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Putting People at the Heart ofPublic Services

The NHS Improvement Plan

The NHS Improvement Plan

Putting People at the Heart of Public Services

Presented to Parliament bythe Secretary of State for Healthby Command of Her Majesty

June 2004

Cm 6268 £17.75

© Crown Copyright 2004

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READER INFORMATION

Policy AllHR/Workforce PerformanceManagement IM & TPlanning FinanceClinical Partnership Working

Document Purpose Policy and action

ROCR Ref: Gateway Ref: 3398

Title The NHS Improvement Plan – PuttingPeople at the Heart of Public Services

Author DH

Publication Date 24 June 2004

Target Audience PCT CEs, NHS Trust CEs, SHA CEs,Care Trust CEs, Directors of PH,Directors of Nursing, PCT PEC Chairs,NHS Trust Board Chairs,Communications Leads, WDC CEs,Medical Directors, Special HA CEs,Directors of HR, Directors of Finance

Circulation List Voluntary Organisations, NDPBS,Directors of Social Services, LocalAuthority CEs, Others

Description

Cross Ref The NHS Plan, July 2000

Superseded Doc N/A

Action Required N/A

Timing N/A

Contact DetailsThe NHS Improvement PlanRoom 431Richmond House79 WhitehallLondon, SW1A 2NS

For recipient use

Contents

Foreword by the Prime Minister 3

Preface by the Secretary of State for Health 5

Executive summary 8

Section 1: Laying the foundations 131) Progress so far 15

Section 2: Offering a better service 252) High-quality and personalised care 273) Supporting people with long-term conditions to live healthy lives 344) A healthier and fitter population 42

Section 3: Making it happen 495) Investment, new capacity and diversity of provision 516) More staff working differently 587) Getting information to work for the patient 648) Aligning incentives with patients and professionals 689) Empowering local communities 74

1 The National Health Service (NHS) is one ofour country’s proudest achievements and anessential strand in the fabric of our nation.Despite past frustrations, the NHS and itsvalues – healthcare for all according to need,not ability to pay – retain overwhelming publicsupport. So, too, do its dedicated, skilled andcompassionate staff.

2 The Government has recognised the crucialrole of the NHS in our national life and hasalso faced up to its problems. The NHS Plan,launched in July 2000, drawn up with the helpof staff, patients and other stakeholders, setout a programme of sustained investment andreform to turn the NHS around, make it moreresponsive to patients and more in tune withthe times. The NHS Plan has delivered realprogress in healthcare across the country.

3 There are thousands more doctors andnurses. Dozens of new hospitals have openedor are under way. Waiting times have beenreduced. Death rates from cancer and heartdisease are sharply down. A series ofauthoritative reports has found the NHS isfirmly on the road to a full recovery.

4 We have made a good start. But, as theNHS has improved, so rightly have people’sexpectations of it increased. With the journeyto a world-class health service in all, not justsome parts, of the NHS still to be completed,now is not the time to falter.

5 There will be voices, we know, urging us toslow down or perhaps stop altogether. In manycases they are the same voices which havewarned against the pace of change over thelast seven years. They are right that

investment alone would have delivered someimprovements in the NHS. But it would notby itself, for example, have halved maximumwaiting times or delivered many of the otherimprovements the public can see in theirown local health services.

6 These improvements have happenedbecause we realised that while the valuesof the NHS remain as relevant today as halfa century ago, the system for delivering themwas badly out of date. A system devised fora time of rationing and shortages cannot beright for a century when the public expect high-quality products, better services, choice andconvenience. So over the last seven years,with the help of NHS staff, we haveoverhauled and modernised the system,focusing on expanding and improving servicesand access to care and treatment.

7 We make no apology for driving many ofthese reforms from the centre. Now we canmove to the next stage envisaged in The NHSPlan to reshape the health service around theneeds and aspirations of its patients, not leastbecause the speed of progress means waitingfor treatment will soon no longer be the majorproblem. And this requires us to put power inthe hands of patients rather than Whitehall.

8 We are investing to continue increasingcapacity throughout the NHS. And becauseof this increased capacity, we can continue toextend choice. So there will be more choicegiven to patients over how they are treatedand where. They will have the power tochoose between hospitals, including the newtreatment centres. We will continue to reducedramatically waiting times from referral by a

THE NHS IMPROVEMENT PLAN: PUTTING PEOPLE AT THE HEART OF PUBLIC SERVICES 3

ForewordTony Blair, Prime Minister

GP to the start of hospital treatment. Morecare for long-term conditions will be providedcloser to home or in the home itself. Easieraccess and more choice over medicines willbe provided to patients. Local communities areto be given more power over the priorities oflocal health services. A greater emphasis willbe given in the NHS to public health, toprevent illnesses and not just to treat them –whether it is old challenges like smoking ornew ones such as obesity.

9 Our aim is to reshape the NHS, building onThe NHS Plan, so it is not just a nationalhealth service but also a personal healthservice for every patient. We want to providemore choice for every patient, irrespective ofthe money in their pocket, funded through thecollective finance of the nation and organisedby the collective nature and standards of theNHS. It is an ambitious goal. This plan showshow we intend to support NHS staff toachieve it.

Tony BlairPrime Minister

4 FOREWORD BY THE PRIME MINISTER

1 The NHS was founded on two fundamentalprinciples. The first is that there should beequal access to treatment for all, based onclinical need and regardless of the patient’sability to pay. The second is that collectivefunding of the NHS, through national taxation,is the most effective way to ensure that qualitycare is available to all, since paying for allhealthcare possibilities is beyond personalfinancial means. These two principles remaincentral to our vision for the future of the NHS.To enable us to implement them we need tomake sure that the NHS is fit for purposetoday, and to do that we need to investand reform.

2 Sustained investment is already transformingthe NHS. Investment has increased from £33billion in 1996/97 to £67.4 billion in 2004/05.Spending on buildings and equipment hasincreased from £1.1 billion to £3.4 billion. Thisinvestment has enabled the NHS to expand itscapacity to care for patients. The NHS todayhas more doctors, more nurses, morehealthcare staff, more and better buildings,state-of-the-art equipment and more life-savingdrugs. But investment without reform is notenough.

3 NHS front-line staff are being incentivised tobecome increasingly innovative and creative.The new pay contracts for nearly all NHS staffprovide a powerful package of incentives toreward the health professions for theircommitment to improving both patient careand the health of the population.

4 This combination of investment and reform isnow beginning to make a real difference, with

patients having faster access to the care theyneed. Since 1997:

l The maximum waiting time for an operationhas fallen from 18 months to less than ninemonths

l The maximum waiting time for an outpatientappointment has fallen from 26 weeks to17 weeks

l 97% of patients are now able to see a GPwithin two days

l Growing numbers of patients are takingadvantage of new services such as NHSDirect and NHS Walk-in Centres

l 94% of patients are seen, diagnosed andtreated within four hours of arrival ataccident and emergency.

5 There have also been improvements inthe quality of care, achieved through thedevelopment and delivery of National ServiceFrameworks and the work of the HealthcareCommission in inspecting NHS services andworking to improve clinical governance. Moretreatment and care are now available closer tohome. Patient choice has begun to have animpact on the way in which the NHS works.There has been clear progress in tacklingthe country’s biggest killer diseases, withpremature deaths from cancers and heartdisease falling at the fastest rate of anyEuropean country.

6 Increases in staff numbers since 1997 arealso improving services for patients. Theyinclude a 22% increase in doctors, a 21%


PrefaceThe Rt Hon John Reid MPSecretary of State for Health

rise in the total number of nurses and a 27%expansion in scientific, therapeutic andtechnical staff. These staff are increasinglyworking in modern environments whichsupport patient safety, good medical practiceand an approach that is centred on improvingthe experience of the patient. Sixty eight majornew hospitals have been commissioned, withtwenty four fully operational since 2000, andthere have been increases in the number ofhospital beds, growth in critical care facilitiesand expansion in intermediate care facilities tosupport people who are leaving hospital aftertreatment. Over 2,200 GP surgeries andprimary care premises have been modernised.

7 In national surveys patients are increasinglypositive about the quality of their care. Beyondthe clinical arena, there has been progress onissues where patients have asked for morefocus, with cleaner hospitals, better food andbetter provision of bedside phones andtelevisions.

8 This reflects the hard work and commitmentof NHS staff combined with increasedinvestment from the public. But everyone –patients, public and professionals – recognisesthat the job of modernising the NHS is not yetdone and that there is further to go before wecan fully realise our vision.

9 To deliver this vision, investment in the NHSwill rise to £90 billion by the year 2007/8.In return for this investment the NHS will offerthe following:

l Patients will be admitted for treatmentwithin a maximum of 18 weeks fromreferral by their GP, and those with urgentconditions will be treated much faster

l Patients will be able to choose betweena range of providers, including NHSFoundation Trusts and treatment centres

l Patients will be able to be treated at anyfacility that meets NHS standards, withinthe national maximum price that the NHSpays for the treatment they need

l Patients will have access to a wider rangeof services in primary care, includingaccess to services nearer their workplace

l Electronic prescribing will improve theefficiency and quality of prescribing

l Users of social care will be empoweredthrough the expansion of direct payments

l In every care setting the quality of care willcontinue to improve, with the HealthcareCommission providing an independentassurance of standards, and patient safetybeing a top priority

l People with complex long-term conditionswill be supported locally by a new type ofclinical specialist, to be known ascommunity matrons

l Major investment in services closer tohome will ensure much better support forpatients who have long-term conditions,enabling them to minimise the impact ofthese on their lives

The vision

Our vision is one where the foundingprinciples underlying the NHS are givenmodern meaning and relevance in thecontext of people’s increasing ambitionsand expectations of their public services.

An NHS which is fair to all of us andpersonal to each of us by offeringeveryone the same access to, and thepower to choose from, a wide range ofservices of high quality, based on clinicalneed, not ability to pay.

6 PREFACE BY THE SECRETARY OF STATE FOR HEALTH

l There will have been further progress intackling the biggest killer diseases, with thecountry on track to secure by 2010 a 40%fall from 1997 in death rates from heartdisease and stroke, and a 20% fall in deathrates from cancer

l The NHS will develop into a health servicerather than one that focuses primarily onsickness and will, in partnership, makefurther in-roads into levels of smoking,obesity and the other major causes ofdisease. There will be a sustained driveto reduce inequalities in health

l Local communities will have greaterinfluence and say over how their localservices are run, with local servicesmeeting local priorities

l Primary Care Trusts will control over 80%of the NHS budget

l All NHS Trusts will be in a position to applyfor NHS Foundation Trust status

l More staff will work in the NHS and will beencouraged to work more flexibly in a waythat best responds to patients’ needs

l There will be incentives for healthcareproviders to offer care that is efficient,responsive, of a high standard and respectspeople’s dignity.

10 Our objective is fairer, faster, better care tomore people than ever before. This will beachieved by giving patients more informationand more choice whilst also giving the publicbetter value than ever before.

The Rt Hon John Reid MPSecretary of State for Health


This document sets out the priorities for theNHS between now and 2008. It supports ourongoing commitment to a 10-year processof reform first set out in The NHS Plan.

Introduction

1 Over the past seven years the NHS inEngland has been on a journey of majorimprovement. After decades of under-investment, the NHS has begun to turn itselfaround, with unprecedented increases in themoney it can spend. As its budget has grownfrom £33 billion to £67.4 billion, the averagespending per head of population has gone upfrom £680 to £1,345.

2 That money has increased the capacity of theNHS to serve patients. It has helped give fasterand more convenient access to care. Access toGPs, accident & emergency care (A&E),operations and treatment is improving withevery passing year. Quality is also improving,as is the range of services available to thepublic.

3 These improvements have been madepossible by steady increases in the number ofNHS staff, who are even more focused on thepersonal care of individual patients and betterenabled to do so. The growth in money andstaff numbers has been matched by anunprecedented period of growth, expansionand modernisation in the buildings, equipmentand facilities available to care for patients. Thatin turn has enabled the NHS to provide betterquality care to patients, with safer and moreeffective treatment, better surroundings andservices that better suit their lives. The NHStoday is fairer as a result. The NHS is now

ready to ensure that care is much morepersonal and tailored to the individual.

4 The next stage in the NHS's journey is toensure that a drive for responsive, convenientand personalised services takes root acrossthe whole of the NHS and for all patients. Forhospital services, this means that there will bea lot more choice for patients about how, whenand where they are treated and much betterinformation to support that. For the millions ofpeople who have illnesses that they will livewith for the rest of their lives, such as diabetes,heart disease, or asthma, it will mean muchcloser personal attention and support in thecommunity and at home.

5 Complementing that drive for a high-qualitypersonal service for individual patients whenthey are ill, there will be a much strongeremphasis on prevention. Death rates fromcancers, heart disease and stroke are alreadyfalling quickly. The NHS will take a greater andmore effective lead in the fight against thesebig killer diseases. It will lead a coalition to stoppeople getting sick in the first place and tomake in-roads into inequalities in health.

6 In taking forward these reforms, the NHS willcontinue to learn from other healthcaresystems. This will enable the NHS to continueto improve its performance as it aspires toworld class standards, where it is not alreadyachieving these. In the next stage, there will bea stronger emphasis on quality and safetyalongside a continuing focus on deliveringservices efficiently, fairly and in a way that ispersonal to each of us. By 2008, the NHS inEngland will be seen increasingly as a modelthat other countries can learn from.

8 EXECUTIVE SUMMARY

Executive summary

Section 1 – Laying the foundations

7 The investment and reform initiated in July2000 by The NHS Plan has delivered forpatients. It is a track record of success, whichgives the confidence to support furtherinvestment and further reform. The money andthe changes promised in The NHS Plan justfour years ago have been made a reality forpatients, the public and the taxpayer. Thosewho argued that the NHS was beyond reform,were profoundly mistaken. The NHS hasdemonstrated that its enduring principles canprosper in the new century.

8 At the core of this plan lies a continuingcommitment to the founding principles of theNHS: the provision of quality care based onclinical need, irrespective of the patient’s abilityto pay, meeting the needs of people from allwalks of life. The programme is instilled witha resolve to ensure that the NHS meets theexpectations of all people in England: enablingand supporting people in improving their ownhealth; Meeting the challenge of making a realdifference to inequalities in health; staying thecourse and supporting those with conditionsthat they will live with all their lives; and quicklytreating people with curable problems so thatthey can get on with their lives and live them tothe full.

Section 2 – Offering a better service

9 Chapter 2 sets out the key commitments thatthe NHS will deliver to transform the patient’sexperience of the health service over the nextfour years. It explains how this will dramaticallychange the experience of waiting for hospitaltreatment.

10 In 1997 patients waited up to 18 months fortreatment – after seeing a GP, after seeing aconsultant, and after diagnostic tests. Thosetimes have fallen and now the maximum waitfor an operation is nine months and themaximum wait for an outpatient appointment is17 weeks. When this programme has beendelivered in four years time, the 1997maximum wait of 18 months for only part of thepatient journey will have been reduced to 18weeks for the whole journey. The previous long

waits for GP referral, outpatient consultationsand tests are included in that pledge. In fouryears’ time, waiting times for treatment willhave ceased to be the main concern forpatients and the public.

11 With much shorter waiting times fortreatment, “how soon?” will cease to be amajor issue. “How?”, "where?" and “howgood?” will become increasingly importantto patients. Patients’ desire for high-qualitypersonalised care will drive the new system.Giving people greater personal choice willgive them control over these issues, allowingpatients to call the shots about the time andplace of their care, and empowering them topersonalise their care to ensure the qualityand convenience that they want.

12 From the end of 2005, patients will have theright to choose from at least four to fivedifferent healthcare providers. The NHS willpay for this treatment. In 2008, patients willhave the right to choose from any provider, aslong as they meet clear NHS standards andare able to do so within the national maximumprice that the NHS will pay for the treatmentthat patients need. Each patient will haveaccess to their own personal HealthSpace onthe internet, where they can see their carerecords and note their individual preferencesabout their care.

13 With waiting times no longer the main issue,the NHS will be able to concentrate more of itsenergies on providing better support to peoplewith illnesses or medical conditions that theywill have for the rest of their lives. Chapter 3sets out our commitment to a radical, far-reaching and ambitious approach to making areal difference to the quality of life of peoplewho live with illnesses every day. While theway we think about the NHS is oftendominated by the easy to understand model ofpeople with diseases being treated and cured,a very significant number of people are livingtheir lives with conditions that can’t yet becured. Diabetes, heart disease, asthma, somemental illnesses and many other conditions aremedical problems that most people live withfrom the time they are diagnosed.


14 The NHS will minimise the impact of theseconditions on people's lives and provide peoplewith high-quality personal care. It will enableand support people in managing theirconditions in a way that suits them, avoidingcomplications, maximising their health andhelping them to live longer lives. It will alsoimprove people's care closer to home –through specialist nurses and GPs with aspecial expertise in their condition – which willlead to fewer emergency admissions tohospitals which cause anxiety for patients andtheir families and are a poor use of hospitalresources. The Expert Patient Programme –designed to empower patients to manage theirown healthcare – will be rolled out nationally,enabling more people to take greater control oftheir own care and to listen to themselves andtheir own symptoms, supported by their clinicalteam. The new GP contract provides cashincentives to GPs who work with their teams ofnurses, social workers, the voluntary sectorand other professionals to ensure that peopleare given the high-quality personal care theyneed to minimise the impact of their illness orhealth problem.

15 Having reduced waiting to the point where itis no longer the major issue for patients andthe public, the NHS will be able to concentrateon transforming itself from a sickness serviceto a health service. Prevention of disease andtackling inequalities in health will assume amuch greater priority in the NHS. With the NHSworking in partnership with others and withindividuals to support people in choosinghealthier approaches to their lives, realprogress will be made on preventing ill healthand reducing inequalities in health. Death ratesfor the under 75s from heart diseases andstroke will be reduced by at least 40% by 2010and death rates from cancers will be reducedby at least 20%. Suicide rates will be reducedby 20% (from a 1997 baseline). Theforthcoming public health White Paper will setout a comprehensive programme to tackle themajor causes of ill health, including obesity,smoking and sexually-transmitted infections.

Section 3 – Making it happen

16 Chapters 5 to 9 set out how the NHS willdeliver these key commitments. A much widerchoice of different types of health services willbecome available to NHS patients, to enablepersonalised care, faster treatment, personalsupport for people with long-term conditionsand better social care.

17 For hospital care, NHS Foundation Trustswill, by 2008, be treating many more patients.NHS patients will also be able to choose from agrowing range of independent providers, withtheir diagnosis and treatment paid for by theNHS. To support capacity and choice, by 2008,independent sector providers will provide upto 15% of procedures on behalf of the NHS.The Healthcare Commission will inspect allproviders, whether in the NHS or in theindependent sector, to ensure high-quality carefor patients wherever it is delivered.

18 In primary care, the NHS will be developingnew ways of meeting patients’ needs closerto home and work. New flexibilities will enablePCTs to commission care from a wider rangeof providers, inlcuding independent sectororganisations, to enhance the range and quality of services available to patients.The Departments of Health will also workwith other government departments and localauthorities to develop better ways of meetingpeople’s broader health needs.

