Select Committee on Health Minutes of Evidence

Annex A


  1.  The Government has introduced a number of broad policy initiatives that, taken together, will assist in delivering high quality, efficient health and social care services.


  2.  The Inquiry recognised the need for a "whole systems approach" when planning future health services. Provision of acute hospital services cannot be looked at in isolation. Acute hospitals need to work in partnership with local primary, community, intermediate and social services. The NBI report set out three possible scenarios as a way of focusing debate. Responses to the consultation confirmed strong support for "care closer to home", envisaging a major expansion of intermediate care services. There was also agreement that the long-term trend of reductions in beds in general, and acute beds in particular, was not compatible with improving access to care.


  3.  The development of intermediate care services is a critical element in the programme to implement the Plan, focussing on:

    —  Preventing avoidable hospital admission.

    —  Promoting timely discharge; and

    —  Avoiding premature dependence upon long-term care.

  4.  The NHS Plan announced extra investment of £900 million annually by 2003-04 for intermediate care and related services to promote independence. Of this, around £255 million was earmarked specifically for NHS investment in intermediate care (the first instalment of £26 million this year). Together with the £150 million made available recurrently from 2000-01, this will bring earmarked NHS resources for intermediate care to a total of £405 million by 2003-04. A substantial component of the £900 million is being provided to local government, mostly through the Personal Social Services SSA, for a range of services that link to intermediate care, for example, through the provision of home care.

  5.  Intermediate care is a key area for early implementation in the NSF for Older People. The NSF builds on intermediate care guidance issued in January 2001 (HSC 2001/001; LAC (2001)01) and sets out key interventions, evidence base, service models, performance indicators and milestones.

  6.  There are many examples of effective, targeted intermediate care schemes around the country. These provide an excellent platform upon which to build. Our aim now must be to ensure that everyone has access to high quality, effective intermediate care services. We shall be looking to develop a more targeted approach to the further expansion of intermediate care services, drawing on the best available evidence. National evaluation of intermediate care has been commissioned, but the results will not be known for two-three years. However, we do have evidence from local, independently conducted evaluations that properly co-ordinated and targeted intermediate care schemes do have a significant impact on admissions and discharges. Further guidance on best practice and successful models is being drawn up and will be issued to the field.

  7.  Intermediate care is not a panacea. However, the Government believes that, with its emphasis on promoting independence, it can make a significant impact at these points in the care pathway, and that this approach is a vital part of the strategy to tackle these issues.


  8.  The NSF, published in March 2001, sets out new national standards and defines service models across health and social services drive up the quality of care for older people whether they live at home, in a care home, or in a hospital or intermediate care facility. It focuses on:

    —  rooting out age discrimination;

    —  providing person-centred care with older people treated as individuals with respect and dignity;

    —  promoting older people's health and independence; and

    —  ensuring that older people are supported by newly integrated services with a well co-ordinated, coherent and cohesive approach to assessing an individual's needs and circumstances and for commissioning and providing services accordingly.

  9.  The NSF specifically addresses those conditions which are particularly significant for older people and which have not been covered in other NSFs — stroke, falls and mental health problems associated with older age. Conditions such as stroke and dementia are not limited to older people, and the standards and service models will apply to all who need them, regardless of age.

  10.  The NSF is a ten-year programme of improvement supported by local action and national underpinning programmes for implementation. It sets out a series of milestones and performance measures to ensure progress. Its implementation will contribute to the reduction in delayed transfers of care through the development of whole systems working:

    —  Standard two (Person centred care) stresses the need for joint commissioning and provision of health and social care services and sets out the requirement for a single assessment process which will improve communications.

    —  Standard three (Intermediate care) Sets out the service models for supporting early discharge and avoiding hospital admission.

    —  Standard four (General hospital care) sets out the need for improved discharge planning.

    —  Standard five (Stroke) contains a service model for stroke. It is well known that organised stroke services reduces length of hospital stay.

    —  Standard six (Falls) Organised services for falls and fractures is known to reduce length of hospital stay and can also help prevent admissions.

    —  Standard seven (Mental Health) Improved mental health services for older people and in particular better management of dementia should impact on discharge. Dementia is often a key factor in difficult discharge.

    —  Medicines Management. Better management of medicines will reduce hospital admissions. (Approximately one in six hospital admissions amongst older people are due to the side effects of drugs).

    —  Implementing the cross-cutting themes of supporting carers and meeting the needs of those from black and minority ethnic communities will support effective discharge planning. Embedding the principles of rooting out age discrimination (Standard one) and promoting user involvement (Standard two) into services will lead to considerably improved services for older people.

  11.  As part of the implementation process, the Department will shortly be issuing guidance on the Single Assessment Process for Older People for implementation from April 2002. The Government is committed to a single national assessment framework and a convergence of local assessment procedures, outputs and outcomes over time.

