APPENDIX
Supplementary evidence by David Lammy
MP, Parliamentary Under-Secretary of State, Department of Health
Following my appearance on 15 May I promised
to provide further information to the Committee on number of areas.
These are set out below.
HEALTH SCRUTINY
IN ESSEX
The first point to make is that on return from
the HSC I made enquiries into the position of health scrutiny
in Essex. I have to say that it was extremely gratifying to learn
that so much good work has already been done, and is planned for
the future. I understand from my officials that the scrutiny team
in Essex has put in place a dynamic and inclusive set of arrangements
that make the best use of the input from all councils across the
county, and that enables real issues to be tackled at the most
relevant local level. I know that when the policy was being developed
last year Essex was often cited as a county that would have difficulty
in bringing together the various perspectives—because of
its size and number of authorities. I can say from my enquiries
that this is certainly not proving to be the case.
Furthermore, I have learned that the NHS bodies
in Essex are also developing excellent working relationships with
the scrutiny panels and committees. I understand that a scrutiny
network has been established between committee officers, NHS officers
and CHC staff and members—ensuring a planned and informed
scrutiny programme is implemented. In particular the group, brought
together by the NHS Chief Executives Forum, is focusing on two
protocols—the health scrutiny process and handling consultations
on substantial variations.
One other piece of feedback I have just heard.
At a national conference held today at which health scrutiny was
being reviewed and discussed Essex again came up as an example
off good practice—both in terms of partnership working between
health services and overview and scrutiny committees, and the
constructive approach taken in recent reviews on cross-cutting
themes affecting the population right across the country.
I am aware that additional funding would be
helpful to supplement the resources that local government is already
making available to support health scrutiny. We are still hoping
to secure funding to provide support to local authorities. However,
I would like to reiterate that funding health scrutiny is part
of wider considerations for the Department and is being weighed
up along with other financial pressures.
I think it is important to point out that resourcing
this area of work is more complex than simply making central resources
available. As is the case in Essex many local authorities around
the country are funding specific scrutiny exercises, believing
that it is best use of their resources to prioritise in favour
of health improvement. The NHS is also contributing. We are continuing
to develop materials to support scrutiny with guidance, with reference
material and through general explanatory information. I am confident
that all of the various contributory factors will add up to a
comprehensive set of support.
YELLOW CARD
SCHEME
Effective pharmacovigilance is dependent on
the availability of information on the safety of drugs in normal
clinical practice. Data from the UK sponaneous reporting scheme,
the Yellow Card Scheme, underpins the process of pharmacovigilance
in the UK. The Yellow Card Scheme was introduced in 1964 after
the thalidomide tragedy highlighted the urgent need for routine
surveillance of the safety of marketed medicines, and is one of
many spontaneous reporting schemes currently used to monitor drug
safety around the world.
Spontaneous reporting of suspected adverse drug
reactions (ADR) is particularly important in signalling as rapidly
as possible the emergence of new hazards (the generation of hypotheses).
Underreporting of ADRs is an inherent feature of spontaneous reporting
schemes. The level of underreporting is unknown and varies between
drugs and for the same drug over time. Although this means that
data from the scheme have limited usefulness in terms of quantifying
the frequency of an ADR, it does not detract from the ability
of the scheme to identify new drug safety hazards. Once a hypothesis
has been granted, other methods are used to confirm and quantify
the risk. The Yellow Card Scheme is recognised to be one of the
best in the world in terms of the level of reporting and has a
proven track record of identifying the new drug safety hazards.
Reporters of suspected ADRs are doctors, dentists,
coroners, pharmacists and nurses. Reports are received directly
from them and via pharmaceutical companies. The scheme is voluntary
for health professionals whereas pharmaceutical companies are
legally obliged to report serious ADRs to the MCA within 15 days
of notification. Since 1964 more than 450,000 reports of suspected
ADRs have been received from the UK.
In order to facilitate reporting through the
Yellow Card Scheme in October last year the Medicines and Healthcare
products Regulatory Agency (MHRA) launched the electronic Yellow
Card, allowing health professionals to report online through the
MCA's website. At that time it also widened the scheme to include
all nurses as reporters. To strengthen the scheme still further,
in April 2003 the MHRA launched a pilot scheme with NHS Direct
to enable patients to report through the NHS Direct phone lines.
This started in one NHS Direct Centre and following evaluation
of the first phase will be rolled out nation wide in the Autumn.
