Select Committee on Health Memoranda


Memorandum by the Department of Health

PUBLIC EXPENDITURE QUESTIONNAIRE 2002

INDEX

1. CURRENT ISSUES

  1.1  NHS Medical Workforce

  1.2  Comparative Health Spending Levels

  1.3  Concordat Activity

  1.4  Buying from Non-UK Providers

  1.5  Information for Health

2.  GENERAL EXPENDITURE ISSUES

  2.1  NHS Financial Balance

  2.2  Overall Expenditure

  2.3  Programme Budgets

  2.4  Special Allocations

  2.5  Expenditure on Community Care

3.  NHS RESOURCES AND ACTIVITY

  3.1  General

  3.2  Inflation

  3.3  Hospital and Community Health Services Allocations and Distance from Targets

  3.4  Public Health

  3.5  Care of Mental Health and Learning Disability Patients

  3.6  Expenditure on Prescribing

  3.7  Allocations to National Specialist Services

  3.8  Management and Administration Costs

  3.9  Activity and Waiting Times

  3.10  Commission for Health Improvement

  3.11  Race Relations (Amendment) Act 2000

4.  PERSONAL SOCIAL SERVICES RESOURCES AND ACTIVITY

  4.1  Waiting times for receipt of care packages

  4.2  Free nursing care

  4.3  Standard Spending Assessments (SSAs)

  4.4  Changes to the SSA formulae

  4.5  PSS SSAs with corresponding budget

  4.6  Changes in Unit Costs of the main social services for children and adults

  4.7  Proportion of social services for adults which are purchased from the independent sector

  4.8  Number of children fostered

  4.9  Number of children involved in schemes which are specifically designed to support families

  4.10  How the delivery of non-residential social services has changed over the last 5 years

  4.11  Specific inflation index for social services

  4.12  Breakdown by client group of gross expenditure on social services activity

  4.13  Changes to statistical information collected on personal social services

  4.14  Details of any research work on the outcomes and effectiveness of social care

  4.15  Fees, Charges and Grants

5.  CAPITAL EXPENDITURE AND INVESTMENT

  5.1  General

  5.2  Primary Care Capital Investment and Facilities

  5.3  Hospital and Community Health Services Capital Prioritisation

  5.4  Long Term Capital Projects and PFI

  5.5  Capital Investment in Social Services


1. CURRENT ISSUES

1.1 NHS Medical Workforce

  1.1.1  Could the Department provide information (a) on numbers of GP trainers for each of the last five years, (b) on current numbers of GP trainees, (c) on numbers completing training this year ?

  1.1.2  In view of the impact of the medical workforce on future NHS costs and effectiveness, could the Department provide an age breakdown of hospital consultants and of unrestricted GP principals? Could the Department also provide estimates for the period 2003 to 2010 of the numbers of: (a) newly graduating medical school graduates; (b) registrars; (c) consultants and (d) GPs expected to reach retirement age.

1.2 Comparative Health Spending Levels

  1.2.1  Could the Department provide estimates of how current levels of NHS spending compare with the European average, and estimates of changes assuming planned rates of growth in spending from now to 2007?

  1.2.2  Would the Department explain how it measures total health care spending, private as well as public, for its estimates of spending as a percentage of GDP? Has the definition of what is included within health care spending changed since 2000 and, if so, in what way?

1.3 Concordat Activity

  1.3.1  How much NHS expenditure has there been on health care purchased from independent UK providers in each of the years 1999-2000, 2000-01 and 2001-02? Can these figures be broken down between acute and non-acute care and by specialty?

  1.3.2  How do prices paid by the NHS in 2001-02 for independently provided inpatient and day case treatment compare with NHS reference costs for the same treatments and procedures?

  1.3.3  How many NHS patients were treated in the private sector under the Concordat by doctors who also work in the NHS, and what proportion of all patients treated under the Concordat does this represent? How many were treated by the same doctor or surgical team they would have been treated by in the NHS, and what proportion of all patients treated under the Concordat does this represent?