19 Greater flexibility and growth in the wayservices are provided will be matched byincreases in NHS staff and new ways ofworking to meet patients’ needs. By 2008 thenumber of staff working for the NHS will haveincreased significantly. In primary care GPs willincreasingly be working with more diverseteams, including GPs with a special interestsand community matrons, to enable patients’needs to be met in new ways in the communityrather than in hospital. Staff will be given morehelp to train and learn new skills, with theircareer progression supported by the NHSUniversity (NHSU). This flexible working todeliver more personalised and user-friendlycare for patients will be rewarded by better payfor NHS staff.

10 EXECUTIVE SUMMARY

20 Information systems will be put in place toenable patients to choose more convenient andhigher-quality personalised care. By 2005 anelectronic booking service will make it easier forpatients to arrange appointments that suit them,and electronic prescribing will make it easier forpatients to obtain repeat prescriptions for theirmedicines. NHS Direct, NHS Direct Online andNHS Digital Television will enable people tocommunicate with health professionals andthese services will also support people inmaking changes that will improve their ownhealth. An individual personal care record willenable health professionals to have easy, rapidaccess to patients’ medical histories at any timeof the day, supporting better diagnosis andtreatment and reducing errors. The technologywill also enable patients to have more influenceover how they are treated, with a new personalfacility called HealthSpace enabling them torecord for health professionals what theirpreferences are about the way they arecared for.

21 Financial incentives and performancemanagement will drive delivery of the newcommitments. The new system of payment byresults will support the exercise of choice bypatients, improve waiting times for patients andprovide strong incentives for efficient use ofresources. This system will be fully operationaland delivering for patients in 2008. At the sametime, Primary Care Trusts will be developingfurther incentives to enable GPs and theirteams to deliver ever higher quality care topatients in a way that is most responsive totheir needs.

22 As money, control and responsibility arehanded over to local health services, thecommunities that they serve will be givengreater influence over the way that localresources are spent and the way that localservices are run. Within a framework of clearnational standards, power will continue to moveswiftly to Primary Care Trusts and to NHSFoundation Trusts. There will be far fewernational targets for the NHS. Local services willset their own stretching targets, reflecting thelocal circumstances, ethnicity and inequalitiesof the communities that they serve and the

local priorities of the people who use them.Performance management arrangements willbe aligned with this new system, giving theincentive of greater freedom from centralregulation and inspection to NHS organisationsthat serve patients and their communities well.

Conclusion

23 The NHS Plan reforms and investmentare transforming the NHS, with dramaticimprovements in key areas. Tackling the twobiggest killers, cancer and coronary heartdisease, has been a priority over the past fouryears and mortality rates are already fallingrapidly.

24 Less than four years into the period coveredby the 10-year NHS Plan, the new deliverysystems and providers are expanding capacityand choice. As these new ways of working reallytake hold across the whole system, the dividendwill be a higher-quality service with even fasteraccess to care. A new spirit of innovation hasemerged, centred on improving the personalexperience of patients as individuals, and this isnow taking root in the NHS.

25 The foundations for success are now inplace and it is time to move on. Improving carefor people with long-term conditions and helpingpeople live healthier lives are essential nextsteps in our drive to improve the quality ofcare for everyone. Over the next four years theculture of waiting which has long been a featureof the NHS will be replaced by a personalisedapproach to care. Appointments will be bookedwith the GP and the maximum time from GPreferral to the start of treatment will be down tojust 18 weeks, with many people being seenmuch quicker than this.

26 NHS Foundation Trusts will be free fromWhitehall control, enabling new ways ofinvolving local people, local staff and localpatients in the running of their hospitals. Newtreatment centres run by the NHS and theindependent sector will offer fast andconvenient treatment that will provide patientswith real choices. Primary Care Trusts willcontrol over 80% of the NHS budget and theywill use this financial muscle to secure the best


possible deal for each and every patient thatthey serve. Patient choice will be a key driverof the system and resources will flow to thosehospitals and healthcare providers that are ableto provide patients with the high-quality andresponsive services they expect. Independentinspectors will provide patients with assuranceof the quality of care wherever it is delivered.There will be a much stronger emphasis onprevention, keeping people healthy andavoiding the need for medical care in the firstplace.

27 In 2008, England will have a very differenthealth service from the one it has today. It willretain all those qualities that sustain suchcommitment from the people of England. It willbe an NHS which is fair to all of us andpersonal to each of us by offering everyonethe same access to and the power to choosefrom a wide possible range of services of highquality, based on clinical need not ability topay. The changes set out in this document willmean, for the first time, that the system willwork with and support those professionalinstincts of the NHS’s dedicated staff andensure high-quality personal care for patients.It will reward the NHS for these efforts, takeaway the barriers to doing the right thing andmake it easier for dedicated doctors, nursesand thousands of other NHS staff to followtheir calling to cure and to care. A modernNHS, equipped and enabled to respondquickly to people’s needs, will mean that theobstacles to what people want from the NHSare torn down and that excellence becomesthe norm for clinical staff and managers alike.The NHS is set to thrive again by properlymeeting the needs of patients and the public.

12 EXECUTIVE SUMMARY

Section 1:Laying the foundations

Introduction

1.1 The programme of investment and reforminitiated by The NHS Plan has enabled theNHS to put in place real improvements, givingthe public and the NHS the confidence tosupport further investment and further reform.This chapter describes the achievements ofrecent years. It shows how the investment andreform promised in The NHS Plan just fouryears ago have rapidly been made a reality forpatients, the public, the taxpayer and NHSstaff. It shows clearly that those who arguedthat The NHS was beyond reform, wereprofoundly mistaken. It demonstrates that theenduring principles of the NHS can prosper inthe new century.

Reducing deaths from cancer

1.2 The NHS Cancer Plan, published fouryears ago, set out the nation’s first evercomprehensive strategy for using prevention,treatment, care and research to tackle one ofthe nation’s biggest killers and provide fastand effective treatment for a group of diseasesthat one in three people will experience duringtheir lives.

1.3 Death rates are falling steadily and patientsare benefiting from real improvements in allaspects of cancer care. Survival rates from allthe major cancers are improving. The NHSCancer Plan has enabled sustainedimprovements:

l Since April 2001 an additional 200,000women have been invited to be screenedas a result of the expansion of the breastscreening service to include women aged65–70 years


Chapter 1 Progress so far

Rapid progress has been made since The NHS Plan in improving the NHS, including:

l Falls in death rates from the major killer diseases

l Faster access to hospital, primary and emergency care

l Improvements to the way services are run

l Increases in hospital activity

l More frontline NHS staff

l Better buildings

l Better healthcare

l Better experiences of the NHS for patients.

l Nearly 99% of patients with suspectedcancer are now seen by a specialist withintwo weeks of being referred urgently bytheir GP. This compares to 63% in 1997

l Cancer patients can now benefit from 15 ofthe newest cancer drugs appraised by theNational Institute for Clinical Excellence

l There are now over 1,000 more cancerconsultants than there were in 1997

l Over 1,000 state-of-the-art pieces of high-tech equipment used to diagnose and treatcancer have been delivered to hospitals,including Magnetic Resonance Imaging(MRI), computer tomography (CT) scannersand breast screening equipment. Thismeans that 44% of MRI scanners, 64% ofCT scanners, and 48% of linearaccelerators now in use are new sinceJanuary 2000.

Reducing deaths from heartdisease

1.4 In 1997 about 140 people out of 100,000died of heart disease or strokes. By the end of2001 that had fallen to about 108 out of every100,000.

1.5 The National Service Framework forCoronary Heart Disease, published in 2000,has enabled NHS staff to make dramaticimprovements to the prevention and treatmentof heart disease:

l The number of NHS heart operationsperformed a year has increased from46,000 in 1999/2000 to over 60,000 in2002/03, a 31% increase. As a result,maximum waiting times for heart operationshave fallen from 18 months to six months infour years and are set to fall to threemonths by March 2005. From that time allpatients will be eligible to choose to betreated in a different hospital at the timethey are told they need surgery

16 CHAPTER 1 PROGRESS SO FAR

Figure 1.1: Death rates from all cancers in England 1993–2002: people under 75

1993/4/50

20

40

60

80

100

120

140

160

1995/6/7 1997/8/9 1999/2000/1 2001/2/3 2003/4/5 2005/6/7 2007/8/9 2009/10/11

progress target

3-year average ratesDeath rate per 100,000 population

141.4

113.1

Rates are calculated using population estimates based on 2001 census. Rates are calculated using the European Standard Population to take account ofdifferences in age structure.ICD9 data for 1993 to 1998 and 2000 have been adjusted to be comparable with ICD10 data for 1999 and 2001 onwards.Source: ONS (ICD9 140–209; ICD10 C00–C97)

baseline

Target:20% minimumreductionfrom 1995–97baselinerate

Cancer mortality targetDeath rates from all cancers in England 1993–2002 and target for the year 2010

126.8

l 1.8 million people are receiving cholesterol-lowering drugs, which reduce their risk of aheart attack

l 81% of patients who have just had a heartattack now receive life-saving clot-bustingdrugs within half an hour of arrival athospital, compared to only 38% in 2000

l Over a million children in more than 7,500schools are receiving a piece of fruit a dayand this year all 4–6 year olds will beentitled to a free piece of fruit each day.

Shorter waiting times

1.6 People are able to access NHS servicesmuch faster since the publication of The NHSPlan.

1.7 These trends are now well established:

l As of March this year there were only48 people who had been waiting morethan nine months for inpatient treatment

l These reductions in waits are accelerating– over the last year there has been a 60%reduction in the number of people waitingmore than six months

l The maximum wait for a first outpatientappointment is now 17 weeks, down from21 weeks a year ago

l The number of patients waiting more than13 weeks for their first outpatientappointment has fallen by nearly two thirdsin the last year.

1.8 The number of patients waiting for hospitaladmissions fell to 906,000 in March 2004, thelowest for more than fifteen years and thetenth successive month that the waiting listhas been below a million. Fewer people arewaiting and they are being seen more quickly.

1.9 Hospital activity levels are are alsoincreasing in order to reduce waits. Between1996/97 and last year the total number ofhospital admissions rose by 22% at the same


Figure 1.2: Death rates from circulatory diseases in England: 1993–2002: people under 75

1993/4/5

0

20

40

60

80

100

120

140

160

1995/6/7 1997/8/9 1999/2000/1 2001/2/3 2003/4/5 2005/6/7 2007/8/9 2009/10/11

progress target

3-year average ratesDeath rate per 100,000 population

141.5

84.9

Rates are calculated using population estimates based on 2001 census. Rates are calculated using the European Standard Population to take account of differences in age structure.ICD9 data for 1993 to 1998 and 2000 have been adjusted to be comparable with ICD10 data for 1999 and 2001 onwards.Source: ONS (ICD9 390–459; ICD10 C100–199)

baseline

Target:40% minimumreductionfrom 1995–97baselinerate

Circulatory disease mortality targetDeath rates from all `virculatory disease in England 1993–2002 and target for the year 2010

108.5

180


Figure 1.3: Inpatient waiting times, England, 2000–04 (months waited)Inpatient Waiting Times England, March 2000 to March 2004

300,000

250,000

200,000

150,000

100,000

50,000

0

Num

ber

of p

atie

nts

wai

ting

for

adm

issi

on

Mar 00 Mar 01 Mar 02 Mar 03 Dec 03 Mar 04

People waiting longer than 6 months People waiting longer than 9 months

People waiting longer than 12 months People waiting longer than 15 months

Source: Chief Executive’s Report to the NHS (May 2004)

Figure 1.4: Outpatient waiting times, England, 2000–04 (weeks waited)

400,000

300,000

200,000

100,000

0

Mar 00 Mar 01 Mar 02 Mar 03 Mar 04

People waiting longer than 13 weeks People waiting longer than 17 weeks (target period)

People waiting longer than 26 weeks

Num

ber

of p

atie

nts

wai

ting

for

appo

intm

ent


time as maximum waiting times were reducedfrom 18 months to nine.

1.10 Similar excellent progress has been madefor patients who need to see their GP or aprimary health care professional.

1.11 New services offered to people bytelephone, the internet or through NHS Walk-inCentres have transformed the way in whichpeople can quickly access the health service:

l NHS Direct – the telephone information andadvice service – is now a well-established

part of the health service, with steadygrowth in the number of patients who useit. There has been a large increase in callsto NHS Direct since The NHS Plan waspublished, rising from 1.7 million to 6.4million a year

l NHS Direct Online, a new internet service,has now supplemented NHS Direct andhas seen particularly rapid growth in use.Last year there were 6.5 million hits on thewebsite www.nhsdirect.co.uk


Figure 1.5: Total inpatient waiting list size

1,300,000

1,250,000

1,200,000

1,150,000

1,100,000

1,050,000

1,000,000

950,000

900,000

850,000

800,000

Mar

ch 9

7

June

97

Sep

tem

ber

97

Dec

embe

r 97

Mar

ch 9

8

June

98

Sep

tem

ber

98

Dec

embe

r 98

Mar

ch 9

9

June

99

Sep

tem

ber

99

Dec

embe

r 99

Mar

ch 0

0

June

00

Sep

tem

ber

00

Dec

embe

r 00

Mar

ch 0

1

June

01

Sep

tem

ber

01

Dec

embe

r 01

Mar

ch 0

2

June

02

Sep

tem

ber

02

Dec

embe

r 02

Mar

ch 0

3

June

03

Sep

tem

ber

03

Dec

embe

r 03

Mar

ch 0

4


Table 1.1: GP and primary health care professional appointment availability

Appointment type March 2002 March 2004 Increase lasttwo years

Percentage of patients ableto see a GP within two days 74.6% 97.4% 22.8%

Percentage of patients able to see a primary healthcare professional within one day 71.7% 97.5% 25.8%

l NHS Walk-in Centres – where patients canbe seen without an appointment – areexperiencing rapid expansion as new sitesopen and others grow in popularity. Thesecentres offer patients faster and moreconvenient access to healthcare. Sinceopening in 2000, staff in the centres haveseen over 4.5 million people. Twenty-twonew NHS Walk-in Centres came on streamin spring this year.

1.12 There has been similar progress insecuring faster emergency care for patients:

l There has been good progress towardsimproving ambulance response times sothat 75% of 999 calls to life-threateningemergencies are responded to withineight minutes

l The NHS Plan set a target that themaximum waiting time in A&E, from arrivalto admission or discharge, should be fourhours. By September 2002, 77% of patientswere treated within four hours. As of March2004, 93.7% of patients were treated withinfour hours. (The September 2002 figure isfor major A&Es while the March 2004 figureis for all A&Es).

Changes in the way services aredelivered

1.13 To make healthcare more convenient forpatients, the NHS is increasingly offeringservices in primary care or in outpatientdepartments, without the need for a hospitaladmission. With more staff, more facilities andnew ways of working, more patients are beingtreated in primary care. As a result last year

there was almost no growth in the number ofpatients referred to hospital by their GP. This,combined with increases in the number ofoperations in hospitals, is helping to bringdown waiting lists and ensure that patients aretreated more quickly and more conveniently.There has been impressive growth in serviceseffectively provided in the community:

l The number of prescriptions issued in thecommunity has risen from 550 million in2000/01 to 615 million in 2002/03. SinceThe NHS Plan the number of prescriptionshas risen by over 11%. Spending on drugshas increased from £6.7 billion in 2000/01to £8.4 billion in 2002/03. Since The NHSPlan there has been a increase in spendingof almost 25%

l In mental health, there has been asignificant increase in the number ofAssertive Outreach Teams since The NHSPlan, rising from 121 to 251 in 2003. Therehas also been an increase in the number ofCrisis Resolution Teams, rising from 85 to137 since The NHS Plan. The number ofEarly Intervention Teams has increasedby 125% over the same period. Theseinitiatives are all supporting more effectivecare in mental health

l In social care there has been a rise of 16%in the number of hours of home careprovided to vulnerable citizens, rising toover 3 million last year. The number ofhouseholds receiving intensive home carehas increased from 68,700 to 87,000 sincethe publication of The NHS Plan, a 27%increase


Table 1.2: New primary care centres

March 2000 March 2004 Increasesince TheNHS Plan(July 2000)

Number of NHS Walk-in Centres 4 43 39

Average visits per centre per day 30 103 73

l Last year the number of procedures carriedout in primary care had risen to an all timehigh of an estimated 725,000

l As growing numbers of primary andcommunity clinics are able to offer moreservices to patients, people canincreasingly avoid a hospital visit. Last yearthe growth in referrals by GPs to hospitalswas only 0.1%. Over 70% of patients’contact with the NHS is now at home or inprimary and community care facilities andthis is set to increase significantly.

Productivity

1.14 With this growing shift of services from thehospital to the community, the old measures ofproductivity do not properly reflect the work ofthe NHS, measuring only the work of hospitals,and ignoring the length of wait for patients,improvements in the quality of care provided,improvements in the outcomes of treatment,work to prevent the development of diseasesand efforts to support people with life-longillnesses. New services such as NHS Directand NHS Walk-in Centres do not feature. So inall the areas in which the NHS has forgedahead in recent years, productivity measureshave failed to keep up. The independentAtkinson Review is working with the Office ofNational Statistics to develop new measures ofproductivity that are appropriate to the realitiesof the NHS today and the new ways in which itis meeting the needs of patients.

More staff

1.15 Big increases in the money available tothe NHS have enabled the service to securerapid growth in its key resource, its staff.Between September 1997 and September2003 the number of doctors increased by19,400 (22%) and the number of nursesincreased by 67,500 (21%). Over the sameperiod the number of scientific, therapeuticand technical staff increased by 25,800 (27%).This growth has been underpinned byunprecedented investment in staff for thefuture. By autumn 2003 extra investment intraining had increased the annual intake ofmedical school students to over 6,000, a rise

of 61% since autumn 1997. There has been a53% increase in the number of nurses enteringtraining since 1997. Investment today willensure that the NHS of tomorrow has thenurses, doctors, therapists, scientists andtechnicians and managers that it needs todeliver a world-class service.

Better buildings for patientsand staff

1.16 The NHS has continued to invest inbuildings, equipment and infrastructure toprovide the additional facilities and beds thatenable NHS staff to deliver modern, safe,convenient and high-quality care. Since 1997,68 major hospital developments worth over£11 billion have been approved and 24 ofthese are already open and serving NHSpatients. By 2004, up to £1 billion will havebeen invested to modernise buildings andfacilities in primary care. Over 2,200 GPpractice premises have already beenmodernised through substantial refurbishmentor replacement with new buildings. Twohundred and eighty six one-stop primary carecentres have been created, bringing primarycare and community services onto one site.Twenty six NHS-run treatment centres havealready opened and a further 20 are indevelopment. They are complemented byindependent-sector treatment centres, with afurther 32 currently in development. By theend of 2005, there will be at least 80 treatmentcentres, providing a further quarter of a millionoperations a year for NHS patients.

Better healthcare

1.17 Patient safety is a top priority for clinicalstaff and over recent years the NHS has put inplace further improvements to support them inthat critical aspect of their work. The NHS isleading the world by introducing the first trulynational patient safety agenda, focusing onimproved patient care through the promotionof a culture of reporting and learning frommistakes and errors. The National PatientSafety Agency has developed a new reportingsystem that has now gone live in the NHS.