The number of reports received through the Yellow
Card Scheme in the past five years is shown below. A projected
figure has been calculated for 2003 based on reports received
from January to April. The peak of reporting in 2000 is due in
part of the Meningitis C vaccination campaign. In addition to
those shown below, 5,679 reports were received from nurses in
that year (who were not formally included as reporters at the
time) as part of a special scheme to monitor the safety of the
Meningitis C vaccine.
The MHRA/CSM closely monitor Yellow Card reporting
levels and, while there has been a decline in general practitioner
reporting, the level of reporting by pharmacists has increased
recently. The proportion of serious reports has also increased.
The MHRA/CSM are considering options to strengthen doctors' ADR
reporting including inclusion in medical school curricula and
post-graduate education.
PATIENT SAFETY
The NPSA was established as a special health
authority in July 2001 to manage a new, anonymous national reporting
and learning system for patient safety incidents.
A pilot took place between September 2001 and
June 2002. Initial results were published shortly after the pilot
was completed, but there were significant problems with the data
quality. The NPSA was asked to carry out a full audit of the pilot
data and a report was published on 8 May 2003 (available on the
Agency's website at www.npsa.nhs.uk). The pilot did successfully
demonstrate that the NHS has the capability to send data electronically
to the NPSA and that staff are willing to report a wide variety
of incidents, including near misses, and not only the very few
incidents which have a very serious outcome. The pilot data audit
collected nearly 29,000 electronic reports from 18 Trusts covering
the period September 2001 to June 2002. This exercise has helped
to clarify the data needed by the NPSA and this has been reflected
in the development of the national reporting system. The reports
collected so far have also helped to inform the NPSA's programme
of work to address a number of patient safety issues.
The NPSA has recently completed a testing and
development phase involving just under 40 NHS sites across the
acute, mental health and primary care sectors, using an electronic
reporting form (eform). The results will be evaluated before the
reporting system is rolled out across the NHS from later in 2003.
The main objective of the reporting system is
not to collect data for its own sake, nor is it about investigating
individual cases. Rather, it will be used to identify trends and
patterns of patient safety incidents at a national level and to
understand the root causes behind them. Where risks are identified,
the NPSA will seek to identify solutions to prevent harm, specifying
national goals and establishing mechanisms to track progress.
For example, the pilot identified a cluster of incidents involving
overdose of intravenous potassium chloride, which resulted in
the NPSA issuing its first patient safety alert in July 2002.
The NPSA is working on 26 projects to identify
solutions to known patient safety problems. For example, work
is underway to address errors associated with infusion devices,
which are commonly used to deliver fluids and drugs via a drip
into the veins of patients receiving rehydration therapy or chemotherapy
treatment. In its first full year of operation (2002-03), the
NPSA worked to establish the root causes of problems surrounding
infusion device use and to identify possible solutions. The Agency
is now working with manufacturers, the NHS Purchasing and Supply
Agency and six NHS Trusts to test practical solutions to improve
the way the devices are purchased, used, stored and maintained.
More information on this work is available in the NPSA's business
plan for 2003-04 (available at www.npsa.nhs.uk).
The NPSA's long term goal is a reduction in
the number of errors and adverse events in order to make the NHS
even safer for patients. Paradoxically, an increase in reporting
of adverse events will be a sign that it has been successful in
encouraging an open and fair culture, where staff feel comfortable
about reporting when things go wrong and can learn from their
mistakes in order to prevent errors recurring.
Experience from other sectors, such as the aviation
industry, shows that as reporting arises, the number of serious
events begins to decline. We will know if the NPSA is succeeding
as the number of events being reported increases and the number
of incidents resulting in serious harm or death increases.
NHS DIRECT
As part of a programme to expand the range of
services offered by NHS Direct, work has begun to develop and
run an NHS Direct information service across all digital TV platforms
in England. This service will complement the extisting NHS Direct
services accessed via the telephone, the internet and at electronic
information points. Television is one of the most pervasive, familiar
and accepted communication devices and its use offers the potential
to reach a wide and inclusive audience, including those who may
not have access to the internet or who choose not to go online.
The development of the service by the Department follows a series
of successful pilot projects conducted during 2001-02, which explored
possible health applications of digital interactive television.
The report of the independent evalulation of the pilot projects
is available at http://www.soi.city.ac.uk/organisation/is/research/dhrg/reports/ditv-final-full.pdf.