  1.3.4  In a letter to the Committee of 9 January 2002, the Department reported briefly on a survey commissioned in September 2001, the purpose of which was to understand the volume, cost and nature of elective treatment provided to the NHS by the independent sector. Would the Department give a more detailed account of the findings of this survey, including tables where appropriate, and in particular the type of procedures making up the volume of cases commissioned, and the prices obtained by the NHS, and how these vary between different regions of the country? Does the Department intend to make the survey data available to independent researchers? When does the Department intend to re-run the survey, and when does it expect to make the results available publicly?

1.4 Buying from Non-UK Providers

  1.4.1  How much has the NHS spent on health care provided outside the UK, for how many patients and for what treatments, in each of the years 1999-2000, 2000-01 and 2001-02? What is the likely spending on health care outside the UK for 2002-03? If possible, distinguish between emergency (E111) care, non-emergency (E112) care and other purchases from non-UK providers.

1.5 Information for Health

  1.5.1  Could the Department provide an annual breakdown of NHS expenditure on IM&T since the launch of "Information for Health" in 1999, for: IM&T infrastructure; Electronic Patient Records; clinical governance system; and staff training?

  1.5.2  Could the Department state what progress has been made on the Maternity Care Data Project? Is it on track to achieve the overall aim of having standardised and consistent recording of data relating to maternity and childbirth, for women and patients, within electronic patient record systems in all affected NHS organisations by April 2003? If this is not likely, what is the revised date for achieving this aim? What steps have the Department and the NHS Information Authority taken to achieve this aim? What resources will be made available to NHS Trusts and maternity units to upgrade their IT to record data in the ways defined, and to link their IT systems to those of other NHS systems?

1.1 NHS Medical Workforce

  1.1.1  Could the Department provide information (a) on numbers of GP trainers for each of the last five years, (b) on current numbers of GP trainees, (c) on numbers completing training this year ?

(a)   Numbers of GP Trainers

  1.  Information is available from 1999-2000 on the numbers available to provide GP training as follows:
1999-20002,111
2000-012,235
2001-022,264

(b)   GP Trainees

  2.  The most recent figure for GP Registrars, qualified doctors training to become GPs, is 1,908 on 31 March 2002. Previous figures recorded in the annual censuses are:
19971998 199920002001
1,3431,4461,520 1,6591,883

(c)   Numbers Completing Training

  3.  The estimated figure based on information received from Directors of Postgraduate General Practice Education for the number completing GP training in 2002 is 1,950. This information is not routinely collected centrally.

1.1  NHS Medical Workforce

  1.1.2  In view of the impact of the medical workforce on future NHS costs and effectiveness, could the Department provide an age breakdown of hospital consultants and of unrestricted GP principals? Could the Department also provide estimates for the period 2003 to 2010 of the numbers of: (a) newly graduating medical school graduates; (b) registrars; (c) consultants and (d) GPs expected to reach retirement age.

  1.  The age breakdown of hospital consultants and Unrestricted Principals and Equivalent (UPE)* GPs is as follows:
Hospital Medical Consultants by Age Band
TotalUnder 30 30-3435-39 40-4445-4950-54 55-5960-64 65-69
25,0747810 4,9075,9535,132 4,2062,7461,128 185
Unrestricted Principals and Equivalent* GPs by Age Band
TotalUnder 30 30-3435-39 40-4445-4950-54 55-5960-64 65-69
27,9562852,441 4,6985,7745,140 4,5253,2811,358 454

  Source: Department of Health Medical and Dental Workforce Statistics: Census on 31 March 2002 and Department of Health General and Personal Medical Statistics: Census on 31 March 2002.

  * UPEs includes Unrestricted Principals, Personal Medical Services (PMS) contracted GPs and PMS Salaried GPs. These are headcount figures.

Medical School Graduates

  1.  The projected numbers of graduates from English medical schools rounded to the nearest 50 is as follows:
Academic Year2002-03 2003-042004-05 2005-062006-07 2007-082008-09 2009-10
No of Graduates3,5503,750 4,0504,4004,950 5,3005,4005,500

Registrars

  2.  The NHS Plan promised to create a further 1,000 SpR posts by 2004. In September 2001 there were 13,220 staff employed as Specialist Registrars (SpRs), Registrars and Senior Registrars (the Registrar Group) an increase of almost 550 over September 1999. An increase of at least 300 SpR posts in 2002-03 is currently being implemented and a further increase of at least 400 SpR posts is planned during 2003-04.