1.18 Patients have the right to expectassurances about the quality of care that theyreceive wherever they receive it in the NHS.The Health Act 1999 set out a statutory dutyof quality to be implemented through aframework of clinical governance, the systemsand practices of which ensure the highestpossible standards of care for patients. Clinicalgovernance support teams have been set up tohelp organisations focus on high-quality clinicalservices, and the Healthcare Commission willregularly be assessing NHS organisations’progress towards implementation.

1.19 The Department of Health recentlypublished a set of new draft standards for theNHS for consultation. The standards are wide-ranging and cover the full spectrum of NHSservices, including primary care and publichealth. They apply to all organisationsproviding services to or for the NHS includingNHS Foundation Trusts and NHS treatmentcentres. These standards will be used by theHealthcare Commission to assess the qualityof NHS healthcare and to supportimprovements in care.

1.20 A Patient Advice and Liaison Service hasbeen established in every NHS Trust and PCTin England to provide information and supportto patients, their families and carers in usingthe NHS. This service works with Patient andPublic Involvement Forums to monitor andreview health services from the patient’sperspective.

Improvements in patient experience

1.21 Since The NHS Plan, the NHS hasincreasingly listened to the patient voice indesigning services. NHS Trusts are nowrequired to collect feedback from service userson a regular and ongoing basis. There is alsoa rolling programme of national patient surveysto ensure that key issues for patients are

picked up quickly and addressed by the NHS.Overall these surveys show that a very largeproportion of patients say the services theyreceive are excellent or very good, a sign thatthe changes set out in this chapter are drivingreal improvements in the way the NHS meetsthe needs of the people that it serves.

1.22 However, these surveys also show thatpatients expect more from the NHS on gettingthe basics right – cleaner hospitals, betterfood, a pleasant environment, and servicesprovided by staff who are even more attentiveto patients’ needs and eager to improve theservice. The NHS has responded to thisfeedback:

l The Better Hospital Food Programme,launched in 2001, has improved the choice,quality and availability of food in hospitals,having a real impact on the 300 millionmeals the NHS provides each year at acost of £500 million. Patients now receivemenus with nutritional information, 24-hourcatering services, snack options and hotevening meals. This has resulted in betterservices for patients and less waste inthe NHS

l 98% of wards are now single-sex and theremaining mixed-sex wards will soon be athing of the past. Widespread work isunderway to convert large dormitory-stylewards into modern accommodation,providing greater privacy, dignity andcomfort for patients

l Through partnership with the private sector,the NHS has secured £100m of investmentin bedside televisions and telephones.At the end of last year 109 hospitals hadintegrated television and telephone bedsideservices, giving 51,000 patients access tothe service. Another 95 hospitals arecurrently installing the system


l Hospital cleanliness is improving. In 2000over 200 hospitals were rated asunacceptable. By 2001 all hospitals inEngland met or exceeded minimumstandards. Hospital cleanliness continuesto be targeted for further improvement.


Figure 1.6: Overall, how would you rate the care you received?

Excellent Very good Good Fair Poor Very poor0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

National A&E survey 2002/03 National outpatient survey 2002/03 National inpatient survey 2002/03


Section 2Offering a better service

Introduction

2.1 By 2008 the NHS will provide patients inEngland with services that compare well withworld-class standards. Choice andresponsiveness to individual needs will be areality for all, not just the more affluent or thebetter informed. Waiting for treatment will havebeen reduced to the point where it is no longerthe major issue for patients and the public.

2.2 Our priorities in this area are based on thepublic’s views captured by the consultationprocess carried out in 2003 and published inBuilding on the Best: Choice, Responsivenessand Equity in the NHS. The aim is a health

service which responds to 21st century publicexpectations by offering:

l flexible access to services shaped aroundindividuals’ needs and preferences, ratherthan an expectation that people will fit thesystem

l greater choice and shared decision-makingbetween patient and clinical team overtreatment and care

l better access to the information andsupport that people need to exercisechoice.


Chapter 2High-quality and personalised care

Waiting for treatment will reduce to the point where it is no longer the major issue forpatients and the public:

l By 2008, no one will have to wait longer than 18 weeks from GP referral to hospitaltreatment, and most people will experience much shorter waits, with even quicker accessin priority areas such as cancer

l Patients will be able to choose from four to five providers for planned hospital care fromDecember 2005

l By 2008, patients will have the right to choose from any health care provider which meetsthe Healthcare Commission’s standards and which can provide the care within the pricethat the NHS will pay

l Patients will be given more access to a wider range of services in primary care

l Patient choice will be supported by the provision of information about waiting times atdifferent providers, and about the quality of care available

l Every care setting will encourage the culture, systems and working practices to assurethe quality of care provided and enable improved quality and more personal care

l Patient safety will be a central focus of health care delivery: care givers will act to furtherreduce risks and learn from things that go wrong.

Improving access

2.3 The NHS Plan set out an aspiration of amaximum three months wait for any stage oftreatment by 2008. The NHS has made goodprogress. Compared to an 18-month inpatientwait, the maximum wait for inpatient treatmentis now nine months and the maximumoutpatient wait is 17 weeks. By next year themaximum wait for inpatient treatment will besix months.

2.4 This is still too long to wait for essentialcare. By 2008 no one will wait longer than18 weeks from GP referral to hospital treatment.Waits from GP to initial outpatient consultationwill not normally exceed six weeks. There willbe even shorter waits for patients whoseconditions require faster treatment. In the caseof patients with suspected cancer, maximumwaits by 2005 will not exceed eight weeks fromreferral to treatment and four weeks fromdiagnosis to treatment.

2.5 While 18 weeks will be the maximum, mostwaiting times will be much shorter than this.On the basis that average waiting times arecurrently under half the maximum, if thisrelationship is maintained, average waits in2008 will be around nine weeks from GPreferal to treatment. PCTs and providers willbe encouraged to set and achieve even moreambitious goals. Some are already achievingthese.

2.6 Because it is not acceptable to patients tohave short waits for inpatient and outpatienttreatment but no maximum wait for all thestages beforehand, waits for consultations,diagnostic procedures and tests are includedin the pledge for the first time ever. In fouryears’ time, waiting times for elective care willhave ceased to be the main concern topatients and the public.

2.7 In the longer term the NHS will also aim tobring waiting times to see other professionals,such as physiotherapists and speech andlanguage therapists, into this target. In themeantime, the NHS will make particularimprovements in reducing waiting times forspeech and language therapy and child and

adolescent mental health services. There willbe further improvements in access to NHSdental services. From April 2005, PCTs will beable to contract directly with dental practices toimprove access for their local populations.

2.8 Access to primary care is also an importantfocus for the next phase of reform. Ongoingtraining and recruitment of new GPs togetherwith the opening up of a wider range ofprimary care services, including NHS Walk-inCentres, minor injuries units and theexpansion of the NHS Direct service are allcontributing to improved access. PCTs arealso now being encouraged to be much moreproactive in their management of local supplyto ensure access for all. Incentives to attractnew providers will be developed to ensure thateveryone has fair access to primary care neartheir home and/or workplace (see Chapter 5).

Empowering patients

2.9 Rapid access is not enough. To meettoday’s expectations, patients need to be ableto choose from a range of services that bestmeet their needs and preferences. Betweennow and 2008, the NHS will be making thechanges which enable patients to personalisetheir care and for those choices to shape thesystem and the way that it is run.

2.10 People will be able to book their hospitalappointments for a time that suits them, froma choice of hospitals:

l From this August, people waiting more thansix months for surgery will be offered fastertreatment at an alternative hospital

l From April 2005, patients who need aheart operation will be offered a choice ofprovider from the time they are referredfor treatment

l By December 2005 all patients who needsurgery will be offered a choice of four tofive alternatives at the time they arereferred for treatment by their GP.

2.11 By 2008, all patients will have a right to beseen and treated within a maximum waiting

28 CHAPTER 2 HIGH-QUALITY AND PERSONALISED CARE

time of 18 weeks. A patient who is referred forplanned hospital care will also have the right tochoose any healthcare provider which meetsthe Healthcare Commission’s standards, whichcan provide the care within the price that theNHS will pay, and which can meet the 18weeks waiting time target. If a patient choosesto be treated by a provider which cannot offera waiting time of 18 weeks or less the patientwill be able to choose another provider orchoose to wait longer for their first choice.Patients making such choices will be fullyinformed of the total time they may have towait for treatment. Patients are guaranteedthat all care provided through the NHS will stillbe based on need and not on the patient’sability to pay.

2.12 In order to ensure that low-income groupsare also empowered to exercise choice, eligiblepatients will be able to have their transportcosts covered by the Hospital Travel CostsScheme, as at present. Guidance will be issuedshortly to PCTs on the implementation of choiceat the point of referral. This guidance willinclude policy on wider support for patientsexercising choice from 2005. Patient supportservices will need to be provided by PCTsappropriate to their local populations. Thesemay include, for example, assistance withlanguage, literacy, or other communications andmobility issues. It is expected that these supportmechanisms will continue to be available aschoice in planned hospital care is expanded.

2.13 Patients will also have more choice froma wider range of services in primary care,helping people to get access to morepersonalised healthcare. In addition todeveloping traditional primary care services,such as GP practices and pharmacies, theNHS will be increasingly working withinnovative new providers. These will beparticularly important in deprived areas whereprimary care is most needed and hastraditionally been weak, and for commuters,for whom the NHS will provide moreconvenient services which will minimisedisruption to their working lives.

2.14 The NHS will also make it easier andmore convenient for patients to get themedicines they need safely. The Departmentof Health will:

l continue to ease the bureaucracysurrounding repeat prescriptions

l free up restrictions on the location of newpharmacies

l expand the range of medicines thatpharmacies can provide without a prescription

l promote minor ailments schemes wherepharmacies can help patients manageconditions like coughs, hayfever andstomach upsets without involving their GP

l increase the range of healthcareprofessionals who can prescribe drugs topatients.

2.15 The NHS will widen choice further,starting with greater choice in maternityservices and greater choice over care forpeople who are terminally ill:

l Local services will promote direct access tomidwives, giving women quicker access tospecialist advice and support. Expectantmothers will have access to local guides tomaternity services

l Building on the strong tradition of end-of-lifecare in cancer and HIV/AIDS services, theNHS will promote a training programme forstaff working in primary care, residentialcare, nursing homes and hospital wards toensure that in time all people at the end oflife, regardless of their diagnosis, will begiven a choice of where they wish to dieand how they wish to be treated.

2.16 In addition, the Expert PatientsProgramme, described in the next chapter, willbe expanded nationally, to enable many morepeople who have long-term conditions to takegreater control of their own treatment,supported by NHS professionals in thecommunity when they need it.


Supporting personalised services –HealthSpace

2.17 A critical component of a personalisedservice will be giving people a bigger say inhow they are treated. As part of that work,an important building block will be to enablepatients to record how they wish to be treatedand give them the opportunity to record theirown information in their personal care records.

2.18 Everyone will have their own HealthSpace,linked to their electronic health record, allowingpeople to make their preferences known to theclinical team treating them. These mightinclude, for example, how they wish to behelped at a time of mental health crisis; next ofkin contacts; or simply how they prefer to beaddressed by staff.

2.19 Patients will be able to record their owninformation securely on the internet. Asfacilities build up over time, HealthSpace willenable patients to access their own electronichealth records and doctors to accessinformation that the patient wants them to see.

2.20 The Department of Health and the NHSwill also be working to ensure that patientshave the right information at the right time toensure that the services they receive areprompt, personal and convenient. Working witha range of partners, the NHS will harness newand existing technology, such as digital TVand the internet, to meet the needs of patients.As part of this work the Department of Healthwill develop a programme to “kitemark”information from a variety of sources so thatpatients know what sources of information arereliable and trustworthy. The Department ofHealth will continue to extend the range oflocal guides to services.

2.21 The Department of Health is currentlyconsidering the development of an NHS Card,which could support smart access to personaldata and speed confirmation of access toappropriate care.

Listening to patients

2.22 Expanding choice and developing apersonalised service for patients depends ongiving patients a stronger voice. Wherepatients choose to go will be important, as itwill affect where resources go and whichproviders thrive. But there will also be agreater readiness, nationally and locally, toseek and listen to the views of patients, and toact on them.

2.23 Patient surveys and other systems will bedeveloped further to provide faster and clearerfeedback about their experiences of the NHS.Patient surveys are managed by theindependent Healthcare Commission and covera wide range of care settings. All the surveysfocus on the issues that patients say areimportant to them and they are used to provideinformation on how the NHS can improve thequality of care it provides.The assessment ofthe patient experience is based on the fiveareas that patients and the public haveidentified as being of greatest importance:

l access and waiting

l safe, high-quality and well co-ordinatedcare

l better information and more choice

l even better relationships between patientsand staff based on respect and dignity

l clean, friendly and comfortableenvironments.

2.24 The Department of Health will alsostrengthen arrangements for monitoringthe impact of improving choice andresponsiveness on equity, and for trackingthe experience of different patient groupsand communities. There will be a particularfocus on the needs of groups which havetraditionally suffered from relatively pooraccess to some elements of care includingblack and minority ethnic groups.


A choice of high-quality services

2.25 For patients to be confident in exercisingchoice, they need the assurance that all of theservices that they are choosing from meet highstandards of clinical care. That confidence isthe bedrock of modern medical practice.Patients have a right to take it as a given thatevery effort is made to ensure that their careand treatment is both safe and effective. Whileevery NHS professional has that aim ingrainedin their professional practice, they needsupport in ensuring that their individualcontributions add up to a system that is safeand effective.

2.26 A great deal of progress has been madeto ensure that this is the case. Thedevelopment of clinical governance in NHSorganisations is supporting the developmentof a system to ensure that improving safetyand clinical care is central to every NHSprofessional’s working life. The developmentof national standards, including NationalService Frameworks, is helping to set a clearframework against which organisations canmeasure their clinical performance. Thecontinuing work of the National Institute forClinical Excellence (NICE) in the developmentof clinical guidelines is also contributing toimproving clinical care. The establishment ofthe independent Healthcare Commission putsin place the inspection system needed toensure that those standards are maintainedand improved upon.

2.27 All NHS bodies will continue this drive forsafer and higher-quality care. This objectivereflects public concerns both about safety inhospitals and about risks in the environment.The main approaches we will take are:

l continuing the drive to create a culture ofgreater patient safety so that it becomes aneven greater priority for all those working inthe NHS, and for the organisations theywork in

l ensuring that learning from incidents thatendanger patient safety is the norm for allNHS staff and organisations

l building on clinical governance so that, likebroader quality issues, safety is of higherpriority throughout all organisations caringfor NHS patients

l supporting the work programme of theNational Patient Safety Agency (NPSA) torun a new national system for reporting,analysing and learning from adverse errorsor mistakes in caring for patients

l ensuring that the work and learning of theNPSA becomes part of everyday clinicalpractice

l ensuring the newly-established HealthProtection Agency effectively supports thedevelopment of frameworks to protect thepatient

l using the investment in IT and informationsystems to contribute to improved safety ofcare for NHS patients through bettercommunication, use of knowledge aboutbest practice, and specific issues on drugs,such as interactions and monitoring.

2.28 An example of the new drive to bettersafety and quality is in our approach toMethicillin Resistant Staphylococcus Aureus(MRSA). National mandatory surveillance forMRSA blood stream infections was introducedin April 2001. The availability of reliable data isenabling NHS Trusts to benchmark theirperformance and to take action to preventavoidable cases. The implementation of theactions set out in Winning Ways will lead to areduction in rates of MRSA and otherhealthcare-acquired infections in England.


2.29 New ways of working for healthprofessionals will be supported by systemsof regulation to ensure the highest quality ofpatient care, complemented by effectiveprocesses for reporting, auditing andinspecting care and by facilitating continuingprofessional development. In the context of awider review of regulation there will be:

l reform of the General Medical Council andother statutory professional regulatorybodies overseen by the Council for theRegulation of Healthcare Professionals

l reform of post-graduate medical trainingoverseen by the Postgraduate MedicalEducation and Training Board

l re-accreditation procedures linked toannual appraisals for staff

l the development of the NHS University(NHSU) to provide ongoing training andlearning opportunities for all NHS staff

l support to employers dealing withpoorly-performing doctors

l following consultation, proposals to takesteps to introduce regulation of other healthcare professionals, such as acupuncturistsand herbalists

l continued work with the General SocialCare Council to better develop the effectiveregulation of social care professionals.



THE NHS IN 2000

Patient has to make an appointment with aregistered GP for advice, diagnosis andreferral.

Patient may wait several days for anappointment with their GP.

GP makes decision about how, when andwhere patient is treated.

GP sends referral letter to NHS Trustrequesting outpatient appointment. NHSTrust then sends appointment time topatient.

Patient waits up to 12 months for anoutpatient appointment. Patient waits up to18 months for inpatient appointment.

Patient waits several hours in A&E.

Patient records owned by hospital, splitbetween the specialties, often go missing orare not available at the right time.

Patient in (mixed sex) Nightingale wards.

Patient has to keep repeating any personalinformation about communication, language,dietary or mobility needs at every contactwith the NHS.

THE NHS IN 2008

Patient chooses whether to make anappointment with a GP or practice nurse,visit an NHS Walk-in Centre or PharmacyService Centre, or contact NHS Direct foradvice and diagnosis.

Patients see a primary care practitionerwithin 24 hours when they need to or within48 hours for a GP.

Patient chooses how, when and where theyare treated – from a range of providersfunded by the NHS and accredited by theHealthcare Commission.

Patient books hospital appointmentelectronically for their own convenience.

Patient waits for specialist care are reducedto no more than 18 weeks from GP referralto treatment.

Patient contacts NHS Direct or visits MinorInjuries Unit. If patient needs to go to A&E,he/she is seen rapidly (maximum four hours).

Patient records owned by the patient; withsecure access for appropriate healthprofessionals.

Mixed sex wards abolished for older peopleand for all but a small number of patientse.g. intensive care.

Patients record their preferences in theirpersonal HealthSpace on the internet, linkedto their patient care record.

Introduction

3.1 With medical technology improving, theprovision of universal healthcare, andimproved prevention, the NHS continues tomake inroads into curable and preventablemedical conditions in England. As people livelonger, growing numbers of people havemedical conditions that they will live with forthe rest of their lives. These long-termillnesses are increasingly common and theability to respond well to the needs of patientswith them has become an important part ofmodern healthcare.

3.2 Long-term conditions affect older peoplemore than younger people and people in lowersocio-economic groups are also more likely tobe diagnosed with one or more condition.Long-term conditions include diabetes,asthma, arthritis, heart disease, depression,psoriasis and other skin diseases that can becontrolled but not cured. They vary in theirdegree and severity but living with such a

condition usually has a major impact on aperson’s life and on their family.

