Select Committee on Health Written Evidence

5.  CAPITAL EXPENDITURE AND INVESTMENT (continued)

  5.3.4  Could the Department provide an update of Tables 5.3.4? [5.3.4]

  ANSWER

  1.  The information requested is provided in Table 5.3.4.

Table 5.3.4

INCREASES TO THE CAPITAL COST OF PFI SCHEMES

A	B	C	D	E	F
	Capital Cost at OBC Stage	Capital Cost Reported Last Year	Capital Value This Year	% Increase Since OBC Stage	% Increase Since Last Year
North	£m	£m	£m
Leeds Teaching Hospitals	125.0	221.0	221.0	76.8%	0.0%
Newcastle upon Tyne Hospitals	129.5	256.2	298.6	130.6%	16.5%
Mid Yorkshire Hospitals	164.1	256.0	265.7	61.9%	3.8%
Hull & East Yorkshire Hospitals (Oncology)	37.6	60.4	63.6	69.1%	5.3%
Northgate & Prudhoe PCT	14.0	24.0	24.0	71.4%	0.0%
Sheffield Teaching Hospitals	30.0	31.2	35.0	16.7%	12.2%
Central Manchester & Manchester Children's	199.0	413.0	511.6	157.1%	23.9%
St Helens & Knowsley	229.8	257.8	380.1	65.4%	47.4%
Salford Royal Hospitals	114.0	186.2	190.0	66.7%	2.0%
Tameside & Glossop	41.0	84.2	114.7	179.8%	36.2%
Selby & York PCT	23.6	24.2	24.2	2.5%	0.0%
East Lincolnshire PCT	24.0	24.0	24.9	3.7%	3.7%
Leeds Teaching Hospitals—Childrens	229.0	N/A	260.0	13.5%	N/A
Tees & North East Yorkshire	73.0	N/A	78.0	6.8%	N/A
South of Tyne & Wearside MH	50.0	N/A	50.0	0.0%	N/A
Aintree Hospitals	50.0	N/A	50.0	0.0%	N/A
Mersey Care	120.0	N/A	120.0	0.0%	N/A
Royal Liverpool Children's Hospital	300.0	N/A	300.0	0.0%	N/A
Royal Liverpool University Hospital	500.0	N/A	500.0	0.0%	N/A
TOTAL NORTH	2,453.6	1,838.2	3,511.4

COMMENT ON ANY INCREASE OVER 10%

Leeds Teaching Hospitals
Initial OBC cost	125
Increased Multi-storey car park requirement	21
Increased building size requirements including incorporation of elements of "improving the patient experience"	25
Detailed review of fixture and fittings	3
Development of M&E services	5
Inclusion of PACS	2
Other equipment changes	2
Specification developments and reviews including linnear accelerator shielding requirements and service requirements	20
MIPS uplift	26
Reduction to enabling schemes	-8
PFI Capital value	221
Newcastle Upon Tyne Hospitals
Increases since last year:
The 16.5% uplift since last report has arisen from inflation (as a result of a protracted construction programme c10 years in the PSC and the further uplift in MIPS to 423); a correction of the DCAG Circulation allowances in the PSC to reflect actual standards in Building Notes as well as inclusion of all Trust alteration schemes necessary to deliver the project.
Mid Yorkshire Hospitals—Wakefield
Capital cost at SOC stage	164.1
increase relating to the NHS Estates Departmental Cost Allowance Guides (DCAGs) taking into account the new principles in order to produce a better patient environment.	23.3
Changes in functional content	12.6
Additional scope and space requirements	3.2
MIPS to present base	66.6
Increases at BAFO stage	21.4
Decreases post preferred bidder	-17.6
Other reductions	-7.9
Current Capital value	265.7
Hull and East Yorks
Capital cost at SOC stage	37.6
Improving the patient environment	2.9
Increased linnear accelerators (3 to 6)	6.1
Inflation	5.8
Undergraduate teaching accomodation	1.2
Reprovision of boiler house	1.5
Other functional and infrastructure changes	1.4
Increase in planning contingency	0.3
Inreased equipment costs	0.8
MIPS increases	6.0
	63.6
Northgate & Prudhoe PCT
The change from £14 million to £24 million at financial close was due to to a revised OBC (Version 1 was RO approved and needed re-approval when the SHAs were founded) and uplift for MIPS.
Sheffield Teaching Hospitals
Inflationary increases to MIPS 427	2.7
Refinements to design at Output specification stage	1.6
Reassessment of contingency provision	0.6
other changes	0.1
Total increases	5
Central Manchester & Manchester Children's
Original OBC figure	199
MIPS increase	12.6
Adult NBI growth & children's Burns and Cleft Lip	36
Energy targets, building regulations and Health and safety	7.75
Mental Health reprovision	7.75
Early Delivery of Children's facilities	26.9
Modernisation
Equipment consequences	7.9
Cardiac services	1.7
Obstetrics new model of care	1.5
Improving the Patient Experience	30.8
New Guidance (Health and Safety, building regulations etc)	12
Service Developments—Nationally/Regionally driven	10.4
Service Developments University or Trust driven	6.9
Spacial/equipment re-alignment	5.2
Other	12.05
Capital Costs as per FBC	378.45
FBC Inflation	53.4
reduction	-7.1
FBC Cost	424.75
Inflation	86.8
Financial close outturn	511.55
St Helens & Knowsley Hospitals
OBC costs	229.8
Exclusion of Primary Care Elements (inc. Newton, Millenium Centre, Elyn Lodge)	-21.8
Consumerism/Capacity Planning/Service changes	17.8
Additional on cost items, (inc Highways, drainage, contamination)	15.8
Functional content changes	18.4
Exclusion of IT elements	-6.1
Equipment requirements	16.5
Inflation Adjustment	47.1
Indexation to MIPS 415 (VOP)	62.6
Revised PSC costs (inc VAT)	380.1
Salford Royal
SOC cost	114
Building Inflation	12
Improving the patient experience	10
Estates standard	9
A&E	4.1
Shift to HDU beds	3.8
Post acute bed	2.5
Neonatal & Childrens	2.2
On costs	18.3
Ceiling limits	1.5
Decked car park	4
Equipment	4.6
Contingency	3.9
Reduction in VAT free costs	3.1
Increase in Health and Social Care centre costs.	3.3
Total	196.3
This figure represents the capital costs of both the Hospital PFI scheme and the four Health and Social Care Centres, these have now been grouped together to reflect the scope and content of the OBC. However, the HSCCs are being procured under Lift and therefore not part of the PFI procurement. The capital costs below show the costs of the Hope Hospital PFI scheme only:
Withdrawal of HSCCs from scheme costs	-19.4
Reconciliation	-3.2
Reduction of new build following review in 2003	-3.6
Increase in MIPs for Hope Hospital from 360 to 395	16.1
	186.2
Acute wards, Childrens Unit omitted	-16.0
Research—retained in existing	-4.0
Womens—retained in existing (previously adapted)	-6.0
General changes in dermatology/diabetes etc	-8.2
sub-total	152.0
Inflation to out-turn	38.0
Planned out-turn capital value	190.0
Tameside & Glossop
SOC cost	41.0
Improving the Patient Experience/modernisation	18.3
Equipment	3.5
Renal	1.0
MRI	1.6
Opthamology	4.2
NBI growth	4.5
EMI	10.1
Total OBC	84.2
Increase in MIPs from 395 to 425	7.4
Original scheme at MIPs 425	91.6
Reduction in scheme content	-8.3
revised scheme at MIPs 425	83.3
Inflation adjustment to out-turn	30.5
Planned out-turn capital value	114.7
Leeds Teaching Hospitals—Children's
Addition of Optimism bias

A	B	C	D	E	F
	Capital Cost at OBC Stage	Capital Cost Reported Last Year	Capital Value This Year	% Increase Since OBC Stage	% Increase Since Last Year
Midlands and Eastern	£m	£m	£m
University Hospital of North Staffordshire	224.0	308.0	391.3	74.7%	27.0%
University Hospitals Birmingham	291.0	440.1	696.0	139.2%	58.1%
Peterborough & Stamford Hospitals	135.0	293.0	381.0	182.2%	30.0%
Cambridge University Hospitals—Addenbrookes	30.0	76.0	76.0	153.3%	0.0%
Mid Essex hospitals—Chelmsford	80.0	121.0	186.0	132.5%	53.7%
Essex Rivers Healthcare—Colchester	79.0	139.0	216.0	173.4%	55.4%
Sherwood Forest Hospitals	66.0	147.4	296.0	348.5%	100.8%
Nottinghamshire Healthcare	13.9	19.4	19.4	39.6%	0.0%
University Hospitals of Leicester	286.0	447.0	574.0	100.7%	28.4%
Daventry & South Northants PCT	19.5	28.2	28.2	44.6%	0.0%
Northamptonshire Healthcare	19.5	28.9	31.2	60.0%	8.0%
Ipswich Hospital	24.9	26.0	35.0	40.6%	34.6%
Brentwood, Billericay & Wickford PCT	20.0	20.0	25.8	29.0%	29.0%
South Essex Partnership	17.0	17.0	25.0	47.1%	47.1%
Derbyshire Mental Health	31.6	31.6	28.5	-9.8%	-9.8%
Royal Wolverhampton1	110.0	312.0	317.0	188.2%	1.6%
Walsall Hospitals1	43.0	127.0	164.5	282.6%	29.5%
East Lincolnshire PCT	24.1	N/A	24.1	0.0%	N/A
East & North Herts/West Herts Hospitals	880.0	N/A	880.0	0.0%	N/A
Papworth Hospital	148.0	N/A	148.0	0.0%	N/A
Sandwell & West Birmingham Hospitals	591.0	N/A	591.0	0.0%	N/A
Southend Hospital	100.0	N/A	100.0	0.0%	N/A
Leicestershire Partnership	52.0	N/A	67.2	29.2%	N/A
TOTAL MIDLANDS & EASTERN	3,285.5	2,581.6	5,301.2
Notes:
1.  Schemes may change in scope after completion of Black Country review

COMMENT ON ANY INCREASE OVER 10%

North Staffordshire Hospitals

Uplift from MIPS 345 to MIPS 415

Inclusion of expansion and education space

Adjustment to outturn price level

University Hospitals Birmingham

MIPS increases (including shift to outturn MIPS reporting)

Additional carparks

Miscellaneous works including Trend Growth, enhanced external fac"ade, extra curtain walling, comfort cooling, patient hotel etc.