  12.  In addition, new guidance on Fair Access to Care Services will be issued to councils shortly. This will provide those with social services responsibilities with a framework for determining eligibility for adult social care services to allow a more consistent approach to eligibility and fairer access to care across the country.


  13.  The Department has developed a local planning model, known as "modelshire". The original version was made available to the NHS in February 2001 and an updated and expanded version in September 2001.

  14.  Modelshire is an analytical tool designed to assist health and local authorities, in collaboration with partner agencies, to produce estimates of their future requirement for general and acute services and beds and for community and intermediate care facilities in 2003-04 in order to deliver the targets in the NHS Plan. The first version was mainly concerned with planning of acute and intermediate care services. The second version includes residential care and intensive home care.

  15.  The Department issued a circular in February 2001—HSC 2001/03: LAC (2001)4—on Implementing the NHS Plan: Developing services following the National Beds Inquiry. The circular required health authorities, in partnership, to:

    —  examine their current patterns of service use;

    —  consider changes needed to make their contribution to the NHS Plan objectives of more general and acute beds and more intermediate care beds and places; and

    —  submit an action plan to NHS Regional Offices.

  16.  The circular invited health authorities to use modelshire in this process. This meant that all authorities were expected to use the original version in preparing the plans, which they submitted last August as part of local modernisation reviews. Queries received on the updated and expended version suggest that at least some health and local authorities are now using the later version.

  17.  Whereas the original version was produced mainly for health authorities, the revised version is designed for use by health and local authorities. There are two similar versions, one operating on 1999 health authority boundaries and one on 1999 local authority boundaries. It is possible to run the model for individual authorities or for user-selected groups of authorities, with a view to use for strategic health authorities.

  18.  Health and local authorities are invited to enter their own data and assumptions and to compare their local plans and projected requirements with projections for a model authority. If their plans and projections differ significantly from the model authority, authorities may want to investigate the reasons for the differences and review their plans and planning assumptions.

  19.  The model is not intended to be prescriptive. The model authority is presented as the national average and not as a blueprint for each area. The model is assumed to cover one per cent of the national population. Authorities are asked to conduct their own planning using the model as a tool but entering their own planning assumptions. The model is inevitably a simplification. It is not possible to represent the complex interactions between different services in a model that is intended to be fairly straightforward to use.

  20.  The model contains national assumptions for changes in hospital admission rates and lengths of stay and for levels of intermediate care and community services. These effectively produce default results for each authority, that is model output for acute, intermediate and community services on national assumptions.


  21.  The Agency's programmes take a variety of approaches, but are typified by that of Collaboratives. That is, to ensure those best practices are shared and spread throughout the service. It is fundamental that the change programmes are clinically led and focus on small-scale, incremental change.

  22.  The Agency does not have a specific programme dedicated to delayed transfers of care at the moment, although much of the Agency's work includes this area. For instance, IDEA (the Ideal Design of Emergency Access) looks at pathways into and out of care. It is a multi-agency programme including Acute, Social Services, Primary Care, NHS Direct, etc. A specific strand of the programme is looking at mapping the pathway of elderly people who have fallen into and out of acute care. This will inevitably look at the issues around discharge and delays to discharge, though the work on this has not yet been completed and is yet to report.

  23.  Another relevant Agency programme is the SMART programme that is constructing care pathways for a number of specific conditions. All of this work starts from the premise that discharge can be predicted upon, or prior to, admission, and can therefore be planned. This allows for the elimination of one or more stages of the process such as the wait for assessment after the decision to discharge.

  24.  Furthermore, the Agency is developing an organisational development competency framework and self-assessment toolkit for PCT's to determine areas for their own further organisational development. The domains include partnership development and securing service provision amongst others, where delayed transfers of care will undoubtedly be a focus for their local agreements.


  25.  This NSF was announced in February 2001 and will look at the care and treatment of people with long-term conditions. The intention will be to improve diagnosis, treatment, care and rehabilitation services for this group of people with the aim of providing integrated health and social care packages at home. An anticipated outcome will be that people will spend less time in acute settings and better, proactive management in the community should help to reduce relapses and hospital readmission. Good support from community-based multi-disciplinary teams will be crucial for this group and this is likely to be a theme reflected in the NSF.

  26.  Another important strand will be the need for community-based health and social care professionals working in partnership with users who are often expert in the management of their condition. A lot of work has already been done on this through the Expert Patient Programme which is looking at effective management of chronic conditions at home (further details of this are given at paragraphs 51 to 52 below). The NSF is likely to reflect the themes in the programme.