3.3 The impact on individual patients and theNHS is enormous:

l About 60% of adults report some form oflong-term or chronic health problem

l People with long-term health problems aresignificantly more likely to see their GP(accounting for about 80% of GPconsultations), to be admitted as aninpatient (on average about twice as likely,given a particular problem) and stay inhospital for longer

l Use of the NHS increases with the numberof problems reported (the 15% of peoplewith three or more problems account foralmost 30% of inpatient days)

34 CHAPTER 3 SUPPORTING PEOPLE WITH LONG-TERM CONDITIONS TO LIVE HEALTHY LIVES

Chapter 3Supporting people with long-term conditionsto live healthy lives

People with long-term conditions will receive higher-quality care:

l The Expert Patients Programme will be rolled out throughout the NHS by 2008 to enablethousands more people with long-term conditions to take more control of their health

l The new contract for GPs introduced in April 2004 will reward family doctors who deliverhigher standards of care to patients

l Patients with complex long-term conditions will be supported by community matrons,and by 2008 every PCT will be offering these services

l People with long-term conditions will benefit from the rapid implementation of NICEguidance on cost-effective drugs.

l There are some patients with more thanone condition whose complex needs meanthat they depend very heavily on hospitalstays to support them. Ten per cent ofpatients who stay in hospital for their careaccount for 55% of hospital stays,compared with 50% of patients who useonly 10% of the bed days.

3.4 The NHS needs to provide a much betterservice for patients with these conditions andprovide high-quality personalised care to meettheir needs. It needs to enable people to takegreater control of their own treatment, and tospend more time at home and in thecommunity with their families and friends.The NHS needs to do much more to supportpatients in avoiding the fear and anxiety ofhaving to go to a hospital in an emergency,by anticipating problems and working withpatients to prevent these worrying episodes.This chapter sets out how the NHS will bothrespond to these needs and build aresponsive service tailored to patients withlong-term illnesses.

3.5 The benefits to patients are argumentsenough for doing so. But responding in thisway will also create a more efficient healthservice that is better able to meet the needs ofall the patients that it serves. There is strongevidence that improved management of theseconditions can lead to:

l Fewer emergency admissions intohospitals, where care is more expensive.Many patients with severe conditionsexperience periods of relatively poorerhealth when emergency admission tohospital is required to stabilise theirconditions. These admissions account fora high proportion of overall emergencyadmissions and of total bed-days. Thisoccurs across a wide range of conditions,including heart disease, chronic obstructivepulmonary disease (including bronchitis andemphysema), diabetes and mental healthproblems


Figure 3.1: Percentage of those admitted as inpatients by cumulative days spent asinpatients

Percentage of inpatients

0.0 10 20 30 40 50 60 70 80 90 1000

10

20

30

40

50

60

70

80

90

1005% of inpatients account for 42% of overall inpatient days



Cum

ulat

ive

perc

enta

ge o

f inp

atie

nt d

ays

Source: Analysis of British Household Panel Survey (2001)

l Fewer admissions for inpatient care.Slowing the progression of disease candelay or prevent the need for treatment inhospital. For example, better managementof high blood pressure and high cholesterolin patients with heart disease means thatfewer of these patients will require heartsurgery. Effective physiotherapy forpatients with arthritis can delay the need forjoint replacements.

Personalised support for patientswith long-term conditions

3.6 Over the next four years, the NHS will beoffering better, more effective, services topeople with long-term conditions.

3.7 The NHS will concentrate on giving theright level of support to patients. While patientswill need individually-tailored care, patients canbe broadly divided into three groups requiringdifferent levels of support. The large majorityof patients are usually able to manage theirown conditions, given the right advice andsupport. Another group needs more proactivesupport in caring for themselves, withparticular support on avoiding complicationsand slowing the progression of their disease.A smaller group of patients with particularly

complex needs require an approach known as“case management”, with more active andspecialist care.

Self-management

3.8 For the first level of care, self-management,people with long-term conditions can often livehealthier lives when they are supported tomanage their chronic disease. In recent years,drawing on international experience andresearch evidence, the Expert PatientsProgramme has been developed in the NHSto find effective ways of giving this option topatients.

3.9 Using trained non-medical leaders aseducators, people with arthritis and otherlong-term conditions have been equipped withthe skills to manage their own conditions.Compared with other patients, “expert” patientsreport that their health is better, and they copebetter with fatigue, feel less limited in what theycan do and are less dependent on hospitalcare. The programme has involved many PCTsacross the country and to date has supportedover 10,000 patients in this way. By 2008, it willhave been rolled out throughout the NHS,enabling thousands more patients to takegreater control of their own health and their


Figure 3.2: The right service for patientsRight Service for Right Patients

Level 3Patients with highly complex conditions

Level 2Higher risk patients

Level 170-80% of patients

Casemanagement

Diseasemanagement

Selfmanagement

Population wide prevention

own lives. The following statements indicatethe benefits reported by patients:

Disease management

3.10 At the second level of care, there is verygood evidence about the positive impact ofbetter disease management on specificconditions like heart disease, chronicobstructive pulmonary disease, asthma,diabetes and depression. With proper supportin primary care and systematic and tailoredprogrammes for individual patients, betterhealthcare and social care can make a veryreal impact on slowing the progression ofthese diseases and delaying or avoidingsevere phases of illness.

3.11 For example, for coronary heart disease,GPs now have registers of all their patientswho suffer from this condition. They can usethese registers to invite patients in once ortwice a year to check that their blood pressureis under control, that their cholesterol levelsare kept in check and that they are providedwith support in stopping smoking or takingmore exercise. It has been estimated thatdrugs for cholesterol alone have saved up to7,000 lives through this approach. Many moreheart attacks have been prevented and fewerpatients have had to go through the trauma ofsurgery as a result.

3.12 The new approach to diseasemanagement will consolidate this work for allpatients who can benefit. The National ServiceFrameworks provide clear models andframeworks for many of these conditions.The National Institute for Clinical Excellenceguidance provides many of the key clinicalunderpinnings for a number of theseconditions. The new contract for GPs providesstrong financial incentives to those practicesthat seek out patients who can benefit fromthis kind of support and demonstrate that theyare making a real difference to their health.

Case management

3.13 At the third level, where patients may oftenhave three or more long-term health problems,the NHS needs to put in much more effort tomeet their complex needs and provide aproper personalised service. Evidence forcase management has come from a rangeof sources, both within the NHS and frominternational experience where it has beensuccessfully implemented. This evidence hasshown that high-quality and personalised casemanagement can improve patients’ livesdramatically, reduce emergency admissionsto hospital and enable patients to return homefrom hospital more quickly when they do haveto be admitted. From the perspective of a moreefficient NHS, a range of UK studies haveshown reductions in admissions of between10% and 20% as well as reductions in thelengths of hospital stays of between 20% and30%. Taking the thought and making the effortto meet the individual needs of patients whoneed help most is not only good for patientsand for their families, but it is good for the NHS.

3.14 The key to meeting the personal needsof these patients will be a new type ofspecialist clinician, often a nurse, who workswith patients and social care providers andwho has particular expertise in responding topatients’ complex problems. These communitymatrons will work with patients with complexproblems to assess their needs and thesupport that they need and then work withlocal GPs and primary care teams to developtailored personal plans to deliver the bestpossible care to them. These nurses will act

l “It gave me new ways of analysing andsolving some of my problems… Ibelieve that this is one of the mostimportant initiatives for those withlong-term conditions.”

l “The Expert Patients Programme hasreally helped me to take more controlof not just my arthritis, but also my life.”

l “I have learnt that I need to takeresponsibility for my health instead ofleaving it all to the GP.”

l “Coming on the programme has givenme real confidence to move on, planfor the future without fear, because Ican now plan and pace – really goodteaching.”


as a fixed point for the patient, takeresponsibility for their care, and co-ordinatethe contribution of all the differentprofessionals who can help, anticipate anddeal with problems before they lead toworsening health or hospitalisation.

3.15 The pilot phase of this approach hasshown that patients’ health is improved quicklyand, following on from that, reductions inadmissions and long stays in hospital alsoreduce pressure on hospital and accident andemergency services. This is because casemanagement avoids many of the admissionsin this complex group of patients which aredue to relatively minor and easy to preventconditions such as dehydration and urinarytract infections, which could be avoided if theNHS was better able to quickly respond topatients’ needs in the community. The additionof these relatively minor problems to patients’existing poor health and complex chronicdisease is often the trigger for admission tohospital, which is upsetting for patients andtheir families and inefficient for the NHS.

3.16 Nine PCTs are working to adapt andimplement case management for vulnerable,older people. Strategic health authorities arenow developing case managementapproaches across their health communitiesfor implementation by April 2005. This modelof care will be adopted by every PCT between2005 and 2008 by which time there will beover 3,000 community matrons using casemanagement techniques to care for around250,000 patients with complex needs.

Care closer to home

3.17 Patients generally prefer to be at homerather than in hospital, provided that they areproperly supported. This programme willensure that more care will be provided closerto home. Where possible, patients will be ableto choose where and when they receive careand will be supported in making these choices.This includes making use of contact throughthe telephone, digital television and theinternet, and applying the benefits of telecare,where there is evidence of cost-effectiveness(see Chapter 7).

3.18 In the case of planned hospital care, wewill build on schemes already in place in partsof the NHS that enable patients to be treatedmore quickly and conveniently without havingto attend hospital. For example, in GreaterManchester, many patients are now diagnosedand treated by GPs with a special interest,specialist nurses and other practitioners.Similarly, in Somerset, a referral managementcentre helps patients make informed choiceswith their GP about where they should bereferred for specialist treatment. The result hasbeen a significant increase in the number ofpatients choosing to see a specialist GP in thecommunity, and this is often more convenientfor them than a hospital appointment.

3.19 In the case of emergency care, theemphasis on supporting people with long-termconditions will help reduce unnecessaryemergency admissions and enable hospitalsto respond more effectively to the needs ofacutely ill patients. This includes makinguse of emergency care practitioners in theambulance service where appropriate. Forexample, the London Ambulance Service has24 emergency care practitioners. They providea service in two boroughs between 10amand 10pm, mainly for people whose conditionsare not life-threatening but who needassistance or advice. Of these people, 83%are dealt with by a single emergency carepractitioner avoiding admission to hospitalaltogether.

Social care

3.20 Effective social care services are oftencritical to meeting the needs of people withlong-term conditions, enabling people to livemore independently and, along with healthcareand other services, improving their healthand the impact that it has on their lives.The following principles will be essential toensuring that the NHS and social careservices work together to meet the needs ofthese patients and provide them with thepersonalised support that they need:


l Social care, like healthcare, needs to beperson-centred and personalised. Servicesneed to cater for the individual’s needs,rather than those of the service providers.This is not only about professionalsinterpreting an individual’s needs andtailoring services to those assessed needs,but also involving people themselves, andtheir families, in the design and delivery ofthose services

l Social services are often provided at a timeof crisis or significant event in a person’slife, and sometimes continue long-termfrom that point. Social care services andthe NHS need to reinforce the focus onproactive services that stop problemshappening and help patients to maintainindependence and existing networks ofsupport. Picking up the pieces after theevent, if it was avoidable, is a failurefor those who require social care andhealth services

l Social care commissioning and provisionwill be further integrated with healthcare todeliver a better experience for the individualand ensure the most efficient use ofavailable resources. Patients and theirfamilies should not have to take the troubleto communicate between different services.That is the job of local NHS and localauthority services

l There will be a greater role for preventativeservices to help people avoidhospitalisation. Social care is critical to thatwork. Effective home care can help patientsavoid going to a residential care home.Creative work to meet people’s needs withbetter transport, housing and leisureservices can also support this effort, ascan excellent examples of work by localauthorities to provide people with social andcommunity networks that sustain them andhelp them to cope with the right support.

3.21 The single assessment process and bettercare co-ordination will be central to achievingthese aims. It will help everyone involved toensure the full range of health and social care

needs of the individual are met. TheDepartment of Health has already put in placea number of building blocks to support greaterintegration. The 1999 Health Act removesmany of the legal barriers to allow jointcommissioning of services by the NHS andlocal government, enabling combined provisionand funding. In some areas, there have beenjoint appointments of senior managers in keyroles in PCTs and local authorities to fostercombined planning of care for the people thatboth organisations exist to serve. TheCommunity Care (Delayed Discharges) Act2003, also gives social services departmentsstrong financial incentives to work withhealthcare partners to ensure a smoothtransition for patients from hospital back tothe community.

3.22 As part of this drive, people will be givenfurther control over their social care needs andthe way that they are met. Direct payments –where people are given the financial resourcesto pay for the services that they need, ratherthan the services that the council offers –empower people to make their own choicesabout the design and delivery of the servicesand equipment that they need. With the optionof support and advocacy functions, directpayments can significantly improve people’ssatisfaction with the help they secure andminimise the risk of making people dependent.Direct payments can also be co-ordinated withhealth commissioning so that, where needed,PCTs can commission integrated packages ofsocial care and community-based healthcare inpartnership with patients. This will be part ofan overall strategy to improve choice in socialcare services.

Older people and long-termconditions

3.23 Older people have a relatively highlikelihood of chronic disease and long-termconditions. They make heavy use ofhealthcare services and are majority usersof social care. Frail older people with poormobility, poor functioning and confusion aremore likely to develop urinary tract infections,suffer dehydration, malnutrition and


hypothermia, and may fail to take medication.Often, the home environment may make itdifficult for them to cope without support,particularly if they are alone, under stress, orhave lost confidence in their ability to manageon their own. In all these cases, well-targetedand co-ordinated community-basedhealthcare, community equipment and socialcare are effective at providing the personalisedcare that they need and preventing stressfuland disruptive admissions to hospital.

Mental health

3.24 The complex medical and socialunderpinnings of mental health and itstreatment make it different from other long-term conditions, but this has often made it aforerunner in delivering combined approachesto delivering more personalised care, usingpreventative services, self-care, treatment inthe community and, overall, more proactivecare. The National Service Framework forMental Health sets out a comprehensiveagenda for improving services for adults.The National Service Framework for Children,to be published later this year, will include anew standard for child and adolescent mentalhealth services.

3.25 A key priority will be to ensure betteravailability of early intervention and preventionservices. In particular, the aim is to ensure acontinued emphasis on assertive outreachservices that seek to engage those withmental illness who are at risk of falling out ofcontact with services. Crisis resolution andhome treatment services that respond rapidlyto people in a crisis and provide support in thecommunity will also be developed. Such teamshave already shown that they can help toprovide more effective support to patients,and they are well-liked by the people who theyserve, helping them to avoid unnecessary timein hospital.



What the future will look like for the patient

Scenario: SayedSayed (15) has had a cough for a week. He knows most coughs get better by themselves butthat they sometimes make his asthma worse so he increases his preventative inhaler therapy.He, his GP and his parents have agreed that he can manage things himself. He accesses hispersonal care record from home, including personalised management plans for asthma andchest infections. Despite having increased his inhaler therapy as planned, his wheeze is worseand his measurement of breathing (peak flow) has fallen. He rings his GP. Sayed has beenon the Expert Patients Programme, and has taken the specific module on managingworsening of his asthma. Therefore they decide that Sayed can go directly to the pharmacyto pick up a three-day course of steroids after the GP sends an electronic prescription. Sayedknows what to do if his symptoms change or if he is still concerned. The next morning he iscontacted by the practice nurse who finds he is making a recovery. The following week theytalk again and amend his care plan to help prevent future exacerbations.

Scenario: LucyLucy (30) has had diabetes since childhood. She has registered a profile of interests onHealthSpace, her own secure place on the internet, that holds her personal care record.She regularly receives updated information about managing diabetes from the NHS, DiabetesUK and a diabetes clinic in Boston that her specialist nurse recommended. Recently, she hasfound that the pharmacy near to work can do full diabetes tests, including blood tests, footchecks and retinal screening. These are put onto her HealthSpace. In 2003, she started ona newer, long-acting, insulin (glarine), as recommended by NICE. Recently, she and herpartner have decided to start a family. Lucy went to her GP and discussed the implications.To back this up, her GP sends some general information to her HealthSpace about preparingfor pregnancy and more detailed information about what diabetic mothers should do, andgives her a link to an evidence-based website on diabetes in pregnancy.

Scenario: EstherEsther (82) has had raised blood pressure, angina, heart disease, diabetes and arthritisaffecting her knees, hips and hands. The pain was getting worse last year so, instead ofincreasing her medication, she went on the Living With Arthritis programme jointly run by herPCT and Help the Aged. It was a great success. Unfortunately, she recently had a smallstroke but made a good recovery in the specialist-run, community-based stroke unit. Sincethen, she has had an emergency admission to the local acute hospital with a urine infection,leading to confusion. This, combined with the fact that she has multiple chronic conditionsand is on more than five medications, automatically alerts her GP to the fact that she is nowat a high risk of repeated admissions. Her GP therefore refers her to a community matronwho, working with Esther’s practice, the local occupational therapy and physiotherapy serviceand social services, manages to help Esther become increasingly independent and less atrisk. After two weeks of intense input and then occasional follow-up for a further two months,the matron hands back her care co-ordination to Esther’s GP practice.

Scenario: PeterPeter (36) has had psoriasis since his early twenties. About eight years ago it became sobad he had to be admitted to hospital for two weeks, but in recent years it has been muchmore stable. For the most part, Peter now manages his own psoriasis, using different creamsand regimes according to how bad his symptoms are. He receives most of his prescriptionsby post after ordering them over the internet. Recently he went to his local pharmacy and gotsome useful advice about exposure to the sun, which he knew helped his psoriasis but wasalso a risk for skin cancer. He is very active in his local psoriasis group, and as a result hasbecome an educational resource for other patients with psoriasis. He has also become partof a group of clinicians, managers, patients and carers who advise the local Primary CareTrusts on how to commission services for patients with skin problems. He was particularlypleased to make sure that a number of different specialist providers are now available. Hethinks that as a result, there are now providers who will suit the needs of many groups ofpeople, including children, younger patients like himself and the elderly.

Introduction

4.1 As the effects of investment and reformgather pace in the NHS, and the health serviceis better able to provide patients with fast andpersonalised treatment, the promotion ofhealth and the prevention of ill-health willassume a much more important role in thework of the NHS. This chapter sets out how,following the publication of a White Paper onpublic health later this year, the NHS willbecome a health service and not just asickness service, leading national and localefforts to tackle the causes of ill-health andnarrowing the gap between the healthiest andunhealthiest parts of the country.

Health in England

4.2 There have been progressiveimprovements in the health of the populationover the last century. Life expectancy at birth

increased by around 30 years between 1901and 2001 (Figure 4.1), and life expectancy atage 65 increased by around seven yearsbetween 1901 and 1991. These improvementshave resulted from better nutrition andhousing, advances in medicine andtechnology, and the provision of healthservices freely available to all.

4.3 The population of England is increasingslowly and is ageing. Changes in thepopulation and new treatments have helped tochange the pattern of illness and diseasewhich affects people in England today. Therehas been a substantial decline in infectiousdiseases such as measles and an increase incancers, heart disease and strokes, which nowaccount for 35% of ‘life years’ lost before theage of 75. Long-term conditions have alsoincreased in importance.

