APPENDIX 2
ISSUES FROM AUDIT COMMISSION REPORTS ON CHOICE
AND VFM
1. Many of our national studies note the
tensions between users' desire for choice and the level of resources
available in the service. There is a need to balance the individual's
desire for choice and the public sector's managerial accountability
for securing overall value for money, for citizens and taxpayers.
The examples below illustrate the issues.
EDUCATION
Special Educational Needs: a mainstream issue
[published November 2002]
2. One in five children—a total of
1.9 million—in England and Wales are considered by their
school to have special educational needs (SEN). This is the second
and final report from an Audit Commission research project on
children with SEN. It looks at how well our system of education
is serving children with SEN.
3. All parents have a right to express a
preference about which school their child should attend and schools
are legally required to admit a child if named in their statement.
However, the parents that we met tended to feel that they had
little choice over which school their child could attend for one
of two reasons:
3.1 There was no school or early years setting
locally which they considered appropriate;
3.2 They felt that some schools and early
years settings did not want their child to attend.
HEALTH CARE
Primary Care Prescribing [published March 2003]
4. This Bulletin presents the findings of
auditor's local work on prescribing in primary care, carried out
in over 120 primary care trusts (PCTs) in England. It provides
practical guidance for PCT board members, chief executives, Directors
of Finance, prescribing advisers and GP leads, to help them get
the most benefit for patients from prescribing budgets.
5. Primary care prescribing is costly and
these costs are rising rapidly. PCTs are finding it very difficult
to fund the growth in prescribing spending, and most are facing
a significant funding gap. Good management of prescribing is about
more than containing costs. It is about improving the quality
of prescribing by putting in place systems to ensure that spending
on drugs is targeted at patients who will benefit from the treatment,
and that the most cost-effective treatment option is used without
compromising patient care.
6. The Audit Commission has developed a
national prescribing savings database, which estimates potential
savings in a number of categories, for example, reducing spending
on drugs considered to have limited clinical value, and ensuring
that certain drugs known to be often over-prescribed, for example
antibiotics and ulcer healing drugs, are only given where clinically
necessary. The study estimated that over £130 million (2.3%
of the drugs bill) nationally could be saved in the categories
of drugs targeted in this database, over the medium term.
7. A key challenge for PCTs is to effectively
influence the prescribers. Many factors influence a GP's decision
on what to prescribe to a patient, including higher patient awareness
of new treatments, and increased expectations. We said in our
report:
. . . Where external influences, such as patient
expectations or pressure from pharmaceutical company representatives,
are counter to the goals of the PCT, a strong line should be taken.
This could involve:
. . . giving GPs advice on how to deal with
the pressure from patients . . .
8. We recognise that, in taking a value
for money stance, our advice to PCTs may affect patients' ability
to persuade their GP on the choice of medication, or on their
preferred brand.
Fully Equipped: the Provision of Equipment to
Older or Disabled People by the NHS and Social Services in England
and Wales [published March 2000]
9. Older people need an environment that
they can shape, and where they can thrive and live life to the
full for as long as possible. The challenge for communities and
councils is to be inclusive, to help older people to stay healthy
and active and to encourage their contribution to the community.
Councils need to accept responsibility for investing in opportunities
and services for older people; to see them as full citizens and
as a resource for society, rather than as dependent on it.
10. Because many people see the elderly
as dependent and frail, rather than as citizens with a contribution
to make, the response of public services is often limited. Services
for older people have been focused predominantly on a narrow range
of intensive services that support the most vulnerable in times
of crisis. Older people are seen as NHS and social care "problems";
any one time, only about 15% of older people are in immediate
touch with care services; meanwhile the majority receive little
attention.
11. This study argues that we need a fundamental
shift in the way we think about older people, from dependency
and deficit towards independence and well-being. When they are
asked, older people are clear about what independence means for
them and what factors help them to maintain it. Older people value
having choice and control over how they live their lives.
What seems to be the matter: Communication between
hospitals and patients [published 1993]
12. Individual patients have different needs,
preferences and expectations in relation to clinical information.
Nevertheless, when they are asked about their experience in hospital,
the theme that recurs most frequently is their desire for more
information about clinical matters. Here are examples of what
patients told our researchers:
Benign Prostatic Hyperplasia:
"They never told me it was my prostrate.
