. A patient is ready for transfer when:

    (a)  A clinical decision has been made that the patient is ready for transfer;

    (b)  A multi-disciplinary team decision has been made that the patient is ready for transfer; and

    (c)  The patient is safe to discharge or transfer.

  This applies to ALL patients of ALL ages who are occupying an acute bed. The delay starts immediately from the time that the decision in (a) and/or (b) is taken and (c) is satisfied.

  Rates of delayed discharges for patients over 75 have dropped steadily since 1997 (see table below):

Sept 2001

12.0 per cent

Sept 2000

13.0 per cent

Sept 1999

12.7 per cent

Sept 1998

14.3 per cent

Sept 1997

15.7 per cent



  Rate and Number of people over age 75 affected by delayed discharge

  Source: Department of Health Quarterly Monitoring Data



Rate of delayed
discharges for people
75 and over

Total Number of
people 75 and over
with delayed discharge

HAs included

01/02 Q4 QA

9.4 per cent



01/02 Q3 QA

10.50 per cent



01/02 Q2 QA

12.00 per cent



01/02 Q1 QA

11.11 per cent



00/01 Q4 QA

11.85 per cent



00/01 Q3 QA

11.71 per cent



00/01 Q2 QA

12.99 per cent



00/01 Q1 QA

12.11 per cent



99/00 Q4 QA

11.31 per cent



99/00 Q3 QA

11.69 per cent



99/00 Q2 QA

12.77 per cent



99/00 Q1 QA

13.41 per cent



98/99 Q4 QA

12.39 per cent



98/99 Q3 QA

12.48 per cent



98/99 Q2 QA

14.29 per cent



98/99 Q1 QA

13.43 per cent



97/98 Q4 QA

13.19 per cent



97/98 Q3 QA

13.87 per cent



97/98 Q2 QA

15.66 per cent



97/98 Q1 QA

13.29 per cent




  Q4 data is not officially published but is placed in the House of Commons library. Data will be available at the end of this month.




  During the hearing, the Committee were concerned to establish that treatment was prioritised according to clinical need, I therefore promised (in my response to question 135) to send more details on the guidance that has been issued to the NHS about access to treatment. As I made clear during the hearing, it has always been the case that clinical priority determines when a patient is treated. "NHS waiting times good practice guide", issued in January 1996, set out advice in this area and in 1997, the Government reinforced this message with guidance (EL(97)42) to the NHS on access to secondary care services. The guidance advised that "clinical priority must be the main determinant of when patients are seen as outpatients or admitted as inpatients". Therefore, emergencies are always treated immediately and patients who need urgent treatment must be given priority.

  The NHS has been expected to implement this guidance in meeting the maximum waiting times targets and waiting list size reduction. Responsibility for decisions about when urgent cases are treated rests with doctors who are best placed to understand when patients should be treated.

  In Summer 2001, the NHS Modernisation Agency released guidance to the NHS called the "Primary Targeting Lists Approach" to assist them in treating patients within the shorter maximum waiting times targets for 2001-02. The guidance states that patients with greatest clinical priority must be treated first and gives NHS organisations the practical advice to treat patients in chronological order within the maximum waiting times targets.

  I would like to confirm that the figures cancer that I quoted in my response to question 136 with regard to cancer waiting for children's cancers, acute leukaemia and testicular are correct. That is to say that from December last year the time from referral to treatment for these cancers was one month.


  In response to concerns raised in question 137 about a briefing paper from the Secretary of the National Association of GP Co-operatives, I promised to look into the issues raised, including concerns around NHS Direct capacity and implementation of the Out of Hours Review.