42 CHAPTER 4 A HEALTHIER AND FITTER POPULATION

The NHS will become more of a health service and not just a sickness service and:

l Inequalities in health will be reduced by targeting people at greatest risk

l Death rates from coronary heart disease and strokes in those under 75 will be reducedfrom 1997 by at least 40% by 2010

l Death rates from cancer in those under 75 will be reduced by at least 20% by 2010

l Death rates from suicide and undetermined injury will be reduced by at least 20% by 2010

l Building on current initiatives will help us in reducing risks of infection from MRSA withsignificant reductions between now and 2010

l The Department of Health’s 2004 public health consultation, Choosing Health?, will leadto comprehensive proposals in a White Paper later in the year for tackling obesity,smoking and sexually-transmitted infections.

Chapter 4A healthier and fitter population

4.4 Analysis undertaken for the secondWanless Report shows that the health of thepopulation of England is not as good as that ofother comparable countries. The factors thatcontribute to poor health include relatively highlevels of smoking (27% of the adult population)and overweight/obesity, and low levels ofphysical activity and consumption of fresh fruitand vegetables.

4.5 The social and economic determinants ofhealth remain important factors as well.Poverty, ethnic origin and low educationalachievement are all potentially significantissues. These determinants of health give riseto inequalities in health between different socio-economic and ethnic groups. Figure 4.3 showshow the gap in life expectancy between socio-economic goups has changed since the 1970s.


Figure 4.1: Life expectancy at birth, England, 1900–2001

100

80

60

40

20

0

1900

Yea

rs

1926 1950 1976 2001

Source: Securing Good Health for the Whole Population: Population Health Trends (2003)

females

males

Figure 4.2: Selected causes of death at the beginning, middle and end of the last century

100%

80%

60%

40%

20%

0%1900 1950 2000

Source: Securing Good Health for the Whole Population: Population Health Trends (2003)

All other causes

Injury and poisioning

Cancers

Circulatory diseases

Respiratory diseases

Infectious diseases

Cigarette smoking accounts for around halfthe difference in survival to 70 years of agebetween socio-economic groups one to five.

4.6 A recent analysis by the World HealthOrganization considered the impact of diseaseon countries in Europe, looking at both deaths

and ill-health in the population. Thisinformation was used to create a measureknown as “disability adjusted life years” or‘DALYs’. Table 4.1 shows that heart diseaseand strokes, mental illness, accidents, injuriesand cancers have the greatest impact on thehealth of the population. The ranking of these


Figure 4.3: Changes in life expectancy at birth, by social class, 1972–99

Figure 4.3: Changes in life expectancy at birth, by social class, 1972-99

Life expectancy at birth in years

85

83

81

79

77

75

73

71

69

67

0

1972–76 1977–81 1982–86 1987–91 1992–96 1997–99

Social Class I

Social Class V

Social Class I

Social Class V

5.3 yrs5.0 yrs

5.1 yrs4.7 yrs

6.4 yrs 5.7 yrs

Females

5.5 yrs

7.7 yrs 7.4 yrs8.8 yrs

9.5 yrs7.4 yrs

Males

Source: Tackling Health Inequalities: A Programme for Action (2003)

Table 4.1: The burden of disease in Europe

Cause Disability adjusted Percentage (%)life years

Cardiovascular diseases 33,381 21.8

Mental illness 31,080 20.3

Injuries 22,707 14.8

Cancers 17,642 11.5

Digestive diseases 7,087 4.6

Infectious and parasitic diseases 6,823 4.4

Respiratory diseases 6,416 4.2

Musculoskeletal diseases 5,304 3.5

Sensory organ disorders 4,150 2.7

Respiratory infections 3,891 2.5

All other causes 14,631 9.5

Total DALYs 153,111 100.0

diseases is expected to remain relativelystable over the period to 2020, so the prioritiesfor improving health in England will focus onthese causes. The World Health Organizationalso identified the key risk factors for thesediseases in developed countries. These aretobacco, high blood pressure, alcohol, highcholesterol and obesity.

A health service, not a sicknessservice

4.7 If England is to secure world-classstandards of health, the enormous human,financial and physical resources available to theNHS need to be focused on the prevention ofdisease and not just its treatment. The NHSwill be prioritising preventative public healthmeasures. The current national public healthconsultation, alongside the recommendations ofthe second Wanless Report, give a strong steeron how this can be achieved. The Departmentof Health will publish a White Paper, ImprovingPeople’s Health, later this year setting out indetail what needs to happen next. This willinclude proposals for further action in relation tocurrent priorities, such as smoking and its linksto cancer and heart disease, and mental health.It will also include recommendations in relationto challenges such as obesity and sexually-transmitted infections.

4.8 In developing these plans, the White Paperwill spell out how the country can build on thegood progress that has already been made.England is experiencing rapidly decliningdeath rates from its two biggest killers –cancer and heart disease – and policies onscreening, smoking and treatment havecontributed to this progress. But as thesebig killers have continued to decline, starkinequalities in health have remained, and forsome important diseases the health gap haswidened. The challenge now is to extend theimprovements in health to all groups in thepopulation and to find ways of reducinginequalities at the same time as improvingthe health of the population as a whole.

4.9 The NHS has a part to play in this, but alsoimportant are the contributions of other publicagencies, the voluntary sector andcommunities. For example, partnerships suchas Healthy Living Centres and Sure Start(see box) can have a significant impact. TheChoosing Health? public health consultation isexploring how this work can be taken forward,looking at how people can be supported tomake healthier choices in a way thatrecognises their social circumstances and theobstacles that these may present to improvingtheir own health. This will include a particularfocus on children – tomorrow’s adults –


Sure Start – action on diet and nutrition in disadvantaged areas

One of the aims of the Sure Start programme is to improve outcomes for children, parentsand communities by helping service development in disadvantaged areas. Improving healthand tackling health inequalities are key themes of the programme. Nutrition and diet areimportant issues.

l In Wear Valley in the north east, the St Helen Auckland Community School operates abreakfast club for children in its nursery classes through a joint Sure Start/Wear ValleyPCT initiative. The club is open from eight o’clock and breakfast includes cereals, fruitjuice, and fruit when possible. It is supported by volunteers and parents are encouragedto join in. Teachers have found the children more responsive in lessons and moremotivated to get to school earlier.

l In east London, the Mapledene Early Years Centre in Hackney has built a flourishingpartnership with a national supermarket chain promoting its healthy food range to ensurethat children eat healthily. This is important because many of the children at the centrecome from disadvantaged backgrounds and attend for breakfast, lunch and tea. Thepartnership also provides cookery skills workshops for parents, and an organic gardenwith a vegetable patch for children.

because of the importance of early influenceson health later in life.

Health and inequalities

4.10 The two Wanless Reports havehighlighted the need for the Government toengage fully with patients and the public inorder to deliver better health outcomes for thepoorest in our communities and easepressures and costs for the NHS in the longrun. This includes ensuring that all NHSorganisations form active partnerships withlocal government and other local agencies topromote population health and reduceinequalities. As this happens, particularattention should be given to the needs ofminority ethnic groups and the health gapbetween these groups and others should benarrowed.

4.11 The NHS will engage citizens andcommunities in health improvement and helpthem to play an increasing part in adoptinghealthy behaviours and promoting the “fullyengaged” scenario outlined in the first WanlessReport. This will include new approaches suchas the “collaborative” techniques which havebeen used to improve health services. In thismodel, NHS organisations sign up to try outnew approaches, share learning about whatworks and seek to achieve specific measurableimprovements in health by working togetherand supporting each other. One such approachhas already reduced accidents among theelderly by 60% in three geographical areas.The White Paper will set out how theseapproaches might be applied to other areasand topics where preventable risks can bedramatically reduced.

4.12 Making a real impact means that the NHSwill need to engage with local communitiesmuch more effectively, building on the goodprogress made and good practice developedin initiatives such as Sure Start, Healthy LivingCentres and work to reduce teenagepregnancies. Models of outreach andcommunity engagement will need to be builtinto mainstream services nationally, onceevaluation has demonstrated their real value.And just as the health service will need to

engage the communities it serves, it will alsoneed to engage the efforts of wider players incivic society – local government, business, thevoluntary sector and the various faiths.

4.13 The contribution of primary care toreducing health inequalities is particularlyimportant. The new General Medical Services(GMS) contract and the forthcoming pharmacycontract will be important drivers, providingfinancial incentives to practices to improve thequality of care for people with long-termconditions and, over time, extending thisapproach to “at risk” groups to preventavoidable deaths and illness.

4.14 In taking forward the public healthagenda there is a need to strengthen thepublic health capacity and delivery systemto ensure that the right people, skills andapproaches are in place both in the NHSand in partner agencies to make sureimprovement, health protection and healthinequalities are actively pursued andperformance managed. One element of thisis to strengthen information and knowledgemanagement systems so that knowledge ofwhat works can be shared and public healthproblems can be detected at an early stage.Strengthening the evidence base for publichealth interventions, including evidence oncost-effectiveness, through a systematicallycommissioned programme of research, will bean early priority.

4.15 Public health priorities include developingand implementing plans for tackling infectiousdiseases including tuberculosis, Hepatitis Cand new diseases such as SARS, as set outin the Getting Ahead of the Curve strategy.Our strategy to reduce MRSA and otherhealthcare-acquired infections is set out in thereport Winning Ways. The Government will setout the next steps for tackling these infectiousdiseases later in the summer. A key objectivehere is improving knowledge of infectiousdiseases and reducing cases of transmission.There is also a need to make further progresson the development and implementation ofimmunisation programmes. The HealthProtection Agency will lead this work.


Partnership working in practice

4.16 We will work to improve the way wesupport effective public health interventionsin partnerships, both locally and with othergovernment departments and agencies.The Choosing Health? public healthconsultation is exploring ways to strengthenLocal Strategic Partnerships. Thesepartnerships facilitate greater co-ordination indelivering health and social care services tolocal populations. Together with othercountries we will also tackle global healthproblems through appropriate bilateral andmultilateral actions. The following areexamples of the ways in which we will achievethis objective.

4.17 The Department of Health will in time bemore outward-looking and focused on thepursuit of health and healthcare objectives aswell as supporting the wider governmentalagenda. The Department of Health will play amore strategic role in engaging with the widerinternational agenda, the World HealthOrganization and the World Trade Organisationin partnership with other governmentdepartments. In so doing, the Department ofHealth will work to align strategies, priorities,objectives and targets more closely acrossother government departments, includingshared objectives to maximise consistencyand ensure effective delivery.


Rehabilitation and occupational health

Building on the work of NHS Plus, the NHS can play an increasingly vital role in ensuringthat employees are able to return to work as soon as possible following illness or injury.The Department of Health will work with the Health and Safety Executive and the Departmentfor Work and Pensions to ensure that a wider occupational health approach is supported bythe NHS. The Department for Work and Pensions and the Department of Health are workingtogether on the Pathways to Work rehabilitation scheme for those on incapacity benefits, inline with Recommendation 6 on NHS rehabilitation services from the Better RegulationTaskforce Report 2004, Better Routes to Redress.

Diet and activity

The Department of Health will work with the Departments for Environment, Food and RuralAffairs, Culture, Media and Sport and Education and Skills (DfES), and the Food StandardsAgency, to address the issue of obesity. This will be done in conjunction with work on theFood and Health Action Plan and with the Activity Co-ordination Team. Transport policiesand local transport schemes have an important impact on the levels of physical activity. TheDepartment of Health will work with the Department for Transport to encourage healthy localtransport schemes to encourage walking and cycling. DfES and the Department of Health arealready working to promote physical activity and a healthy diet among children and youngpeople through the National PE and School Sports Strategy, Sure Start, the National HealthySchools Programme, the Healthy Schools: Healthy Living Action Plan, and the Food inSchools Programme.


Public health in 2000

Many aspects of health in England lagbehind comparable industrialised countries.

People expect the NHS to treat them whenill and view health as the responsibility ofdoctors.

At national level, public health is seen as theresponsibility of the Department of Health.

Local approches to public health are notjoined up.

Focus of public health policy is on healtheducation and health promotion.

Obesity rates are rising but with limitedawareness of its implications.

Smoking rates reach a plateau.

Rates of MRSA increasing with incompletereporting of cases and a limited awarenessof implications.

GPs have incentives to focus on cervicalscreening, immunisation targets and newpatient health checks.

GPs send letters to recall enrolled populationfor screening interventions in order to meettarget payments.

There is a weak evidence base for informingpublic health policy or resource allocationdecisions of purchasers, and there are lowlevels of investment in prevention.

Public health in 2008

Health in England has improved and the gapwith other countries has narrowed.

People see the NHS as helping them to livehealthy lives and view health as a sharedresponsibility.

There is an interdepartmental agenda onpublic health and health inequalities withclear roles and responsibilities identified.

Collaboration at local level on public healthwith local government, PCTs and thecommunity.

Co-ordinated set of policy levers, communitydevelopment and individual behaviouralchange.

Growth rates of obesity among children andyoung people have flattened out as a resultof co-ordinated action by all stakeholders.

Smoking rates are falling in response toconcerted action.

MRSA rates declining with extendedsurveillance of infections and awarenessacross the NHS that infection control iseverybody’s business not just specialists.

GPs and other primary care providers haveincentives to manage actively the health oftheir registered population.

Electronic reminders are sent to individualsto alert them to the need for screening andprovide information about screeningprocedures and the meaning of differentresults.

PCT commissioning includes prevention, andis informed by a sound evidence base ofboth the effectiveness and cost-effectivenessof public health interventions and bestpractice guidelines.

Section 3Making it happen

5.1 Increased capacity will be introduced inorder to reduce waiting times for elective careand facilitate choice across the system. Newand existing providers will become increasinglydynamic, and more open to the demandsplaced on them by ever more informed andempowered users. The contribution of theindependent sector will expand, particularly inrelation to planned hospital care and diagnosticservices, in the next wave of independentsector procurement. Growth (or otherwise) ofalternative providers will be a function of thechoices patients make. The new financialincentives being introduced into the NHS(see Chapter 8) will enable resources to flow tothose providers offering care that is responsiveto patient needs and of a high standard.

New capacity

5.2 We will continue to renew and expandNHS capacity through direct investment andin partnership with the private sector. By 2008a further 54 new hospital schemes are dueto be opened. This will mean that we are on

course to exceed The NHS Plan goal of 100new hospitals by 2010. It will also mean thatthe associated goal of ensuring that 40% ofthe NHS estate is less than 15 years oldby 2010 will have been achieved. We willcontinue to invest in and promote the PrivateFinance Initiative to further upgrade physicalcapacity thereafter.

5.3 Our investment in primary care, throughthe use of Local Infrastructure Finance Trustprojects (the programme to developpublic/private partnerships in primary care andcommunity services known as LIFT) and othersources will also accelerate. There arecurrently 42 NHS LIFT projects and work hasbegun on 12 of the new LIFT premises.By 2008 we will have delivered at least 54LIFT projects able to provide new primary carefacilities for some 50% of the population, andwork will have begun on hundreds of newprimary care facilities. Most of these projectswill be in the most deprived areas of ourcommunities, thus helping further to reducehealth inequalities.


Chapter 5Investment, new capacity and diversity of provision

NHS Foundation Trusts, treatment centres and independent sector providers of NHSservices will enable patients to have a greater degree of choice:

l By 2008 all hospital trusts will be in a position to apply for NHS Foundation Trust status

l A wider range of primary care services will facilitate greater access and convenience for all

l NHS capacity will continue to grow. Independent sector providers will also increase theircontribution and may provide up to 15% of operations and an increasing number ofdiagnostic procedures to NHS patients by 2008

l The Healthcare Commission will inspect all providers of care and provide assuranceof quality of care wherever it is delivered.

New providers

5.4 By 2008 all NHS acute trusts in England willbe in a position to apply to become NHSFoundation Trusts, working as independentpublic benefit corporations, modelled onco-operative and mutual traditions. NHSFoundation Trusts will be controlled and runlocally, with freedoms to retain any operatingsurpluses and to access a wider range ofoptions for capital funding to invest in delivery ofnew services. They will be able to use their newcapital and management freedoms to respondmuch more quickly to the needs of patients.They symbolise the Government’s commitmentto community-based public services whilstremaining firmly within the NHS. We are alreadyseeing the benefits. Examples include:

5.5 By the end of 2005, the Department ofHealth expects that there will be a total of 46NHS-run treatment centres, with 34 run by the

independent sector. Treatment centres providesafe, fast, pre-booked surgery and diagnostictests by separating scheduled treatment fromemergencies. They will increasingly provide awide range of surgical procedures anddiagnostic tests whilst concentrating on thoseservices where there are bottlenecks. They willmake an essential contribution towardsimproving access to services and meetingthe new 18 weeks access target set out inChapter 2. We anticipate that, by 2008, theindependent sector will carry out up to 15% ofprocedures per annum for NHS patients, paidfor by the NHS.

5.6 Our most recent procurement for additionalcapacity has been at a significant discount toprices previously negotiated between the NHSand the independent sector. We are clearlybeginning to see a fundamental shift in thepricing structure of private providers as we usethe corporate buying power of the NHS moreeffectively. The Independent Sector TreatmentCentre (IS-TC) programme will bring additionalbenefits as they spread new ways of working,spur NHS providers to increase theirresponsiveness to patients and, as a result ofincreased contestability, drive down the levelof inefficient spot purchasing.

Diversifying and expanding services

Primary care and long-term conditions

5.7 The expansion of provision will also affectthe primary and community sectors. Patientchoice in primary care has been increasedthrough the development of new services likeNHS Walk-in Centres and NHS Direct. Therehas also been an increase in the number ofstaff working in primary care. The developmentof new staff roles such as GPs with a specialinterest has enabled more care to be providedcloser to home, and there has also been anexpansion in the role of communitypharmacists. In the case of long-termconditions, the introduction of casemanagement through community matrons hasstarted the process of targeting people atgreatest risk, and in Chapter 3 we set out ourplans for implementing case managementthroughout the NHS.

l Countess of Chester – developing anew emergency centre, which willhouse the traditional A&E service,medical and surgical assessmentfacilities, and some diagnostic supportservices.

l Homerton – accelerated building of anew perinatal centre up to two yearsahead of schedule (antenatal, deliverysuite, neonatal intensive and specialcare unit).

l Moorfields – increase of at least£6 million in its capital spend, includinga £2 million extension to a communityoutreach centre and £1 million on newand replacement equipment for clinicsand theatres.

l Peterborough – £2 million of extracapital spend on essential equipmentupgrades and replacements, as well asinstallation of automatic doors inpatient areas and improvement ofward flooring

l Stockport – investing in new operatingtheatres and a new cardiology andsurgical unit.

52 CHAPTER 5 INVESTMENT, NEW CAPACITY AND DIVERSITY OF PROVISION

5.8 In the next four years, we will extend theseinitiatives and will focus on the provision of anincreasing number of specialist services bycommunity and primary care providers in localsettings and an increased choice of providersfrom all sectors. New forms of service deliverywill be supported by both the addedcommissioning freedoms available to PCTsand the introduction of new contractualarrangements such as Alternative ProviderMedical Services (APMS), Personal MedicalServices (PMS) and Primary Care TrustMedical Services (PCTMS). The flexibilitiesavailable to PCTs will enable the NHS to buildon the traditional strengths of primary care,particularly in areas where there may bedifficulties in recruiting GPs or where newforms of provision may be needed, forexample for commuters. This will include PCTsdirectly providing care, and contracting withthe independent sector where this is the bestoption. Early initiatives in these areas includethe licensing of 1,300 GPs with specialinterests. We will also develop six instantaccess GP-led primary care centres, aimed atcommuters based in London, Manchester,Leeds and Newcastle. These centres will openduring 2005 and will offer a full range ofprimary care services, plus minor injuriesservices. Further centres will open in 2006.