I think they expected me to know"
"Perhaps it (cancer) should be talked
about a little more to put your mind at rest"
"He didn't tell me much more about the
operation, only that I needed it"
"They don't discuss much with patients.
I would have preferred that they had explained more."
"I didn't even know if it was malignant
. . . Perhaps they leave it to your imagination"
"I don't think you get enough counselling
. . . it seems like they all want to avoid the subject"
"They just told me I was going to have
a mastectomy. No choice, no explanation"
"I was told `it's best to have it all
off' but I still don't know why"
"I felt that if I hadn't asked [about
radiotherapy treatment], I wouldn't have been told half the things."
"Why is it that no-one wants to discuss
it. . .?"
"They just say `keep moving, it will
stop one day'. . . . They could tell you there's not much they
can do—be straight with us"
"It wouldn't hurt to know the side effects
of the drugs."
"You have to fight to be told what's
wrong . . ."
"[I] would like to have known about my
condition, treatment and the future. . ."
"I would have like to have discussed
aftercare"
"If I'd been given some information when
I had the first attack and . . . told . . . what was really wrong,
it would have stopped me from getting worse." [78]
SOCIAL CARE
13. The social care sector is operating
within a context of rising demand and increasing expectations.
All Our Lives: Social Care in England 2002/2003
[published March 2004]
14. The report provides a commentary on
the performance of social care services in England in 2002-03.
It was produced jointly by the Social Services Inspectorate (SSI),
the National Care Standards Commission (NCSC) and the SSI/Audit
Commission Joint Reviews team. It combines evidence from these
three sources, including early findings from NCSC's inspections
of care homes as well as conclusions about the performance of
council services in 2002/3. These extracts from the report show
how the issue of choice occurs repeatedly throughout social care:
Choice, flexibility and respect are the qualities
that many adults said they were looking for in social care services.
[page 11];
Continuing closures of care homes are creating
a shortage of places in some regions, reducing the choices available
[page 23] . . . Home closures have also disproportionately affected
people with dementia. This means that in some parts of the country
there is a serious lack of choice. [page 27];
Without good planning, care is likely to be
inconsistent and uncoordinated and personal choices and requirements
will be overlooked. [page 29];
Continuing to increase the range of choices
available to older people, and helping them to exercise those
choices, especially by offering more older people direct payments
and ensuring that they are better informed about their rights
and entitlements and about the services available. [page 29];
Four principles underpin the government white
paper Valuing People [published in 2001]; these are—rights,
independence, choice and inclusion;
Some good progress has been made in offering
people with learning disabilities a wider choice of accommodation
options;
More people are taking up the option of using
direct payments—cash payments that promote independence
by enabling people to make their own decisions about purchasing
care services and so gaining greater choice and control over their
lives;
Direct payments have transformed my life—now
I know and can trust my carers—I have chosen them myself—I
have confidence in the support available—I am a different
person;
Enabling people to have greater choice and
control over their lives and to live the way they choose by means
of increased access to direct payments, better involvement in
care planning, and improvements to the quality of care options.
[page 41].
Services for Disabled Children [published September
2003]
15. Over 240 disabled children and their
families told us what matters to them, described their experiences
of public services, and shared their ideas for service improvement.
We took these views back to services.
16. We found: a lottery of provision, dependent
on where people live, and how hard they pushed for the services
they need; too little being provided, too late, with long waits
for information, equipment and treatment; a maze of services,
that frustrates and confuses families; and pockets of good and
innovative practice, and service champions. For example:
In many cases families faced the choice of
using a service where their child felt out of place because of
their age, or not having a service at all;
Many families felt frustrated that, for much
of the time, the help that they needed was not given at the time
they needed it, nor was it the kind of help they needed. They
described problems with services in relation to meeting individual
needs; being consulted on preferences; and cultural awareness;
"What do they think? That I don't have
a view, that my views don't count, that I don't know or care about
my daughter, or that what they do has no impact on anyone else,
including the children they're teaching? Do you see how little
sense it makes not to involve me as a partner in Amy's care?"
While parents might be consulted, disabled
children and young people themselves might not be. They recognised
that this could cause problems. One housing representative said:
"Users need greater awareness of what's
on offer so that they can identify their choices."