  Turning to the first concern, around NHS Direct capacity, the questioner said that NAGPC are going to end their partnership with NHS Direct at a national level because none of the exemplar sites are saying the system is working well. I acknowledge that some of the exemplar sites are experiencing difficulty with NHS Direct, and the Core Implementation Team are working with them to resolve these. The lessons learnt from the experience of the exemplars will inform the national rollout in line with the recommendations in the Out of Hours Report. I was pleased to see that at the last Council meeting of the NAGPC on 30 May, the Council unanimously agreed to continue working with NHS Direct in order to make the Government's plans for out of hours care work.

  Your second concern raised was that the targets set out in the out of hours review (OOH) are not achievable. The targets do not have to be fully met until 2004 so there is time to "build up" to meet them. All of the targets are from the OOH Review, recommended by the OOH team and accepted by the Department. Professional bodies, including the NAGPC and GPC were part of the National Advisory Group for the review, and supported the recommendations as achievable.

  Turning to your last point, that single call access for patients is not working and has never been adequately sorted. NHS Direct is the largest call-centre based health advice service in the world and as such is often a pioneer in technological and scale terms. There will always be difficulties to overcome in modernising and implementing new ideas on such a scale, and NHS Direct has a strong record in delivering realistic solutions on time.

  NHS Direct has handled about 12 million calls in total, advising callers to where their issues can be most successfully and appropriately resolved. The National Audit Office found that NHS Direct's interventions with callers saved approximately 45 per cent of its running costs, the service had a very strong safety record and consistently high levels of patient satisfaction were recorded month on month.

  NHS Direct has an ongoing process of feedback from patients—through user days and monthly satisfaction surveys; from stakeholders—through feedback forms, involvement of stakeholders in development of the systems and regular meetings; and internally—through monthly mystery shopper exercises, suggestions being fed through from front-line staff, and application of its performance framework. NHS Direct is developing the call taking and nurse capacity required to support full integration with out of hours providers by December 2004.


  At question 142, the Chairman asked me about the redundancy costs of chief executives in the NHS made redundant as a result of the changes brought about by our Shifting the Balance of Power policy.

  At the time that you tabled your original PQ in March, the redundancy figures were not available, nor had we finalised the arrangements for collecting this information.

  However, I can now provide you with the provisional position. Health Authorities estimate that, at today's prices, they are liable to pay out about 12.5 million in respect of Chief Executives' severance costs. Against this the NHS will gain savings of some 100 million from the abolition of health authorities and regional offices which will be used to fund improved childcare for NHS staff.

  It may be helpful to explain some of the context. The staff changes required to deliver Shifting the Balance of Power are very significant. We estimate that around 20,000 staff have moved employment as part of the changes. Our policy is to avoid redundancy wherever possible. The vast majority of staff affected are moving to other posts in the NHS where their knowledge and expertise will be a valuable asset. However, with a change of this magnitude, it is inevitable that a number of very senior managers will be leaving the service and will be entitled to redundancy packages which reflect their length of service in the NHS. Final figures for the totality of the changes will not be available until after 31 March 2003.

  I believe that this addresses all the points outstanding from the hearing itself, and I attach at Annex A further information to address the questions raised by the Committee in your letter of 17 June 2002. I hope that the Committee finds this useful.

17 July 2002

Annex A


Responses to the follow-up questions raised by the Committee in their letter of 17 June 2002



"If a foundation hospital drops from a three-star to a lower star rating, will foundation status be revoked?"

  We would not expect foundation status to be automatically revoked if a Foundation Trust dropped from three-star to a lower rating. What is important is that the system of regulation, inspection, and performance assessment for Foundation Trusts is responsive to changes in performance and that the right incentives are put in place to facilitate remedial action. There will need to be a series of measures, linked to ongoing performance assessment, that can be applied differentially where there are concerns about a Foundation Trust's performance.


"Could you confirm how many extra general and acute care beds have been opened in the NHS since July 2000?"

  Bed numbers are formally monitored by the Department annually through the collection of the average number of beds available each year. The latest figures show that general and acute bed numbers in NHS Trusts in England increased from an average of 135,080 in 1999-2000 to an average of 135,794 in 2000-01; an increase of 714.

