House of Commons - Health

Select Committee on Health Memoranda

6. Questions on the Departmental annual report

6.1.1 In respect of SR2002, target 1, why are figures provided for the number of patients waiting more than four months when the target is to reduce the maximum wait for an out-patient appointment to three months? Figures on the Treasury web-site indicate that in March 2004, 43,800 people had been waiting more than three months (13 weeks) for an out-patient appointment. Are these figures correct?

6.1.2 In respect of SR2002, target 1, was the (interim) NHS Implementation Plan target of reducing the maximum in-patient waiting time to nine months by the end of March 2004 actually met?

6.1.3 Given that it is now more than a year into the timeframe of SR2002 targets, has the Department finally established a target date and baseline for the one hour A&E waiting time target (SR2002 target 2)?

6.1.4 Was the interim March 2004 milestone in respect of bookings of outpatients' appointments met (SR2002, target 4)?

6.1.5 When will the 2004 patient survey results be available (SR2002, target 5)?

6.1.6 The 2003 survey of emergency department patients in acute trusts showed that 8% of patients thought the emergency ward was "not very clean" or "not at all clean" (twice that number in London hospitals) whilst 15% felt the toilets were "not very clean" or "not at all clean". Are these figures the baseline in this area? What are the target figures for the "cleanliness and comfort theme" of SR2002, target 5?

6.1.7 What are the reasons for the slower than expected rate of progress in establishing Crisis Resolution Teams (SR2002, target 7)? When does the Department expect that the 2004 target of 335 teams will be achieved?

6.1.8 Could the Department provide actual figures for the number of people aged 65+ who have been supported intensively to remain at home (SR2002, target 8)? What is the reason for reporting performance on this measure only in terms of the proportion of elderly people supported to live in residential care?

6.1.9 Overall, there does not appear to be any increase in the number of people aged 65 and over who receive help to live at home ((Figure 7.9). Is it the Department's intention to boost the provision of help for the elderly to live at home more generally?

6.1.10 The number of elderly people supported in residential care or nursing homes has only increased very marginally in recent years (Figure 7.9), and reports indicate that up to 75,000 care home places have been lost over the past seven years.[4] Is the Department planning to prioritise this area, and set targets to increase the support for elderly people in residential care as part of SR2004?

6.1.11 Could the Department supply annual data on the national teenage pregnancy rate (pregnancies per 1,000 females aged 15-17) from 1998 to date (SR2002 target 9)? Was the original (SR2000 target 2) 2004 milestone of a 15% reduction by 2004 met?

6.1.12 Has the interim target of a 55% increase in the number of problem drug users participating in treatment programmes by the end of 2003-04 been achieved (SR2002 target 10)?

6.1.13 What are the primary policy instruments being used to reduce the class-based differentiation in infant mortality and life-expectancy required by SR2002 target 11?

6.1.14 When evaluating progress on the value-for-money target across the NHS and Personal Social Services (SR2002 target 12), how do you adjust the unit cost for "quality"?

6.1.15 Why were the efficiency targets for social services not met in 2001-02 and 2002-03 and what is the Department doing to ensure they are met in future? Page 106 of the Annual Report says that efficiency measures for 2003-04 to 2005-06 will be in two parts both with targets of one% annual improvement. The targets for 2001-02 and 2002-03 were 3% and 2.5% respectively, why have the efficiency targets been reduced for later years?

6.1.16 Could the Department supply monthly data on the proportion of out-patients' appointments and in-patients' elective admissions respectively that have been pre-booked since January 2003? (SR2000, target 3)

6.1.17 Is it the Department's intention that all hospitals should eventually have ward-housekeepers? If yes, what is the target date? If no, why not (SR2000, target 5)?

6.1.18 If the current rate of annual progress were maintained, at what point in time will at least 95% of hospitals offer patients "good quality" food (SR2000, target 5)?

6.1.19 The Department has indicated that the rate of emergency re-admissions for patients of all ages declined very slightly in 2003 ((SR2000, target 6). Was this decline statistically significant? Could the Department provide data for the first quarter of 2004? Could the Department provide quarterly data for the numbers and proportions of emergency re-admissions among patients aged over 75?

6.1.20 Does the Department expect to reduce the "coefficient of variation", measuring "the dispersion of costs between NHS trusts' to zero (SR2000, target 10)? What is the target timeframe for this?

6.1.21 The measures used to determine progress on each of the (CSR98) PSA targets 1, 2, and 5 have been adjusted as a result of data from the 2001 Census. In all three cases, this has apparently led to the figures changing in an undesirable direction. Please provide a full time-series of the revised data on all three targets.

6.1.22 Is the Department on course to meet the 2005 milestones for the Our Healthier Nation targets included in SR2002 targets 6 and 7?

6.1.23 Progress on (CSR98) PSA target 3 (reduction in the rate of deaths from accidents) has slipped so that the most recent figure stands at a higher level than the 1995-97 baseline figure. Could the Department provide a breakdown of fatalities across different types of accidents, and an outline of the measures taken to bring you back on course for achieving this target?

6.1.24 The Department claims to have "nearly met" (CSR98) PSA target 7, waiting time to see cancer specialists, on the basis of July—September 2003 figures. In last year's report, you quoted March 2002 figures. Could the Department provide monthly data for this measure covering the past two years so that in order to gauge the trend as well as seasonal variations?

6.1.25 The Departmental report states that the Department "narrowly missed" meeting (CSR98) PSA target 21 concerning the emergency psychiatric re-admission rate. However, you did in fact miss it by 20%. Would the Department normally consider missing a target by 20% a narrow miss? Is the improvement of 1.6 percentage points statistically significant?

6.1.26 Also with regard to (CSR98) PSA target 21, the Department states that the introduction of new service models are expected to result in a decline in emergency psychiatric re-admission rates after 2002-03. Could the Department provide us with data to show whether this expectation has been fulfilled?

6.1.27 Why has there been no progress on achieving (CSR98) PSA target 32 on reducing sickness absence among NHS staff? And what steps is the Department taking to achieve this target?

6.1.28 Following the NAO and Public Accounts Committee report in 2003, has the Department now developed a complete method of investigating the extent and causes of long-term discharge delays for elderly patients? Does your strategy for dealing with this problem extend beyond the Delayed Discharges Grant (Annex D, para.6)?

6.1.29 How many foreign nurses have been recruited directly by the NHS in each year since 1997? How many foreign nurses have transferred from the UK private sector into NHS posts in each year since 1997? How many have been recruited from Commonwealth countries? What proportion of all nursing staff recruited since 1997 has come from Commonwealth and third world countries respectively?

6.1.30 What is the overall cost of the development and implementation of the Departmental change programme?

6.1.31 Have external management consultants been employed in the process to restructure the Department? If so, how much has been spent on such consultancy services?

6.1.32 Will staff be made redundant as part of the Change Programme in the Department? If so, what are the total costs of redundancies?

6.1.33 The Departmental report states that the Department will be reduced in size by 38% as a result of the Change Programme (para. 1.33), and that this programme will be complete by the end of 2004 (para 8.4). However, it goes on to state that these changes have not yet been fully incorporated into departmental budgets. Has the Department now got revised forecasts available for the net departmental administration costs and paybill costs for 2004-05 and 2005-06?

6.1.34 The Departmental report states that the Department will employ a lighter touch on performance management in future (para. 1.35), and that, following the Change Programme, the 28 Strategic Health Authorities will operate as local headquarters of the NHS. Does that mean that RHAs will take on a greater role in performance management? What will be the procedures with regard to "arm's length" organisations perceived as failing?

6.1.35 Could the Department supply annual data on the amount of money paid out in compensation and legal fees respectively (through the NHS Litigation Authority and otherwise) in cases of medical negligence over the past five years?

6.1.36 What is the total annual administration costs (rather than just wage costs, as quoted in Annex C) of the National Treatment Agency?

6.1.37 Could the Department explain why the aggregate deficit of NHS Trusts increased by £54 million between 2001-02 and 2003-04?

6.1.38 Could the Department provide a list of the 50 NHS Trusts with a deficit in 2003-04 and the 22 PCTs that overspent in 2002-03, in both cases detailing the amount of deficit/overspending involved?

6.1.39 The 2002-03 Resource Accounts show provisions for clinical negligence increasing again to £5.9 billion. What are you doing to reduce claims for clinical negligence and is there any evidence that these measures are having any impact on such claims?

1. The maximum waiting time for a first outpatient appointment was 17 weeks (4 months) in March 2004, and therefore the data reflect this standard. Progress against the 13 week (3 months) target by December 2005 will be monitored up to this date. The figures on the Treasury website are correct, and reflect provider based figures at the end of March 2004.