Cambridge University Hospitals

Inclusion of a genetics centre—capital cost £9 million. This was originally a separate scheme but has now been merged with the larger scheme. Inclusion of new DCAGs for "improving the patient environment". Inclusion of an integrated capital development to be funded by the University of Cambridge and the MRC (c £20 million)

Mid Essex Hospital

Inclusion of new DCAGs for "improving the patient environment"; 70 extra beds and two additonal theatres; removal of staff accommodation element.

Cost now based on outturn MIPS of 469 and 510 (two phased construction).

Peterborough

Inclusion of new DCAGs for "improving the patient environment". Expansion of cancer, renal and neo-natal intensive care services. Inclusion of £23.8 million Mental Health scheme.

Capital cost now based on outturn MIPS

Essex Rivers

Inclusion of new DCAGs for "improving patient experience", indexation and incorporation of NHS Plan targets and revised activity figures.

Capital cost now based on outturn costs

Sherwood Forest Hospitals

Inclusion of "improving the patient experience" standards; expansion of services, including emergency care and pathology; indexation. Changes since last year are mainly due to the impact of inflation (MIPS 415), development of the clinical design, inclusion of backlog maintenance, equipment requirements and increasing car park capacity.

Nottinghamshire Healthcare

Improvement of ICU facilities; additional office space; indexation

University Hospitals of Leicester

UHL Pathway project has increased by 56.3% since SOC approval. This is due to a number of factors: the application of "improving the patient environment" standards, inflation and the inclusion of the reprovision of academic space due to be replaced within the PFI. The difference between £447 million and £574 million is partly represented by £33 million on design development costs and the balance is due to inflation (MIPS)

Daventry & South Northants

Increase in capital cost due to inclusion of VAT, recalculation of inflation allowance and additional costs related to Local Authority planning requirements.

Northampton Healthcare

Revised models of care and "improving the patient environment". Trust currently working with commissioners to reduce the impact of changes to the original proposal.

Ipswich

Capital cost now based on outurn MIPS

Brentwood Billericay Wickford

Capital cost now based on outturn MIPS 452

South Essex Partnership

Inclusion of "improving the patient experience", indexation and the inclusion of additional community services

Derbyshire Mental Health

Derbyshire Mental Health—capital sum now excludes group 3 & 4 equipment and construction cost amendments

Wolverhampton

SHA has not yet signed off OBC due to Trust financial position; case being reworked for 2006

Walsall Hospitals

£127 million based on MIPS 385; latest value based on MIPS 448; further increase due to inclusion of Multi Professional Education Scheme in PFI (previously separate scheme)

Leicestershire Partnership

Leicestershire Partnership (AMHIRP) at SOC stage only—OBC expected March 2006. Figure quoted in column B at SOC stage—subsequent increase due to Building Inflation (MIPs).

Table 5.3.4

INCREASES TO THE CAPITAL COST OF PFI SCHEMES

A	B	C	D	E	F
London	Capital Cost at OBC Stage	Capital Cost Reported Last Year	Capital Value This Year	% Increase Since OBC Stage	% Increase Since Last Year
	£m	£m	£m
Barts & The London	620.0	1,052.0	1,128.0	81.9%	7.2%
Wandsworth PCT	20.5	57.4	75.4	267.8%	31.4%
Kingston Hospital	22.1	32.7	32.7	48.0%	0.0%
North Middlesex	73.0	100.8	108.0	47.9%	7.1%
Barnet & Chase Farm	41.0	79.8	79.8	94.6%	0.0%
Whipps Cross1	184.0	329.7	328.0	78.3%	-0.5%
North West London Hospitals—Northwick Park	305.0	N/A	305.0	0.0%	N/A
Royal National Orthopaedic Hospital	121.0	N/A	121.0	0.0%	N/A
Hillingdon Hospital	314.9	N/A	337.9	7.3%	N/A
LONDON TOTAL	960.6	1,652.4	2,515.8
Notes 1.  Whipps Cross is writing an options paper after second bidder pulled out of scheme. It is not yet known what format the new scheme will take. Comment on any increase over 10%

Barts and The London

  The Barts and The London OBC was approved at a cost of £462 million. The figure reported previously (£620 million) included an estimate for building cost inflation, due to the complexity and duration of the scheme. The increase to the current forecast outturn is explained as follows:

	£m
OBC approved capital cost (MIP295)	462
Changes in scope of project (MIP295)	237
Building cost inflation	429
Current forecast outturn cost (equivalent to MIPS 460)	1,128

  The OBC was submitted in November 1999 and used the then current MIPS index of 295 giving a base date for inflation calculation of 1997.

  The changes in scope include an additional 125 beds and other supporting facilities, improvements to the patient environment in line with the NHS Plan, and the removal of ICT systems (to be procured separately) from the scheme. All changes have been agreed with the Trust's commissioners.

  The current forecast outturn assumes construction takes place between 2005 and 2013. The £353 million building cost inflation equates to an increase of 51%. Building cost inflation, as measured by the NHS Estates MIPS index, has increased by 33% since 1997.

  Building cost inflation is estimated to be rising at approximately 3% to 5% per annum (this needs to be treated with caution as the predictive accuracy of the MIPS index is not strong and building costs can be volatile, particularly in London). The current forecast outturn includes an estimate of inflation up to the completion of the majority of the new build in the scheme in 2009.

  It should be noted that the increase from £620 million to £1,128 million is the cumulative increase over the last four years since the OBC was approved. All these figures relate to the Trust's Public Sector Comparator that has been updated periodically throughout the last four years to reflect the changing content of the scheme. A full review of the of the PSC was carried out during summer 2002 and more recently building cost inflation assumptions were updated in the light of information available to the Trust from its bid development process.

Wandsworth PCT

  The building price index (MIPS) has increased the base capital cost by £13.170 million. The location factor has increased from 12% to 23% as Wandsworth is deemed an Inner London Borough. This has increased costs by a further £2.551 million. Gross inflationary increases are £15.721 million. The SHA took a decision to include Mental Health (69 beds, Day Hospital and CMHT bases) and Shell Space to allow for future service provision in Summer 2002 amounting to a furhter cost of £19.236 million. Additional costs of equipment, lifecycle costs and revisions to programme resulted in an extra cost of £2.036 million.

Kingston

  OBC capital cost was £22.1 million based on a MIPS index of 310. The FBC capital cost is £32.7 million based on a MIPS index of 422. The movement due to inflation is £8.1 million. The movement due to changes in specification is £2.5 million which is 11% of the OBC cost.

North Middlesex Hospital NHS Trust

  The main reason for the increase is the 18% increase in out-turn inflation of £13.2 million due to upwards revision of MIPS indices since OBC. Pressures on accommodation requirements, including the issue of new HBNs has resulted in an increase in functional content of £4.8 million, or 4.6%. The active switching element of IT—£1.2 million—was expected to be funded directly by the Trust, however there is insufficient block capital funding available. The overall increase in the net cost of equipment is £3.7 million. The scheme also now includes Ophthalmology—£1.7 million, which the PCTs have asked to be included but was not in the original OBC, and approximately 2,200 sq m of shell space—£3.0 million.

  Since the last return the increase is primarily made up of some minor content changes and a separate Business Case approval (July 2005) for a new energy centre and 100% standby generation facility for the site which is now part of the project scope.

Barnet & Chase Farm Hospitals NHS Trust

  The functional content of the project has been revised to include an additional two theatres and an additional endoscopy suite. An additional 17 beds are also to be provided. The capital costs have also increased in line with the increase in MIPS and the consequent increases generated by this in fees, contingencies etc.

  The Trust has reviewed project scope and functional content with PCTs and the SHA to ensure congruence with Local Delivery Plans and commissioners' expectations. A revised OBC is being prepared and next year's return will reflect the agreed OBC position.

Whipps Cross University Hospital NHS Trust1

  The OBC was approved in principle in July 2003 and finally approved by the SHA in January 2004. The scheme cost has increased due to: changes in the MIPS index, change in location factor and the consequent increases in associated costs (fees, contingencies etc). The project has also responded in full to improving the patient experience and the revised space standards. The approved OBC sum was £328 million (with the SOC being £184 million). A schedule of decanting and enabling works has been developed to assist the future PFI provider in clearing the site. One of these early schemes is the creation of a new energy centre on the site which would have been necessary in any event. An uplift was agreed to the cost of this (due to building price inflation) which added a further net £1.7 million to the project control total.

Table 5.3.4

INCREASES TO THE CAPITAL COST OF PFI SCHEMES

A	B	C	D	E	F
South	Capital Cost at OBC Stage	Capital Cost Reported Last Year	Capital Value This Year	% Increase Since OBC Stage	% Increase Since Last Year
	£m	£m	£m
Taunton and Somerset—Cardiac	16.0	18.0	18.0	12.5%	0.0%
Portsmouth Hospitals	127.7	192.0	193.0	51.1%	0.5%
Oxford Radcliffe Hospitals—Cancer	60.0	99.7	129.0	115.0%	29.4%
Plymouth Hospitals1	101.0	274.4	N/A	N/A	N/A
New Forest PCT—Lymington	36.0	36.0	36.0	0.0%	0.0%
South Devon	65.0	250.0	341.2	424.9%	36.5%
Southampton	52.0	80.0	80.0	53.8%	0.0%
Maidstone & Tunbridge Wells	175.0	292.5	427.6	144.3%	46.2%
Heatherwood & Wexham Park Hospitals	550.0	N/A	550.0	0.0%	N/A
Taunton & Somerset	75.0	N/A	75.0	0.0%	N/A
Plymouth Hospitals1	200.0	N/A	200.0	0.0%	N/A
Plymouth Hospitals1	400.0	N/A	400.0	0.0%	N/A
North Bristol/South Gloucestershire	310.0	N/A	310.0	0.0%	N/A
TOTAL SOUTH	2,167.7	1,242.6	2,759.8
Notes 1.  The scheme at Plymouth has been halted due to lack of bidder interest. After rescoping it plans to go out to market as two separate schemes. Comment on any increase over 10%

Taunton & Somerset

  Increase from MIPS 325 to MIPS 360

Portsmouth Hospitals

  Impact of change from MIPs 378 to MIPs 415

  Improving the patient environment

  Additional 20 Maternity beds

  Impact of building regulations

Oxford—Cancer Centre Scheme

  Scheme increase from last year's figure of £99.7 million is optimism bias and VAT

South Devon Healthcare

Increases since last year

The movement in MIPS to take us from current cost, which the estimate last year was based on, to outturn cost when the hospital is completed is £76 million.	76
In addition we have reviewed the provision of a small number of services and made some minor amendments to the scheme to incorporate the Breast Care Unit, the TAIRU Unit and Occupational Therapy Building, Total Value £6 million. Previously the services provided in these areas were not being included within the PFI project.	6
In addition the figure submitted last year of £250 million was an estimated figure prior to the completion of an OBC. Since that time we have completed an OBC which was signed off by the SHA in May of this year. The work conducted for the OBC provided a more accurate costing and meant a movement in the figures of £9 million.	9
Total Increase in Year	91

Southampton

  Change to scope of scheme as SOC is updated.