  27.  In 2000-01 the PCT Primary Care Access Fund was established. This is intended in the first instance to support local delivery of fast and convenient access to primary care services and, in particular, achievement of the NHS Plan targets access to a GP or other primary care professional. This Fund, which will total £168 million in 2002-03 may also be used to support services or schemes which support the development of intermediate care (for example, rapid response or rehabilitation teams working in community settings). Alongside this, General Medical Service Local Development Schemes give PCTs (and PCGs) flexibility to improve the development and responsiveness of general medical services, by giving local GPs financial incentives beyond those set out in the Statement of Fees and Allowances for providing additional or enhanced services. Such schemes may be used to pay GPs to provide additional support to older patients, so contributing to packages of care, which enable more patients to be treated and supported at home.

  28.  Personal Medical Services (PMS) pilots are an opportunity to test different ideas for delivering existing primary care focusing on local services problems and bringing about improvements. Health care professionals identify the needs of the practice population and taking advantage of the flexibility of PMS, they negotiate a contract with the HA or PCT that best serves these needs thus addressing delivery, inadequacies of existing services and inaccessible or inappropriate provision. PMS pilots generally focus on new approaches to nurses' role and skill mix within primary and community care; new approaches to addressing the needs of deprived areas and tackling recruitment issues in under doctored areas; faster, more convenient and accessible services for local patients and closer working with social care.

  29.  PMS plus (PMS+) pilots provide a wider range of services over and beyond that normally provided through GMS. GPs, community nurses and other professionals can work together as a single integrated clinical team, delivering primary and community health services to provide defined secondary care services within the primary care setting, subject to local agreement and funding.


  30.  The NHS's performance management at national, regional and local level has a key role to play in managing the reduction of the numbers of delayed transfers of care. The 2001-02 Planning and Priorities Guidance made specific reference to what the NHS is required to do and by when to reduce delayed transfers of care. Similarly, the social services performance assessment system ensures councils make their contribution to this shared agenda and provides additional evidence about their performance in this area. Both the NHS and social services Performance Assessment Frameworks include a delayed discharge indicator that is compared with the national target. This has ensured that the issue has been given a high profile, that health and social services are held jointly to account, and already some degree of success is being achieved.

  31.  Moreover, it is envisaged that, from this year, primary care trusts will be measured on how they have performed against one of their key targets "PCTs/HAs must ensure, with acute trusts and social services partners, that people move on from acute settings with the minimum of delay." Poor performance in this area could affect the star rating a trust receives. Similarly, the level of delayed discharge will be taken into account when determining the star ratings received by social services. We believe this too will raise the importance of this issue.

  32.  The Department uses the "Health and Social Service Performance Review" to monitor quarterly progress towards implementing the NHS Plan. The HSSPR contains quarterly information at a national, regional and local level on delayed transfers of care. This information is monitored closely and any variation from plan can be detected quickly so that any remedial action that may be necessary can be taken at an early stage.


Social Care

  33.  Approximately one million people work in the social care sector in England. Of these staff, 80 per cent have no relevant professional qualifications. The largest group amongst professionally qualified staff is qualified social workers. Social care staff work in a wide range of different roles and settings, and in both the private, public and voluntary sectors. Estimates of the proportion of care that is provided by the private and voluntary sectors vary, but may be in the region of 60 per cent. The high proportion of care provided by the private and voluntary sectors is due to an increasing emphasis on local authorities commissioning services rather than providing them directly.

  34.  The Government is aware that there are problems in recruiting social workers and other social care staff and is taking a leading role in working with employers to tackle the problems.

  35.  In March 2001, the Government announced the introduction of a three-year degree level qualification in social work to replace the current two-year Diploma courses. This will be a unique opportunity to transform the status, image and position of social workers and build on the best of social work education and training. The degree level qualification will come into effect in England from September 2003.

  36.  In addition, on 19 October last year, the Secretary of State launched a £1.5 million social work recruitment campaign. The campaign consists of national advertising, leaflets, posters, local and national PR activity, a help line, and a website. It has three main aims, to:

    —  Raise the number of people applying for social work training by 5,000 by 2004.

    —  Inform the public about what social workers actually do; and

    —  Make existing social workers realise that their work is valued.

  The campaign is going very well. The help line has so far received over 14,000 calls, and the website has had over 11,000 visitors.


  37.  The NHS Plan acknowledges that a shortage of human resources is the biggest constraint faced by the NHS today and sets out the Government's commitments to increasing the size of the NHS workforce. By 2004, compared to the number in 1999, there will be:

    —  7,500 more consultants;

    —  20,000 more nurses;

    —  2,000 more general practitioners; and

    —  6,500 more therapists and other health professionals.

  38.  Between September 1999 and September 2000 (figures for 2001 should be available later in February) there were:

    —  1,100 more consultants;

    —  6,300 more nurses (Provisional figures for 2001 published in NHS Emergency Pressures — Making Progress indicate an increase of 10,000 nurses between September 2000 and September 2001.);

    —  126 more GPs; and

    —  1,440 more therapists and other health professions.