  3.  The method of planning the number of SpR posts has recently been changed. A stronger service led element is being introduced whereby NHS Trusts are invited to bid to create additional SpR posts where a need is identified locally for an increase in training capacity. We would therefore expect the increase in SpR numbers to be significantly in excess of the NHS Plan increase.

Consultants

  4.  The projected number of consultants is as follows:
Sep 2002Sep 2003 Sep 2004Sep 2005 Sep 2006Sep 2007 Sep 2008Sep 2009 Sep 2010
Total27,50529,814 31,30131,93232,369 32,93234,04035,510 36,784


  These projections are based on the number of doctors already in and planned to enter SpR training schemes who will obtain their CCSTs and become eligible to take up consultant posts by 2010. The projections up to September 2004 also include the impact of recruitment and retention measures being taken to ensure the NHS Plan target is achieved.

GPs Reaching Retirement

  5.  The numbers of GPs projected to reach retirement age between 2003 to 2010 is as follows:
YearEstimated UPE retirements
2003667
2004725
2005805
2006826
2007882
2008918
2009946
2010977

  6.  The projections are based on the numbers forecast to leave the workforce aged 55 and over. They assume that the proportion of leavers in each age group will remain the same as 2001.

1.2 Comparative Health Spending Levels

  1.2.1  Could the Department provide estimates of how current levels of NHS spending compare with the European average, and estimates of changes assuming planned rates of growth in spending from now to 2007?

  1.  The latest available data shows that the EU (unweighted) average spend is 8 per cent of GDP—based on data produced by the OECD in 2002. This reflects an average of 6 per cent public expenditure and 2 per cent private expenditure. The table below sets out how UK expenditure will compare from this year until 2007-08.

2002-03
plan
£m
2003-04
plan
£m
2004-05
plan
£m
2005-06
plan
£m
2006-07
plan
£m
2007-08
plan
£m
UK Public Expenditure as per cent of GDP 6.6%6.9%7.2% 7.5%7.8%8.2%
Plus
Private Healthcare Expenditure1.15% 1.15%1.15%1.15% 1.15%1.15%
Total Health Expenditure as per cent of GDP 7.7%8.0%8.3% 8.7%9.0%9.4%

1.2 Comparative Health Spending Levels

  1.2.2  Would the Department explain how it measures total health care spending, private as well as public, for its estimates of spending as a percentage of GDP? Has the definition of what is included within health care spending changed since 2000 and, if so, in what way?

  1.  The forecasts for the UK are based on expected gross NHS expenditure in cash and the historic level of private expenditure as compiled by ONS and published by the OECD. The latest figures take account of work by the ONS to improve the international comparability of the UK's health expenditure figures. ONS published experimental figures in February 2002 using methodology that accorded more closely with the international definition. Specifically:

    —  Research & Development (R&D) and Education & Training (E&T) by health administrations has been subtracted.

  2.  Note that the importance of both R&D and E&T to the health system is reflected in the international definitions by treating this as health-related expenditure. ONS continues to work on improving the comparability of these experimental figures, and will incorporate these improvements when they publish a further year's figures—calendar 2001—as well as the already published 1997 to 2000 figures—in February 2003.

1.3 oncordat Activity

  1.3.1  How much NHS expenditure has there been on health care purchased from independent UK providers in each of the years 1999-2000, 2000-01 and 2001-02? Can these figures be broken down between acute and non-acute care and by specialty?

  1.  The table shows expenditure by NHS bodies on the purchase of healthcare from non-NHS bodies. The figures include expenditure on services provided by all non-NHS bodies, including local authorities and other statutory bodies, as well as independent healthcare providers. The figures cannot be broken down between different types of provider, nor between acute and non-acute care, nor by specialty. The 2001-02 figure is a provisional figure based on returns from all but 1.5 per cent of NHS bodies.

Table 1.3.1

EXPENDITURE ON PURCHASE OF HEALTHCARE FROM NON NHS BODIES
YearExpenditure on Purchase of Healthcare from Non NHS Bodies
(£000's)
1999-20001,301,196
2000-011,549,172
2001-021,786,875

  Source: Annual financial returns of NHS trusts, primary care trusts and health authorities

1.3  Concordat Activity

  1.3.2  How do prices paid by the NHS in 2001-02 for independently provided inpatient and day case treatment compare with NHS reference costs for the same treatments and procedures?