6.1.2 In respect of SR2002, target 1, was the (interim) NHS Implementation Plan target of reducing the maximum in-patient waiting time to nine months by the end of March 2004 actually met?

1. At the end of March 2004 there were 56 patients for whom English commissioners were responsible waiting over 9 months for an inpatient admission. Therefore, the March 2004 maximum inpatient waiting standard was delivered to all but a handful of patients.

2. The vast majority of Trusts have eliminated waiting times of over nine months and are now concentrating on eliminating over six month waiters to deliver the December 2005 target.

1. We have been reviewing the proposal for a one-hour target for A&E made in the Department's Priorities and Planning Framework 2003-06. A&E departments with more complex case mix will have a higher than average number of patients who need over one hour's care before they are clinically ready to be discharged. There are therefore concerns about the clinical appropriateness of setting a blanket national standard.

2. We remain committed to supporting the NHS in reducing the proportion of patients waiting more than one hour. We are therefore minded to develop a system that will enable the NHS to benchmark the proportion of patients seen in one hour or less, rather than setting a blanket national standard. We intend to seek further views from stakeholder organisations before reaching a final decision on the way forward.

6.1.4 Was the interim March 2004 milestone in respect of bookings of outpatients' appointments met (SR2002, target 4)?

1. Yes. At the end of March 2004, 76.6% of outpatient appointments were booked, exceeding the milestone of two thirds (66.6%).

6.1.5 When will the 2004 patient survey results be available (SR2002, target 5)?

1. In 2002, Public Service Agreement (PSA) targets between the Department of Health (DH) and HM Treasury (HMT) included a commitment to improving the patient experience (Target 5):

"Enhance accountability to patients and the public, and secure sustained national improvements in patient experience as measured by independently validated surveys"

2. Progress against this PSA target is, therefore, measured via the national patient survey programme. The Technical Notes for this target further outlines that progress will be measured in terms recording improvements across five distinct patient experience domains or dimensions, themes which extensive research has demonstrated are of importance to patients and the public:

— Access and waiting;

— Safe, high quality coordinated care;

— Better information, more choice;

— Building closer relationships; and

— A clean, friendly and comfortable place to be.

Publication of national patient survey results

3. Patient surveys are conducted by each NHS Trust under the administration of the Healthcare Commission (CHAI). Results from the 2003-04 national patient survey programme were published by CHAI on their website on 4 August 2004. In this wave of the survey programme, five separate surveys were conducted—of which, two were repeat surveys, and three were baseline surveys:

Repeat surveys

— Adult inpatients—previously conducted in 2001-02

— Primary care residents—previously conducted in 2002-03

Baseline surveys

— Young inpatients

— Mental health service users

— Ambulance service users

4. For each survey, CHAI publish a number of documents, detailing survey results:

A Summary report

An overview of the 2003-04 survey programme, survey technical details and key findings (at a nationally aggregated level) of all five surveys;

A series of detailed reports

Presenting an outline of national results for each survey

A series of local benchmark reports

Comparing the performance of each trust against other trusts on each survey question (ie highest 20%, lowest 20% and all other trusts)

A complete database of survey results

Containing, for each question, the results of all trusts, "trust clusters" (ie similar trusts) and the nationally aggregated average

5. In this wave of the national patient survey programme, over 300,000 patients were asked about their experiences in 568 English NHS trusts. A consistent positive theme across the NHS is the patients' high opinion of the care they receive. They say they have trust and confidence in the clinical staff, they are listened to and they are treated with respect and dignity. Other highlights from the surveys include:Adult inpatients

An improvement in admission time from accident and emergency (A&E) department to a ward (only 26% waiting more than four hours down from 34% in 2002). But fewer people rated the toilets and bathrooms in hospitals as "very clean" (48% down from 51%).

Young inpatients

Communication with staff was rated highly but there is still scope to improve the explanations given about procedures and the risks, benefits and expected outcomes of treatments.

PCTs

Many more patients obtaining GP appointments within two working days (54% up from 31% in 2003) but one in five smokers who want help in giving up aren"t receiving it

Ambulances

A very positive overall picture but one in five wanted more pain relief.

Mental Health Services

The majority of patients were positive about their care from clinical staff but they need to be more involved with decision making.

6.1.6 The 2003 survey of emergency department patients in acute trusts showed that 8% of patients thought the emergency ward was "not very clean" or "not at all clean" (twice that number in London hospitals) whilst 15% felt the toilets were "not very clean" or "not at all clean". Are these figures the baseline in this area? What are the target figures for the cleanliness and comfort theme" of SR2002, target 5?

Cleanliness of the A&E Department—Baseline results

1. Nationally aggregated results from the 2003-04 A&E patient survey establishes the baseline. The Healthcare Commission administered the survey and 155 trusts with a main emergency department took part. Fifty nine thousand patients responded.

2. Results suggest that the overwhelming majority of patients are positive about the cleanliness of the hospital environment—with four in five or more rating the cleanliness of the Department and bathrooms/toilets as "fairly" or "very clean" (91% and 84% respectively). The margin of error at national level is around +/- 1 percentage point.

3. We note that the cleanliness results for London shows a variation from the national picture. This is consistent with evidence from other patient surveys, with those trusts that serve ethnically diverse, deprived and younger populations scoring less well.

Target figures for the cleanliness and comfort theme SR 2002 target 5

4. Patients tell us that they want their healthcare environment to be "clean, comfortable and friendly". This is just one of five dimensions that patients rate as important for a good experience. The Healthcare Commission applies a "score" to each question response (out of a maximum of 100), and the scores for a set of core questions are aggregated to form a Patient Experience Index score for each of the five dimensions:

— Access and waiting

— Safe, high quality, co-ordinated care

— Better information, more choice

— Building better relationships

— Clean, friendly, comfortable environment

Patient experience index scores—PSA 5 baselines

5. Employing the PSA methodology outlined above, baseline index scores have been established for all surveys conducted so far. Index scores for this set of surveys are presented in Table 6.1.6. Work is currently underway to calculate scores for surveys conducted in 2003-04.

6. By repeating this approach for all surveys conducted within the programme, it is then possible to measure the extent to which national improvements in the patient experience have taken place.

7. Since different questions are used to calculate index scores for each survey, reliable comparisons across NHS settings cannot be made—ie comparing A&E "clean, comfortable and friendly place to be" index scores with outpatient index scores for the same dimension. The real purpose of this approach is to compare index scores for each dimension in a specific survey against results for each dimension when the survey is repeated.

Table 6.1.6

BASELINE INDEX SCORES


3A—ADULT INPATIENTS	DIMENSION	BASELINE INDEX SCORES 2001-02

2003-04
Access and waiting	80	Scores under construction
Safe, high quality, coordinated care	64
Better information, more choice	68
Building better relationships	82
Clean, friendly, comfortable place to be	78

3B—PCT SURVEY	DIMENSION	BASELINE INDEX SCORES 2002-03

2003-04
Access and waiting	71	Scores under construction
Safe, high quality, coordinated care	81
Better information, more choice	82
Building better relationships	87
Clean, friendly, comfortable place to be	81

3C—A&E SURVEY	DIMENSION	BASELINE INDEX SCORES 2002-03

2004-05
Access and waiting	64	Survey being developed
Safe, high quality, coordinated care	80
Better information, more choice	78
Building better relationships	80
Clean, friendly, comfortable place to be	83

3D—OUTPATIENT SURVEY—2002-03	DIMENSION	BASELINE INDEX SCORES 2002-03

2004-05
Access and waiting	70	Survey being developed
Safe, high quality, coordinated care	85
Better information, more choice	81
Building better relationships	87
Clean, friendly, comfortable place to be	78

Core PSA Questions

OUTPATIENT SURVEY

(Question numbers relate to the 2002-03 survey)

ACCESS AND WAITING

B1. How long after the stated appointment time did the appointment start?

A1. Overall, from the time you were first told you needed an appointment to the time you went to the Outpatients Department, how long did you wait for an appointment?

SAFE, HIGH QUALITY, CO-ORDINATED CARE

F5. Sometimes in a hospital or clinic, a member of staff will say one thing and another will say something quite different. Did this happen to you?

H5. Did a member of staff tell you about what danger signals regarding your illness or treatment to watch for after you went home?

D8. Did you have confidence and trust in the doctor examining and treating you?

E4. Did you have confidence and trust in him/her? (Nurse/physiotherapist/dietician/ pharmacist/radiographer/someone else)

QD9. Did the doctor seem aware of your medical history?

BETTER INFORMATION, MORE CHOICE

F6. Were you involved as much as you wanted to be in decisions about your care and treatment?

H3. Did a member of staff explain the purpose of the medications you were to take at home in a way you could understand?