Older People—Independence and Well-being
[published February 2004]
17. We live in an ageing society. In the
UK, the 2001 census has shown that, for the first time, there
are more people aged 60 and over than children under 16. We prepared
this report in collaboration with Better Government for Older
People. This report summarises a series of five reports that explore
the nature of change required from public services in relation
to the independence and wellbeing of older people. It covers both
the majority who have no need of care services (but who have a
wide range of other concerns), and the minority of frail older
people who may need support and care.
18. The reports in this series are:
18.1 Older people: a changing approach;
18.2 Older people: building a strategic
approach;
18.3 Supporting frail older people;
18.4 Assistive Technology;
18.5 Support for carers of older people.
19. The most important messages about choice
from these studies are:
Older people have strong and consistent views
on what helps them to stay independent. At the heart of older
people's sense of independence and well-being lies their capacity
to make choices and to exercise control over how they live their
lives;
The expectations of older people are changing,
as the young adults of the 1960s move towards retirement. They
have very different attitudes towards independence, care and participation,
and different expectations of public services from today's older
people, who grew up with a vision of a "cradle to grave"
welfare state The next generation will be more confident in demanding
greater choice and control over the way that services are delivered;
. . . the choices more and more older people
are making and the lives they are choosing to live, challenge
fundamental preconceptions about how government and society at
large, views them. Yet whilst older people are changing, the public
services they are offered remain rooted in the old paternalistic
welfare culture . . .;
20. If older people are to exercise choice
about where to live, they need a range of housing options from
which to choose, as well as advice on what is likely to be most
appropriate for them. Local planning and housing strategies must
allow for a range of flexible options, including support to allow
older people to remain in their own homes, as well as sufficient
supported housing, including extra care sheltered housing that
meets older peoples' priorities in terms of space, design and
location.
Take Your Choice: A Commissioning Framework for
Community Care [published December 1997]
21. Since the implementation of the community
care reforms, social services departments have taken on increasing
responsibilities for commissioning community care. Commissioning
is the process of specifying, securing and monitoring services
to meet individuals' needs both in the short and long term. This
practical handbook covers the purchasing process as well as a
strategic approach to shaping the market for care to meet future
needs. Our handbook helps departments to develop their approach
to commissioning, by setting out a framework which they can use
to look at their arrangements.
"Users and carers should be at the heart
of the commissioning process . . . the centre must help users
to make informed choices, enable them to complain and get action
when things go wrong, and take on board their views in commissioning
services for the future.". . .
22. The necessity of involving and consulting
users runs throughout the framework. Section 2 of the manual is
entitled "Making commissioning user-led". It emphasises
the importance of helping users influence and control their care,
for example—by supporting user choice:
22.1 Providing the information users need
on services;
22.2 Promoting choice of provider through
administrative arrangements; and
22.3 Promoting choice of provider through
contract arrangements.
The ability of users and carers to make an
informed choice over what, where and by whom, care is to be provided
is of huge importance . . . For most older people this is likely
to be a choice about where they will spend the rest of their lives
. . . Authorities should seek:
To help users make an informed choice;
To ensure artificial barriers to choice are
not established by contracting arrangements; and
To help ensure choice is offered, by recording
and monitoring the choices offered and made.
23. The handbook contains many examples
of good practice.
HOUSING
Promoting Positive Practice [published March 2003]
24. This part of the Audit Commission's
Housing Review promotes some of the positive practice found during
inspections from 1 July 2001 to 30 June 2002. We found these examples
involving choice:
24.1 Ealing Council's choice-based lettings
pilots for sheltered housing and on one estate appeared to have
achieved service improvements and efficiencies.
24.2 Westminster City Council had also
pursued a number of initiatives to increase the options for re-housing,
including a choice-based lettings pilot led by Camden, the appointment
of a dedicated choice and mobility officer, and participation
in the LAWN (London Alliance West, North) project. These initiatives
produced flexibility and choice, and better use of stock. In the
pilot choice-based lettings scheme, more local applicants had
been able to access housing in their preferred areas.
24.3 The "Choices Steering Group"
of tenants, officers and councillors in Gloucester City Council
used theatre (through a play performed by tenants and officers)
to explain the various options for the future of its homes. Meetings
of the Steering Group were video-recorded so that other people
could watch the debate unfold.
78 Source: Patient interviews by the College
of Health on behalf of the Audit Commission. Back
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