  1.  Please refer to the answer given to 1.3.4

1.3  Concordat Activity

  1.3.3  How many NHS patients were treated in the private sector under the Concordat by doctors who also work in the NHS, and what proportion of all patients treated under the Concordat does this represent? How many were treated by the same doctor or surgical team they would have been treated by in the NHS, and what proportion of all patients treated under the Concordat does this represent?

  1.  The vast majority of consultants practising in independent hospitals in this country also hold NHS appointments. Therefore, the vast majority of NHS patients treated in such hospitals will have been treated by a consultant who also works for an NHS Trust or other NHS body. The Department has no information on how many of those patients were seen by the same consultants they would have seen had their treatment been carried out in an NHS hospital.

1.3  Concordat Activity

  1.3.4  In a letter to the Committee of 9 January 2002, the Department reported briefly on a survey commissioned in September 2001, the purpose of which was to understand the volume, cost and nature of elective treatment provided to the NHS by the independent sector. Would the Department give a more detailed account of the findings of this survey, including tables where appropriate, and in particular the type of procedures making up the volume of cases commissioned, and the prices obtained by the NHS, and how these vary between different regions of the country? Does the Department intend to make the survey data available to independent researchers? When does the Department intend to re-run the survey, and when does it expect to make the results available publicly?

  1.  In October 2001, the Department's statisticians carried out a survey of NHS bodies' use of the independent sector for acute elective care. It asked about actual use from April—September 2001. (It also asked about planned use from October 2001 to March 2002, but this was before the announcement of the allocation of an additional £40 million to help NHS bodies make use of spare capacity in the independent sector over the winter months.)

  2.  The survey got a very poor response rate of less than half of all hospital trusts, primary care trusts and health authorities, together with a small number of primary care groups.

  3.  The organisations responding to the survey reported commissioning a total of 13,226 procedures from the independent sector between April and September 2001, at a total cost of around £22.1 million.

  4.  It is estimated that this represents around 123 procedures commissioned from the independent sector for every 10,000 NHS elective inpatient and daycase procedures carried out (a rate of around 1.2 per cent).

  5.  The poor response rate means that the survey results are not reliable.

  6.  The Department will consider the best way to make the findings publicly available once it has completed a further survey to obtain information on activity and prices in the second half of 2001-02. The further survey is currently in progress.

1.4 Buying from Non-UK Providers

  1.4.1  How much has the NHS spent on health care provided outside the UK, for how many patients and for what treatments, in each of the years 1999-2000, 2000-01 and 2001-02? What is the likely spending on health care outside the UK for 2002-03? If possible, distinguish between emergency (E111) care, non-emergency (E112) care and other purchases from non-UK providers.

  1.  There are two separate systems in operation in the years in question. For all three years specified, Regulations (EEC) 1408/71 and 574/72 have co-ordinated the social security and health care systems of the member states of the European Community and the European Economic Area. These Regulations cover, amongst other things, emergency health care for temporary visitors (the E111 arrangements) and referral of patients specifically for treatments of pre-existing conditions (the E112 scheme).

  2.  Between January and April 2002 there was also a pilot in south east England whereby a number of surgical procedures were commissioned directly by the NHS from healthcare providers in France and Germany outside the scope of the European Community arrangements. 190 patients were treated during this pilot and the total cost of their treatment and travel was approximately £1.1 million.

  3.  The data in table 1 below shows, in resource terms, costs of treatment provided under the terms of the Regulations to UK insured persons. Actual treatment costs are used for both emergency care (E111) and for patients referred specifically for treatment (E112) as well as other categories of persons covered. But claims do not necessarily distinguish between categories so that no cost distribution between E111 and E112 arrangements is available. Patient numbers are not available since claims may cover several episodes of care for a single individual. However, the UK approved the following number of patient referrals under E112 arrangements as follows:-
1999-2000 852
2000-011,075
2001-021,167


  4.  Lump sum costs cover, in particular state pensioners who have relocated to other member states; the costs of their health care lie with the member state paying the pension (unless they also have a pension from the member state of residence).

  5.  No precise information is available on types of treatment covered. For E111, emergency care covers the range from minor ambulatory care to major trauma. E112s cover maternity care, ongoing treatment begun in the UK, specialised care not available in the UK and care for which there is a long UK waiting time.