H4. Did a member of staff tell you about medication side effects to watch for?

F4. While you were in the Outpatients Department, how much information about your condition or treatment was given to you?

QG7 Before any treatment, did a member of staff explain any risks and/or benefits in a way you could understand?

BUILDING BETTER RELATIONSHIPS

D7. If you had important questions to ask the doctor, did you get answers that you could understand?

E3. If you had important questions to ask him/her, did you get answers that you could understand? (Nurse/physiotherapist/dietician/pharmacist/radiographer/someone else)

F3. Did doctors and/or other staff talk in front of you as if you weren't there?

D2. Did you have enough time to discuss your health or medical problem with the doctor?

QD5. Did the doctor listen to what you had to say?

CLEAN, COMFORTABLE, FRIENDLY PLACE TO BE

C1. In your opinion, how clean was the Outpatients Department?

B2. Were you told how long you would have to wait for the appointment to start?

QJ2. Overall, did you feel you were treated with respect and dignity while you were in the outpatient department?

1. The target date for local services to deliver the full the complement of 335 teams remains December 2004. In addition, a target has been set for December 2005 for those teams to deliver services to the number of people (100,000 per annum) estimated to need them. Although it has taken longer to establish as many crisis resolution teams as, say, assertive outreach teams (where the target date was, in any case, earlier), no trajectories or other expectations concerning the pace of progress towards the crisis resolution team targets have been set by the Department of Health.

2. The Department has acknowledged that local variations in population need and variation in the pattern of provision are important to recognise in translating national policy into effective local services. Therefore, guidance on Fidelity & Flexibility was issued which has formed the basis for discussions with Strategic Health Authorities on drawing up local delivery plans. Strategic Health Authorities have subsequently given a commitment to full delivery of all targets by the dates set and their local delivery plans have been approved. The Department expects that the targets will be met by the dates that have been set.

1. The latest available figures are shown in Table 6.1.8.

Table 6.1.8

NUMBER OF HOUSEHOLDS RECEIVING INTENSIVE HOME CARE, 1998-2003


	Number of households receiving intensive home care(1,2)

1998	60,700(3)
1999	68,700(3)
2000	72,300
2001	77,400
2002	81,400
2003	87,000(4)

Notes: England, survey week during September. Numbers rounded. Source: DH annual returns HH1 and KS1.

1. Intensive home care is defined as more than 10 contact hours and six or more visits during the week.

2. Households receiving home care purchased with a direct payment are excluded.

3. Excludes households receiving home care from more than one sector which in total is an intensive package.

4. Provisional data from HH1. The DH annual return on home care services (HH1) only collects information on the number of households receiving intensive home care, not the number of clients. Information is not available on the age of the person in the household. Information on home care broken down by age group of the eldest client within the household was last collected in September 1998. At that time about 85% of households receiving home care related to clients aged 65 and over, however this information was not available only those households receiving intensive home care.

2. The reason for reporting performance on this measure only in terms of the proportion of elderly people supported to live in residential care is that the general policy intention is to support people to live in their own home where this is the most appropriate setting for their care needs. The measure therefore takes the proportion of those supported intensively to live independently at home and compares this to the number supported intensively at home or in residential care.

1. Older people themselves have stated in evidence to the Royal Commission on Long Term Care and elsewhere that they generally prefer to live in their own home rather than move to residential care, and this is reflected in our general policy development. Obviously our main concern is to deliver the best outcome for clients, and providing enhanced support for them to live at home is an efficient use of limited funding where this is the most appropriate outcome to meet the individual needs. This is reflected in our Public Service Agreement targets, and we are monitoring progress against this to ensure that we meet these obligations.

6.1.10 The number of elderly people supported in residential care or nursing homes has only increased very marginally in recent years (Figure 7.9), and reports indicate that up to 75,000 care home places have been lost over the past seven years.[5] Is the Department planning to prioritise this area, and set targets to increase the support for elderly people in residential care as part of SR2004?

1. The Department seeks to provide the most appropriate care for individual clients with due regard for their wishes and value for money. Given the general policy direction to help people to live in their own home, it would have been inappropriate to have set such targets as part of SR2004.

TARGET

By 2010, to reduce by 50% the under 18 conception rate for England from the 1998 baseline, with an interim target of a 15% reduction by 2004.

1. The provisional under 18 conception rate for England in 2002 was 42.6 per 1,000 females aged 15-17. This represents an overall decline of 9.4% from the 1998 baseline rate of 47.0 per 1,000 females aged 15-17. ONS will be releasing revised 2002 conception data in November 2004.

2. Under 18 conception data for England for each year from 1998-2002 is shown in the following table.

Under 18 Conceptions for England


Year	Total Conceptions	Conception Rate*	% change in rate from 1998

1998	41,089	47.0	—
1999	39,247	45.3	-3.6
2000	38,699	43.9	-6.6
2001	38,439	42.3	-10.0
2002**	39, 286	42.6	-9.4

*per thousand females aged 15-17
**provisional estimate. Revised data will be available in November 2004

3. It is not possible to report on the 2004 milestone of a 15% reduction until February 2006 when provisional conception data for 2004 will be released[6].

6.1.12 Has the interim target of a 55% increase in the number of problem drug users participating in treatment programmes by the end of 2003-04 been achieved (SR2002 target 10)?

1. Figures produced by Manchester University and published by the National Treatment Agency (NTA) on 30 September reveal that 54% more drug misusers were in contact with drug treatment services in 2003-04 by comparison to the baseline year of 1998-99.

2. Whilst this falls very slightly short of the target of 55%, it is excellent news. It shows that the extra money that has been invested in treatment over the last three years has already made a real difference. More people are being seen more quickly than ever before and the Government is on track to meet the national target to enable twice as many problem drug users to get into treatment in 2008 as were able to get help in 1998.

6.1.13 What are the primary policy instruments being used to reduce the class-based differentiation in infant mortality and life-expectancy required by SR2002 target 11?

THE TARGETS

1. The SR2002 PSA target 11 aims to reduce the gap in infant mortality across social groups, and narrow the gap in life expectancy across geographical areas. There is not a specific class-based target for life expectancy in SR2002, or SR2004. The SR2004 PSA retained a focus on health inequalities with the infant mortality and life expectancy target (containing some slight revisions—as set out in the appropriate HMT Technical Note[7]), along with health inequalities aspects of cardiovascular disease and cancer mortality targets, and a target to reduce smoking in manual groups.

THE PROGRAMME FOR ACTION

2. "Tackling Health Inequalities: A Programme for Action"[8] (July 2003) sets out a plan to tackle health inequalities, across all Government departments, regional and local bodies, to established the foundations required to achieve the SR2002 PSA target. While focusing on actions to achieve the 2010 target, the broader aim of the Programme for Action is to get sustainable structures in place to tackle health inequalities in the years beyond.

LIFE EXPECTANCY

3. The evidence suggests that there are a number of specific interventions among disadvantaged groups most likely to have an impact on achievement of the 2010 target. Key interventions and primary policy instruments that will contribute to closing the life-expectancy gap are:

Reduce smoking in manual social groups

Target to reduce smoking in routine and manual groups—

Preventing and managing other risks for cardio-vascular disease and cancer (such as poor diet and obesity, physical inactivity and hypertension) through effective primary care and public health interventions

Coronary Heart Disease National Service Framework/The Cancer Plan—

Improving access to, and quality of, health services for currently under-served areas and groups—

Improving housing quality by tackling cold and dampness and reducing accidents at home and on the road

Department for Environment, Food and Rural Affairs target—

Housing Health and Safety Guidance—

Healthy Communities Collaborative—

Dealing with Disadvantage initiative—

Sure Start child health target—

INFANT MORTALITY

To close the gap in infant mortality, key interventions and primary policy instruments include:

Improving the quality and accessibility of antenatal care and early years support in disadvantaged areas

Neonatal Services Review—

Sure Start Programme—

Children's NSF—

Reducing smoking and improving nutrition in pregnancy and early years

Reducing smoking in pregnancy—

Action to improve breastfeeding—

Healthy Start Scheme—

Preventing teenage pregnancy and supporting teenage parents

Teenage Pregnancy Strategy—

Improving housing conditions for children in disadvantaged areas

Decent homes—

6.1.14 When evaluating progress on the value-for-money target across the NHS and Personal Social Services (SR2002 target 12), how do you adjust the unit cost for "quality"?

INTERIM VALUE FOR MONEY MEASURES

1. Comparing an input series which is inflated by expenditure on improving the quality of NHS services to an output series that does not capture changes in quality would give an unfair comparison of NHS value- for-money. As part of our work developing "interim" value for money measures, we propose to subtract estimated expenditure in improving quality (after adjusting for inflation and activity growth) from the input series. This should provide a like-for-like comparison of inputs and outputs, net of the impact of quality change.