5.9 Where possible, the focus will be not onlyon alternative providers of similar services butalso on choices of integrated packages andpathways of care. For example, GP practicesmay decide to collaborate to offer a widerrange of services to the patients they serve,and PCTs may engage in alliances with theproviders of acute services to offer integratedprovision, for example for people withdiabetes. PCTs and GP practices may alsochoose to commission care from independentsector providers where this offers bettervalue for money. As a result, patients willincreasingly be able to select not only thetype and location of provider, but also fromnew models of care.

5.10 To ensure that PCTs are successful intheir role as commissioners and in their useand application of existing and alternative

providers, the Department of Health is workingwith a number of agencies to promote a rangeof initiatives supporting PCT development.This includes managed care organisationsfrom the United States, pharmaceuticalcompanies with expertise in diseasemanagement, and independent sectorproviders in the UK. The Department of Healthis also exploring what more needs to be doneto expand patient choice in primary care.From the end of the year we will also havemade it easier for new pharmacies to locate inareas such as one-stop primary care centres.The Department of Health will facilitate theestablishment of pharmacies intending to openmore than 100 hours a week or to operatewholly via mail order or the internet.

Diagnostics

5.11 Building on the success of the recentprocurements of ground-breaking mobilecataract and MRI scanning services, newmarket entrants will play an important role notonly in providing additional new capacity, butalso by acting as catalysts for innovation.The emphasis will be on flexibility andresponsiveness to patients’ needs, with moreresources being invested in forms of servicedelivery that can respond quickly andeffectively to shifting burdens of disease.

5.12 Our aim is to transform diagnosticservices by expanding capacity and makingthe best use of the resources we already have.Increasingly, the NHS will provide diagnosticservices closer to the patient’s home or work.Efficient diagnostics will enable faster andmore appropriate access to acute care wherethis is needed and should also enable a widerrange of care options to be considered withoutnecessarily falling back on the acute sector.Investment in and procurement of improveddiagnostic services from both public andprivate providers will be an increasinglyimportant feature of the new system. Patientswill be offered greater choice in where, whenand how they access diagnostic services.Where appropriate, GPs will also be able torefer patients direct to a diagnostic facility,


cutting out patient waits associated with goingto diagnostic services via a consultant.

5.13 As a result of new technology, x-rays andother images will be securely transmitted withinand between hospitals, primary care and otherhealth settings at the touch of a button. Thiswill reduce the need for repeat tests, speed uppatient treatment and reduce the pressure onmedical and other clinical staff.

5.14 As a first step, 80,000 extra MRI scansa year are being commissioned through amobile service run by the independent sector.This represents a 10% addition to NHScapacity and this will be followed by a market-testing exercise to assess the capacity of newproviders for other diagnostic services, aswell as imaging. Reflecting the urgency ofdeveloping diagnostic capacity andencouraging innovative solutions, the nextwave of independent sector procurement islikely to include diagnostic services. TheDepartment of Health will also be looking toexpand diagnostic provision in primary careand “high street” settings, and via the letting ofone or more major contracts to new providersto process electronic and routine diagnostictest results remotely.

Emergency/unscheduled care

5.15 Emergency/unscheduled care will beexpanded and increasingly provided in awider range of settings to provide efficient,convenient and effective services for patients.This will include the development of minorinjury units, NHS Walk-in Centres, ambulanceservices, out-of-hours primary care services,NHS Direct/Online and pharmacists. We willpromote further integration between primaryand secondary care.

New approaches, capacity anddiversity in social care

5.16 Social care services have been and willcontinue to be provided by a wide range oforganisations, from small community andvoluntary organisations, private providers,private and public companies to direct localauthority providers. This diversity allowsservices to be closely matched with people’sneeds, and offers a very high degree ofcontestability. To exploit the potential ofintegrated care, social care providers will beencouraged to integrate with healthcareproviders, e.g. integrated mental healthprovider trusts.

5.17 The Department of Health will continue tosupport councils and others to invest in newcapacity and diversity in social care. Councilsare responding to the preferences of peoplethat use social care services in expandingsocial care capacity where it is wanted. Theprovision of care in people’s own homescontinues to grow rapidly, particularly veryintensive home care services. Respite carehas a critical role. The Department is alsopromoting an increase in the provision ofnewer forms of care such as extra carehousing, which provides purposefully designedand safe housing for people combined with anin situ care team. This model can cater for awide range of needs, perhaps even those ofthe most dependent people and will provide arealistic and attractive option for many.

5.18 The Department is also committed tohelping people maintain their independence forexample using aids and adaptations to theirown homes. To this end, councils are makingadditional aids and adaptations up to a valueof £1,000 available without charge. Assistivetechnology offers great potential to maintainthe independence of older or disabled people,with encouraging early evidence about itscost-effectiveness.


5.19 The Department is promoting a significantexpansion in the use of direct payments, whichwill empower more people to arrange care andsupport that is tailored to their individualneeds. The Department has now made directpayments the first choice for most peopleeligible for assistance from social services.Councils are obliged to offer all those eligiblea direct payment before an offer of councilarranged services. This is becoming morecommonplace.

The Healthcare Commission andthe Commission for Social CareInspection

5.20 As the provision of health servicesdiversifies and localises, it will be increasinglyimportant to ensure that service qualitycontinues to be enhanced. The Department ofHealth will publish new healthcare standardslater this year, following the recent consultationperiod. The Healthcare Commission will haveresponsibility for developing the criteria toassess quality which it will use to review theperformance of all healthcare providers. It willalso take up responsibility for the annualassessment of NHS Trusts via performanceratings.

5.21 People who use social care services canalso expect good-quality and consistent careservices. The Commission for Social CareInspection (CSCI) is responsible for promotingcontinuous improvement and highperformance in social care organisations.It supports integrated working focused on userneeds, ensuring that service providers deliverservices of an appropriate standard whether inthe statutory or the independent sector. Thisincludes the registration and regular inspectionof the full range of providers from care homesand domiciliary care providers through tofostering agencies. The national minimumstandards used by CSCI were drawn up bythe Government in consultation with the socialcare industry and people using health andsocial care services to promote best practiceand identify areas for improvement. It is thefirst time that there have been nationalminimum standards for social care in England.



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6.1 Delivering world-class services withimprovements in quality and responsivenesswill require extra capacity. This capacity will bedelivered by an expansion in the numbers ofstaff working in and with the NHS and socialcare system and by using those staff moreeffectively.

6.2 Over the past five years, growth in the totalNHS workforce has increased by an averageof 3.6% every year. The total workforce in theNHS is now at its highest level yet. Currenttrends will continue over the next four years inorder to further increase the size of theworkforce, focusing on growth in clinical staff.We will do this through a range of measuresincluding:

l increasing the supply of healthcare workers

l working to retain existing staff

l more flexible retirement and extending theproductive life of staff

l planned and ethical international recruitmentto supplement key skills – including nurses,doctors, dentists, pharmacists, radiographers,healthcare assistants, allied healthprofessionals and other staff groups

l developing and working with otherproviders, including new public/privatepartnerships, independent sector treatmentcentres, volunteers, the charitable sectorand expert patients

l making the NHS a model employer.

6.3 More staff alone will not deliver high-qualityand responsive services. We will take steps toensure that staff work where they are needed.Temporary staff will be better supported andmore effectively deployed and sickness andturnover rates will reduce. The NHS willcontinue to develop and implement policies –such as Improving Working Lives – to make ita “model employer”. However, staff will needto work differently too.

58 CHAPTER 6 MORE STAFF WORKING DIFFERENTLY

Chapter 6More staff working differently

More staff and more flexible working will contribute to better quality and more choice

l There will be continuing increases in frontline NHS staff where these are required to meetpatients’ needs

l Staff will be supported in working differently, making the best use of skills. For example,GPs and other practitioners with special interests will be enabled to deliver care moreflexibly

l Staff will be supported to fulfil their potential with the NHSU and Skills Escalator helpingstaff develop throughout their careers

l Extra pay for staff and pay linked to performance will create stronger incentives to deliverpersonalised care.

Improving roles in a more flexibleworkforce

6.4 In the NHS, rigid demarcations betweenstaff can mean that patients seeing a numberof different health professionals often have torepeat the same details at each stage. Theseunnecessary barriers between professionalslead to frustration for patients, waiting, theinappropriate use of staff and a failure to fulfilthe potential of clinicians and support staff.

6.5 There is a significant appetite fordeveloping new roles in the service. Attitudesto workforce flexibility have also changed, withthe Royal Colleges and other professionalbodies now actively leading these changes.Updated regulatory frameworks allow greaterflexibility while ensuring quality and patientsafety. For example:

l We now have around 1,300 GPs witha special interest providing 700,000procedures in the community previouslydone only in hospital. The accreditationframeworks for these GPs have beendeveloped with the Royal College of GPs.An independent evaluation of GPs with aspecial interest in ear, nose and throats(ENT) showed that a GP could see 30 to40% of ENT patients referred to secondarycare. GPs with a special interest in ENTlead to significantly shorter waits and highlevels of patient satisfaction

l Nurses make up the biggest single group inthe NHS and have been at the forefront ofdevelopments. The number of nurses andmidwives in advanced roles will increaseand the NHS will build on the currentnumber of nurse and midwife consultants,going beyond the target for 2004 of 1,000.The NHS will continue to increase thenumber of nurses who are able to prescribeand the range of medicines they canprescribe. In addition to their extendedclinical roles, nurses will be given a leadrole in improving the experience of patientsin both the hospital and the community.This will build on the success of themodern matron.

6.6 The Changing Workforce programmehas sponsored national trials, followed byaccelerated development programmes, thathave spread many new roles. The followingare some examples:

l Over 50% of NHS Trusts have redesignedroles in radiology and radiotherapy servicesto reduce waiting. Advanced RadiographerPractitioners can now interpret the resultsof diagnostic tests, with AssistantPractitioners being trained to undertakediagnostic procedures

l One hundred and sixty new roles formedical secretaries have freed up doctors’time for patient care and created a clearskills escalator-based career structure.If most consultants in the country were ableto free up two hours a week by the moreeffective use of administrative staff, theywould create at least 1,000 additionalwhole-time equivalents worth of consultantactivity

l Over 300 emergency care practitioners arebeing trained, working across 118 NHSTrusts in out-of-hours, minor injuries, A&Edepartments, NHS Walk-in Centres andambulance services. These posts combinethe skills of nurses and paramedics tocreate a more flexible workforce, with moremotivated staff

l Practitioner trials in surgery, anaesthesia,critical care, renal services, medicalassessment units and primary care alreadyshow great promise for staff taking on workpreviously covered by doctors

l The hospital-at-night scheme both improvesthe use of medical skills, createsopportunities for other staff to take on awider range of healthcare responsibilitiesand helps the NHS comply with theEuropean Working Time Directive.

6.7 By 2008, the workforce will be much moreflexible and adaptable. Educational incentivesand regulatory systems will support this. In linewith the NHS career scheme, staff will be able


to transfer skills gained in one job to other jobsor in one healthcare organisation to another.Rapid Roll Out programmes will ensure allteams are trained to use new roles, especiallyAssistant and Advanced Practitioners forclinical services. Changing skill-mix andimproving the way the NHS uses the skills ofall its staff will deliver care more efficiently andincrease capacity. New IT systems will alsocontribute, in particular through the newpersonal care records and electronic booking,which will streamline and simplify workingprocesses resulting in staff saving time thatcan be used for patient care.

Learning, education and training

6.8 Modernising education, training andopportunities for learning are essential. In thefuture, education, training and learning will bemore flexible and based on transferable,competency-based modules. The Departmenthas already funded joint programmes incommon learning and inter-professionaleducation between higher educationinstitutions and the NHS. These programmeswill achieve national coverage as we ensurethat people learn together so they may betterwork together in the NHS. Such developmentsare backed nationally by arrangements for jointworking between the Department of Healthand the Department for Education and Skillsthrough the Strategic Learning and ResearchAdvisory Group for Health and Social Care.Health and Education Strategic Partnershipsbetween strategic health authorities and locallearning and research institutions will mirrorthis partnership. Health and EducationStrategic Partnerships will ensure that wedeliver the learning needs of staff at a locallevel in a co-ordinated and tailored fashion.

6.9 There will be a new focus on experience-based learning. Already, accreditationframeworks for practitioners with a specialinterest, such as nurses, GPs and allied healthprofessionals, are based on competencies andvocational based training. In addition, doctorsoutside formal training will have their skilllevels formally recognised and accredited andwill be able to progress their careers towardsconsultant or GP status if they wish.

6.10 The skills escalator will help the NHSattract people who previously could not accesshealth careers. It brings together differentprogrammes – Lifelong Learning, Recruitmentand Retention, Pay Modernisation and theChanging Workforce programme – to deliverthe objective of a growing and changing NHSworkforce. It will attract a wider range ofpeople to work within the NHS by offering avariety of career and training options.

6.11 Traditional entry points such aspre-registration programmes for theestablished professions will continue, but theywill be complemented by other entry routessuch as cadet schemes and role conversion,attracting people in other careers who areseeking new challenges and drawing peopleback into the labour market. This offers thedual benefit of expanding the NHS workforcewhilst also tackling problems of longer-termunemployment and social exclusion, whichhave such a high correlation with poor health.The Department of Health will work closelywith the Department for Work and Pensionsand Job Centre Plus in this area.

6.12 Employers will benefit because astructured programme of skills developmentwill help them to recruit and retain staff to fillposts which are traditionally hard to fill.Individuals will benefit in a range of ways:those who are finding it difficult to get intopermanent employment, or who have limitedformal education, and older people lookingfor second careers will have access to newemployment opportunities. Those alreadywithin the NHS will benefit from the opportunityto develop and enhance their skills and takeon new and more challenging roles.Communities will benefit from an activeapproach to employing and developing staffby major local employers. This approach willextend to migrant workers and refugees,ensuring the NHS makes the best use of theirskills and helps their integration into localcommunities.

6.13 Access to education and training materialswill change with an increasing focus onelectronic access. E-based learning


programmes will develop. For example, underthe Radiology Integrated Training Initiativethe 400 modules that make up the radiologycurriculum will be available electronically.Other staff, such as radiographers, nursesand anaesthetists will be able to access thesemodules to develop competencies in areasthat affect their roles, thus providingtransferable, competency-based team skills.By 2008 such developments will be muchmore widespread, with the NHSU leading theirdevelopment.

6.14 Major changes to postgraduate medicaltraining will arise as a result of theModernising Medical Careers Initiative,launched in April 2004. This will take a radicallook at the way we train doctors, the speedand quality with which we do it and the endproduct of that process. We will takeopportunities for streamlining medical trainingand increasing flexibility in medical careersfor the benefit of both doctors and patients.From August 2005, new graduates in medicinewill undertake a comprehensive two-year

foundation course, which will equip them withall the basic skills needed for clinical practice.In addition, by 2009, all stages of training willbe delivered through structured programmes tomaximise the available time. Programmes willbe robustly managed. Consultants will takeless time to train because training time will befully utilised. There will be no diminution in thequality of training and patient care.

New contracts

6.15 We are embarking on a period ofsignificant change with new contracts for GPs,consultants and staff included in the Agendafor Change programme. New contracts fordentists, opticians and pharmacists are on theway. These contracts cover over 1 million staffand will provide a secure platform fordeveloping, recruiting and retaining theworkforce we need. They are backed bysignificant new investment in pay to 2007/08.The new GP and consultant contracts andAgenda for Change will reward thosehealthcare professionals who are committed


NHSU

NHSU will contribute to radical change and improvement in health and social care throughthe transformation of learning.

NHSU will make a key contribution to the fulfilment of The NHS Plan. In the short term, it willdevelop learning programmes to meet the immediate and urgent needs of the NHS inconsultation with the Department of Health, the NHS and other key stakeholders.Increasingly, it will design learning services and programmes to support team working andenable all staff to work more effectively across traditional occupational, professional andorganisational boundaries.

As a dedicated “corporate university”, NHSU will make a critical contribution to health andsocial care through:

l the Learning Needs Observatory which will work to identify the changing skills needsof the NHS and social services agencies, and ensure that NHSU provides programmeswhich address those needs directly

l a service-wide learning platform delivering online learning, providing individuals withinformation, advice and guidance on learning needs and opportunities, and establishingcommunities of practice focusing on specific priorities and areas of development

l working at community level, developing networks of Local Learning Resource Centres– located within strategic health authority areas – so that learning is available locally

l research expertise focusing on the contribution of learning to effective practice and theextent to which it results in real, tangible improvements for patients and service users.

to the NHS and provide services that aretailored to the needs of the local population.

6.16 The new primary care contracts:

l will deliver 33% increase in investmentover the next three years in primary care,building extra capacity in primary care

l are based around the GP practice, drivingnew employment models and skill-mix

l are based on quality indicators withproviders rewarded for outcomes notinputs. This will drive skill-mix as GPpractices tailor services with the investmentthey have to meet local need

l include opportunities for new entrants intothe market place through new routes suchas Alternative Provider Medical Services,designed to bring private and voluntarysector providers into the field

l include guaranteed investment in enhancedservices, designed to deliver specialist carein primary care settings and helping todevelop new types of practitioner

l support the development of higher qualitycare for people with long-term conditions

l provide new opportunities for flexibleworking.

6.17 The new contract for consultants:

l offers greater rewards to those who givemore to NHS patients

l helps to increase efficient use of time andclinical provision

l includes objectives linked to servicepriorities

l allows flexible working and has incentivesfor those working evenings and weekends,leading to improvements in access

l provides sustained incentives for high-quality performance over the course ofa career

l contributes to improvements in recruitmentand retention

l offers stronger assurance that privatepractice will not disrupt provision of care toNHS patients.

6.18 The Agenda for Change programmeincludes:

l a job evaluation-based process thatharmonises reward mechanisms andimproved structures for learning commonlearning, knowledge and skills framework,continuing professional development

l a common pay spine, rather than separatepay arrangements for different staff groups

l rewards for increased knowledge and skillsrather than time served

l real incentives for staff and managers tochange existing patterns of working andembrace new ones.

6.19 The contracts are just part of making theNHS a better place to work, which in turn willenable staff to give better patient care. Therewill be more flexible employment schemes,allowing staff to have part-time roles andcareer breaks whilst still keeping abreast ofclinical practice. Ensuring staff have a betterwork-life balance and better working conditionsmeans that more staff will either stay or returnafter a spell away.


6.20 In addition, some of the principal elementsof reform in the NHS have the potential toraise workforce productivity in new ways.In particular:

l Payment by results and choice for patientswill provide trusts and staff with far greaterincentives to improve performance andreap the gains that changes in skill-mix,for example, can deliver. Similarly, the newGMS contract will provide incentives toreview and change skill-mix in primary careto the benefit of staff and patients

l As cost effective, low-wait NHS Trustsexpand as a result of the implementation ofpayment by results and choice, activity willflow to those trusts that get the best fromtheir staff, which will deliver a significantimprovement in efficiency.

