Letter from the Secretary of State for
Health to the Chairman of the Committee (PE 1A)
At the Health Committee Public Expenditure Inquiry
session on the morning of 8 December I promised to write to you
on three points:
— figures on optimum bed occupancy
levels to guarantee efficiency and safety based on the National
Bed Enquiry;
— the latest data on progress with
the SHAs' review of cases of people wrongly charged for continuing
care which had not been completed as of 31 July 2004; and
— the latest figures for rates of emergency
readmission to hospital within 28 days of discharge for the over
70s.
I will address the points in turn.
OPTIMUM BED
OCCUPANCY RATES
The National Bed Enquiry issued in February
2000 identified that the National Health Service needs to be able
to respond to the peaks and troughs in demand. To achieve this,
bed occupancy levels need to be maintained at a sensible average
level: high enough to avoid inefficiency and low enough to avoid
unresponsiveness. The enquiry drew on earlier research which found—based
on the way NHS services were managed at the time—that average
bed occupancy over 85% was associated with growing problems in
handling emergency admissions.
The 85% occupancy level was intended to be taken
as a guide rather than an absolute. It is for the NHS locally
to decide how best to deliver services. Some hospitals operate
at occupancy levels in excess of 85%, whilst still delivering
a high quality of care, patient safety and the key access targets.
Optimum occupancy levels will vary depending on the range and
type of services provided and on the efficiency with which elective
arrivals and discharges are managed over the course of each day.
We are investing in significant additional capacity,
of which the Treatment Centre programme is part, which will ensure
that there is enough capacity to deliver front line services efficiently,
effectively and safely.
Treatment centres provide predominantly day
case elective procedures. Efficient utilisation is therefore based
on referrals not occupancy. This planned surgery is separate from
emergency surgery, relieves the pressures on hospital beds, and
helps to speed up the treatment of patients admitted to emergency
care.
Demand for Treatment Centre capacity is expected
to increase as the NHS expands activity to deliver reduced waiting
times and increased patient choice.
SHA REVIEW OF
CONTINUING CARE
CASES
Based on the latest information received, the
Department believes that all but two SHAs have now cleared their
pre April backlog and those two will have cleared the backlog
by the end of January.
EMERGENCY RE
-ADMISSION RATES
WITHIN 28 DAYS
OF DISCHARGE
FOR OVER 75
YEAR OLDS
Although the committee asked about re-admission
rates for over 70 year olds I believe the question was intended
to be about the discontinued measure which was for over 75 year
olds. I have therefore provided information on this basis.
The performance indicator for emergency re-admission
rates for over 75 year olds was dropped in favour of a measure
for over 16 year olds. This is because a measure that focused
on over 75 year olds has the potential to give a perverse incentive
such that elderly people may be denied hospital treatment when
it was appropriate for them to receive it.
The new star rating performance indicator is
the emergency re-admission rates for over 16 year olds and is
based on hospital episode statistics (HES) data rather than quarterly
monitoring returns. The indicator based on HES data is more sophisticated
that the quarterly monitoring data and has been developed over
a number of years to capture the true picture on re-admission
rates.
The HES data can also be used to provide data
on the emergency re-admission rates for the over 75 age group
and data for the last three year is given in the table below.
Table 1
EMERGENCY RE-ADMISSION RATES FOR OVER 75
YEAR OLDS
| Year | Rate %
|
| 2001 | 10.9 |
| 2002 | 11.3 |
| 2003 | 11.6 |
| |
I would like to re-emphasise that we would not normally publish
this information and it is no longer a NHS performance indicator
for the reasons given above.
26 January 2005
Further letter from Secretary of State for Health to
the Chairman of the Committee (PE 1B)
At the Public Expenditure Inquiry evidence session on the
8 December 2004 I was happy to agree to provide written answers
to questions the Committee were unable to ask due to time constraints.
The Clerk of the Committee submitted the questions to the Department
on the 14 January 2005 and my response to each is in the annex
to this letter.
1 February 2005
Annex
PERSONAL SOCIAL
SERVICES
1. Are national vacancy rates of 10% for social workers,
19% for occupational therapists, 11% for care staff and nearly
double the national average rates in London acceptable? Is this
having an impact on performance?
1.1 No, they are not acceptable. It would be foolish
to pretend that such large workforce supply gaps do not have a
serious effect on performance. Inspection reports for a number
of years have highlighted the impact on the quality of social
care services of high vacancies and turnover of staff. It is of
course for the employers of these staff to take a lead in reducing
vacancies, and questions must be asked of local councils and the
private and voluntary sector employers who are responsible for
the provision of social care services, but the DH has been providing
considerable support over the last few years.