2. Any expenditure on quality must in turn by justified in terms of improved service effectiveness, which we plan to measure by using data showing improvements in areas such as hospital mortality rates, waiting times and the patient experience. We recognise however that it will be difficult to fully capture changes in the quality of NHS services since current indicators will only measure a small fraction of the quality delivered by the NHS.

6.1.15 Why were the efficiency targets for social services not met in 2001-02 and 2002-03 and what is the Department doing to ensure they are met in future? Page 106 of the Annual Report says that efficiency measures for 2003-04 to 2005-06 will be in two parts both with targets of 1% annual improvement. The targets for 2001-02 and 2002-03 were 3% and 2.5% respectively, why have the efficiency targets been reduced for later years?

1. The efficiency measures for 2003-04 to 2005-06 were agreed as part of the 2002 Spending Review settlement and comprised 1% cost and 1% quality improvements. The inclusion of quality improvements was an innovation to recognise the need to assess the impact of changes on the quality of services delivered alongside cost effectiveness, and to provide some stretch for local authorities to improve the quality of the services that they deliver.

2. Efficiency targets are reviewed by the Department and the Treasury during the Spending Review negotiations. The final targets reflect judgements about what is reasonably challenging, but hopefully achievable at a particular point in time. The Department monitors councils activity but it cannot performance manage local councils in the same way that it does NHS organisations, nor would it be appropriate for it to do so, as this would run counter to local government decision making and accountability. Market forces obviously have an impact on the success in the delivery of efficiency savings, and in the case of residential and home care there is competition with other sectors to recruit and retain staff, especially unqualified staff.

3. As part of the 2004 Spending Review settlement the Department agreed with the Treasury to achieve savings targets of around 2.5% per annum from 2005-06. To ensure these savings are delivered the Department has set up the Care Services Efficiency Delivery programme which is overseen by a steering board that is chaired by the DH Director of Finance, and comprises membership from Care Services, Commercial Directorate, ODPM, ADSS and the LGA. The programme will involve working with local councils, the NHS and providers of care services to help them develop new, innovative and collaborative commissioning models and service delivery systems.

1. The information requested is provided in Table 6.1.16.

Table 6.1.16

MONTHLY DATA ON INPATIENT AND OUTPATIENT BOOKING RATES JANUARY 2003 to JUNE 2004


	Inpatient Day Case Booking Rates	Inpatient Combined Booking Rates	Outpatient Booking Rates

January 2003	51.2%	42.4%	23.5%
February 2003	61.8%	51.0%	28.8%
March 2003	73.8%	59.8%	33.3%
April 2003	73.2%	59.3%	32.9%
May 2003	71.1%	58.8%	36.1%
June 2003	75.6%	61.6%	34.6%
July 2003	75.0%	61.6%	35.1%
August 2003	73.0%	62.3%	35.5%
September 2003	76.0%	63.7%	39.9%
October 2003	78.3%	65.9%	42.1%
November 2003	80.0%	68.1%	45.1%
December 2003	81.7%	70.9%	48.5%
January 2004	84.6%	75.1%	52.7%
February 2004	90.2%	81.7%	60.4%
March 2004	96.9%	89.9%	76.3%
April 2004	96.5%	89.6%	75.9%
May 2004	96.4%	89.9%	77.0%
June 2004	96.6%	90.6%	77.9%

Source: Monthly monitoring returns

6.1.17 Is it the Department's intention that all hospitals should eventually have ward-housekeepers? If yes, what is the target date? If no, why not (SR2000, target 5)?

1. The Department recognises the valuable role that ward housekeepers play in delivering basic care services to patients and support their widespread introduction.

2. In line with the Shifting the Balance of Power reforms, and the setting of fewer national targets for the NHS, we have not set a specific target for the introduction of ward housekeepers in every hospital.

6.1.18 If the current rate of annual progress were maintained, at what point in time will at least 95% of hospitals offer patients "good quality" food (SR2000, target 5)?

1. We estimate that 95% of hospitals will provide food rated as being of "good quality" by 2007. Assessments are undertaken by Patient Environment Action Teams, as part of their annual inspection of the quality of the patient environment in NHS hospitals.

1. Although the rate of emergency re-admissions fell in the quarter between July and September 2003, this fall has not continued in later quarters. The latest data are attached in Table 6.1.19(a).

The department no longer collects quarterly data on the number of re-admissions for patients over 75. Figures up to and including 2002-03 are attached in Table 6.1.19(b), along with the up to date data on re-admissions of patients of all ages.

Table 6.1.19(a)

NUMBER OF PEOPLE AGED 75+ READMITTED AS AN EMERGENCY WITHIN 28 DAYS OF DISCHARGE, 1996-97—2002-03


Financial Year	Quarter	No of people aged 75+ discharged from hospital	No of people aged 75+ readmitted as an emergency within 28 days of discharge	Rate of 28 day emergency readmission for people aged 75+

2003-04	Mar-04	no data	no data	no data
2003-04	Dec-03	no data	no data	no data
2003-04	Sep-03	no data	no data	no data
2003-04	Jun-03	no data	no data	no data
2002-03	Mar-03	468,965	38,666	8.2%
2002-03	Dec-02	443,378	36,170	8.2%
2002-03	Sep-02	420,252	34,394	8.2%
2002-03	Jun-02	440,765	32,966	7.5%
2001-02	Mar-02	437,034	31,493	7.2%
2001-02	Dec-01	429,124	31,427	7.3%
2001-02	Sep-01	422,143	30,083	7.1%
2001-02	Jun-01	408,817	29,878	7.3%
2000-01	Mar-01	409,335	31,538	7.7%
2000-01	Dec-00	411,137	29,896	7.3%
2000-01	Sep-00	406,761	28,820	7.1%
2000-01	Jun-00	390,010	28,735	7.4%
1999-00	Mar-00	377,277	28,611	7.6%
1999-00	Dec-99	368,244	26,523	7.2%
1999-00	Sep-99	368,329	26,758	7.3%
1999-00	Jun-99	346,079	26,702	7.7%
1998-99	Mar-99	365,801	29,933	8.2%
1998-99	Dec-98	361,266	29,110	8.1%
1998-99	Sep-98	357,275	28,839	8.1%
1998-99	Jun-98	342,787	29,213	8.5%
1997-98	Mar-98	343,170	24,435	7.1%
1997-98	Dec-97	335,188	23,771	7.1%
1997-98	Sep-97	333,781	22,385	6.7%
1997-98	Jun-97	326,996	23,557	7.2%
1996-97	Mar-97	339,389	23,625	7.0%

Source: LDPR/SaFFR returns

Table 6.1.19(b)

NUMBER OF PEOPLE OF ALL AGES READMITTED AS AN EMERGENCY WITHIN 28 DAYS OF DISCHARGE, 2002-03—Q1 2004-05


Financial Year	Quarter	No of people of all ages discharged from hospital	No of people of all ages readmitted as an emergency within 28 days of discharge	Rate of 28 day emergency readmission for people of all ages

2004-05	Jun-04	2,516,164	147,746	5.9%
2003-04	Mar-04	2,558,785	146,703	5.7%
2003-04	Dec-03	2,529,886	143,187	5.7%
2003-04	Sep-03	2,491,500	136,701	5.5%
2003-04	Jun-03	2,402,573	135,153	5.6%
2002-03	Mar-03	2,501,481	138,742	5.5%
2002-03	Dec-02	2,429,606	131,704	5.4%
2002-03	Sep-02	2,334,696	124,176	5.3%
2002-03	Jun-02	2,313,818	125,085	5.4%
Source: LDPR/SaFFR returns

6.1.20 Does the Department expect to reduce the "coefficient of variation", measuring "the dispersion of costs between NHS trusts" to zero (SR2000, target 10)? What is the target timeframe for this?

1. The "coefficient of variation" is used to show how much variation there is in the cost of care commissioned from trusts, measured using the Reference Cost Index. As the prices charged by the more expensive trusts come into line with those elsewhere there will be less variation in costs between trusts. To ensure financial balance under the Payment by Results regime, NHS trusts must over the next four years ensure that their prices tend towards national averages. This will result in a substantial reduction in the variation of trusts prices, which will in turn lead to a reduction in the coefficient of variation of the Reference Cost Index.

1. Mortality rates were recalculated using revised population estimates following the 2001 Census. Some of the recalculated mortality rates were adjusted to take account of the effect of concurrent, although unrelated, changes in the International Classification of Diseases used for coding mortality.

2. The effect of changes to population estimates and ICD coding have resulted in small increases to baselines and milestones and targets (of the order of 1% for the circulatory disease and cancer targets). These changes therefore have no effect on the "achievability" of targets or the arguments presented in "Saving Lives".