  A snapshot census carried out at the end of December 2001 suggested that the number of available beds has continued to increase in 2001-02. We will publish final figures for 2001-02 from the annual data collection in late summer.


"Could you confirm how many extra consultants, nurses and GPs have joined the NHS since July 2000?"

  Workforce information is collected annually as at 30 September. Between 30 September 2000 and 30 September 2001 the number of consultants increased by 1,380, GPs by 200 and nurses by 14,430.


"How do you propose to rectify the huge shortfall in doctor numbers identified in the Wanless report?"

  The model used to project activity in the Wanless report assumed that demand for staff was projected on current working practice and therefore did not allow for different workforce configurations, wider use of skill mix and changes to professional roles. We are already working in all of these areas. We also have in place a series of measures to increase overall doctor numbers. Delivering the NHS Plan, published in April 2002, includes the latest forecasts for growth in the NHS Workforce. By 2008 we expect the NHS to have net increases over the September 2001 staff census of at least 15,000 consultants and GPs.


"What is your response to concerns raised by the BMA General Practitioners' Committee that current increases in both GPs and GP trainees are `woefully inadequate'? What steps are being taken to rectify this?"

  The NHS Plan set targets for 2,000 extra GPs and for 450 more training places for GP Registrars, subsequently raised to 550, by 2004 over the 1999 baseline.

  While the targets for GPs are challenging they are achievable. The Government is committed to easing the pressure GPs face, expanding the primary care workforce and improving services for patients.

  Between 1991 and 1996 the number of GP Registrars fell by over 20 per cent to a low of 1,300. Between 1996 and 2001 there has been a 44 per cent increase.

  Since 1999 there has been an increase of around 360 (13.5 per cent) GP Registrars to 1,880 and numbers are at their highest for over 20 years. These are the GPs of the future. We are looking to increase the number of GP Registrars entering into practice sooner, and encourage those who may have decreased their commitment or left entirely, back into practice with various recruitment and retention initiatives:

    —  the golden hello payments for newly qualified doctors or GPs coming off the retainer scheme, with additional payments for those who work in underdoctored areas;

    —  encouraging more qualified GPs to return to NHS work through an enhanced Retainers' Scheme.

    —  developing policies designed to improve GPs working lives, eg funding 20 days higher professional education for newly qualified GPs to acquire business and management skills plus 21 million has been allocated for the introduction of an Occupational Health Service for GPs and their staff;

    —  the lifting of the funding bar on recruiting non-EEA doctors to GP Registrar posts. To further increase supply, the Home Office's Highly Skilled Migrant Entry Programme now includes provision to facilitate the recruitment and retention of suitable qualified overseas doctors who wish to work as general practitioners for the NHS;

    —  a pilot international recruitment campaign that has recruited GPs from Spain to work in the North East and is currently being expanded;

    —  the introduction of the Personal Medical Service with new flexible ways of employing doctors and practice staff;

    —  recruiting extra nurses, health visitors and other community staff who will take on more tasks allowing GPs to concentrate on those who really need their expertise.

  The BMA has questioned whether the planned increase for GPs is adequate and has argued that 10,000 extra GPs are required in England if quality of care is to be improved. However, we believe the target in the NHS Plan for more GPs reflects what is reasonable and practicable, taking into account factors such as the time it takes to train a new GP and the increasing size of other parts of the primary care workforce.

  Whilst working towards the NHS Plan targets, the Government has also committed to further expansion in doctor numbers. The manifesto before the last election includes a commitment for 10,000 more doctors by 2005 over the 2000 baseline. Delivering the NHS Plan, published in April 2002, includes the latest forecasts for growth in the NHS Workforce. By 2008 we expect the NHS to have net increases over the September 2001 staff census of at least: 15,000 consultants and GPs.