1.2 In 2001 the DH launched a National Social Work/Care
Recruitment Campaign, a campaign that has now reached its ninth
phase. The Campaign works through a variety of media channels,
including TV, and the numbers of people contacting the helpline
telephones and website is now well into six figures. The number
of applications to Social Work courses is up, and the number of
student registrations has increased by over 40% since 2000.
1.3 Over the same period the DH has led with the reform
of the Social Work profession, from a two year Diploma to a three
year degree, the institution of the General Social Care Council
and the opening of the professional register of Social Workers,
the review of the post qualifying framework, and many related
initiatives designed to transform Social Work into a modern profession.
1.4 From 2003-04 the DH introduced a new grant through
local councils to support better human resource management and
recruitment and retention. The grant began at around £10
million and rises to £63 million in 2005-06. This is in parallel
with a new National Training Strategy Grant that will be £95
million in 2005-06 to support employers in developing the skills
in the workforce.
1.5 In relation to Occupational Therapists, following
discussions the DH with employers commissioned a survey to be
undertaken by the Local Government Employers Organisation. The
survey is about to report, and working with employers and the
College of OTs, we will be examining how we can tackle OT vacancy
levels.
1.6 The importance of workforce planning cannot be overlooked,
and many employers are engaged in joint planning of services across
agency boundaries. The Social Care Institute for Excellence and
the Association of Directors of Social Services, among others,
have produced guidance to help employers with workforce planning.
TOPSS England disperses a £15 million DH grant, the National
Training Strategy Implementation Fund, through its regional structure.
Receiving grant funds is conditional on evidence of local workforce
planning across the relevant agencies.
1.7 But part of the response has to be to acknowledge
that simply getting more of the same staff is only part of the
solution: it is also necessary to look at how staff can work differently
and more efficiently. The DH is funding TOPSS England to manage
a programme of pilot projects to look at "New Types of Worker"
and new ways of working. This programme started in 2003 and now
HAS 28 pilots.
1.8 This is not an easy task. The social care workforce
is growing—almost a 60% growth in employment of Social Workers
over the last decade—but the government, in partnership
with the employers and all stakeholders in social care services,
have been and will continue to work hard to develop the supply
of social care workers to meet service demands.
2. The CSCI report raises a number of issues that should
be considered before extending the reimbursement scheme to mental
health, community hospitals or palliative care. What is your intention
for extending the scheme, and do you recognise some of the dangers
highlighted by CSCI and others, notably around insufficient intermediate
and community provision?
Background to the CSCI report and Reimbursement
2.1 The CSCI report highlights the positive effects of
the reimbursement policy after only six months of application.
It stresses that this policy has brought together health and social
services, improved communication, has structured and strengthened
the discharge process and has lead to a reduction in the number
of people who are delayed in an acute bed.
2.2 Reimbursement has, as acknowledged in the report,
provided an injection of cash and an impetus to invest in local
services which help people live independent lives at home after
periods of hospitalisation and has increased investment in services
that prevent hospital admissions.
2.3 The driving principle of reimbursement is to ensure
that patients receive the right care, in the right place, at the
right time and that people are not delayed in an environment which
may reduce their independence and confidence, increase risks of
infection, or break links in their support network.
What is your intention for extending the scheme?
2.4 It has always been the intention to extend reimbursement
in a phased way based on a consideration of the benefits for each
patient group. Further parliamentary debate would be required
for the inclusion of mental health patients.
2.5 Patients not currently affected by the scheme are
still covered by the principles that they will not be discharged
until a multi-disciplinary team has agreed that they are ready
and fit for discharge, and the needs of the patient are always
at the centre of any care plan drawn up.
2.6 The NHS and their partners are improving their discharge
procedures and it should be pointed out that the policy of Reimbursement
does not change the responsibility and statutory duty of health
and social care partners to provide people with the care they
need, only to ensure that this is done in a timely way.
Worries about insufficient community services and intermediate
care provision
2.7 This year an extra £100 million of funding will
be made available for Adults' PSS and has been added to the Access
and Systems Capacity grant, this money has been made available
to ease the pressure on and improve the quality of existing community
services.
2.8 There has been a significant increase in intermediate
care services. By the end of September 2004, there were an additional
4,692 intermediate care beds and over 10,000 extra non-residential
intermediate care places. These enabled over 200,000 more people
to benefit from intermediate care services compared to the 1999-2000
baseline.
2.9 The extension of reimbursement will provide the incentive
to invest in community and residential services which will allow
for the discharge of patients who no longer require hospital care.