3. See Table 6.1.21 which shows original data, recalculated data as a result of the revised population estimates and, where appropriate, adjusted recalculated data as a result of the coding change.

Table 6.1.21

DEATH RATES PER 100,000 POPULATION IN ENGLAND (COMPARISON OF THREE YEAR AVERAGE TRENDS)

All Malignant Neoplasms (ICD10 C00-C97)

PERSONS <75

ADJUSTMENT FACTOR4 1.010985435

SINGLE YEAR DATA


Data period	Original1 (Cen 1991)	Revised2 (Cen 2001)	Adjusted (Cen 2001, ICD10)

1993 ICD9	147.95	148.01	149.64
1994 ICD9	145.03	145.17	146.77
1995 ICD9	142.67	142.76	144.33
1996 ICD9	140.71	140.83	142.37
1997 ICD9	135.78	135.97	137.46
1998 ICD9	134.49	134.67	136.15
1999 ICD9/ICD10	130.04	131.81	n/a
2000 ICD9	127.27	127.59	128.99
2001 ICD10		126.35	n/a
2002 ICD10		124.95	n/a
2003 ICD10		122.75	n/a

THREE YEAR AVERAGE DATA


Data period	Original 1 (Cen 1991)	Revised 2 (Cen 2001)	Adjusted (Cen 2001, ICD10)

			Target Monitoring data
1993/4/5	145.22	145.31	146.91
1994/5/6	142.80	142.92	144.49
1995/6/7	139.72	139.85	141.39
1996/7/8	136.99	137.15	138.66
1997/8/9	133.43	134.15	135.14
1998/9/2000	130.60	131.36	132.32
1999/2000/01		128.58	129.05
2000/1/2		126.29	126.76
2001/2/3		124.68	n/a
MILESTONE (2004/5/6)	123.0	123.1	124.4
TARGET (2009/10/11)	111.8	111.9	113.1

All Circulatory Diseases (ICD10 I00-I99)

PERSONS <75

ADJUSTMENT FACTOR4 1.0103510924

SINGLE YEAR DATA


Data period	Original 1 (Cen 1991)	Revised 2 (Cen 2001)	Adjusted (Cen 2001)

1993 ICD9	160.99	160.98	163.15
1994 ICD9	148.73	148.82	150.83
1995 ICD9	145.47	145.47	147.44
1996 ICD9	140.69	140.72	142.62
1997 ICD9	132.64	132.72	134.51
1998 ICD9	128.03	128.09	129.82
1999 ICD9/ICD10	120.34	121.87	n/a
2000 ICD9	112.73	112.89	114.42
2001 ICD10		108.08	n/a
2002 ICD10		102.90	n/a
2003 ICD10		98.78	n/a

THREE YEAR AVERAGE DATA


Data period	Original 1 (Cen 1991)	Revised 2 (Cen 2001)	Adjusted (Cen 2001)

			Target Monitoring data
1993/4/5	151.73	151.76	153.81
1994/5/6	144.96	145.00	146.96
1995/6/7	139.60	139.64	141.52
1996/7/8	133.78	133.84	135.65
1997/8/9	127.00	127.56	128.73
1998/9/2000	120.37	120.95	122.03
1999/2000/01		114.28	114.79
2000/1/2		107.96	108.47
2001/2/3		103.25	n/a
MILESTONE (2004/5/6)	104.7	104.7	106.1
TARGET (2009/10/11)	83.8	83.8	84.9

Intentional Self-Harm and Injury of Undetermined Intent, Excluding Verdict Pending (ICD10 X60-X84, Y10-Y34 excl. Y33.9)

ADJUSTMENT FACTOR 4 NO ADJUSTMENT REQUIRED 5

SINGLE YEAR DATA


Data period	Original 1 (Cen 1991)	Revised 2 (Cen 2001)

1993 ICD9	9.64	9.73
1994 ICD9	9.25	9.37
1995 ICD9	9.42	9.56
1996 ICD9	8.95	9.09
1997 ICD9	8.83	9.00
1998 ICD9	9.77	9.98
1999 ICD9/ICD10	9.46	9.85
2000 ICD9	9.16	9.32
2001 ICD10		8.83
2002 ICD10		8.61
2003 ICD10		8.57

THREE YEAR AVERAGE DATA


Data period	Original 1 (Cen 1991)	Revised 2 (Cen 2001)
		Target Monitoring data

1993/4/5	9.44	9.55
1994/5/6	9.21	9.34
1995/6/7	9.07	9.22
1996/7/8	9.18	9.36
1997/8/9	9.35	9.61
1998/9/2000	9.46	9.72
1999/2000/01		9.33
2000/1/2		8.92
2001/2/3		8.67
MILESTONE (2004/5/6)	8.0	8.1
TARGET (2009/10/11)	7.3	7.4

1 The rates used previously, based on ICD9 (unadjusted) and 1991 census based population estimates

2 Revised data using ICD10 for 1999 and 2001 and unadjusted rates for ICD9 and 2001 census based population estimates

3 Revised data using ICD10 for 1999 and 2001 and adjusted rates for ICD9 (using the adjustment factor above) and 2001 census based population estimates .

4 Adjustment factor for persons, calculated from an average of the adjustment factors for men and women weighted using the 1999 population estimate based on 2001 census data.

5 Change from ICD9 Suicides to ICD10 Intentional Self-harm not statistically significant. Thus no adjustment factor required.

Rates for 2003 are provisional (based on 2002 population estimates). All rates subject to change when ONS revisions to population estimates published in late 2004.

ICD9 Code equivalent:

Malignant Neoplasms—ALL MALIGNANT NEOPLASMS (ICD 140-209)

Circulatory Diseases—ALL CIRCULATORY DISEASES (ICD 390-459)

Intentional Self-Harm And Injury Of Undetermined Intent, Excluding Verdict Pending—SUICIDES AND UNDETERMINED INJURY LESS INQUEST ADJOURNED CASES (ICD E950-959 + E980-989—E988.8)

6.1.22 Is the Department on course to meet the 2005 milestones for the Our Healthier Nation targets included in SR2002 targets 6 and 7?

SR2002 TARGET 6: 2005 MILESTONE FOR CORONARY HEART DISEASE, STROKE AND RELATED DISEASES

1. Analysis of provisional monitoring data for the "Our Healthier Nation" mortality target on coronary heart disease, stroke and related diseases (ie all circulatory diseases) shows that the 2005 milestone has provisionally been passed in the three-year period 2001-03, three-years ahead of schedule.

2. The target is set and monitored in terms of three-year rolling averages (plotted against the middle year) and the 2005 milestone was to contribute to a national reduction in death rates from these diseases of at least 25% in people under 75 by 2004-06 compared to 1995-97, targeting the 20% of areas with the highest mortality rates from these diseases.

3. Three-year average rates have fallen for each period since the baseline and are now 27.1% below the baseline rate.

SR2002 TARGET 7: 2005 MILESTONE FOR CANCER

4. Analysis of provisional monitoring data for the "Our Healthier Nation" mortality target on cancer shows that the 2005 milestone is likely to be achieved in the three-year period 2002/3/4, two year ahead of target. The target is set and monitored in terms of three-year rolling averages (plotted against the middle year) and the 2005 milestone was to contribute to a national reduction in the death rate from cancer by at least 12% in people under 75 by 2004-06 compared to 1995-97. Three-year average rates have fallen for each period since the baseline and are now 11.8% below the baseline rate.

1. Table 6.1.23 shows the breakdown of accidental deaths among main categories of accident, for 1996 and 2003. This shows that, of the specific categories identified, falls account for the main part of the increase in accidental deaths.

2. The prevention of falls is the subject of Standard Six of the NHS National Service Framework for Older People. The NHS Priorities and Planning Framework for 2003-06 required the establishment of an integrated falls service across all local health and social care systems by April 2005.

3. In September, the National Institute for Clinical Excellence (NICE) will publish guidelines on falls prevention. A Healthy Communities Collaborative sponsored by the National Primary Care Development Team reduced falls in older people by a third in its first year in disadvantaged areas of Easington, Gateshead and Northampton Primary Care Trusts. The lessons learned from the Collaborative have been disseminated through workshops. We have funded Help the Aged to publish and disseminate other examples of effective falls reduction.