Table 1.4.1

EXPENDITURE UNDER REGULATIONS (EEC) 1408/71 AND 574/72
YearClaim type Member States
claims against the
United Kingdom
(£000's)
1999-2000Total176,400
Actual cost25,800
Lump sums 150,600
2000-01Total187,200
Actual cost25,600
Lump sums161,600
2001-02Total212,800
Actual cost25,500
Lump sums 187,300


  Notes:

  1.  All figures relate to the UK.

  2.  Figures are based on latest available information as used in the 2001-02 Resource Accounting and Budgeting (RAB) outturn exercise. This information is compiled in line with the requirements of the Government Accounting 2000 and National Audit Office (NAO);

  3.  Claims against UK are made in national currency and converted in sterling by using the quarterly mean exchange rates published by the EU commission;

  4.  Actual costs under Article 93 of Regulation 574/72 eg E111 (covering temporary visitors) and E112 cases (referred patients).

  5.  Lump sums under Articles 94 and 95 of Regulation 574/72 eg E121 (pensioners).

  6.  £237million resource provision has been made in Parliamentary Estimates for 2002-03 for treatment under Regulation 1408/71. With respect to treatment directly commissioned by the NHS, although it is the Government's preference for the NHS to treat patients close to home, some patients are likely to travel to other countries in the European Economic Area, for example in patient choice schemes. Their treatment will be paid for from local budgets.

1.5 Information for Health

  1.5.1  Could the Department provide an annual breakdown of NHS expenditure on IM&T since the launch of "Information for Health" in 1999, for: IM&T infrastructure; Electronic Patient Records; clinical governance system; and staff training?

  1.  The Department does not separately record expenditure by local NHS organisations on IM&T in general or on any specific element of the IM&T programme. Targets are set through the planning process and funding is made available via general allocations. Local NHS organisations then plan to meet the targets and progress is measured in terms of the operational achievement rather than financial investment.

1.5  Information for Health

  1.5.2  Could the Department state what progress has been made on the Maternity Care Data Project? Is it on track to achieve the overall aim of having standardised and consistent recording of data relating to maternity and childbirth, for women and patients, within electronic patient record systems in all affected NHS organisations by April 2003? If this is not likely, what is the revised date for achieving this aim? What steps have the Department and the NHS Information Authority taken to achieve this aim? What resources will be made available to NHS Trusts and maternity units to upgrade their IT to record data in the ways defined, and to link their IT systems to those of other NHS systems?

SUMMARY

  1.  A maternity data dictionary project has developed definitions for maternity which can be used to populate electronic records. As part of the Information for Health programme basic electronic records are expected to be in place in the NHS in 2005 with more sophisticated integrated electronic records becoming available by 2008. Services are expected to use the definitions in the maternity data dictionary as they develop electronic records. Funding for the development of IM&T in maternity services is included in general Information for Health funds (to be announced as part of the spending review settlement). As part of the Children's Services National Service Framework, the Department will ensure that issues relating to the development of electronic records using the maternity data dictionary are addressed.

DETAIL

  2.  The NHS Information Authority Maternity Data Dictionary Project has developed a Maternity Data Dictionary, which contains agreed definitions for a core of maternity data items. This standard was developed in conjunction with the relevant professional organisations.

  3.  The practicality of adopting the standards was evaluated with two maternity hospitals and three workshops involving a wide range of maternity healthcare professionals. It was clear from this process that adoption of the standard would not place any significant burden on the service.

  4.  However, it was concluded that adoption of the standard would only be practical with electronic information systems. IT suppliers were therefore engaged via the Computer Suppliers and Services Agency (merged with the Federation of Electronics Industry in May 2002 to intellect) to seek their support with integration of these standards within their products. This was accepted as a principal and "would be adopted when confirmed as NHS standards".

  5.  Work is outstanding to obtain approval from the recently formed NHS Information Standards Board (ISB) for the maternity data dictionary. However, the ISB has recently agreed to approve the addition of the maternity dictionary contents to the NHS Data Dictionary, identified as work in progress. This should provided limited guidance to maternity system suppliers and Trusts allowing them to adopt the standard whilst more formal approval is sought.


 
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