3. When is the "vision" for adult social care
going to be published? Is it not the case that the consultation
around this new vision was badly handled and publication has been
delayed because of the poor level of response?
3.1 A Green Paper on Adult Social Care will be launched
during the course of this parliamentary session.
3.2 Consultation on the vision has been extensive and
is ongoing. So far, it has provided a rich supply of ideas, views
and documentary material to inform the drafting of the Green Paper.
3.3 Over the summer of 2004 we consulted with a range
of stakeholders by means of a website questionnaire hosted by
the Social Care Institute for Excellence, but in August took the
view that there was still more to do. We wanted to ensure that
we heard from as many people as possible at the receiving end
of services, their carers and families, and so we extended the
period of consultation to allow more people an opportunity to
have their say.
3.4 Between August and November 2004 Dr Ladyman and his
officials conducted a rigorous exercise of informal consultation,
including the following:
— The Social Care Institute for Excellence (SCIE)
re-opened its website questionnaire until early October and held
a series of seminars for 16 focus groups, including sox consisting
of service user representatives.
— Dr Ladyman met 30 major service user and carer
representative stakeholder organisations.
— Officials wrote to around 250 voluntary organisations,
inviting them to propose ideas/comments for the Green Paper.
— Officials met a large number of key stakeholder
groups. These ranged from NHS chief executives, through the Department's
Older People's Reference Group to a Joseph Rowntree Policy Seminar.
3.5 The Department commissioned three pieces of work
to inform the debate. These were from the Institute for Public
Policy Research (IPPR), the Tavistock Institute and the Social
Policy Research Unit at the University of York.
FUTURE HEALTH
SPENDING
4. The Treasury's spending projections set out its report
Long-term public finance report: an analysis of fiscal sustainability
project NHS spending at 8.1% of GDP in 2013-14. However the Wanless
Report made a minimum projection of 9.1% by 2012-13. How can these
different estimates be reconciled? What is the Department's own
assessment of the likely growth of health spending beyond 2007-08?
4.1 The difference between the Long-Term Public Finance Report
and the Wanless Report is accounted for by the fact that the former,
in projecting future health spending, only takes account of demographic
changes. The Wanless Report assumes in addition an impact on spending
from non-demographic drivers such as patient's preferences and
expectations and technological change, the modelling in the Long
Term Public Finance Report assumes these factors were to remain
constant over time.
5. From now to 2007-08 health spending will rise by 7.3%
a year in real terms, more than twice as fast as likely growth
in GDP (3%). After that, will there not be major re-entry problem
as health spending growth slows to nearer the growth rate of GDP?
How will the service cope with slower growth of spending when
there are so many cost commitments in the pipeline which will
not come through fully until 2008 or later?
5.1 Levels of health spending beyond 2007-08 will be
determined in future spending reviews and it would not be appropriate
to speculate out the outcome now.
5.2 The purpose of the spending review process is to
ensure that sufficient funding is made available for public services
to deliver Government objectives. The 2006 spending review will
therefore take account of existing commitments that run beyond
2007-08 as well as any new commitments agreed during the review.
The review will also take account of the substantial investment
in the National Programme for IT and reforms such as patient choice,
payment by results and workforce modernisation which improve the
future productivity and efficiency of the NHS. The review will
also take account of the impact of our investment in disease prevention
through improved public health measures and more effective management
of long term conditions such as diabetes on the resources required
do deliver health care in the future.
6. Tax funded health services with strong public health
and primary care in Finland and Sweden seem to provide good outcomes
and services with much lower level of funding as shares of GDP—7%
and 8.7% respectively. Why is the NHS heading for a level of spending
which will be higher than those found in many insurance based
systems? Could we not get the same value for money levels as in
Scandinavia?
6.1 It is inherently difficult to provide a comparison
of value for money of health systems in the UK, Finland and Sweden.
This is because, to compare value for money requires a comparison
of the health inputs and outputs in each country.
6.2 To date, measures of UK health productivity have
failed to reflect the improving quality the NHS provides. The
Atkinson Review recommends that quality should be included in
a comprehensive measure of productivity.
6.3 Whilst there exists high level quality indicators,
such as life expectancy, mortality rates and cancer survival rates,
these health outcomes are not fully attributable to the health
systems and reflect only a subset of health activity.
6.4 The OECD report that in 2002 Public Health Spending
as a proportion of GDP was 6.4% for the UK, 5.5% for Finland and
7.9% for Sweden. The figures for Total Health Spend as a proportion
of GDP in 2002 were 7.7% for the UK, 7.3% for Finland and 9.2%
were Sweden. The share of Public and Total Health Spending as
a proportion of GDP increased between 2000 and 2002.