"We have heard that despite past and proposed increases in medical school, academic medicine is facing serious problems, with a nationwide shortage of clinical academics, and cuts in teaching resources in certain medical schools. What action are you taking to co-ordinate a joined up response to this?"

  During the recent bidding exercise to allocate extra medical school places, universities and medical schools were required to ensure that they would be able to provide both the staff resources and physical facilities necessary to deliver high quality medical education to the extra students they were seeking. All those who submitted bids said that they could recruit the required numbers of extra staff. The need to ensure medical schools have sufficient staff is one reason for phasing the increases in medical intakes over five years. However, as autonomous institutions, medical schools are responsible for their own administration, including the recruitment and retention of staff. Financial allocations to departments and other organisational issues are matters for universities to determine in the light of their own operational needs and circumstances.

  The Department of Health and the Higher Education Funding Council for England (HEFCE) have established a monitoring group to oversee the implementation to the medical school expansion. Part of their remit will be to monitor recruitment of posts needed to facilitate the expansion of medical students and to identify other issues relating to the expansion that action may need to be taken on.

  However, it is important to recognise that the number of clinical academics required should not simply be based on extrapolating from current models of teaching. Innovative career models, including inter-professional approaches, offer the prospect of increases in capacity and opportunities. We will be working with key partners to consider and explore new ways of delivering (medical) education including the resourcing of clinical learning and teaching.

  The Government is committed to establishing effective Health and Education Sector Partnerships between the NHS and the higher education sector to deliver workforce targets, and to ensure that the strategies of academic institutions harmonise with, and support, local health service priorities and plans.

  We are aware of recent concerns raised by certain medical schools about the impact of the HEFCE's Research Assessment Exercise (RAE) (ie some of the schools are saying that they are being under funded under the RAE to the extent that medical school staff are being cut).

  Responsibility for distributing funding for research according to the quality ratings arrived at through the RAE lies with HEFCE. Research funding of individual institutions with medical schools is allocated in relation to the assessed quality of their research and the volume of activity. There can be both gainers and losers under this system. There can be similar relative gains and losses within an institution, between disciplines. However, although this is how the funding is calculated by HEFCE, it is up to each institution to decide how it allocates its money internally.

  HEFCE have recently announced a review of RAE and we look forward to contributing to and working with them on this.


"How do the 2 per cent increases in NHS productivity projected in Delivering the NHS Plan relate to the 5 to 6 per cent activity increases the Wanless Report specifies as necessary to deliver waiting time targets?"

  There is no inconsistency between these figures . The Wanless Report correctly identifies the need for an increase in the rate of activity growth to c. 6 per cent. We have taken a prudent view as to how this activity growth should be generated, ie from a combination of growth in capacity (for example, accelerating the development of Diagnostic and Treatment Centres, enhanced day surgery capacity) and improved productivity and the more effective use of hospital beds (for example, by increasing day surgery rates—which will also free-up beds, reducing delayed transfers of care and avoidable emergency admissions, process redesign).


"In light of recent claims that activity has actually fallen in recent years despite increased funding, how will necessary activity improvements be secured?"

  We have asked Health Authorities to draw up capacity plans which will analyse trends in demand, assess the physical and human capacity needed to meet predicted demand, identify any potential shortfall in provision, and develop robust proposals to secure any necessary additional capacity. This could be through the development of Diagnostic and Treatment Centres, enhanced day surgery provision, expanded and more integrated intermediate care, concordat working with the independent sector, the use of overseas clinical teams, etc. Once capacity plans have been agreed, Health Authorities will be held to account for their delivery. Substantial investment in new capacity—targeted particularly at areas and specialties with long waits and service constraints—will be complemented by new incentive systems (particularly through the proposed new financial regime and the new consultant's contact) which will reward productivity and the delivery of waiting time targets. The Modernisation Agency will also provide effective development support to help Trusts and PCTs modernise services and adopt good practice, for example through aiding process redesign in orthopaedics or increasing day surgery rates.


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