Maidstone & Tunbridge Wells

  MIPS

  VAT & Optimism bias

  5.3.5  Could the Department provide an update of Tables 5.3.5, showing, for major projects (those greater than £25 million in value), a comparison between the PFI price and the publicly financed option. The publicly financed comparator's costings should be broken down as follows:

Basic construction contract, broken down between pre-implementation and post implementation costs;

The value of risk adjustment, again broken down between pre-implementation and post implementation costs, in both pounds and percentage terms, and

The final total real full life cost of both options. [5.3.5]

  ANSWER

  1.  The information requested is given in Tables 5.3.5(a) to (f).

Table 5.3.5(a)

NEWCASTLE UPON TYNE HOSPITALS

	Publicly funded option				PFI option
Phase of project	NPC (£m)	Risk (£m)	Risk (%)	NPC (£m)	Risk (£m)	Risk (%)
Pre-implementation	178.7	24.3	13.6	N/a	6.8	N/a
Post-implementation	85.6	17.1	20.0	N/a	1.3	N/a
Total	264.3	41.4	15.7	288.4	8.1	2.8
Risk adjusted total	305.7			296.5

Table 5.3.5(b)

CENTRAL MANCHESTER & MANCHESTER CHILDREN'S HOSPITALS

	Publicly funded option				PFI option
Phase of project	NPC (£m)	Risk (£m)	Risk (%)	NPC (£m)	Risk (£m)	Risk (%)
Pre-implementation	1,765.2	4.6	0.3	N/a	4.6	N/a
Post-implementation	2,856.7	64.7	2.3	N/a	5.2	N/a
Total	4,621.9	69.3	1.5	4,658.3	9.7	0.2
Risk adjusted total	4,691.2			4,668.0

Table 5.3.5(c)

LEEDS TEACHING HOSPITALS

	Publicly funded option				PFI option
Phase of project	NPC (£m)	Risk (£m)	Risk (%)	NPC (£m)	Risk (£m)	Risk (%)
Pre-implementation	383.7	7.5	2.0	N/a	1.1	N/a
Post-implementation	146.3	22.7	15.5	N/a	5.6	N/a
Total	530.0	30.2	5.7	535.7	6.7	1.3
Risk adjusted total	560.2			542.4
CGF benefit				(1) 535.3
Notes 1.  Leeds is the first of two pilot schemes to sign that utilises the Credit Guarantee Finance (CGF). 2.  Under CGF, instead of the private sector raising the money through traditional bond or bank debt finance, the Government provides the project funding (Senior debt) through issuing Government gilts. Benefits are that Government gilts are always cheaper than private sector borrowing. The private sector still retains the financial risks on the projects for which it adds a premium. The trust noted that the use of CGF in this case had created a £7 million saving to the public sector.

Table 5.3.5(d)

SHEFFIELD TEACHING HOSPITALS

	Publicly funded option				PFI option
Phase of project	NPC (£m)	Risk (£m)	Risk (%)	NPC (£m)	Risk (£m)	Risk (%)
Pre-implementation	29.2	4.4	15.1	N/a	1.0	N/a
Post-implementation	107.0	3.3	3.1	N/a	0.3	N/a
Total	136.2	7.7	5.7	140.5	1.3	0.9
Risk adjusted total	143.9			141.8

Table 5.3.5(e)

KINGSTON HOSPITAL

	Publicly funded option				PFI option
Phase of project	NPC (£m)	Risk (£m)	Risk (%)	NPC (£m)	Risk (£m)	Risk (%)
Pre-implementation	24,502.7	4,147.4	16.9	N/a	2,015.0	N/a
Post-implementation	187,511.5	26,288.1	14.0	N/a	6,809.1	N/a
Total	212,014.2	30,435.5	14.4	228,098.0	8,824.1	3.9
Risk adjusted total	242,449.7			236,922.1

Table 5.3.5(f)

NEW FOREST PCT—LYMINGTON

	Publicly funded option				PFI option
Phase of project	NPC (£m)	Risk (£m)	Risk (%)	NPC (£m)	Risk (£m)	Risk (%)
Pre-implementation	32,113.0	5,909.0	18.4	N/a	1,364.0	N/a
Post-implementation	174,790.0	6,281.0	3.6	N/a	3,074.0	N/a
Total	206,903.0	12,190.0	5.9	211,708.0	4,438.0	2.1
Risk adjusted total	219,093.0			216,146.0

  5.3.6  Could the Department provide an update of Table 5.3.6? [5.3.6]

  ANSWER

  1.  The information requested is given in Table 5.3.6.

Table 5.3.6

DONATED CAPITAL ADDITIONS (BY REGION) 1999-2000 TO 2001-02

	Land			Buildings, Installations & Fittings			Assets under Construction			Equipment			Totals
	1999-2000	2000-01	2001-02	1999-2000	2000-01	2001-02	1999-2000	2000-01	2001-02	1999-2000	2000-01	2001-02	1999-2000	2000-01	2001-02
	£000	£000	£000	£000	£000	£000	£000	£000	£000	£000	£000	£000	£000	£000	£000
Northern & Yorkshire	0	1	0	1,149	2,004	139	2,676	776	86	5,186	8,051	8,601	9,011	10,832	8,826
Trent	0	5	0	2,820	4,612	2,322	509	778	6,571	6,196	8,304	8,369	9,525	13,699	17,262
Eastern	96	0	0	3,318	3,356	1,269	2,128	1,304	2,828	2,805	5,316	5,842	8,347	9,976	9,939
London	192	115	0	18,443	6,478	5,791	9,665	22,875	20,603	8,558	12,281	12,837	36,858	41,749	39,231
South East	186	0	20	5,002	8,275	1,530	4,949	4,602	8,456	10,317	12,681	10,388	20,454	25,558	20,394
South West	0	0	0	4,517	4,142	2,825	5,822	6,094	12,953	4,000	9,526	5,590	14,339	19,762	21,368
West Midlands	0	0	115	2,305	3,190	1,614	2,947	3,558	1,354	4,354	7,580	7,701	9,606	14,328	10,784
North West	52	450	0	2,040	1,703	2,580	6,185	10,482	12,954	4,766	4,329	5,807	13,043	16,964	21,341
Total	526	571	135	39,594	33,760	18,070	34,881	50,469	65,805	46,182	68,068	65,135	121,183	152,868	149,145

DONATED CAPITAL ADDITIONS (BY DIRECTORATE OF HEALTH AND SOCIAL CARE) 2002-03

	Land	Buildings excl. dwellings	Dwellings	Assets under construction & payments on account	Plant & Machinery	Transport Equipment	Information Technology	Furniture & fittings	Totals
	£000	£000	£000	£000	£000	£000	£000	£000	£000
London	3	4,604	0	41,494	7,334	0	968	54	54,457
Midlands & the East	0	6,305	284	9,141	14,662	183	494	102	31,171
North	0	5,294	52	4,908	14,926	128	476	115	25,899
South	64	4,252	216	13,061	19,490	120	346	847	38,396
Total	67	20,455	552	68,604	56,412	431	2,284	1,118	149,923

DONATED CAPITAL ADDITIONS (BY STRATEGIC HEALTH AUTHORITY AREA) 2003-04

	Land	Buildings excl. dwellings	Dwellings	Assets under construction & payments on account	Plant & Machinery	Transport Equipment	Information Technology	Furniture & fittings	Totals
	£000	£000	£000	£000	£000	£000	£000	£000	£000
Avon, Gloucestershire and Wiltshire SHA	0	653	0	152	1,858	19	10	43	2,735
Bedfordshire and Hertfordshire SHA	0	2,571	0	84	196	713	8	153	3,725
Birmingham and the Black Country SHA	0	643	0	532	3,387	0	70	26	4,658
Cheshire and Merseyside SHA	0	1,655	0	457	1,697	13	78	13	3,913
County Durham and Tees Valley SHA	0	17	0	28	658	0	0	107	810
Cumbria and Lancashire SHA	0	148	0	906	2,975	0	7	23	4,059
Dorset and Somerset SHA	0	909	0	495	1,939	0	0	9	3,352
Essex SHA	0	30	0	0	1,708	0	5	5	1,748
Greater Manchester SHA	29	819	0	682	1,916	0	30	57	3,533
Hampshire and Isle of Wight SHA	0	6,988	0	537	2,448	30	0	0	10,003
Kent and Medway SHA	0	103	0	0	1,502	0	10	0	1,615
Leicestershire, Northamptonshire and Rutland SHA	0	141	0	0	894	0	0	0	1,035
Norfolk, Suffolk and Cambridgeshire SHA	0	234	0	217	1,286	0	72	3	1,812
North and East Yorkshire and Northern Lincolnshire SHA	0	1,322	0	0	385	0	2	0	1,709
North Central London SHA	0	1,272	0	27,379	854	0	295	5	29,805
North East London SHA	0	1,945	0	6,326	2,527	0	23	5	10,826
North West London SHA	0	3,565	0	532	3,424	0	537	92	8,150
Northumberland, Tyne and Wear SHA	0	537	0	179	2,849	27	117	6	3,715
Shropshire and Staffordshire SHA	0	1,107	0	954	1,397	0	28	24	3,510
South East London SHA	0	810	1	22,148	2,337	37	185	20	25,538
South West London SHA	0	274	0	4,224	2,851	0	0	0	7,349
South West Peninsula SHA	0	435	0	790	1,337	0	5	0	2,567
South Yorkshire SHA	0	464	7	9,093	2,527	130	111	45	12,377
Surrey and Sussex SHA	0	1,332	0	2,427	3,271	40	35	17	7,122
Thames Valley SHA	0	2,079	10	1,747	1,905	0	8	6	5,755
Trent SHA	0	1,538	0	3,068	1,695	22	5	7	6,335
West Midlands South SHA	0	214	0	0	965	8	81	0	1,268
West Yorkshire SHA	0	1,248	0	27	2,647	94	86	32	4,134
Total	29	33,053	18	82,984	53,435	1,133	1,808	698	173,158
Notes: 1.  Figures for 2003-04 are final and are shown by Strategic Health Authority area. Figures for 2004-2005 are not available. 2.  Figures for 2002-03 and 2003-04 are presented under different categories from previous years and cannot be readily shown by the old Regions. 3.  Donated capital additions is not separately disclosed in the NHS trust summarisation schedules from 2001-02 onwards and a proxy figure has been calculated from the total donated and government granted additions less the movement in government granted assets during the year. 4.  This introduces a small variance due to depreciation charged in the year on the government granted assets in effect increasing the value of donated additions in the table by the amount of depreciation. 5.  2004-05 figures (when available) will not include data from NHS foundation trusts.