6.5 Total Health Spending as Proportion of GDP (OECD
Health Database)
| 1998 | 1999
| 2000 | 2001 |
2002 |
| UK | 6.9% | 7.2%
| 7.3% | 7.5% | 7.7%
|
| Finland | 6.9% | 6.9%
| 6.7% | 7.0% | 7.3%
|
| Sweden | 8.3% | 8.4%
| 8.4% | 8.8% | 9.2%
|
| | |
| | |
6.6 By 2007-08 UK spend on healthcare (public and private)
is estimated to reach 9.2%, the same level as Sweden in 2002.
WAITING LIST
TARGETS
7. Your new waiting list target will measure the time
from referral to treatment. When will this be published? What
is your best estimate of the average time from referral to treatment
at present? Why have we had to wait so long for this measure to
be introduced?
7.1 The Department's new Public Service Agreement target
for elective waiting times is that NHS patients should wait no
more than 18 weeks from GP referral to start of treatment. This
will include the stages leading up to treatment, including diagnostic
procedures and tests. This target was announced in the NHS Improvement
Plan in June 2004. Further detail was then set out in the Local
Delivery Plan technical guidance in November 2004.
7.2 There are no current measures of the average time
from referral to treatment and on the basis of current data and
targets we do not have a reliable basis for estimating this average.
7.3 In previous Public Service Agreements, the Government
deliberately focused on two priority areas for improving NHS performance
on elective waiting times—the time from GP referral to an
initial outpatient consultation and the time it takes from a patient
being told that they need an operation to actually entering hospital
for treatment. This focus has enabled the NHS to make huge progress—halving
the maximum inpatient wait from 18 months to a maximum of nine
months and reducing the maximum outpatient wait to 17 weeks. By
the end of this year, the maximum wait for inpatient treatment
will be six months and the maximum outpatient wait will be 13
weeks. This progress now provides the basis on which the NHS can
move on to the more challenging target of reducing the whole patient
journey from referral to treatment to a maximum of 18 weeks.
8. Officials told us told us that some GP practices restrict
appointment booking to just the next 48 hours and prevented patients
from booking further in advance in order to meet the 48 hour access
targets, and that this was a recognised problem. How many practices
restrict appointments in this way? What are you doing to tackle
it?
8.1 The Department recognises that practices which are
not allowing patients to book ahead are not delivering a patient-centred
service.
8.2 The Department is committed to working with Strategic
Health Authorities to support Primary Care Trusts in managing
out this practice. The aim of this work is ensure that all patients
have the opportunity to book ahead;
8.3 The Department has:
— Written to SHAs asking them to:
— remind PCTs that this is not acceptable practice;
— ensure that PCTs take steps using the available levers
to manage out this practice; and
— remind PCTs that when validating monthly performance
data they are expected to ensure that practice figures are reported
on the basis of appointment systems which allow patients appropriate
flexibility in booking appointments.
— extended monthly performance data to include information
on the extent of restricted booking;
— circulated to all practices a joint DH/National
Primary Care Development Team (NPDT) leaflet "When do patients
want to be seen? Who do they want to see?"; and
— published a guide to Improving appointment booking
systems, This builds on the joint leaflet and includes action
for PCTs to take.
8.4 There is evidence of improvement. Monthly performance
data suggest that 8% of patients cannot book more than two days
ahead. This compares with 13% in November 2004 the first month
when these data were collected.
OUTPATIENT WAITING
LISTS
9. The March 2004 milestone from your outpatient waiting
list target was that no one should wait more than four months
from referral to appointment. However, at the end of June almost
3,400 waited longer than four months. Why was this and are you
confident that the target for next March and those beyond will
also be met?
9.1 The Department collects data on time waiting for
a first outpatient appointment following a GP or G(D)P referral
to consultant.
9.2 At the end of June the provider based return showed
3,390 patients waiting over 17 weeks for a first outpatient appointment.
The majority of these patients were Welsh residents waiting for
an outpatient appointment at an English trust. The number of patients
for whom English commissioners were responsible, waiting over
17 weeks, was 626 (465 of whom were waiting at Royal National
Orthopaedic Hospital NHS Trust).
9.3 At the end of September the provider based return
showed there were 3,109 patients waiting over 17 weeks for a first
outpatient appointment. Again, the majority of these patients
were Welsh residents waiting for an outpatient appointment at
an English trust. The number of patients for whom English commissioners
were responsible, waiting over 17 weeks, was 151.
9.4 Most patients receive their first outpatient appointment
within 17 weeks. In the quarter ended 30 September 2004, 98.4%
were seen within 17 weeks.