Table 6.1.23

ACCIDENTAL DEATHS BY CAUSE 1996 AND 2003

Accidental deaths by selected causes, England in 1996

Coded using the 9th revision of the International Classification of diseases (ICD9)


Persons	All Accidents	Motor Vehicles (E810-E819)	Falls (E880-E886, E888)	Poisoning (E850-E869)	Choking and Suffocation1 (E911-E913, E915)	House Fire (E890)	Drowning and submersion (E910)	Other1

All ages	9,211	2,934	2,002	940	378	156	184	2,617
Percentage (%)	100.0	31.9	21.7	10.2	4.1	1.7	2.0	28.4

Due to the change to the ICD10 there are small discontinuities in the comparison of data for 1996 to data for 2003 as not every death is coded to the same cause.

(For example, over 1,300 "fractures of unspecified cause" that were coded as "falls" under ICD9, are now thought to be coded under ICD10 as part of "exposure to unspecified factor" and thus appear within the "others". [ONS, HSQ19 Autumn 2003]. Code E887 has been excluded from "falls" in ICD9 above in order to be approximately comparable with "falls" in ICD10 below.)

1 No conversion ratio available, status of comparison cannot be assessed

Accidental deaths by selected causes, England in 2003

Coded using the 10th revision of the International Classification of diseases (ICD10)


Persons	All Accidents	Motor Vehicles (V01-V90)	Falls (W00-W19)	Poisoning (X40-X49)	Choking and Suffocation1 (W75-W84)	House Fire (X00,W02)	Drowning and submersion (W65-W74)	Other1

All ages	10,485	2,966	2,529	764	276	231	186	3,533
Percentage (%)	100.0	28.3	24.1	7.3	2.6	2.2	1.8	33.7

1 No conversion ratio available, status of comparison cannot be assessed

Source: ONS Mortality Data

Change (in percentage points*)

1996 to 2003<nt0.0<nt-3.6<nt2.4<nt-2.9<nt-1.5<nt0.5<nt-0.2<nt5.3<et

* This is the difference of the percentages (ie 31.9 minus 28.3 equals a 3.6 percantage point fall), this is NOT a percentage change.

"Falls" and "Building Fires" (and "Other accidents") account for a larger proportion of accidental deaths in 2003 than in 1996.

1. Cancer two week outpatient waiting time data has been collected and reported quarterly via the Quarterly Monitoring of Cancer Waits (QMCW) form since 2000. We are unable to provide monthly performance data, as this level of report was not collected, but the table provided shows excellent performance both of increased numbers of patients referred urgently, and percentage seen within 14 days, by quarter since the target was introduced in December 2000.

2. 100% achievement of this target nationally is not expected, as patients may choose to delay their first appointment, but modernisation of systems to enable appointments to be offered within 14 days has led to a very high percentage achievement. We therefore consider this target to be "met" rather than "nearly met".

3. Working with the NHS Information Authority a cancer waiting times database has been developed which monitors cancer waiting times along the patient pathway using relevant data items from the national cancer dataset. Data will be extracted from the database to monitor performance of the two week outpatient waiting time standard from Qtr 1 2004-05. Monthly reports are available from the system to the NHS for management and planning purposes, but these are not submitted to the Department for publication, as the numbers for some cancers are small and would make patients potentially identifiable.

Guarantee of maximum two week wait from urgent GP referral to outpatient appointment (when referral was received within 24 hours): NHS Trusts, England:

All cancers: Quarter 4 2000-01 to Quarter 4 2003-04


Year	Quarter	Total patients seen	Patients seen within 14 days	% Patients seen within 14 days

2000-01	4	57,782	54,024	93.5%
2001-02	1	65,398	60,458	92.4%
2001-02	2	74,104	67,650	91.3%
2001-02	3	77,609	73,813	95.1%
2001-02	4	79,541	76,243	95.9%
2002-03	1	85,415	81,466	95.4%
2002-03	2	94,931	91,529	96.4%
2002-03	3	97,284	95,190	97.8%
2002-03	4	92,883	91,241	98.2%
2003-04	1	100,039	98,498	98.5%
2003-04	2	109,021	107,580	98.7%
2003-04	3	110,379	109,145	98.9%
2003-04	4	109,581	108,685	99.2%

Source: Department of Health form QMCW

1. The target to reduce the psychiatric re-admission rate by 2 percentage points by 2002 from the 1997-98 baseline of 14.3% was missed by 0.4 percentage points.

2. Although the target was missed, the number of readmissions fell by 20% from 16,384 in 1997-98 to 13,121 in 2001-02 which shows that we have made good progress with reducing the psychiatric readmission rate through facilitating better access to services in the community.

1. As local services have implemented the new models of care, there is emerging evidence that the number of admissions to inpatient units has decreased as highlighted in the Commission for Health Improvement's clinical governance review of Newcastle, North Tyneside and Northumberland Mental Health NHS Trust (October 2003) and in Availability of mental health services in London—A report for the Mayor of London (produced by Dr Foster, August 2003).

2. It is anticipated that the readmission rates will mirror the fall in admission rates. We are developing databases to track these changes across the country.

6.1.27 Why has there been no progress on achieving (CSR98) PSA target 32 on reducing sickness absence among NHS staff? And what steps is the Department taking to achieve this target?

1. Figures for the NHS compare favourably with other public sector employers and following a small but steady reduction year on year across the service from 1995 to 2000 as NHS managers introduced initiatives to reduce short term sickness absence through better management practice we have maintained a steady level around 4.5% from 2000-01 to the present.

2. This has been aided by the Improving Working Lives (IWL) initiative that promotes more flexible working and consequently removes many of the causes of short-term absenteeism such as child and other family care problems. In most NHS employers we now have short term sickness absence reduced to very similar levels to the private sector, but we do still suffer from high levels of long term sickness absence.

3. All research into the cause and extent of sickness absence indicates that organisations going through change experience increased levels of sickness absence however this does not appear to have happened in the NHS. A comparison of figures for sickness absence for the last four years shows they have remained relatively steady.


	2000	2001	2002	2003

NHS Staff in England	4.7%	4.5%	4.6%	4.7%

Source: Department of Health—Statistics Division

4. Long Term sickness absence seriously affects an organisations sickness absence figures. The NHS because of the dangers inherent in its running; manual handling, violence, stress, substances hazardous to health; has a great deal of long term sickness absence which is contributing to the higher rates reported. This is particularly the case in ambulance trusts which suffer from higher than average incidents of Musculoskeletal disorders (MSDs) and back pain that usually result in longer term absence.

WHAT IS THE DEPARTMENT DOING ABOUT IT?

Short term absence

5. Better management at ward and office level have resulted in a reduction in the NHS in short term sickness absence. The introduction of return to work interviews after short term absence has shown staff that their absence has been noted and they will be required to discuss the reason for their absence with their line manager.

6. Research shows that the introduction of simple return to work interviews usually produces a drop of at least 30% in short term absence. As in any organisation that has a majority female workforce the NHS found that a lot of short term sickness absence was due more to family obligations than to actual sickness. Mothers taking sick leave when it was their child who was ill. The introduction of more flexible working and schemes such as time banks and carers leave has helped reduce short term absence.

Longer term absence

7. An investigation into the causes and management of long term sickness absence is underway, particularly around one of the major causes—musculoskeletal disorders. The Department has funded research into understanding musculoskeletal related sickness absence and job loss in nurses and nursing assistants at Leeds University. This is aimed at developing a tool for identifying the need for early preventative vocational rehabilitation and reducing the numbers of staff who succumb to back pain and injuries.

8. The Department has also been proactive in getting the message to the NHS through the Back in Work Campaign which promotes good practice and practical advice through its website and more recently by running a series of workshops and the annual Back in Work Awards. We are currently working with colleagues in the field to identify best practice in fast tracking rehabilitation, short term redeployment and the use of early referral for treatment which will, in time, reduce the incidence of long term sickness absence.

1. National Standards, Local Action—Health and social Care standards and planning 2005-06—2007-08 laid out the move away from a health service driven by national targets, to one driven by standards, with a devolution of decision making to local organisations.

2. This includes a reduction in the amount of information and data the Department of Health requires centrally, on a regular basis, from the NHS. It is the responsibility of local areas to formulate strategies for resolving issues where individual patients with complex problems may experience longer than average delays in being discharged from hospital.

3. Many areas collect detailed local information in order to ensure they are tackling these issues as soon as they arise. Nationally numbers of delays have fallen by over 4,200 since September 2001 and numbers of patients delayed for more than 28 days dropped from nearly 2,800 in September 2001 to just over 1,100 in September 2003.

4. The Department provides several levels of support for areas seeking to deal with this specific issue; beyond the potential to fund additional capacity via the Delayed Discharges Grant and the financial incentive to minimise all delays provided by charges under the Community care (Delayed Discharges etc) Act 2003.