  5.3.7  Could the Department provide an update of Table 5.3.7, specifying the cost of the unitary fee for PFI hospitals above that negotiated in the original contract? [5.3.7]

  ANSWER

  1.  The information requested is given in Table 5.3.7.

Table 5.3.7

INCREASE IN UNITARY FEE

A	B	C	D	E
Trust	Unitary fee at FC	Revised Unitary Fee	% change	Reason
	£000	£000
Worcestershire Acute Hospitals	19,399	22,280	14.9	Additional services extended to Newtown Site, Additional Equipment and other design and building changes required by the Trust.
Luton & Dunstable	1,021	1,139	11.6	Provision of an additional ward
West Middlesex University Hospital	9,700	10,746	10.8	Variations relating to new areas and charges for other areas receiving more usage than designed in the contract. In the first year of the scheme, other variable costs were incurred not identified in original unitary charge calculation. A 2.35% increase is reported over last year for further changes to the FM contract.
North Cumbria Acute Hospitals	13,377	14,772	10.4	Clinical & Domestic waste, Utilities and cumulatative effect of minor change orders.
South Manchester University Hospital Trust	19,754	21,697	9.8	Increased maintenance costs for the non-PFI estate. Increased number of wards and patient numbers leading to increased portering and catering requirements across the site and triggering volume payments for these services (totalling £3.14m) since FC. Also to note that the unitary fee is not level throughout the contract and some increases are due to the approved payment profile..
Nuffield Orthopaedic Centre	3,973	4,358	9.7	Contract variation the result of enhanced plant and changes to decant programme.
Queen Elizabeth Hospital	16,649	18,192	9.3	FM in the Education Centre (£114k), increase in Linen volumes due to additional activity (£188k), 24 hour food (snack boxes) (£50k), enhanced security (£78k), increased maintenance (£25k), enhanced catering (£150k), night service (£65k) and a reduction in payment for waste (£13k).
Leeds Teaching hospitals— Wharfedale	1,579	1,717	8.7	RPI from FC to completion, additional services.
University Hospitals Coventry & Warwickshire	50,211	53,926	7.4	In this first negotiation of the new Retention of Employment (ROE) model, trust accepted risk that Whitley pay rises would exceed RPI.
Barnet & Chase Farm Hospitals	16,679	17,775	6.6	Increase in IM&T Services (£138k), additional medical equipment (£691k), increased domestic and catering services (£321k) and maintenance (£17k).
Whittington Hospital	3,460	3,690	6.6	Variation to include retail area fit-out in scheme. Trust recoup money by acting as direct leaser of retail units.
Barking, Havering & Redbridge Hospitals	31,003	32,653	5.3	The increased unitary charge arose from the first Deed of Variation signed in August 2005. A new coronary care unit has been commissioned, (utilising "grey space" from the original design) which will create additional capacity for ITU and HDU beds in the hospital. A 60-bed emergency ward (again utilising "grey space") is being constructed, not to be immediately staffed, but to be set in reserve to accommodate future pressures on bed demand. The Trust has also strengthened the hospital's IT infrastructure by enhancements to cabling, cooling and physical security specification.
				Within the increase there are other variations such as increased cot space within NCIU/Neonatal services and the construction of an additional bunker for a linear accelerator for Cancer services. The increased unitary tariff arises from both the construction and on-going facilities management costs.
Norfolk & Norwich	28,401	29,788	4.9	Variations for provision of additional 144 beds; other variations including additional renal and cardiology facilities. In 2003-04 a refinancing of original deal led to a £1m reduction to the Unitary payments for a 30 year period. Variations on soft FM services. The revised fee is 0506 forecast fee and includes indexation increases.
King's Healthcare	17,989	18,811	4.6	Activity & meterage variation £411k, single use theatre drapes account for £504k increase, average service deduction £72k (increase in cost to Trust of theatre drapes partially offset by cessation on non-PFI external contract saving £208k).
St George's Healthcare	7,327	7,629	4.1	Last year's increase was due to an additional cardiac theatre, 12 cardiac beds, hot laboratory and additional ITU pendants reported in 2003/04. For this year an additional 126k per annum variation for ward hostess service is included.
County Durham & Darlington Hospitals - North Durham	10,916	11,303	3.5	8.3% Contract variation; 16.5% Benchmarking of FM services
Berkshire Healthcare	4,020	4,151	3.3	Contract variation to include relocation of Reading PCT intermediate care beds.
Greenwich Healthcare	18,620	19,073	2.4	Last years real terms increase due to Maintenance requirements of conference centre and IT. This year the Unitary Payment has increased for introduction of Better Hospital Food, Increased laundry volumes, increased cleaning and MRSA control, increased clinical waste volumes and portering changes.
Dudley	26,727	27,277	2.1	0.9% Pathology Contract variation; Extension of IT services
Northumbria Healthcare	3,706	3,779	2.0	Variation to add a small residences block.
Wandsworth PCT—Queen Mary's Roehampton	9,700	9,840	1.4	Increase relates to Trust variations for inclusion of a Burns Dressing Clinic, amendments to Trust Equipment Specification due to changes in technology (under Managed Equipment Service) and minor design changes. All figures are Trust estimates as the revised financial model has not yet been agreed.
RBBS PCT—Essex & Herts Hospital	1,873	1,895	1.2	Additional £158k of capital works, change to scope of portering and estates management services
Hereford Hospitals	9,690	9,803	1.2	Additional services and upgrade costs required by the Trust.
Swindon & Marlborough	17,956	18,121	0.9	Contract variation
County Durham & Darlington Hospitals—Bishop Auckland	5,728	5,743	0.3	Contract variation
Cambridge University Hospitals	6,295	6,308	0.2	Comfort cooling systems
Brent PCT—Willesden Health Centre	2,911	2,913	0.1	Minor variation

5.4  Capital investment in social services

  5.4.1  Could the Department update the figures provided last year on the acquisition, upgrade and sale of personal social services assets? [5.4.1]

ANSWER

  1.  The information requested is provided in Table 5.4.1.

Table 5.4.1

LOCAL AUTHORITY PERSONAL SOCIAL SERVICES CAPITAL EXPENDITURE AND INCOME 2000-01 TO 2004-05

	2000-01	2001-02	2002-03	2003-04	£ million 2004-05 provisional
Maintenance	12.3	12.5
New acquisitions	143.7	145.5
TOTAL SPEND	156.1	158.3	199.3	260.0	299.0
Sale of buildings	49.6	64.5
Sale of equipment	12.4	5.5
TOTAL SALES	62.8	70.4	75.0	74.5	77.0
NET SPEND	93.3	87.9	124.3	185.5	222.0
Notes: 1.  Figures may not sum due to rounding. 2.  From 2002-03 the breakdown between maintenance and new acquisitions and the sale of buildings and equipment is no longer available. 3.  Figures include children's services.

  5.4.2  Could the Department provide an update on PFI projects currently supported, or being considered by the Departments? [5.4.2]

  ANSWER

  1.  The Department's criteria for supporting PFI projects remain broadly unchanged: the Department is seeking to support innovative approaches to problems associated with social exclusion. This can apply to any social services client group such as older people, people with learning disabilities and people with mental health needs. The Department sponsors projects that are part of long term strategic service planning, that provide evidence of value for money and of flexibility. A joint white paper, designed to deliver integrated health and social care systems, will bring together proposals for both adult social care and all care received outside of hospitals. We will evaluate the criteria against the new White Paper.

  2.  Table 5.4.2 shows the PFI projects that have been approved to date.

Table 5.4.2

APPROVED PFI PROJECTS

Coventry	New Homes for Older People
Croydon	Older People
Dudley	Health and Social Care Centre
Ealing	Resource Centres for Older People
Enfield	Resource Centre for Older People with Cognitive Impairment
Greenwich	Neighbourhood Resource Centres for Older People
Hammersmith and Fulham	Nursing Care and Extra Care Housing for Older People
Harrow	Care Services for Older People
Harrow	Mixed Services for People with Learning Disability and Mental Health needs
Hertfordshire	Children's Homes Project
Kent	Integrated Health and Social Care Services
Leeds	Learning Disabilities
Northampton	Specialist Care Services for Older People with dementia
Portsmouth	Mixed Services for People with Learning Disabilities
Richmond	Care Services for Older People
Sheffield	Intermediate Care
Shropshire	Community Services for people with Learning Disabilities and Older People including a Joint Service Centre
Staffordshire	Children's Small Homes
Surrey	Services for Older People
Westminster	Resource Centre for Older People

  3.  Ministerial approval has been given to the following schemes on 29 July 2005:

BIRMINGHAM

  This bid, for £34.7 million, is set in the context of a five-year strategy for future provision of services to older people.

EAST SUSSEX

  This bid focuses on services for older people, and contains a very clear description of the intended sites (4) and the nature and quantity of services to be provided from them. PFI credits of £34.7 million have been requested.

MEDWAY

  This bid, proposed to be procured via a LIFT, is for developing two centres of excellence focused on older people. The services will include preventative, enabling, recuperative and rehabilitative facilities (separate bid to ODPM). PFI credits of £17.34 million are sought.

TOWER HAMLETS

  This bid, for PFI credits of £15.97 million, is to deliver three health and social care centres via LIFT. The focus is independent living—people with disabilities, people with learning disabilities.

WOLVERHAMPTON

  This bid is for £22.6 million of PFI credits, DH only, to deliver a range of social care services through LIFT. The services will be a range of adult social services: older people, mental health and learning disabilities, provided on a "hub and spoke" model. Three hubs and three spokes are envisaged.

  4.  Social Services PFI continues to increase, including for people with learning disabilities and people with mental health needs. The demand for services for older people remains the highest. Generally, much of the demand is in response to Local Authorities' long-term strategic planning and Best Value reviews of their current provision of care services for social services client groups, for example, residential and nursing care for older people. Social Services' joint working with health is well established, with some developing partnerships with other key services such as housing, where the Department of Health works with ODPM. Links are developing with NHS LIFT schemes (Local Investment Finance Trusts, for capital investment in primary care building stock), particularly in Sheffield where the PSS scheme is joint with the local LIFT.