The NHS Direct digital TV service, which will
be launched in 2004, will provide information on health conditions
and treatments, healthy living, medicines, health advice for travellers,
health and safety advice and details of local NHS services, including
performance information.
INDEPENDENT RECONFIGURATION
PANEL
The Panel has received its first case. The consultation
on modernising hospital services in East Kent was referred to
the Panel on 11 April.
The terms of referral are as follows:
— whether the proposals for change
set out in the decision of 25 March 2002 will ensure the provision
of safe, effective health services for the people of East Kent
in the speediest and most efficient manner; and
— if not, how the panel considers this
could be best ensured.
The panel is expected to report to the Secretary
of State by 12 June.
MATRON AND
FOUNDATION TRUSTS
Foundation Trusts would have freedom to put
in place the staffing and management structures that ensure the
necessary mix of skills to provide the best standard of care to
patients. Since modern matron posts had been a successful innovation,
we would expect Foundation Trusts to take this into account when
making a decision on skill mix.
ACCIDENT AND
EMERGENCY (A&E)
Modern matrons are helping to bring about significant
improvements in those wards for which they are accountable. We
believe they can also make a considerable contribution to improvements
to the patient experience in A&E departments. We recently
announced that we are making £10,000 available to every A&E
matron to help improve patient care in A&E departments.
ORTHODONTIC SERVICES
Significant resources are currently spent on
orthodontic treatment and we consider it important that these
should be targeted on the greatest need. There is also evidence
that in some cases the treatment outcome shows little or no improvement.
Our aim is to ensure that dentists can identify the appropriate
cases for treatment and use the most clinically effective and
cost effective approach for orthodontic treatment.
This will help concentrate NHS resources more
on the cases of greatest clinical need. Our aim is better targeted
resources and shortened waiting times not savings.
THE OPTIONS
FOR CHANGE
The proposals in the Health & Social Care
(Community Health & Standards) Bill mark the most significant
change for NHS dental services since they were introduced.
Initially, this will involve using the £1.8
billion (gross) currently invested in the general dental service
differently. The aim is to create an integrated primary dental
service; in addition to GDS spend within an area PCTs have resources
invested in community dental services; personal dental services
and hospital dental services. We believe that by giving PCTs a
commissioning responsibility they will be able, over time, to
gain better value for all this investment and improve the oral
health of their populations where this is a matter of concern.
While the focus of the field sites is to look
at new ways of doing things and not simply increasing volumes
of work, changes in the way dentists are paid is likely to lead
to a change in prescribing patterns. Using the learning from existing
PDS and from the field sites we hope to learn more about these
changes and enable PCTs to measure the impact they will have on
oral health and access.
The currently centrally held GDS budget will
be allocated to PCTs on the basis of existing general dental services
spend within their areas. Whereas under the current system when
GDPs withdraw from the NHS for whatever reason the money they
have been using to treat local people also goes back into the
central pot. In future this money would revert to PCTs which will
then be able to make alternative arrangements.
Field sites which are looking at different ways
of paying dentists and their teams will receive their existing
spend from the GDS budget; until legislation enables full local
commissioning, PCTs will agree contracts with the practitioners
under existing PDS legislation and most of the participating practices
are likely to be paid in 12 monthly instalments.
We recognise that there is a lot of work involved
in setting up and running a field site and in ensuring that all
the learning is captured for the benefit of others and for the
full system roll out. The Modernisation Agency has provided each
field site with some funding to support its preliminary work and
the Department has made available additional resources, particularly
to support the bigger sites which require project management to
ensure that rapid progress is made.
DENTAL THERAPISTS
There are seven classes of dental auxiliary,
or professionals complementary to dentistry, as they are now known:
dental therapist, dental hygienist, dental technician, maxillo-facial
technician, clinical dental technician, orthodontic therapist
and dental nurse. Only dental therapists and dental hygienists
are currently registered with General Dental Council, but an Order
is in preparation to empower the GDC to register the remaining
groups during a transitional period commencing in 2004.
Registration will provide a major impetus to
team working in dentistry, which will enable dentists to delegate
routine functions. To this end, regulations have already been
amended to extend the range of duties which dental hygienists
and dental therapists may carry out under the direction of a dentist
to including the administration of local anaesthesia. Restrictions
on the areas of dentistry in which dental therapists may work
have also been removed. They may now work in general dental practices
as well as community dental services clinics and hospitals.
12 June 2003
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