5. Through the guidance Discharge from Hospital: Pathway, process and practice (DH, January 2003) and the work of the Change Agent Team (CAT) it has been possible to spread patient centred best practice to avoid the marginalisation of complex cases. Part of CAT's work programme is to investigate delays over 28 days, as well as offering intensive practical assistance with all aspects of discharge practices. This is in addition to the range of support offered through the Department of Health and discharge training websites. Further, the Department promotes the use of Health Act flexibilities as a way of enabling services to be responsive, patient centred and locally tailored in how they meet individuals' needs.

Code of Practice

1. The NHS in England is committed to an ethical approach to recruiting healthcare professionals from overseas. As such, the Code of Practice for NHS employers involved in the International Recruitment of Healthcare Professionals was published in October 2001. This identifies guiding principles to promote high standards in the recruitment and employment of healthcare professionals from overseas. It is also concerned with the protection of developing countries and seeks to prevent targeted recruitment from developing nations who are experiencing shortages of healthcare staff. The Code of Practice is also observed by the NHS in Wales, Scotland and Northern Ireland and its principles underpin NHS international recruitment activity in those countries.

2. The NHS in England was the first, and remains the only, developed country to implement and review systematic policies that explicitly prevent the targeting of developing countries in the area of international recruitment.

3. A review of the Code of Practice is also to be undertaken. This will build upon the experience developed through implementation of the current version and ensure that the NHS in England remains at the forefront in the ethical recruitment of healthcare professionals.

Nursing and Midwifery Council (NMC)

4. The Nursing and Midwifery Council (NMC) registers all nurses who work in the NHS in England. The NMC holds the statistics for the number of overseas nurses who are accepted onto their register.

5. This information can be obtained from the NMC at www.nmc-uk.org

6. The NMC statistics detail nurses that are registered to work in the NHS in England and not just in the NHS. A large proportion of these nurses will be working in the independent sector.

7. The Department of Health did not start its recruitment initiatives until 2001 and do not have any figures other stats provided by the NMC.

8. Although the NMC register all nurses who work in the NHS in England, in the private sector as well as the NHS, it would be a fair assumption that a substantial proportion of these nurses will be working in the NHS in England.

Developing Countries

How many nurses have been recruited from Commonwealth countries? What proportion of all nursing staff recruited since 1997 has come from the Commonwealth and third world countries respectively?

9. The Nursing and Midwifery Council registers all nurses who work in the United Kingdom and hold statistics for the number of overseas nurses who are accepted onto their register.

10. For more information, refer to the table below.

How many foreign nurses have transferred from the UK private sector in NHS posts in each year since 1997?

11. Unfortunately, the department does not collect this information.

International Recruitment Statistics

How many foreign nurses have been recruited directly by the NHS in each year since 1997?

12. The government-to-government agreements and Memorandums of Understanding with Spain, India and the Philippines are now established. To date, 763 nurses from Spain, 370 from India and 176 from the Philippines have already arrived and are working in the NHS. The table below details the 25 countries that have had the highest number of overseas entrants accepted onto the Nursing and Midwifery Council Register, for each year for the past five years.


Country	1998-99	1999-2000	2000-01	2001-02	2002-03

Philippines	52	1,052	3,396	7,235	5,593
India	30	96	289	994	1,830
South Africa	599	1,460	1,086	2,114	1,368
Australia	1,335	1,209	1,046	1,342	920
Nigeria	179	208	347	432	509
Zimbabwe	52	221	382	473	485
New Zealand	527	461	393	443	282
Ghana	40	74	140	195	251
West Indies	221	425	261	248	208
Pakistan	3	13	44	207	172
Kenya	19	29	50	155	152
Zambia	15	40	88	183	133
USA	139	168	147	122	88
Mauritius	6	15	41	62	59
Malawi	1	15	45	75	57
Canada	196	130	89	79	52
Botswana	4	—	87	100	39
Malaysia	6	52	34	33	27
Singapore	13	47	48	43	25
Poland	—	—	—	—	23
Sri Lanka	—	—	—	—	23
Czechoslovakia	—	—	—	—	22
Saudi Arabia	—	—	—	—	22
Nepal	—	—	—	—	21
Japan	—	—	—	—	20
TOTAL	3,437	5,945	8,403	15,064	12,730

13. Note that not all overseas nurses registered by the NMC will be practising in the NHS in England. Some may have used the registration as a means to work in another country or may still be resident in their home country with the option of being able to seek employment within the NHS in England at a later date.

Trends

14. The trend for higher overall international registrations is continuing with over 14,000 total registrations in 2003-04. A breakdown of 2003-04 figures is not yet available.

6.1.30 What is the overall cost of the development and implementation of the Departmental change programme?

1. The overall cost of the development and implementation of the Change Programme in 2003-04 was £3.8 million. This can be broken down into staff plus related costs of £1.07 million and other costs of £2.73 million. The other costs include costs related to assessment centres, communications and engagement, interims, support for managers, outplacements and change consultancy support.

6.1.31 Have external management consultants been employed in the process to restructure the Department? If so, how much has been spent on such consultancy services?

1. External management consultants have been employed to the restructuring of the Department. In 2003-04, £1.6 million was spent on such consultancy services.

6.1.32 Will staff be made redundant as part of the Change Programme in the Department? If so, what are the total costs of redundancies?

1. Although it is the Department's policy to avoid compulsory redundancies where possible, we cannot guarantee that they can be avoided altogether.

2. Initial expenditure on voluntary redundancies is £17.48 million. Further expenditure will depend on a number of factors, including the level of transfers to partner organisations, further take up of voluntary early retirement/severance, natural wastage and the number of staff the Department is able to redeploy.

6.1.33 The Departmental report states that the Department will be reduced in size by 38% as a result of the Change Programme (para 1.33), and that this programme will be complete by the end of 2004 (para 8.4). However, it goes on to state that these changes have not yet been fully incorporated into departmental budgets. Has the Department now got revised forecasts available for the net departmental administration costs and paybill costs for 2004-05 and 2005-06?

1. The Change Programme will, by the end of 2004, have completed the reduction in the Department's staffing. However, the linked changes in budgets will:

(a) follow later, as economies in overhead costs and related costs are realised;

(b) be less than proportionate to the 38% reduction in staffing, as the shift in focus of the Department requires a different skill mix which has resulted in the staffing reductions focussing disproportionately on the lower paid staff; and

(c) reflect the fact that there are elements within the Department's non-staff costs which are fixed and are not affected (for example work associated with medical benefits abroad or ONS analysis of cancer reporting) and others which are essentially overhead and can be reduced much less (eg costs of litigation and office services.)

2. The present forecast for net administration cost for 2004-05 is in the region of £285 million (including the costs of those staff who will transfer out of the Department during the course of the year as part of the change programme). However there are several uncertainties and so these will be reviewed towards the end of September. Principal amongst these is the pace at which the Department will downsize and the cost of this, ie early retirements and redundancies. Of the £285 million we presently forecast £30 million will be redundancy costs and £134 million will be payroll.

3. For 2005-06 the net administration costs are forecast to be in the region of £219 million (provided the redundancy payments all fall within 2004-05). Of this approximately £110 million will be payroll.

6.1.34 The Departmental report states that the Department will employ a lighter touch on performance management in future (para 1.35), and that, following the Change Programme, the 28 Strategic Health Authorities will operate as local headquarters of the NHS. Does that mean that SHAs will take on a greater role in performance management? What will be the procedures with regard to "arm's length" organisations perceived as failing?

1. There has been no change in the role of the Strategic Health Authorities as a result of the DH Change Programme during 2003-04. SHAs were established in April 2002 as the local headquarters of the National Health Service with the following main functions:

— Creating a strategic framework to deliver the NHS plan in their area

— Managing the performance of NHS Trusts and PCTs in their area (but not NHS Foundation Trusts)

— Building capacity and supporting performance improvement across all local health agencies

2. The DH Change Programme abolished the four regional Departments of Health and Social Care so the SHAs are now performance managed by the Delivery Group with the DH. However their role in performance managing NHS Trusts and PCTs in their area remains unchanged.

Procedures for Arms Length Bodies perceived as failing

3. The Department has recently completed a review of all of its arm's length bodies. This covered not only their organisation and remits, but also the scope for the rationalisation of their number and staffing: and will lead to a one-third reduction in their number.

4. The Department has formal measures in place for assessing the performance (and the continuing need for) all of its arm's length bodies. These include annual reviews between the Department and the body; and the appointment of senior sponsors within DH who are individually responsible for ensuring that good working relations are maintained with the body.

NHS Litigation Authority

1. Total payments for compensation and legal fees for medical negligence made by the NHS Litigation Authority over the last five years are shown in the table below. It is not possible to separate out the money paid in compensation and legal fees


Year	Medical negligence In-year payments

1998-1999	£221m
1999-2000	£373m
2000-01	£425m
2001-02	£446m
2002-03	£446m

Note: Figures are from the National Audit Office's NHS summarised accounts for the latest available years. Changes to accounting procedures imposed by HM Treasury over the years mean that the figures are not directly comparable.