  5.4.3  Could the Department compare actual capital spend by social services departments with the funding provided through credit approvals and capital grants? [5.5.4]

  ANSWER

  1.  Table 5.4.3 compares total actual capital spend by social services departments with the funding provided by the Department through supported capital expenditure. The table shows that capital support provided by the Department is only one source of capital for local authorities. Local authorities can fund their capital requirements in other ways, through capital receipts, joint funding, EC funding and through the Private Finance Initiative. Additional capital support is also provided by the Department for Education and Skills which took over responsibility for children's social services from 1 April 2003.

Table 5.4.3

LOCAL AUTHORITY PERSONAL SOCIAL SERVICES CAPITAL EXPENDITURE, DEPARTMENTAL SUPPORTED CAPITAL EXPENDITURE 2001-02 TO 2004-05

	2001-02	2002-03	2003-04	£ million 2004-05 provisional
TOTAL SPEND	158.0	199.3	260.0	299.0
Capital grants	9.3	40.7	25.0	25.0
Credit approvals/supported capital expenditure (revenue)  55.7		55.7	50.2	52.9
TOTAL PROVISION	65.0	96.5	75.2	77.9
Notes: 1.  Figures may not sum due to rounding. 2.  Figures include children's services up to 2002-03. 3.  Credit approvals were abolished on 31 March 2004.

6.  Questions on the Departmental Annual Report

  6.1  The Department has re-profiled administration spending review figures for 2004-05, 2005-06 and 2006-07, bringing forward £23 million from the latter two periods to 2004-05 to meet the upfront costs of the change programme. Can you provide more detail of this re-profiling. What has the £23 million been spent on? Is this a straight transfer, or will further savings need to be found in 2005-06 and 2006-07 to pay for this movement?

  ANSWER

Detail of re-profiling

  1.  £12 million was brought forward from 2005-06 to 2004-05 and £11 million from 2006-07.

What was the £23 million spent on

  2.  The money contributed to the upfront costs of the Department's major change programme which saw the Department slim down from 3,645 to 2,245 staff and refocus to become a more strategic organization with operational delivery devolved throughout the system.

Is this a straight transfer?

  3.  This is a straight transfer; no specific further savings will need to be made in 2005-06 or 2006-07 to accommodate it. However, the Department—along with the NHS and Social Services—is committed to making efficiency gains in the region of 2.5% per year over the period.

  6.2  The Department has exceeded its own target of reducing data collection by 20% by March 2005. Can you list the data no longer collected. Do you have any sense of the extent to which data users have been affected by the cessation of such collections and associated Departmental analyses. Can you list any new data collection that has been undertaken since the setting of the target.

  ANSWER

  1.  Table 6.2(a) lists all ongoing (ie recurrent) DH data collections discontinued between 1 April 2004 and 31 March 2005. Table 6.2(b) details new ongoing DH collections approved from 1 April 2004 to the present.

Target and achievement

  2.  In March 2004 PS(L) set a target for the reduction of the burden of ongoing data collection by DH from the NHS by 20% by the end of March 2005. The burden is expressed in person years, which are an estimate of the total time the NHS spends on producing information for others. The target implied a cut of about 120 person years from the estimated total of 600 in March 2004; in fact a net reduction of one third or 200 person years was achieved.

Reduced burden

  3.  The total reduction included collections completely discontinued, as well as those reduced in scope; both are shown in Table 6.2(a).

Effects of cutting collections

  4.  All proposals to drop or reduce central collections were subject to consultation with internal DH and (where applicable) external users. The risks of stopping collection, eg perceived reductions in accountability or ability to manage through lack of information were considered and weighed against the benefit to the service of freeing resources for more patient related work. In all cases agreement was reached that the information was no longer required for central purposes, or could be satisfied by less frequent returns (eg reducing quarterly returns to annual). Generally there has been no adverse reaction to the cuts, though through the consultation process the Society of Chiropodists and Podiatrists did initially raise objections to the discontinuation of the annual KT23 Chiropody activity return; these were withdrawn when assured that alternative data would continue to be collected.

New collections

  5.  Table 6.2(b) lists all new ongoing DH data collections approved since 1 April 2004, when the target for reduction in burden was set. The list excludes changes to existing collections, and as noted above the net effect on the overall burden was a reduction of one third by March 2005. Since the target was set, agreed new collections have had only small burdens—those listed amount to less than 10 person years in total.

Background

  6.  All information collections by the NHS and its arm's length bodies (ALBs) are regulated by the Review of Central Returns (ROCR) process, which since 1 April 2005 has been based in the NHS Health and Social Care Information Centre. The process ensures that all collections are fit for purpose, keep the burden on the NHS to a minimum, and that only essential information is collected. ROCR's remit until recently covered only DH returns, but has now been extended to regulate those from ALBs too, as well as the burdens placed on the service by other Government Departments, regulatory bodies and the private sector.

  7.  The burden of an information collection is the amount of work the NHS have to do to collect, complete and return the data required to the collecting organisation; if the NHS already gathers the information for its own purposes, those "internal" costs are not included. ROCR was created in 1997 to regulate this overall burden and measure the impact on the service, and person years was chosen as it allows us to quickly establish an estimate of burden, providing a useful balance between accuracy and timeliness. In particular, it has proven beneficial when considering the relative merits of collections and should be seen in that light rather than an absolute measure. It is understood by the service, is used by the NHS and as the basis of other burden measurement systems in government.

Table 6.2(a)

ONGOING COLLECTIONS DISCONTINUED OR REDUCED IN SCOPE 1 APRIL 2004-31 MARCH 2005

Name of collection	Description
Discontinued collections
Patient Care in the Community: District Nursing KC56	Annual collection of District Nurse activity data, previously used in the implementation and monitoring of Caring for People and Community Care Reforms.
Patient Care in the Community: Community Mental Health Nursing KC57	Annual collection of Community Psychiatric Nurse activity data, previously used to monitor the provision of Care in the Community and implementation of NSFs. Replaced by data available from the Mental Health Minimum Dataset.
Patient Care in the Community: Community Learning Disability Nursing KC58	Annual collection of Community Learning Disability Nurse activity data, previously used in the implementation and monitoring of Caring for People and Community Care Reforms.
Patient Care in the Community: Specialist Care Nursing KC59	Annual collection of Specialist Care Nurse activity data, previously used in the implementation and monitoring of Caring for People and Community Care Reforms.
Practices below a minimum standard	Collected annual data on Practices below a minimum standard to monitor against the improvement of GP practice premises against targets. Discontinued as the Disability Discrimination Act changes criteria for measuring premises compliance.
Summary of Chiropody Services KT23 Summary of Clinical Psychology Services KT24 Summary of Occupational Therapy Services KT26 Summary of Physiotherapy Services KT27 Summary of Speech and Language Therapy Services KT29	Annual returns on activity of these Allied health professionals groups; discontinued as similar information already available from DH Reference costs data.
Cancer Waiting Times (Monitoring the two week target QMCW	Quarterly information on full range of cancer waiting times by time bands, superceded by Cancer waiting times database
Consultant Outpatient Clinical Activity KH09	Annual performance management data on "did not attends" and ratio of first to subsequent attendances; central monitoring no longer required
NHS Day Care Availability and Use of Facilities KH14	Annual return used to monitor NHS Day Care Facilities; central monitoring no longer required
Summary of Ward Attenders KH05	Measures hospital activity for patients seen in hospital by nursing staff; central monitoring no longer required
GP Landlords expenses survey: notional rents and interest on loans	Survey of HAs, Health Boards and GP accountants to establish what proportion of the notional rent payments are used to cover interest on loans; superceded due to new GP contract
GP Accounts Survey	Collected financial information from GPs and their accountants; superceded due to new GP contract
Acute Hospital Patient Centred and Clinical Information Systems Survey	Annual survey providing feedback on the level and status of systems implementation in England
Monitoring violence, accidents and harrasment targets	Annual return monitoring progress towards NHS Plan targets, now expired
Progress on implementing S21 of the Disability Discrimination Act	Annual return of resources and workload of the units comparisons by authority area; no longer required as monitoring completed
Controls Assurance Data	Provided evidence for the system of internal control in NHS Trusts, and underpinned the Duty of Quality. Information no longer required centrally under Shifting the Balance of Power (StBOP) arrangements.
Health Visiting and other professional advice and support in the community KC55	Annual activity data on Health Visitors. Monitored changes in health visitng workload, also used in negotiations, resource allocation to the NHS and departmental accountability
Quarterly monitoring of Cancer Bookings (QMCB)	Collection from trusts and PCTs monitoring target that all cancer patients benefit from pre booked care from 2004 Discontinued as the introduction of Choose and Book whic changed the processes by which GP referrals are made has made and which also covers cancer patientshas made a separate collection unnecessary.
NHS Plan - Monitoring of planned workforce increases	Monitors proposed increases in staff numbers as part of the NHS Plan; no longer required as targets met or monitored adequately by other returns.
Collections reduced in scope
Weekly SITREPS	Collection focusing on emergency care; information collected on capacity, demand and performance. Some data items discontinued—ambulance B&C category calls, A&E closure times, ordinary and day case admissions. Emergency and cancelled operations data changed from weekly to monthly collection.
ERIC return (collection of data on NHS Estates and facilities)	Discontinuation of some data items, others made voluntary
General Opthalmic Services Sight tests, vouchers and repairs/replacements survey SBE515	Reduced in scope and burden; data now obtained from central payments system
Medical and Dental workforce census and other workforce returns	Reduction in frequency of workforce collections from quarterly to annual
Patient's Charter Key Standards return QMOP	Quarterly monitoring of outpatients; reduction in number of questions
DH Finance returns	A general review of financial data led to reductions in scope and frequency of many returns
Workforce Vacancies collection	Reduction in level of detail, removal of staff in post element
Monthly Monitoring Return	Data on progress towards key waiting times targets and underpinning capacity assumptions; reduced in burden by stopping returns in quarter ending months, already collected elsewhere
Community Dental Health Services KC64 Emergency Dental Services EDS1	Annual collections of dental data; reduced in scope and now collected online
Newly Reported HIV Infected Persons (Cumulative)	Reports prepared under the AIDS (Control) Act 1987. To provide information about the progress and treatment of the disease; three reports amalgamated into one and reduced in scope.

  *Source: Review of Central Returns database.