Modernising services

6.21 A world-class workforce also needsworld-class management. There is now awealth of research that makes the linkbetween progressive people management andimproved productivity and patient outcomes.The NHS is now in a position to capitalise onthe progress made to build world-classmanagers with the knowledge, skills andsupport from human resource services toapply the good practice from that research.In particular, we will improve team working,appraisal and diversity and create a workingenvironment that supports the acquisition ofnew skills and a culture responsive to change.

6.22 By 2008 there will be an improvedcapability to drive forward and sustain newways of working. This will be deliveredthrough the cumulative impact of the NHSModernisation Agency-led work to buildcapability and the appetite for change, thedelivery of new contracts such as Agenda forChange to incentivise staff to embracechange, the business imperatives that drivechange and sustained leadership, and supportat both local and national levels.


Information and the NHS

7.1 Accurate information is crucial if patientsare to have choice and receive the right careat the right time. A key aim of the NationalProgramme for Information Technology in theNHS is to give healthcare professionalsaccess to patient information safely, securelyand easily whenever and wherever it isneeded.

7.2 The National Programme for IT is anessential element in delivering The NHSPlan. It will create a multi-billion poundinfrastructure, which will improve patient careby enabling clinicians and other NHS staff toincrease their efficiency and effectiveness. Itwill do this by:

l creating an NHS personal care recordservice to improve the sharing of patients’records across the NHS with their consent

l making it easier and faster for GPs andother primary care staff to book hospitalappointments for patients

l providing a system for electronictransmission of prescriptions

l ensuring that the IT infrastructure can meetNHS needs now and in the future.

7.3 Better IT is needed in the NHS becausethe demand for high-quality healthcarecontinues to rise and the care now provided ismuch more complex, both technically andorganisationally. There are over 300 millionconsultations in primary care annually. Lastyear, there were 650 million prescriptionsdispensed in the community; nearly 5.5 millionpeople were admitted to hospital for plannedtreatment; there were 13.3 million outpatientconsultations; and nearly 13.9 million peopleattended A&E, of whom 4.3 million wereemergency admissions.

64 CHAPTER 7 GETTING INFORMATION TO WORK FOR THE PATIENT

Chapter 7Getting information to work for the patient

Better use of information and information technology will drive improvements inpatient care:

l The patient care record will enable healthcare professionals to have 24-hour access toinformation about patients; this will improve diagnosis and treatment and reduce errors,with the first phase going live in 2004

l By 2005 the electronic booking service and e-prescribing will make it easier for patientsto arrange appointments and to order repeat prescriptions

l NHS Direct, NHS Direct Online and NHS Digital TV will help people to take moreresponsibility for their own health and to communicate with healthcare professionals

l Patients will have a bigger say in how they are treated and will be able to enterinformation about their preferences on HealthSpace.

7.4 In parallel, diagnosis and treatment areincreasingly specialised. Managing manyconditions can require a number oforganisations and people to work togetherpredictably, reliably and safely. Also, patients’knowledge and understanding has increasedand many want more ownership of andinvolvement in the management of their care.

7.5 Traditional paper-based recording andstorage systems have long since ceased tosupport the health service in an efficient andeffective manner. As a result, many generalpractice surgeries and hospitals now havesome form of personal care record that can beshared internally. But this information cannotcurrently be shared across the NHS.

7.6 The National Programme for IT will addressthis, creating an NHS electronic highway. TheNHS will in this way take a major step towardsproviding seamless care for patients throughGPs, hospitals and community health services.It will also provide fast, convenient publicaccess to information and care through onlineinformation services and telemedicine, andensure effective use of NHS resources byfacilitating the secondary use of information,for example, for medical audit purposes.

7.7 For all this to happen, major co-ordinatedinvestment and change must take place.Most existing IT systems in NHS trusts arebased on either buildings or departments.They do not usually support the movementof information between buildings anddepartments. Consequently, within a singleorganisation, several records are often createdfor the same patient.

7.8 Similarly, in primary care, individualpractices have their own IT applications anddatabases, so that personal care records arenot easily transferred to other practices or careproviders. As a result, the development andeffective implementation of care pathways isinhibited. Many are still paper-based, delayingmodernisation and the delivery of NationalService Frameworks.

7.9 By creating world-class IT infrastructure andsystems for the NHS, the National Programmefor IT will ensure that organisations and staffcan work together more effectively. Thisstrategy has long been recognised as essentialby many within the NHS, but achieving robustinformation systems, including personal carerecords, has proved difficult to achieve.However, there are now the resources anddetermination to achieve this goal.

7.10 Information technology is now beingdesigned and delivered around the needs ofpatients and service users. A shift has begunfrom systems running along institutional lines,dealing only with a portion of patientinteractions, to integrated health and socialcare community systems that track and recorda user or a patient’s progress in the NHS.The main healthcare elements of the NationalProgramme for IT are now described in moredetail.

The NHS Care Records Service

7.11 The NHS Care Records Service is beingdeveloped to provide a live, interactivepersonal care records service accessible24 hours a day, seven days a week by healthprofessionals, whether they work in hospitals,primary care or community health services.It will enable clinicians to access personal carerecords securely, when and where they areneeded, via a nationally maintainedinformation repository. When fullyimplemented, the NHS Care Records Servicewill function across care settings andorganisations and will support planned,emergency and unscheduled care.

7.12 Patients will benefit because the NHSCare Records Service will improve the qualityand convenience of care by ensuring that theright information is available to the right peopleat the right time. It will also improve choice forpatients and, in due course, will allow themeasy, secure access to their NHS personalcare record. Clinicians will benefit from beingable to access patient information wherever itis needed. This will improve diagnosis andtreatment, and facilitate the provision of saferand higher-quality care. Clinicians will also be


able to identify patients missing out on optimalcare, and they will be able to support clinicalaudit through the use of information drawnfrom the NHS Care Records Service.

7.13 The first phase of the NHS Care Recordsproject is expected to go live in summer 2004.It will provide clinicians with basic functionality,including the ability to view and communicatean initial set of patient information and to bookoutpatient appointments. The second phase,due to be introduced in June 2005, will giveaccess to more detailed personal carerecords and allow electronic referrals,requests and orders.

The electronic booking service

7.14 “Choose and Book” is the name of thenew national IT system that will connect allGPs and primary care services to all hospitalsand other secondary care providers. It willallow patients and staff to book initial hospitalappointments at a time and place convenientto the patient. Patients will be able to leave thesurgery with their appointment time and date.If they prefer, they will be able to make theirappointment later after consulting with familyor work colleagues, either online or via atelephone booking management service.

7.15 The first patient booking using this systemis scheduled for summer 2004 and roll-outwill be completed by the end of 2005, whenall hospital appointments will be booked inthis way.

E-prescribing

7.16 The e-prescribing programme will enableprescribers to create and transfer prescriptionselectronically to a patient’s communitypharmacist and the Prescription PricingAuthority. As well as being more convenientfor patients, this should improve safety byreducing prescription errors and providingbetter information at the point of prescribing.It will also ensure that prescription informationforms part of each person’s NHS personalcare record. In addition, e-prescribing will savestaff time and costs by requiring information tobe entered only once, instead of on three

occasions as at present. With over 600 millionprescription items issued annually, the benefitswill be considerable.

7.17 Following a number of pilot projects, thescope and objectives of e-prescribing havebeen agreed with the overall aim ofimplementing a national service by 2005 for50% of transactions, with full implementationby 2007.

HealthSpace

7.18 The National Programme for IT will help toempower patients through the development ofHealthSpace. This was launched in 2003 andenables patients to access their personal carerecords held in a secure place on the internet.Users are able to add personal information totheir HealthSpace, such as their blood group,weight, allergies and medication. In addition,users can register to receive e-mail remindersto attend appointments.

7.19 Using HealthSpace people are able toadd addresses and telephone numbers, datesand times of appointments, and favouritehealth related weblinks. HealthSpace ensuresthat whenever a clinical team consults thepersonal care record, they are reminded ofthese important points about the patient,without the patient having to repeat them.

7.20 As well as HealthSpace, patients are ableto access information from NHS Direct, NHSDirect Online and from 2004 NHS DigitalTelevision. This will be the biggest dedicatedpublic service on digital television and will offeran innovative way of providing healthinformation to the public. The service willinclude information on health conditions,treatments and healthy living, health advice fortravellers, health and safety information, andinformation on local NHS services. Usingdigital television, it will be possible to reachgroups in the population who are currentlyunderserved by other information channelssuch as the internet.

66 CHAPTER 7 GETTING INFORMATION TO WORK FOR THE PATIENT

Telecare

7.21 Telecare involves the use of IT to supportthe delivery of care to people in their ownhomes or in the wider community. Evidenceindicates that telecare can bring substantialbenefits in providing people with greaterchoice over their care, assisting people toremain in their own homes, reducinginappropriate admissions, facilitating dischargefrom hospital, and providing advance warningof deterioration in a patient’s condition. Peoplewith long-term conditions are particularly likelyto benefit from telecare, for example by beingable to monitor their conditions and relayinformation by phone to surgeries andhospitals. A range of technologies are used intelecare, and many of these are being pilotedin different parts of the NHS. The Departmentof Health will monitor the development oftelecare and will ensure that the benefits arerealised in the NHS when cost-effectiveapproaches have been identified.


8.1 The new NHS will be incentivised to deliverfor patients more effectively. Developmentsare now being made in three broad areas.Firstly, the performance managementframework is being developed in line with thenew lead role of commissioners, in order toensure that personalised care is commissionedeffectively. Secondly, we are both empoweringpatients and users to have far more choice oftheir provider and extending legal contractualrelationships with a more diverse range ofproviders. Thirdly, we have introduced asystem of financial incentives, of whichpayment by results is a major first step.

8.2 Recognising that the system being put inplace will need to be modified in the light ofexperience, the Department of Health will bemonitoring how the new incentives work,and will make changes where necessary.This is a dynamic system which requires bothconsistency and flexibility to make it work.

Developing commissioning systems

8.3 Commissioning of care to promote theefficient management of long-term conditionswill be led by PCTs. PCTs will commissionfrom a range of providers and will use theincentives contained within new GeneralMedical Services and Personal MedicalServices contracts to ensure that practices aredelivering high standards of care to peoplewith chronic diseases. PCTs will also use theirleverage to achieve more effective integrationof care, both between primary and secondarycare and between health and social care.

8.4 For those requiring planned hospital care,PCTs will be able to use information andpayment by results to select and thencommission services from those best able toprovide them. This will be achieved througha combination of core contracts withsignificant local (and sometimes regional andnational) providers, as well as more flexiblearrangements to support the flow of funds to

68 CHAPTER 8 ALIGNING INCENTIVES WITH PATIENTS AND PROFESSIONALS

Chapter 8Aligning incentives with patients and professionals

Incentives will be aligned with patients and professionals:

l The performance management regime for commissioners will support more effectivepurchasing of care

l Primary care trusts will be supported to develop incentives to enable GPs to deliver carethat is more responsive and of a higher standard

l The new system of payment by results will provide strong incentives to increaseefficiency and improve access, and it will be implemented in full by 2008

l Patients will work increasingly in partnership with professionals with the support ofdecision aids and information to help them make the right choices.

alternative providers where patient choiceand/or capacity demands dictate.

8.5 As greater diversity of provision emerges,the Department in partnerships with strategichealth authorities and PCTs will undertakenational development work to ensure thatthere is a clear process for specifying andmonitoring performance under contracts, and aclear route for action where organisations arefailing to deliver. PCT development will receivehigher priority in the next stages of reform withstrategic health authorities supporting PCTs torealise the potential of commissioning and thefinancial incentives being put in place toimprove access, extend choice and improvethe quality of care for people with long-termconditions.

8.6 As waiting times continue to fall and choiceis extended, it will be important to ensure thatcare is provided to patients in need and whoare able to benefit clinically. Experience inother countries highlights the risk that referraland treatment thresholds may fall with patientsbeing treated unnecessarily as capacityexpands and responsiveness improves. PCTsare well placed to manage this risk. As theorganisations that control over 80% of theNHS budget, PCTs have an incentive toprovide as much care as appropriate outsidehospital, and to avoid unnecessary hospitaladmissions and investigations.

8.7 As part of the support programme forPCTs, the Department of Health will be givingpriority to ways in which PCTs can makebetter use of information and care pathways topromote the appropriate use of services. PCTswill also work with practices and the providersof acute services to develop explicit criteria forreferral and treatment thresholds and triggerpoints within service level agreements andcontracts. This includes involving patientsmore directly in decisions about treatment andpromoting shared decision-making betweenpatients and healthcare professionals.A further strand will be the devolution ofcommissioning to GP practices.

Practice-level commissioning

8.8 Consistent with the principle of greaterdevolution of responsibility, the Departmentrecognises the important role that GPpractices play in commissioning services fortheir patients and local populations. Practice-level commissioning models may includeprofiling and peer review, indicative budgets,real budgets with PCT-facilitated collaborationbetween practices, partial real budgets orfully-devolved practice budgets. TheDepartment continues to develop appropriatemodels of practice-based incentives inpartnership with strategic health authorities,PCTs and GPs.

8.9 We have already undertaken nationaldevelopment work (through North BradfordPCT) to support indicative budgets, and theDepartment of Health will be evaluating fully-devolved models as they become established.These devolved arrangements will support theempowerment of patients through enablingmore decisions to be made locally. As a firststep, from April 2005, GP practices that wishto do so will be given indicative commissioningbudgets. This will provide GPs with furtherincentives to manage referrals effectively withany savings being reinvested in NHS services.

Social care commissioning

8.10 The Department of Health in partnershipwith local government will also develop thesystem for commissioning social care. Thesocial care system already has an establishedsystem of payment for results. This is basedon local price negotiation, as is appropriategiven the local accountability of councils.Reimbursement against delayed dischargeof people from hospital is promoting moreefficient use of services to allow people toleave hospital at the appropriate time. TheDepartment will also review whether use ofthe existing flexibilities for combined workingbetween health and social care are supportedby sufficiently strong direct incentives.In particular, the Department, with the NHS,will look to develop incentives that help toreduce unnecessary hospitalisation.


Developing direct incentives

8.11 Payment by results will support patientchoice by enabling funds to follow individualpatient choices for treatment. By 2008,patients referred by their GP will be able tochoose any provider able to meet NHSstandards and to deliver care at tariff.

8.12 Delivering The NHS Plan, published inApril 2002, introduced a new national systemof payment by results. Under this system,hospitals and other providers of care will bepaid a fixed price for each patient treated.Prices are based on healthcare resourcegroups (defined by the patient’s condition anddiagnosis) that reflect the complexity and costof providing care. A national tariff is now beingimplemented in stages and it is expectedthat within the next four years the majority ofhospital and community healthcare will be paidfor through the tariff.

8.13 The incentives within this system will helpto increase the number of treatments provided,by rewarding providers for the work done. Theywill also stimulate greater efficiency asproviders take action to bring their costs intoline with the tariff, for example by reducinglengths of stay in hospital. Providers will beable to invest any financial gains from the tariffin quality-enhanced local services and facilities.

8.14 For primary care trusts, payment byresults will support the development of a moreeffective approach to commissioning. In placeof block contracts or service level agreements,primary care trusts will commission thevolume and mix of activity needed by theircommunities. The introduction of a nationaltariff will remove the need for price negotiationand focus discussion on the quality of care.

8.15 As the organisations that control over80% of the NHS budget, primary care trustswill have an incentive to provide as much careas possible in the most appropriate settings,and to avoid inappropriate admissions tohospital. In this way, the new system will helpsupport the development of care closer tohome, and the emphasis on improving thequality of care for people with long-term

conditions. In particular, primary care trustswill be able to explore ways of commissioningalternatives to hospital care, and developservices in accessible “high street” locations.

8.16 Payment by results is a major reform anddraws on international experience. Similarschemes are already operating or are beingdeveloped in the United States, Australia,Norway, the Netherlands, Germany and othercountries. Experience of these schemes hashelped to inform the development of paymentby results for the NHS. The system now needsto develop into a more sophisticated regime ofdirect incentives that will promote the deliveryof the overall vision for health services ofwhich hospital care is only a part. This willinvolve:

l continuing with improvement of the currentpayment by results arrangements

l developing incentives for the whole patientjourney – not just the hospital element

l developing commissioning systems toachieve strategic aims

l engaging practices more directly incommissioning

l improving incentives to integrate social careprovision into the patient experience.

Improving the existing system

8.17 The existing payment by results systemwill need regular review, to ensure that theeffects are in line with the policy aims.Following consultation, the clarification andrevisions will be made from April 2005.(A summary of which is set out overleaf).

8.18 We are already aware of other issues thatcould cause unintended consequences, andwe are planning to address these as follows.

8.19 Coding and costing: it is possible for tariffsystems to result in an increase in funding forhospitals due to accounting issues, such asselective interpretation of coding orcategorisation rules, and a resulting mismatch


between codes and the full range of actualactivity providers undertake. This runs counterto the policy aim that financial rewards shouldreflect real results.

8.20 As coding and costing improve, this shouldbecome less of an issue, but we recognise theneed to ensure the system is robust in theshort term. We are therefore developing plans

to undertake regular audit compliance reviewsof providers in line with international bestpractice. There will be significant penaltiesfor deliberate non-compliance.

8.21 Perverse incentives: payment by resultscreates incentives for increased activity inelective or planned care in order to reducewaiting lists and improve access. Roll-out of


Clarification and revision in response to consultation on payment by results

Separate tariff for planned and non-planned activity – we will retain a dual tariff for thenear future. This will ensure that access to emergency services, which tend to cost more thannon-planned, will be paid for at full cost. There is therefore no financial penalty in maintainingsufficient capacity for non-planned patients.

Short stay patients – we are to introduce a tariff that adequately compensates for short staypatients. This will ensure that there is no financial incentive to inappropriately retain, orclassify, patients for very short stays. This will also impact on capacity and balance this withthe needs of access.

Long stay patients – we will introduce a system that will allow for additional payments forpatients who, for clinical reasons, remain in care beyond the expected length of stayrecognised in the tariff. There is therefore no incentive to discharge patients until their clinicalposition determines it to be right.

New technologies – to ensure that new technologies and services are developed andintroduced, we will introduce a process that allows for local, time-limited, payments inaddition to the tariff.

Choice – we will set tariffs for a wide range of services. From April 2005 any patientexercising choice will be paid for, by their host PCT, at the national tariff. There will be noprice negotiation, and hence no administrative delays, to frustrate choice. The tariff will bepredetermined and known to all.

Independent sector, extended capacity and choice – services for NHS patients providedby the independent sector will, in time, be paid for at no premium to NHS tariff. This will givecertainty to the independent sector in planning new developments, and enable the NHS, andpatients, to judge the relative merits of providers on the basis of access and quality, notprice. As with other NHS providers, independent sector providers will be required to offerboth care and appropriate hotel facilities free at the point of use to NHS patients.

Transition – in order to allow providers with costs currently above the tariff price to makeefficiency savings gradually, in line with full tariff implementation in 2008/09, we will allow atransition period during which these providers can be paid above the standard tariff. Theseproviders will be expected to make gradual savings year-on-year until their costs fallsufficiently.