9.5 The 13 week maximum wait for an outpatient plan is
to be met by the end of December 2005. 82.2% of patients were
seen within this target at the end of September 2004. The Department
continues to monitor progress through SHAs and is confident that
the NHS will continue to make progress and meet the 13 week maximum
waiting time target.
NHS DENTISTRY
10. The NHS Plan said that everyone who wanted an NHS
dentist would be able to get one—how far are we away from
this? Do you have any figure for the number of registrations you
are aiming for?
10.1 At no time since provision was made for NHS dentists
to register patients in 1990 has the proportion of the population
registered exceeded 60%. Some people are content to rely on the
arrangements for occasional or emergency treatment. Nevertheless
we accept that there is currently unmet demand and have set a
target of increasing the number of patients currently registered
(22 million) by 2 million by the end of 2005.
11. You have recently launched another initiative to boost
NHS dentistry. How will this succeed where others have failed
if it only plans for an additional 1,000 dentists when the Primary
Care Dental Workforce Review found there was a shortage of 1,850?
11.1 The recruitment of the equivalent of 1,000 more
dentists is an interim measure whilst the benefit of the extra
170 training places for dental undergraduates to be funded form
October 2005 is realised. By 2010, when the first cohort of dentists
qualifies, there will be an additional 850 dentists in training.
We are also confident that the new contractual arrangements, to
be introduced by April 2006, will attract dentists to increase
their NHS commitment, but plan to review these assumptions in
2006.
CLINICAL NEGLIGENCE
12. Provision for clinical negligence has been increasing
rapidly and stood at £6 billion last March. Do you agree
with the National Audit Office when they say that "The cost
of clinical negligence continues to be a major challenge for the
NHS and represents a significant and increasing drain on resources
available for patient care"? And if so what are you doing
to slow these increases and when can we expect provisions for
clinical negligence to fall?
12.1 The cost of clinical negligence is rightly of concern
to the public, the NHS and the Government. However, it is right
that NHS patients who are injured as a result of clinical negligence
should be able to obtain correct and full compensation. The actual
amount paid out in connection with clinical negligence claims
in the NHS currently stands at over £400 million per year[2]
While this is a significant sum of money, it is a declining proportion
of annual NHS expenditure and for 2002-03 accounted for less than
1%.
12.2 The NAO figure of £6 billion represents the
estimated value at 31 March 2003 of all known claims, together
with an actuarial estimate of those incurred but not reported
(IBNR) which may settle or be withdrawn over future years[3]
It is the theoretical cost of paying all outstanding claims immediately,
including those relating to unreported incidents. The NAO's own
figures in their May 2001 report on clinical negligence suggest
around three quarters (62% of ELS claims and 83% of CNST claims)
would be withdrawn by the claimant, and that of the claims that
went to court in 1999-2000, only 61% were successful. Nevertheless,
it is financially prudent to ensure provision is made to meet
all potential liabilities so that resources are available to provide
compensation to patients where clinical negligence has occurred.
12.3 The focus of the NHS is on taking measures to reduce
the incidence of clinical negligence in the NHS, improve the way
claims are resolved and provide care and compensation for those
injured through poor quality NHS treatment. We are working to
reduce clinical errors in the first place through the National
Patients Safety Agency who record errors, mistakes and near-misses
and speed up the process of sorting them out. The Department of
Health, along with the Lord Chancellor's Department and the NHS
Litigation Authority, has already done much to improve the system
for resolving claims. This has includes adopting the Civil Procedure
Rules (in line with Lord Woolf's "Access to Justice"
recommendations), reforming the legal aid system, establishing
the Legal Services Commission and encouraging the use of mediation
as an alternative to court action. We also need to ensure that
money spent on claims goes to the patients who deserve it—not
legal costs. Making Amends, published in June 2003, proposes an
NHS Redress Scheme which would investigate when something went
wrong, offer explanations and apologies, care and rehabilitation
when needed, and financial compensation in certain circumstances
without the need to go to court.
2
£422.5 million was paid out in connection with clinical negligence
claims in 2003-04, representing a 5% fall from the comparable
figure in 2002-03 of £446.2 million. These figures include
both damages paid to patients and the legal costs borne by the
NHS. Back
3
The NHS Litigation Authority estimate that as at 31 March 2004,
it has potential liabilities of £7.78 billion relating to
clinical negligence claims. This estimate is strongly affected
by the "discount rate" set by Government, which was
changed on 1 April 2003 from 6% to 3.5%. Had the new discount
rate of 3.5% been applicable to the 2002-03 Accounts, the potential
liabilities reported in those Accounts would have been £7.3
billion at 31 March 2003 rather than the £5.96 billion reported.
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