Table 6.2(b)

NEW ONGOING COLLECTIONS APPROVED SINCE 1 APRIL 2004

Name of collection	Description
New collections approved 1 April 2004-31 March 2005
NHS Pension Scheme Contributions	Collection to gather assurance from contributors to the NHS Pension Scheme that they are paying the correct level of contributions.
Department of Health Stakeholder Perceptions Audit (DH Stakeholder Survey)	Biannual survey to obtain more rigorous data on how DH is perceived as a department.
Number of frontline 999 ambulances in full operational use with 12 lead ECG equipment	To establish ambulance service capacity of 12 Lead ECG equipment.
National Orthopaedics Project—position statement	A quarterly collection of a position statement from SHAs as part of the National Orthopaedic Project.
Primary Care Modernisation Programme—Market Research Project	Biannual research project to help improve communications on aspects of the NHS modernisation programme amongst primary care health professionals.
Monitoring PPF Cancer Targets (T10 and T11)	Biannual collection to support performance management of cancer targets untiol 2010, when cancer mortality target is due to be met.
National Programme for IT—Baseline NHS Tracker	Annual survey to assess awareness and understanding and support for the National Programme for Information Technology.
Health Professionals 2004 Childhood Immunisation survey	Annual telephone survey to ascertain the impact of the Childhood Immunisation campaign amongst GPs, health visitors and practice nurses.
Consultants Claiming an Award	Annual collection of information from commissioning organisations to support allocation of money to pay the Distinction and Clinical Excellence Awards.
Consultants Clinical Excellence Awards	Information collected for the Annual Report for Clinical Excellence Awards from Local Awards Committees, used to demonstrate that the process was completed fairly and in accordance with guidelines issued by ACCEA.
Genito-Urinary Medicine waiting times	A six monthly audit of attendees at GUM clinics, to monitor a 48 hour access to services target.
Supply Chain Excellence Programme	Monthly collection of pharmacy purchasing data by download from NHS Trust systems, to enable effective national contracting for the supply of pharmaceuticals to the NHS in England.
New collections approved since 1 April 2005
Database of Countermeasures	A quarterly report on maintenance of emergency equipment held for chemical, biological, radiological or nuclear incidents by Ambulance Trusts.
"Buy back" of local NHS dental capacity	Numbers of additional dentists SHA's have purchased with the £50 million special allocation of 2004-05; time limited collection until targets are met.

  *Source: Review of Central Returns database.

  6.3  No explanations are given for any of the four PSA targets described as being subject to "slippage". Can this be provided please.

ANSWERTeenage Pregnancy Targets

  1.  Over the five years from 1998 (the baseline year for the Teenage Pregnancy Strategy) to 2003, the under 18 conception rate for England fell by 10%. This rate of decline suggests the 2004 15% reduction target is likely to be missed. Furthermore, to reach the target of halving the under 18 conception rate by 2010 there needs to be a markedly steeper rate of decline from 2003 onwards.

  2.  A regional breakdown shows that under 18 conception rates in all regions, apart from London, have declined overall between 8% and 16% from 1998-2003 (Table 6.3(a)). In London, rates have remained unchanged.

Table 6.3(a) CHANGE IN UNDER 18 CONCEPTION RATES BY REGION 1998-2003

	1998	2003	1998	2003	% change
Region	Number	Number	Rate	Rate	(1)1998-2003
England	41,089	39,560	46.6	42.1	-9.8
North East	2,731	2,604	56.5	51.9	-8.1
North West	6,457	6,149	50.3	44.9	-10.7
Yorkshire & Humber	4,806	4,587	53.1	46.7	-11.9
East Midlands	3,632	3,323	48.8	41.2	-15.5
West Midlands	5,085	4,957	51.7	47.2	-8.7
East	3,592	3,369	37.9	33.3	-12.2
London	6,042	6,500	51.1	51.1	0.0
South East	5,384	4,927	37.8	33.0	-12.7
South West	3,360	3,144	39.4	34.2	-13.3
Source: National Statistics and Teenage Pregnancy Unit, 2005 Notes: 1.  Change in rates calculated from unrounded figures

  3.  Local authority and ward level data show the geography of teenage pregnancy is strongly associated with deprivation and is highly concentrated, with 50% of teenage pregnancies occurring in the 20% of wards with the highest under 18 conception rates. To achieve the steeper rate of decline required to meet targets the Teenage Pregnancy Strategy is strengthening and intensifying delivery of the Strategy to high rate neighbourhoods and vulnerable groups. Additional work with Government Office for London is also underway to address the increasing teenage pregnancy rates in many London Boroughs.

  4.  Provision of effective contraceptive services is a key aspect of the strategy to reduce teenage pregnancies. The Government recognised in the Choosing Health White Paper that contraceptive services are in need of resources and increased priority. £40 million will be invested in 2006-07 and 2007-08 (£20 million each year) to address gaps in service provision. This will be informed by a comprehensive national contraceptive audit so that we can be sure that we are clear, both locally and nationally, exactly how to best modernise this important part of sexual health services. In addition, £50 million is being invested, in a new high profile media campaign aimed at young people. This will highlight the risks of unsafe sex and promote the use of condoms, which can prevent sexually transmitted infections and unintended pregnancies. Both of these measures should support achievement of the Teenage Pregnancy Strategy targets.

ACCIDENT DEATH RATES AND SERIOUS ACCIDENTAL INJURY

  5.  Latest data for 2001-03 for CSR 1998 target 3 (reduction in the death rate from accidents) show an increase of 0.8% from the baseline (1995-97). The 65 and over group accounts for the main part of the increase in the death rate from accidents, and falls account for the main part of the increase in the death rate from accidents in those over 65. See Tables 6.3(b) and 6.3(c).

  6.  Latest data for 2002-03 for CSR 1998 target 4 (reduction in the rate of hospital admission for serious accidental injury) show an increase of 3.8% from the baseline (1995-96). Again, the 65 and over group accounts for the main part of the increase in the admission rate. Falls account for nearly three-quarters of admissions for serious accidental injury in the 65 and over group, and are a key factor in the increase in the admission rate. See Table 6.3(d).

  7.  The latest data for CSR 1998 targets 3 and 4 (for 2001-03 and 2002-03 respectively) pre-date many of the interventions put in place to tackle falls in older people, whose impact is not yet reflected in the currently available data:

—  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. The main increase in integrated falls services took place towards the end of 2003 and throughout 2004. By April 2005 nearly 90% of primary care trusts had met the milestone, and full compliance is expected by October 2005.

—  In November 2004, the National Institute for Clinical Excellence (NICE) published guidelines on falls prevention. Also NICE published in January 2005 a technology appraisal on "The clinical effectiveness of technologies for the secondary prevention of osteoporotic fractures in postmenopausal women." In addition it is due to publish another technology appraisal covering the clinical effectiveness of technologies associated with primary prevention in September 2005, and comprehensive guidelines on the assessment of future risk of osteoporosis and the prevention of fractures in individuals at high risk in February 2006.

—  Lessons learned from the Healthy Communities Collaborative have been disseminated through workshops and the Department of Health has contributed to disseminating other examples of effective falls reduction eg examples of falls services across England published in 2003, and guidance for staff in residential care homes in May 2004.

—  Help the Aged have continued development of the Slip, Trips and Broken Hips website which dedicates a section for practitioners providing resources, research and links to help work with older people and to reduce the risk of falling

—  The Department of Health is also funding projects on increasing and encouraging physical activity in residential care and the availability of training for those offering exercise as part of falls prevention.

  8.  Despite the slippage in the over 65 age range, there are encouraging signs with the latest data for 2001-03 showing a reduction in accident mortality rates in age bands under 15 and 15-24 years. This suggests that various Government funded initiatives and partnerships with organisations such as the Child Accident Prevention Trust and the Royal Society for the Prevention of Accidents are contributing to reducing deaths and serious injury in younger age groups.

Tackling health inequalities: Status report on the Programme for Action

(www.dh.gov.uk/Publications AndStatistics/Publications/PublicationsPolicyAndGuidance/Publications

PolicyAndGuidanceArticle/fs/en?CONTENT—ID=4117696&chk=OXFbWI) was published in August and it reports primarily on data to 2003. This does not necessarily reflect the impact of current policies. However, it does indicate that some of the headline indicators like reducing child poverty and improving housing quality are moving in the right direction.

  15.  By 2006, we will have new data on smoking throughout pregnancy and breastfeeding initiation rates from the 2005 Infant Feeding Survey. These are proxy measures for maternal and infant health and risk factors for infant mortality. These new data will update information from the 2000 Infant Feeding Survey, and will give an early indication of progress in these important areas.

Table 6.3(b)

DEATH RATES FROM ACCIDENTS— PROGRESS BY SELECTED AGE GROUPS

Age group	Death rate from accidents per 100,000 population
	1995-97	2001-03	% change 1995-97 to 2001-03
Under 15	4.1	3.0	-26%
15 to 24	17.8	15.3	-14%
25 to 64	13.0	13.1	1%
65 and over	50.1	56.6	13%
Source: Notes 1.  Death rates are directly age-standardised rates for all persons, England 2.  A % change less than 0 is a reduction, greater than 0 is an increase 3.  1995-97 data coded using ICD9 (codes E800-E928 exc E870-E879 used for accidents); 2001-03 data coded using ICD10 (codes V01-X59 used for accidents). Due to the change from ICD9 to ICD10 there are small discontinuities in the comparison between the two periods

Table 6.3(c)

DEATH RATES FROM ACCIDENTS AMONG AGES 65 AND OVER— CONTRIBUTION OF SELECTED ACCIDENT CATEGORIES

Accident category	Death rate from accidents per 100,000 population
	1995-97	2001-03	Contribution to all accidents % change for ages 65 and over
Land transport accidents	7.8	7.0	-2%
Falls	14.1	19.0	10%
Drowning and submersion	0.4	0.4	0%
Smoke, fire and flames	2.3	1.6	-1%
Poisoning	1.1	0.9	0%
Other and unspecified accidents	24.3	27.7	7%
Total % change			13%
Source:  ONS Notes: 1.  Death rates are directly age-standardised rates for all persons, England 2.  The contributions from each accident category are the impact of each category on the change for all accidents (not the % change in the death rate for each category) 3.  The contributions from each accident category sum to the % change for all accidents for ages 65 and over 4.  A contribution to % change less than 0 is a reduction, greater than 0 is an increase 5. 1995-97 data coded using ICD9; 2001-03 data coded using ICD10. Due to the change from ICD9 to ICD10 there are small discontinuities in the comparison between the two periods.

Table 6.3(d)

ADMISSION RATES FOR SERIOUS ACCIDENTAL INJURY—PROGRESS BY SELECTED AGE GROUPS

	Admission rate for serious accidental injury per 100,000 population
Age group	1995-96	2002-03	% change 1995-96 to 2002-03
Under 5	131.7	97.2	-26%
5 to 14	120.8	84.1	-30%
15 to 64	221.2	223.3	1%
65 and over	1,280.2	1,442.5	13%

  Source: Hospital Episode Statistics

  Notes

1.  Admission rates are directly age-standardised rates for all persons, England.

2.  A % change less than 0 is a reduction, greater than 0 is an increase.

3.  ICD10 codes V01-X59, Y40-Y84 used for all accidents.

4.  Figures for 1995-96 are estimates based on trend for subsequent years (due to data quality problems for some areas in 1995-96).