Local unavoidable cost variation – we are wedded to the principle of commissionershaving to pay the same price for the same procedure from any hospital. We will thereforeuse a centrally funded arrangement to reimburse hospitals for unavoidable cost differencesthat result from the different costs of staff, land and buildings in the locality in whichhospitals operate.

similar systems elsewhere suggests thatincentives of this kind can lead to providersundertaking inappropriate levels of activityand/or engaging in other actions (such aspremature discharges) which might not be inthe patient’s best interests. This runs counterto our intention that we should improve choice,responsiveness and quality through increaseduse of community-based care andmanagement of long-term conditions. Therole of the market-forces factor (which aimsto equalise the costs of delivering services indifferent regions) can also lead to undesirableprice competition across regional boundaries,and we will develop processes that ensure thatany competition is based on quality, accessand choice and not on price.

8.22 We will develop the expanded system ata pace that will ensure these problems areavoided. Subject to testing the effects inpractice, we intend to manage these issues byreviewing utilisation rates, reducing payment forre-admissions, grouping episodes, improvingaudit, and assessing PCT commissioningbehaviour. Where appropriate, we will alsoextend payment by results to cover careservices provided outside the hospital.

8.23 Incentives for staff: the financial incentivescreated by payment by results work onorganisations. It is important that theseincentives are transmitted down to the staffdirectly providing care. We are, therefore, alsopiloting the use of fee-for-service paymentsdirect to clinical teams that can augment theircontracted income in return for higher levelsof quality care.

8.24 Payment by results will be extended tocover services outside the hospital where thatis appropriate. Work has begun to incorporatemental health and primary/community care intothe system, as well as the balance of hospitalactivity. This comprehensive system will bebased on the principle of a single national tarifffor comparable treatments, to support choiceand quality rather than cost reduction.

8.25 In addition, we will consider newgroupings of healthcare activity, which reflectthe desired patient journey, rather thantraditional institutional boundaries. We will beseeking a solution which allows payment byresults for care packages. We will developthe tariff so that discrete elements of it(e.g. diagnostic procedures) can be taken inisolation, and made to fit appropriate localcircumstances. This is particularly important ifwe want to achieve our goals in respect oflong-term conditions.

Contestability

8.26 The introduction of greater choice forpatients, the flow of funding throughcommissioners and the extension of the rangeof providers is designed to support moreresponsive, innovative and efficient provisionof service. It will allow the majority of providersto grow and flourish in response to patients’needs, whilst the poorest performers will eitherimprove their ability to satisfy patients’ needsor face remedial action ultimately leading toclosure. We want to ensure that thiscontestability remains real so that patients andthe public, rather than monopoly institutions,can make choices about where, when andhow care is delivered. As part of this, weunderstand the need to manage the loss ofpoor performers in order for contestability tofunction effectively.

8.27 We have also considered the question ofcontestability of commissioning – whetherpatients should be able to choose theircommissioning body. We have concluded thatthe current population-based system based onPCTs is the right model. In reaching thisconclusion, the deciding considerations were:

l the need to ensure that commissionerswere prepared to accept vulnerable orhighly-dependent patients

l the need to ensure that commissionerswould be motivated to address inequalities.


Both goals are better achieved throughassigning a defined population base. Strategichealth authorities should, however, be able totransfer commissioning responsibilities toanother organisation if a PCT is failing in itscommissioning role.

Performance assessment andmanagement

8.28 Healthcare professionals, NHS managersand organisations have values and beliefswhich strongly influence how they behave andhow systems work. Professional standards andthe service ethos are a dominant force whichwill be used as a powerful lever to enhancepatient care; conversely, if the wrong approachis used, these commendable values can havethe opposite effect. Shifting the Balance ofPower recognised the need for a newapproach, based on the Government’sprinciples of public sector reform. This policycreated a new system of planning,management and performance assessmentbased on devolving power to the front line.This includes not only the possibility ofachieving NHS Foundation Trust status forhigh-performing organisations but also to thepossibility of franchising for under-performingorganisations.

8.29 We are developing this system to makeit work more in line with the new emphasis oncommissioning. We have also devolved theannual performance assessments (star-ratings) to the independent inspectorates.We will ensure that star-ratings reflect ourevolving aims for both health and social care,and the Department of Health will develop aclose relationship with the HealthcareCommission and with the Commission forSocial Care Inspection to ensure that thishappens each year. Within this policy, one ofthe most powerful incentives for delivery isearned autonomy (the reduction of centralcontrols for high-performing organisations).We will continue with our aim of maximisingthe number of organisations that can achieveearned autonomy.

Empowering patients

8.30 Increasingly, patients will be involved indecisions about their treatment and care.Ensuring that all patients are empowered tomake decisions about their care and treatmentmeans that individuals must have thenecessary skills to access, understand anduse information. Improving the population’shealth literacy will be a key element in realisingthe potential of the information revolution wehave embarked on and ensuring that accessto information results in reduced inequalitiesin health and reduced inequities in accessto care.

8.31 Patients will be further supported toconsider treatment decisions that keep themin the community as far as possible and mayresult in a reduced need for hospitalinterventions. Some evidence suggests thatdecision aids are particularly effective whereused together with interviews and advice.Building on current pilots and researchevidence, the Department of Health willsupport the development and application ofdecision aids that support patients and helpthem to make the right choices.


National to local

9.1 As in any major transformation, phase oneof the reform of the NHS focused on aconcerted effort from the centre to drive throughnecessary changes at all levels of the service.Now that improvements are being delivered, weare moving on to a second phase in order tofurther engage front-line staff and patients inbuilding on these successful reforms. In future,

therefore, there will be an increasing emphasison devolving decision-making to as near thepoint of delivery as possible in a partnershipbetween commissioners, service providers andpatients. The objective is to create a dynamicsystem where responsibilities and rolesincreasingly gravitate to those best able todeliver them. The centre will continue to havea leading role in creating the environment forsuch dynamism to thrive.

74 CHAPTER 9 EMPOWERING LOCAL COMMUNITIES

Chapter 9Empowering local communities

Local communities will take greater control of budgets and services:

l The balance of power in the NHS will shift even further towards PCTs and NHSFoundation Trusts, within the context of national standards

l There will be fewer national targets for the NHS, linked to a new emphasis on NHSorganisations setting stretching local targets

l There will be fewer arm’s length bodies at national level, reducing the regulatory burdenon local NHS organisations

l Patients and the public will be given more voice in how services are planned and provided

l The Department of Health will have a continuing role in supporting reform.

Figure 9.1: Shifting balance: between national/local and patient drivers

National initiatives

System makes choices

Local initiatives

Patient makes choices

2003 2008

9.2 Improving choice for patients and theoverall responsiveness of the system is centralto our plans. Breaking down some of theinstitutional and other barriers in the systemwill allow patients to have greater options.Developing a more diverse supply side witha greater plurality of providers will supportpatients to exercise real choice. Within the

NHS, PCTs will control over 80% of thebudget, and NHS Foundation Trusts willsymbolise the shift towards greater localengagement in the NHS.

9.3 We have already made progress here.Examples of the new freedoms and benefitsfor NHS organisations since 2000 include:


For all For good performers – earned autonomy

Strategic HealthAuthorities

Primary CareTrusts

NHS Trusts

NHS FoundationTrusts

– Freedom from Department of Health performance management– Freedom from central control – accountability is to local people,

commissioning PCTs and the Independent Regulator, rather than to theSecretary of State

– Flexibility to implement new governance structures to reflect localcircumstances

– Freedom to borrow from either private or public lenders– Freedom to retain surpluses and the proceeds of surplus asset sales to

invest in developing new patient-centred services

– Fewer national targets– Reduced monitoring– Reduced bureaucracy– Local flexibility within new

consultants’ contract and Agendafor Change

– More access to capital throughNHS Bank

– Removal of management costlimits

– Opportunity to shape and pilotnational policy

– Higher delegated limits for capitalprojects

– Retention of more of the proceedsof land sales

– Less frequent national monitoring– Eligibility for NHS Trusts to apply

for NHS Foundation Trust status

– Control 80% of NHS funding– Three-year allocations and plan

approval (previously annual)– Fewer national targets– Reduced monitoring– Reduced bureaucracy– More scope for local flexibility in

GP contracts

– Less frequent national monitoring– National requirements for planning

reduced– Intervention from the centre only in

the event of failure

– Three-year allocations and planapproval (previously annual)

– Fewer national targets– Reduced monitoring– Reduced bureaucracy– Participation in national policy and

leadership forums

Stewardship, regulation andinspection

9.4 The Department of Health will increasinglynarrow and deepen its core focus to promoteeffective stewardship of the nation’s health.This will involve the fulfilment of the followingfunctions:

l Agree priorities, direction and standards.

l Maintain and develop the values of theNHS.

l Secure and allocate resources.

l Develop the capability and capacity of thesystem.

l Account to Parliament and the public forthe performance of the whole system.

9.5 The Department of Health will be held toaccount through public service agreementswith HM Treasury that define agreed prioritiesand resource allocation at the national level.The Department of Health will not, in future,micro-manage local-level commissioning ordelivery decisions.

9.6 Strategic health authorities will lead inperformance-monitoring PCTs to ensureeffective commissioning on behalf of patients.Where necessary, strategic health authoritieswill trigger new commissioning arrangementsif a PCT is consistently failing in its duties.

9.7 Regulation and inspection of bothcommissioning and supply of health serviceswill increasingly be devolved to a smallnumber of key agencies. Functions will centrearound accreditation, compliance anddevelopmental standards.

l The Healthcare Commission will monitorand report on the quality of commissioningand services across the NHS and,increasingly, the private sector. TheHealthcare Commission will be independentof the Department of Health and will reportto Parliament, whilst also working with theDepartment of Health and with theIndependent Regulator for NHS FoundationTrusts to support quality delivery ofservices.

l The Office of the Independent Regulatorfor NHS Foundation Trusts will authorisethe establishment of and then regulate thecorporate conduct of NHS FoundationTrusts, including the enforcement of anysanctions resulting from non-compliancewith national standards.

l The Commission for Social Care Inspectionwill perform similar functions in themonitoring and regulation of social carecommissioners and providers. In addition,CSCI will lead in the development ofstandards and specification against whichcommissioners are assessed.

9.8 The Department of Health’s arm’s lengthbodies are currently under review. TheDepartment of Health will shortly be publishingits findings in order to ensure that theregulatory burden on local NHS deliveryorganisations does not exceed that essentialto promote quality and effective delivery ofcare. The review will also ensure that,whenever possible, resources are releasedto support front-line delivery.

9.9 The Department of Health and itsresponsible agencies will also continue torequire information on commissionerperformance and on the public’s health, to bidfor and allocate resources and to ensure thatcare is being commissioned in line with agreedpriorities and to the appropriate standards.A Health and Social Care Information Centrewill be opened to facilitate accessible andreliable information flows between patients,commissioners and suppliers. The Health and


Social Care Information Centre will improvethe credibility of reported NHS performance.

Planning and priority-setting fora devolved NHS

9.10 In order to be effective, we not onlyneed to reflect the goals for the changingsystem in our new Public Service Agreements(PSAs), but the form of the PSAs must meetour goal of devolution. We will move towardsfewer national targets in the PSA. There will beno new requirements beyond thesenational PSA targets in the next Planningand Priorities Framework, which operationalisesthe PSA targets for the NHS. There willtherefore be greater headroom for locally-determined priorities and target-setting.

New target areas

9.11 Four broad themes for new PSAs for2005-08 have been agreed between theDepartment of Health and HM Treasury.

9.12 The new PSA approach will ensure that:

l there is a degree of continuity from theprevious PSA, with a continued emphasison access, patient experience and healthoutcomes

l there are now only four PSA areas asopposed to the previous 12

l there is a new target area for long-termconditions, highlighting a new emphasis onchanging patterns of care from a secondaryto primary setting and increasing use ofself-care and preventative approaches

l there is a stronger emphasis on overall health

l we retain the flexibility tightly in operationalterms to set more high-level generic targetsthat allow the service to determine throughlocal target setting how improvements willbe delivered.


Figure 9.2: Future objectives for the NHS

Healthof the population

covers health promotionand ill-health prevention,

so that people arekept out of thecare system

whereverappropriate

Accessto services

ensures people have fairand prompt access to care,to the point where waiting

should no longer be anissue for the majority of

service users

Chroniccare

managementsupports health

by promoting betterself-care and treatmentin a community settingor in people’s homes to

avoid hospitalisationwhereverpossible

Patient/user/carerexperience

promotes maximuminformation and choice,

as well as a positiveexperience so thatservice provision is

more consumerfocused

Assessing and managingperformance – clarifying roles

9.13 In 2005/06 several important elements willcome together in a redesigned format. Therewill be:

l a new Planning and Priorities Frameworkprocess for 2005–08, as the basis for anew three-year planning round which willlock in a commitment to the reforms set outin this document, in order to allow morescope for locally determined targets andpriorities, whilst not setting any furthernational targets beyond the key PSA ones

l agreed healthcare standards criteria, anddefined methods which the HealthcareCommission will use to review performanceagainst standards and priorities as set outin the PSA

l a redesigned performance ratings systemfrom the Healthcare Commission,incorporating the healthcare standards

l confirmation of NHS funding, alreadysecured to 2008.

9.14 Although the Department of Health,strategic health authorities and the HealthcareCommission have three distinct roles, they areclearly linked, and the revised performanceregime that will oversee delivery of the newPSA will be at its most effective if they formpart of an integrated system. Each of the threehas responsibility for a key component of thenew performance regime, so it is essential thatthese components map closely to each otherso as to avoid creating perverse incentivesand conflicting priorities for the service.

9.15 The components are:

l national targets and standards, set by theGovernment in its PSA, the Planning andPriorities Framework and the newhealthcare standards document

l delivery of national and local priorities,managed and monitored by strategic healthauthorities, in partnership with NHS Trustsand PCTs, through the local deliveryplanning process

l assessment and inpection, undertakenindependently by the Healthcare Commissionand publicised through inspection/reviewreports and performance ratings.

Greater patient/public involvement

9.16 The NHS is becoming more accountableto local communities as more power isdevolved. There is a statutory duty on the NHSto involve and consult patients and the publicin service planning, service operation and thedevelopment of proposals for changes. Localauthority overview and scrutiny committees,made up of elected representatives, are nowable to scrutinise local service changes andensure adequate public consultation takesplace. Patient Forums in every NHS trustensure that local views inform thedevelopment of local services. The newgovernance structures of NHS FoundationTrusts mean that increasingly the providers ofhealth services will be directly accountable tothe public and their members. As the NHSmoves from a centralised service to one that ismore community-based, the voices of patientsand the public, together with greater choice,will play an important role in shaping thehealth service in future.

Managing the transformation

9.17 Four years ago, at the time of the launch ofThe NHS Plan, the Department of Health dealtdirectly through its Regional Offices with all NHSorganisations. Currently it manages the NHSthrough the strategic health authorities, each ofwhich acts as the local headquarters of theNHS. The Department of Health performancemanages the strategic health authorities, whichin their turn performance manage PCTs andNHS Trusts. Other partners such as NHSFoundation Trusts and the independent sectorhave separate accountability for governancepurposes, but are contractually responsible toPCT commissioners.


9.18 To ensure a cohesive managementapproach, the NHS Chief Executive bringstogether the NHS leadership consisting of theDepartmental Management Board, the nationalclinical directors and the chief executives ofstrategic health authorities. This group takesan overview of performance, addressesnational issues corporately and contributes tonational policy. Each chief executive in turnmeets with their local leadership group drawnfrom the local NHS organisations and,frequently, their partners from local authorities.Increasingly, as the provider base develops,these discussions will also need to include keyprovider partners.

9.19 During the next five years we will need tointroduce four changes to supplement and inpart replace these arrangements:

l devolving more responsibilities to the NHSitself to take corporate decisions andactions – for example, through the strategichealth authorities working together tomanage the NHS Bank or through the NHSConfederation taking on a new role as anemployers’ organisation

l moving away from a system ofdepartmental monitoring and regulation oforganisations, to one where responsibilitysits with new inspectorates and the newOffice of the Independent Regulator forNHS Foundation Trusts, and developing asystem where incentives start to have animpact

l strengthening commissioning of services byPCTs to create a system of alternativeservice providers within which patients canexercise individual choices and where theyhave more control over their care

l developing new relationships between theDepartment of Health, the NHS, localauthorities and the new bodies – theHealthcare Commission, the Office of theIndependent Regulator for NHS FoundationTrusts, the Commission for Social CareInspection and National Institute for ClinicalExcellence, and the Social Care Institutefor Excellence – which between themmanage and shape the whole systemwithin which health and social care aredelivered.


The Department of Health will lead the transformation to the new system:

l The NHS Chief Executive and the Departmental Management Board have overallresponsibility for leading the transformation, working with ministers

l The Healthcare Commission, Commission for Social Care Inspection and the Office ofthe Independent Regulator for NHS Foundation Trusts have key roles in ensuringaccountability for quality and financial viability

l The NHS Chief Executive and the Departmental Management Board work closely withNHS leadership – consisting of the leaders of the 28 strategic health authorities togetherwith clinical directors

l Strategic health authorities as the local headquarters of the NHS lead the transformationat a local level

l PCTs have the capability to commission services from a more diverse provider base

l Providers are increasingly accountable to patients and the public, augmented byaccountability to PCTs through contracts

l Patients will be empowered to take an active role in maintaining their own health,choosing which provider treats them and controlling healthcare decisions.

9.20 This period of transition needs carefulmanagement. It will not be a linear process –it will require continual dialogue betweenministers, the Department of Health, localleaders and associated bodies to ensure thatsensible short-term decisions are taken whichallow both day-to-day services to be wellmanaged and the new system to beintroduced. Relationships throughout thesystem will change and will be reviewed inthe light of experience.

9.21 Responsibility for overall management –integrating the strategic and the day-to-day –rests with the NHS Chief Executive and theDepartmental Management Board. In thelonger term the Department of Health willmove away from its managerial role but retainresponsibility for the whole system, its valuesand standards, its direction, its majorinvestments, its integrity and its accountability.The current restructuring of the Department ofHealth is designed to support this, with theChief Executive supported by three businessgroups:

l Quality and Standards: setting thestandards within the widest context ofhealth, health services and well-being

l Delivery: managing implementation andthe interface with the NHS

l Strategy and Business Development:developing the strategy and ensuring itsintegrity and coherence whilst maintainingthe core accountability and governancefunctions.

9.22 By 2008, we expect to have a systemwhere:

l patients have a choice, they have morecontrol over how they are treated, and theyare empowered to take control of their ownhealth

l providers, whether NHS or independent,providing NHS services are empowered torespond to patients’ needs and choices,and are primarily accountable to patientsand their local communities

l primary care commissioners are able tocommission what their patients needand want

l the strategic health authorities developlocal strategy, set the local framework forplanning services and performancemanage PCTs

l the independent inspectorates and theOffice of the Independent Regulator forNHS Foundation Trusts ensure thatprovider organisations meet nationalstandards and governance duties

l the Department of Health sets nationalstrategy, develops the system andaccounts to Parliament for overallperformance.


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