Other

2. Total ex-gratia payments made by NHS Trusts for clinical negligence over the last five years are shown in the table below.


Year	Ex-gratia medical Negligence payments

1998-1999	£266,056,000
1999-2000	£224,626,000
2000-01	£(11,894,000)
2001-02	£106,392,000
2002-03	£92,000

Note: Figures are from the NHS Summarised Accounts.

3. The movement of the administrative responsibility for the relevant schemes to the NHS Litigation Authority explains the significant changes to the figures year on year.

4. Clinical negligence payments made under legal obligation cannot be separately identified in the audited summarisation schedules of NHS bodies. The total compensation payments made under legal obligation has reduced from £38 million in 1998-99 to £2 million in 2002-03 for all relevant categories.

6.1.36 What is the total annual administration costs (rather than just wage costs, as quoted in Annex C) of the National Treatment Agency?

1. There is no generally accepted definition of "administration costs" for Arms Length Bodies. Gross operating costs for the NTA were £9.1 million in 2003-04.

6.1.37 Could the Department explain why the aggregate deficit of NHS Trusts increased by £54 million between 2001-02 and 2003-04?

1. From 2002-03 the Department improved the transparency of financial performance by implementing a policy of letting deficits lie where they are incurred. This means that where deficits have occurred in year through poor financial management, managing SHAs did not provide additional financial support to the bodies concerned. This has contributed to the increase in the number of reported deficits.

2. However, the failure of some organisations to achieve financial balance did not prevent the NHS from achieving overall financial balance in aggregate. The NHS as a whole has achieved financial balance in 2001-02 and 2002-03, a position of sustained financial balance across the NHS. This is shown in the following table.


Year	PCTsNumber in deficit	Net Surplus/ (Deficit) £m	NHS Trusts Number in deficit	Net Surplus/(Deficit) £m	Overall NHS Position Net Surplus/ (Deficit) £m

2001-02	0	111	50	(40)	71
2002-03	21	189	50	(94)	96

1. The information requested is provided in the attached tables.


NHS Trusts with a Retained Deficit in 2002-03	2002-03 Retained Deficit £000s

North Bristol NHS Trust	(44,620)
Royal United Hospital Bath NHS Trust	(24,784)
East Kent Hospitals NHS Trust	(11,371)
Worcestershire Acute Hospitals NHS Trust	(9,926)
United Bristol Healthcare NHS Trust	(9,281)
South Manchester University Hospitals NHS Trust	(6,980)
Royal Cornwall Hospitals NHS Trust	(5,210)
Berkshire Healthcare NHS Trust	(4,357)
Maidstone and Tunbridge Wells NHS Trust	(4,040)
Princess Alexandra Hospital NHS Trust	(3,714)
Isle of Wight Healthcare NHS Trust	(3,704)
Royal Surrey County Hospital NHS Trust	(3,563)
South Buckinghamshire NHS Trust	(2,974)
Dartford and Gravesham NHS Trust	(2,710)
Stoke Mandeville Hospital NHS Trust	(2,404)
New Possibilities NHS Trust	(2,300)
Northern Birmingham Mental Health Trust	(2,245)
Epsom and St Helier NHS Trust	(2,193)
Barnet and Chase Farm Hospitals NHS Trust	(2,145)
Queen Mary's Sidcup NHS Trust	(1,954)
Newcastle, N Tyneside and Northumberland Mental Health NHS Trust	(1,941)
Frimley Park Hospital NHS Trust	(1,904)
Royal Shrewsbury Hospitals NHS Trust	(1,889)
North Cumbria Acute Hospitals NHS Trust	(1,803)
East Sussex Hospitals NHS Trust	(1,450)
Milton Keynes General Hospital NHS Trust	(1,394)
Royal West Sussex NHS Trust	(1,349)
Ashford and St Peter's Hospitals NHS Trust	(1,328)
The Princess Royal Hospital NHS Trust	(1,188)
Avon and Wiltshire Mental Health Partnership NHS Trust	(994)
Whittington Hospital NHS Trust	(988)
Medway NHS Trust	(967)
Buckinghamshire Mental Health NHS Trust	(916)
Royal Free Hampstead NHS Trust	(847)
Good Hope Hospital NHS Trust	(839)
Rob Jones and A Hunt Orthopaedic NHS Trust	(792)
Royal Berkshire and Battle Hospitals NHS Trust	(786)
West Middlesex University NHS Trust	(779)
East Sussex County NHS Trust	(747)
Barnet, Enfield and Haringey Mental Health NHS Trust	(686)
Burnley Health Care NHS Trust	(626)
West Sussex Health and Social Care NHS Trust	(324)
East Kent Community NHS Trust	(310)
Weston Area Health NHS Trust	(190)
Ealing Hospital NHS Trust	(183)
Oxford Radcliffe Hospital NHS Trust	(179)
Wolverhampton Health Care NHS Trust	(67)
Essex Ambulance Service NHS Trust	(58)
Kettering General Hospital NHS Trust	(6)
North West Surrey Mental Health NHS Partnership Trust	(2)

Source: NHS Trust Summarisation Schedules for 2002-03


PCTs with an Overspend in 2002-03	2002-03 Revenue Resource Limit Overspend £000s

Central Cornwall PCT	(5,650)
North and East Cornwall PCT	(5,498)
West of Cornwall PCT	(5,059)
Hammersmith and Fulham PCT	(3,215)
Hounslow PCT	(1,599)
Suffolk West PCT	(1,581)
Eastbourne Downs PCT	(1,394)
Dartford, Gravesham and Swanley PCT	(1,189)
Harrow PCT	(946)
Chingford, Wanstead and Woodford PCT	(658)
Bedfordshire Heartlands PCT	(526)
Guildford and Waverley PCT	(476)
Hastings and St Leonards PCT	(432)
Suffolk Coastal PCT	(432)
Ipswich PCT	(413)
Burnley, Pendle and Rossendale PCT	(350)
Sussex Downs and Weald PCT	(298)
Bristol South and West PCT	(289)
Waveney PCT	(176)
Chelmsford PCT	(48)
Uttlesford PCT	(20)
Epping Forest PCT	(3)

Source: Primary Care Trust Summarisation Schedules for 2002-03

1. The Department has a number of initiatives which will contribute directly to reducing the numbers of clinical negligence claims. This includes preventing things going wrong in the first place, changing the way the NHS handles things that do go wrong. Specific initiatives include:

— The National Patient Safety Agency (NPSA) has been established to focus efforts to improve patient safety in the NHS and to run a new national reporting and learning system for patient safety incidents. It has begun a programme to roll out this across NHS organisations during 2004. This work is already gaining international recognition and praise.

— The NPSA is working on a range of practical solutions to help to make care safer for NHS patients and issued its first patient safety alert in July 2002.

— As part of the quality agenda to improve health care services, all NHS organisations are expected to submit a clinical governance development plan to Strategic Health Authorities (SHAs), who will performance manage the organisations' progress against them.

— One of the criteria for membership of the Clinical Negligence Scheme for Trusts (CNST) is that the NHS Litigation Authority should assess standards of risk management at least once every two years. The NHSLA report that the overall level of risk management in NHS Trusts is improving. This is a progressive system and the aim is to steadily improve the quality of clinical risk management across the NHS. One of the performance targets reported by the Healthcare Commission is the level of risk management assessed by the NHS Litigation Authority.

— The Department is undertaking a reform of clinical negligence in the NHS, which will include the establishment of an NHS Redress Scheme The scheme will assure effective investigations when things go wrong, explanations and apologies; care and rehabilitation when needed; and financial compensation where appropriate. It will provide speedier access to an appropriate response when things go wrong and support the development of an open culture in the NHS.

— A Quality Assurance Partnership framework will be introduced in 2005 The Department is working in partnership with other agencies to put in place robust mechanisms to assure and enhance the quality of the education programmes which healthcare students undergo, both before professional registration and as part of their continuing professional development. It will be the main mechanism for driving quality improvement across NHS funded learning programmes.

4 The Guardian: Long-term care: the issue explained; 6 February 2004. Back

5 The Guardian: Long-term care: the issue explained; 6 February 2004. Back

6 Conception statistics are compiled from abortion notifications and birth registrations. Data are available 14 months after the end of the calendar year to which they relate. For example, data on conceptions in 2004 will be available in February 2006. Back

7 The Technical Note is at www.hm-treasury.gov.uk/performance Back

8 The Programme for Action is at www.dh.gov.uk/publications Back



© Parliamentary copyright 2005	Prepared 21 February 2005