  6.4  In respect of SR 2004 target 1, on what basis have the links between the sub targets and the specific life expectancy targets been established? How much control can the Department and frontline staff realistically be expected to have over life expectancy given the importance of external factors such as the overall state of the economy?

  ANSWER

  1.  The sub-targets in PSA target 1 will contribute to achievement of the overall life expectancy objective and to the life expectancy element of PSA target 2 on health inequalities. Other PSA targets will also support the life expectancy targets, particularly the PSA 3 sub-targets. On their own this suite of targets cannot achieve the life expectancy targets, but their impact is expected to be significant. It will be necessary for a wide range of other activity, by a range of organisations and individuals, to be taken to improve overall life expectancy and to narrow geographical health inequalities. For inequalities, the breadth of activity has been set out in Tackling health inequalities: A Programme for Action.

  2.  Because such a wide range of activity is needed, and because there is a large range of factors and interventions, which change over time and will impact on the target over different timescales, and which are themselves inter-related (eg smoking impacts on cancer, heart disease and respiratory disease), it is not possible to determine precisely what the contribution of each PSA 1 sub-target will be, particularly in respect of the 2010 target date. However, between them they cover the big killers (cancer and cardiovascular disease (CVD)) and, in suicide, an important marker of effective mental health services which impact on morbidity and mortality. These three causes of death combined are currently responsible for around 70% of all deaths under the age of 75 in England.

  3.  As far as control is concerned, improvements in life expectancy cannot be delivered solely through the action of the Department of Health and NHS frontline staff, but will depend also upon non-health sectors, including other Government departments and agencies, business and the community and voluntary sectors, as well as individuals, and also upon wider societal influences. However, DH and NHS staff do have a major role to play, especially on the achievement of mortality targets where the 2010 time horizon means achievement will depend on delaying the premature mortality of those who already have disease or are at high risk of disease. Developing and communicating policy, implementing the National Service Frameworks, modifying risk factors such as smoking, providing treatment services, primary and secondary prevention are activities which will have high impact on reducing mortality quickly. The White Paper Choosing Health—Making healthy choices easier (2004) and its delivery plan (2005) set out a broad programme to make it easier for everyone to choose health, including giving priority to tackling health inequalities.

  6.5  In respect of SR 2004 target 3, is the sub target of halting the year-on-year rise in obesity among children under 11 by 2010 a sufficiently challenging aim? At what point will the trend be reversed?

  ANSWER

  1.  Obesity in 2-10 year olds rose, on average, by 0.8% per year between 1995 and 2002. England is not the only country to experience a rapid increase in the prevalence of obesity. Although the rates differ between countries, virtually all countries have shown an increase over the last two decades. Halting the rise in obesity by 2010 is indeed a challenge as no country has yet managed to neither halt nor reverse the trend. England is however acknowledged particularly in Europe as being ahead of the game with a clear strategy and focus to tackle obesity as set out in the Public Health White Paper.

  2.  Obesity is a complex multi-factorial condition with wide-ranging causes—social, cultural, behavioural factors requiring a multi-pronged approach. Several interventions are already well in train, and several more are in development and will come on stream over the 18 months including the Obesity Social Marketing campaign and the impact of restricting Food Promotion to children.

  3.  Central to tackling obesity is the National Healthy Schools Programme that has now been made more rigorous. From September, schools will be required to satisfy all the criteria under four core themes, which include "Healthy Eating" and "Physical Activity". More funding has been provided this year to local programmes to strengthen delivery and we will ensure that programme staff are supported and resourced to effectively promote and co-ordinate action on obesity.

  4.  We expect that the cumulative impact of the above multiple interventions to improve diet and increase physical activity would be significant. Many of the planned interventions aim to bring about a sustained change in behaviour to make healthy lifestyle a norm.

  6.6  In respect of SR 2004 target 4, is the baseline for emergency bed days confirmed as being the expected 2003-04 number rather than the actual figure? Does this not create a situation in which a 5% reduction from the baseline could fall short of achieving the desired outcome?

  ANSWER

  1.  The baseline figure for emergency bed days is the actual figure taken from the Hospital Episodes Statistics (HES) data collection.

  2.  A subsequent refresh of the 2003-04 data is currently being undertaken as errors were found in data submissions from a small number of NHS trusts. We would expect the refresh to show a minimal change in the baseline as only a small number of trusts were found to have deficiencies in their 2003-04 HES data.

  6.7  In respect of SR 2004 target 6, will the participation sub target be measured in absolute terms? Does this not ignore the potential for the population of problem drug users to grow, which could allow for the target of 100% increase in participation to be met alongside an increase in the number of problem drug users not participating in drug treatment programmes?

  ANSWER

  1.  There is currently no direct link between the numbers in treatment as we do not yet understand the relationship between successful prevention and treatment interventions, prevalence of drug use and the growth (or decline) of the problem drug user (PDU) population. Understanding this is a priority to future planning of drug strategy delivery and is currently being explored as part of a Prime Minister's Delivery Unit/National Treatment Agency (NTA) review of treatment effectiveness, which also involves officials from the Department of Health and the Home Office.

  2.  We are currently working on an assumption that the number of PDU will remain constant at around 280,000 so that when we meet our PSA target to double the numbers in treatment by 2008, 60% of PDUs will enter treatment during the course of each year.

  3.  It should also be noted that increasing numbers of dependent users are now stabilised and rehabilitated, no longer offending or experiencing significantly increased health harms but are receiving long-term methadone maintenance. At the moment they are still be regarded as PDUs, this may also need to be reviewed.

  6.8  In respect of SR 2004 target 7, why is success defined merely as achieving increasingly positive national survey results under each patient dimension, rather than stipulating some magnitude of increase?

  ANSWER

  1.  Progress against the patient experience PSA target is measured via the national patient survey programme, which the Healthcare Commission is responsible for managing. The survey programme is one of (if not the) largest programmes in existence: surveys are setting-based (each trust and PCT is responsible for conducting their own survey in line with standardised guidance) and, since 2001, around a million patients have taken part in 13 surveys across seven care settings.

  2.  The survey programme is designed to provide a robust and detailed measure of the experience of recent service users at a national and local level. While the PSA is reported at a national level, the "national average" is simply an aggregation of the results of all trusts participating in each survey wave. This means that each trust contributes towards the PSA target—positively (ie improved performance over time) or negatively (declining performance or no change). In this way, the PSA target relies on the continuous improvement of each trust in their performance on the surveys, as measured against their own baseline.

  3.  The survey programme is relatively young, and until analysts at both DH and the Healthcare Commission have the opportunity to fully inspect a run of time series data, then it is not possible to make a judgement on a pass/fail measure or indeed any other absolute figure for improvement.

  4.  The design of the current survey programme balances the desirability for frequent patient feedback with the financial costs involved for participating trusts and PCTs. On this basis, baseline data and repeat surveys are only now just becoming available. Research is ongoing during 2005-06 to assess the extent to which systematic differences in trust performance may be associated with different organisational practices. Clearly, this information was not available when setting PSA targets for SR 2002 and SR 2004. However, this evidence base will inform decisions on future outcome measures.

  6.9  In respect of SR 2004 target 7, does the sub target of ensuring that individuals are fully involved in decisions about their healthcare, including choice of provider, mean that survey results should show 100% agreement with this statement? Why is no timeframe set out for this sub target?

  ANSWER

  1.  The PSA for SR 2004 carries forward from SR2002, but now with explicit reference to involvement in decisions about healthcare. This acknowledges the top priority reported by the public and users in the national consultation Choice, Responsiveness and Equity. Choice of provider is explicit in the wording of the PSA to highlight what is a significant reform.

  2.  These elements are tested using the same vehicle as for the rest of the PSA ie through the national survey programme administered by the Healthcare Commission. We have not stipulated a timeframe as both elements are live and will be tested in relevant surveys during the full period of the PSA ie 2005-08.

  3.  All questionnaires test the theme of involvement. For example, patients are asked: "Were you involved as much as you wanted to be in decisions about your care and treatment?" They are invited to select one of the following response categories. This example shows results from the 2004 adult inpatient survey.

  Were you involved as much as you wanted to be in decision about your care and treatment?

  In patient survey published August 2004

	National average %	Number
Yes, definitely	52%
Yes, to some extent	36%
No	11%
Total specific responses		85,773
Missing responses		2,535

  Answered by all

  4.  This shows that 88% of inpatients reported that they were involved. Whilst this is already a high figure the challenge is to move more respondents into the "yes, definitely" category, and to reduce the number who respond negatively. It is highly unlikely that any subjective questionnaire on public services would result in 100% of the sample reporting in the top response category.

  5.  For the choice of provider element of the PSA, we are working with the Healthcare Commission to ensure that survey design accurately captures the choice policy from December 2004.

  6.10  In respect of SR 2004 target 8, the second sub target details a numerator of "those supported intensively to live at home" and a denominator of "those being supported at home or in residential care." The technical note defines the denominator as the number of people being supported intensively to live at home plus the number of people in residential or nursing homes whose care is funded by the local councils. Why is the word "intensively" not used in the denominator of the target itself?

  ANSWER

  1.  When Department of Health officials wrote the technical guidance for this target they were keen to make the supporting technical note's introductory headlines for each PSA target as readily understandable as possible.

  2.  Although the wording of the headline subject—on page 18 of the guidance you refer to—did not make it clear that the denominator only includes people receiving intensive home care, the supporting technical note, on the same page, was clear that they were included.

  3.  The technical note is available on the DH website at the address below:

www.dh.gov.uk/assetRoot/04/08/69/19/04086919.pdf

  4.  On reflection, we recognise that it may have been clearer to include the word "intensively" in the reference to the denominator in the measure's headline introduction. We will ensure we do so in future references to this target.

  6.11  In respect of the evolution of SR 2004 target 3 and SR 2002 target 9, on the under-18 conception rate, from SR 2000 target 2, why was the interim target of 15% reduction by 2004 dropped between the 2000 and 2002 reviews?

  ANSWER

  1.  This was done to simplify and focus the target. However, the 15% reduction by 2004 remains a target in the NHS plan and we believe that it is important to achieve this in order to reach 50% by 2010 (hence the comments concerning slippage in response to question 6.3).

  6.12  SR 2004 target 2 is a slight (wording only) modification of SR 2002 target 11. The target 11 assessment in the DAR describes the infant mortality sub target as subject to slippage and the life expectancy sub target as being "challenging", with the data showing that the relative gap in life expectancy between England and the lowest fifth of local authorities increased for both males and females. Given the divergence from target, does SR 2004 target 2 remain realistic? In terms of reporting, shouldn't all targets be challenging?

  ANSWER

  1.  The SR2004 PSA target set gave a higher profile to health inequalities. In addition to retaining a target on narrowing the life expectancy gap across geographical areas and narrowing the infant mortality gap across socio-economic groups, the SR2002 targets on Cancer and Cardio Vascular Disease were revised to include new sub-targets to narrow the gap in mortality between the fifth of areas with the worst health and deprivation indicators and the population as a whole by 2010. In order to assist local delivery it was decided to base these new sub-targets and the inequalities life expectancy sub-target on the same geographical basis, keeping the same areas until the target delivery date (2010) and selecting the areas on the basis of the baseline date for the mortality targets (1995-97). The selection of areas with the worst health and deprivation indicators, or Spearhead Group, was based on factors relevant to all three sub-targets, and includes the areas which are in the bottom fifth for three or more of the following five factors:

—  Male life expectancy at birth

—  Female life expectancy at birth

—  Cancer mortality rate in under 75s

—  CVD mortality rate in under 75s

—  ODPM Index of Multiple Deprivation (2004), LA summary, average scores

  2.  The Spearhead Group was announced in November 2004 and consists of 70 local authorities which map across to 88 primary care trusts.

  3.  The 2002 PSA11 sub-target on inequalities in life expectancy was, in contrast, based upon the bottom quintile for life expectancy, with areas changing each year based upon the latest statistics, and with target achievement based on the baseline of 1997-99.

  4.  While all targets do need to be challenging, the Department has always acknowledged that the trends in health inequalities are stubborn, persistent and very resistant to change. Tackling Health Inequalities: Status Report on the Programme for Action (August 2005), overseen by the Department's independent and advisory Scientific Reference Group on health inequalities, notes that the health inequalities gap continues to widen in line with the existing trend. This is as expected and explicitly was noted in the Programme for Action. It said that changes in the gap were unlikely to be seen until closer to the target date of 2010. It noted that the first challenge was to stop health inequalities widening further. The report said that there are, however, some encouraging signs, in particular in reductions in child poverty, improvements in housing and reduction in the inequalities in CVD and cancer death rates (in absolute terms). These—and other changes —will have an impact on the trend in the health gap over time. The report highlighted the overall challenge that remains in meeting the PSA target as well as other areas for action. Action to tackle health inequalities remains a priority, as set out in the White Paper Choosing Health—Making healthy choices easier (2004) and its delivery plan (2005).

  6.13  In respect of SR 2002 target 1, the number of outpatients waiting more than four months fell from 24,495 in December 2003 to 2,847 in March 2004, while the number of inpatients waiting more than nine months fell from 19,407 in February 2004 to 41 in March 2004. How were such substantial reductions achieved in such a short space of time? Has there been any external validation of the figures?

  ANSWER

  1.  The numbers quoted by the committee are provider-based statistics. The preferred measure for waiting times figures is commissioner based as this excludes Welsh patients not subject to the waiting times targets. The relevant figures are:

  2.  The number of outpatients waiting longer than 17 weeks (four months) was 21,076 in December 2003 and 378 in March 2004. The number of inpatients waiting more than nine months fell from 19,404 in February 2004 to 223 in March 2004.

  3.  The operational standard since 31 March 2004 has been 17 weeks for outpatient waits and nine months for inpatient waits. The new target to be delivered is 13 weeks for outpatients and six months for inpatients by the end of December 2005.

  4.  The key strategies for reducing waiting times included:

—  Clear and challenging, but achievable national targets and standards

In 2000, the Department published the NHS Plan, which set out clear targets for improving access to NHS services. This publication set out how, by the end of 2005, maximum waiting times for a first outpatient appointment with a consultant would be reduced to 13 weeks (from over 26 weeks) to six months for inpatient treatment (surgery) from 18 months. In addition to this, the Department set targets for even shorter maximum waits for the priority conditions such as cancer and Coronary Heart Disease. The targets of 17 weeks and nine months were milestones designed to support delivery of the December 2005 targets.

More recently, in the NHS Improvement Plan (2004) the Department has gone even further, and has set a target that, by the end of 2008, the maximum length of time any patient should have to wait will be just 18 weeks from General Practitioner referral to start of treatment. This includes all stages that lead up to the start of treatment including diagnostic tests.

—  National Orthopaedic Project

We concluded that on the basis of existing strategies (NHS treatment centres, independent sector treatment centres, choice at six months, CPaT (see below) and performance management) the NHS should be able to deliver 13 weeks and six months for most specialities but that a particular focus was needed on orthopaedics. The National Orthopaedic Project was established in January 2004 to implement an integrated national strategy under four key workstreams: increasing the focus on orthopaedics to ensure awareness and ownership; maximising the impact of other initiatives; risk-based performance management; and a tailored support programme to support the NHS. A team was developed to co-ordinate the input from the NHS, the Department of Health, the Modernisation Agency, and professional bodies including the British Orthopaedic Association. Since the project's inception, the number of patients waiting longer than six months for orthopaedic surgery has fallen from over 57,000 to 16,000, a reduction of 72%. The March 2005 milestone of an 80% reduction from the December 2002 baseline was met, and the latest weekly PTL data shows that the NHS is on track to deliver the December 2005 target.

—  Improved waiting list management

We have developed a number of national tools to help NHS Trusts manage waiting lists effectively. For example:

  Primary Targeting Lists (PTLs): In Summer 2001, the NHS Modernisation Agency released guidance to the NHS called the "Primary Targeting Lists Approach" to assist them to treat patients within the shorter maximum waiting times targets for 2001-02. This has since become the basis for the work done by the DH and SHAs to monitor progress towards waiting time targets and, where necessary, offer support and intervention for challenged trusts or health economies.

  Clinically Prioritise and Treat (CPaT): In September 2003, the Modernisation Agency released guidance to the NHS called Clinically Prioritise and Treat (CPaT) to assist them to treat patients within the waiting time targets. The guidance makes it clear that patients with greater clinical need must be treated first and gives NHS organisations the practical advice to treat patients in broad chronological order within the maximum waiting times targets. CPaT enables local clinicians to incorporate clinically agreed definitions of "priority" and "routine"patients into a robust mechanism for managing waiting lists.

  CPaT is a very simple approach, supported by a toolkit that does three things:

  (a)  Provides Trusts with tools so that they can see and understand how they are managing their waiting lists;

  (b)  Offers training techniques to promote shared understanding by clinicians, managers and administrative staff; and

  (c)  Suggests ways to improve waiting list management and introduce transparent, systematic processes that are fairer to patients and reduce maximum waiting times.

Validation

  5.  Spot-checks on waiting lists and waiting times have been carried out for the last three years and have now covered all acute trusts. Responsibility for the spot-check programme fell to the Audit Commission for the first two years and then moved to the Healthcare Commission in April 2004, although the Audit Commission still operationally manage the process. Spot-checks are a quick way of establishing whether there is evidence of problems in a system, such as deliberate misreporting or inadvertent errors and they can highlight areas for improvement in the management systems.

  6.  The Audit Commission issued "Information and Data Quality in the NHS" on 31 March 2004. The report stated that national figures on waiting times and waiting lists are now reliable. Audit Commission Chairman James Strachan said: "The NHS has been working hard to improve the accuracy of its data. This is absolutely vital for building public confidence that healthcare services are getting better. Recent improvements in waiting times are real. They are the result of a greater focus on improving the experience of patients and not the result of misreporting or inadequate data".

  6.14  In response to question 6.1.3 in last year's Public Expenditure Questionnaire,[2] you claimed that, with respect to SR 2002 target 2, you were: "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" and that you were intending to: "seek further views from stakeholder organisations before reaching a final decision on a way forward". Have you now reached this decision?

  ANSWER

  1.  Yes. Following further discussions with stake-holders we have concluded that a blanket national standard would not be appropriate. The sharp differences in case mix, particularly between major departments and units seeing only minor injury or illness, mean that any blanket standard for the proportion of patients seen within an hour would risk compromising clinical care in departments seeing more complex cases. By contrast, there are no clinical reasons why any A&E department cannot meet the operational standard of at least 98% of patients spending no more than four hours in A&E.

  2.  We have, however, now made available to all trusts and PCTs a standard national tool that allows analysis of performance against a range of benchmarks for the time spent in A&E. Amongst other benefits, the tool allows trusts and PCTs to look at the proportion of patients discharged within given time-bands and compare performance with organisations that provide services with similar case-mix.

  6.15  In respect of SR 2002 target 5, the summary includes no figures, but instead provides a link to detailed survey results. Why have no summary figures been produced? Can these be supplied now please.

  ANSWER

  1.  The Healthcare Commission publish the results of all surveys on their website - this includes a summary report of national findings and "local benchmark reports" for each trust or PCT, which compare their performance with all other organisations for each survey question.

  2.  To date there have been 13 surveys carried out across seven NHS settings. In order to summarise results we have agreed a metrics system with the Healthcare Commission. NAO is currently validating the methodology together with internal and external analysts. Table 6.15 presents the current set of scores by way of illustration only, since the validation work is still ongoing.

  (see table 6.15)

  3.  The metrics for measuring progress against the patient experience PSA were designed in collaboration with the Healthcare Commission, who also calculate the final results for the Department. The methodology is essentially based on the approach used in the Healthcare Commission's annual performance assessment of NHS organisations: the results for each trust or PCT on a number of performance indicator questions are scored, and are then aggregated to produce an index score for each of five themes or dimensions that patients say are the most important for a good experience:

—  Access and waiting.

—  Safe, high quality and co-ordinated care.

—  Better information, more choice.

—  Building better relationships.

—  A clean, friendly and comfortable place to be.

  4.  A "national average" is then calculated for each dimension, representing a high-level summary of performance. The questions, which are used to construct these scores, are different for each survey, so it is not appropriate to compare performance across settings. However, since the performance indicator questions, which are used in each separate survey, will not change, comparisons over time for the same survey setting can be made.

  5.  The PSA Technical Note for SR2004 summarised this methodology, and also presented index scores for the first series of baseline surveys (2001-02 and 2002-03). Since this was first published, the Healthcare Commission have made a number of technical adjustments to the methodology. The Department is working closely with the Healthcare Commission to review and validate this change.

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2   Public Expenditure on Health and Personal Social Services 2004: Memorandum received from the Department of Health containing replies to a Written Questionnaire from the Committee, HC 1113, Q6.1.3. Back

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Prepared 5 May 2006