  39.  The Government's manifesto before the last election rolled forward the workforce commitments. By 2005, over the 2,000 baseline, there will be 10,000 more doctors (GPs and consultants) and 20,000 more nurses. In the longer term, the increases in training announced in the NHS Plan will provide for sustained growth. The Plan announced increases of:

    —  5,500 more nurses and midwives being trained each year by 2004 than there were in 1999;

    —  4,450 more therapists and other key professional staff being trained by 2004;

    —  1,000 more specialist registrars by 2004;

    —  450 (since increased to 550) more GP registrars by 2004; and

    —  Up to 1,000 more medical school places by 2005 in addition to the 1,100 that had been announced previously.


  40.  The 1999 Health Act Partnership arrangements are tools designed to help break down the barriers between services, removing existing constraints, avoiding duplication, and helping agencies commission and provide services across boundaries more effectively. Pooled budgets, lead commissioning and integrated provision can all be used to provide integrated services for older people, intermediate care, child and adolescent health, nursing home places, learning disabilities, mental health and equipment, as well as interim care arrangements for winter pressures.

  41.  The Department has so far been notified of 64 Partnership arrangements to date, amounting to over £800 million. They also form the basis for the development of Care Trusts, as set out in the NHS Plan and the Health and Social Care Act, 2001.


  42.  Care Trusts will be able to commission and/or provide for all health-related local authority functions, including some aspects of housing and education, from a single organisation. They will be statutory NHS bodies, established by an application from both partners made to the Secretary of State, and jointly governed by representatives from the NHS and local government. Care Trusts form one option for taking forward the Government's proposals for making the NHS a patient-centred service, with a single strategic approach applied across health and social care to the management of the care of individuals. Previous arrangements had allowed for integrated services but not a single organisational model.

  43.  By joining together teams and resources, Care Trusts will provide a more responsive service, with a "one stop shop" approach. On the workforce side, joint planning and budgeting will allow a more efficient use of resources, cross-fertilisation of ideas and skills, integrated training, and a more rewarding working environment. The client groups to be covered will be determined locally, though Care Trusts are likely to focus on mental health services and older people's services, as these groups tend to use a complex combination of health and social services, and will often need a co-ordinated care pathway, for example, following discharge from hospital.

  44.  15 sites are working to develop Care Trust proposals locally, of which six will be based on an NHS trust model and nine on a Primary Care Trust (PCT) model. The first Care Trusts should be set up and functioning between April 2002 and April 2003.


  45.  Following this initiative, the NHS is undergoing a radical structural change with the aim of creating a culture that empowers frontline staff and patients. The structural changes develop and extend the role of PCTs, create fewer, larger strategic health authorities and refocus the role of the Department of Health.

  46.  By April 2002, responsibility for providing primary and community health services to their populations, and securing the provision of acute and specialised services, will have transferred to PCTs. By 2004, PCTs will be controlling over 75 per cent of NHS funding. PCTs will:

    —  be led by clinicians and local people;

    —  be the most local NHS organisation;

    —  be the cornerstone of the NHS;

    —  involve local people in decisions that affect their local health services;

    —  pass more power to frontline staff;

    —  be responsible for health improvement and commissioning services to meet needs of local community;

    —  build partnerships—including with local authorities, Strategic Health Authorities & NHS Trusts.

  Their main functions will be:

    —  assessing the health needs of the community and preparing plans for health improvement;

    —  strengthening the public health function in support of needs assessment and for surveillance;

    —  community development, health promotion and education and occupational health services;

    —  to work as part of Local Strategic Partnerships to ensure co-ordination of planning and community engagement;

    —  responsibility for securing the provision of a full range of services for their local population;

    —  responsibility for all family health service practitioners;

    —  responsibility for management, development and integration of all primary care services;

    —  the integration of health and social care working with local authorities.

  47.  Discharge planning needs to commence before planned admission or immediately upon admission. Where actual or perceived multiple health and social care needs exist, it is essential that there is an integrated approach to the assessment, planning and delivery processes. It is PCT's who have responsibility for integrating health and social care and will also use Health Act flexibilities to pool resources where appropriate.

  48.  PCT's also have responsibility for assessing the health needs of their local population and securing services based on those needs. Part of this process will focus on analysing current care pathways and health outcomes. Where closer integration and joint working between primary, secondary care and social services is required, services will be redesigned and commissioned accordingly.

  49.  PCT's have responsibilities for addressing inequalities and securing access to consistently high quality rehabilitation and intermediate care services will continue to be a priority for them.

  50.  The nursing strategy, "Making a Difference," highlights how nurses within primary and secondary care can strengthen their contribution towards meeting local health and health care needs. In partnership with other disciplines they are developing new roles and ways of working centred on the patient and their individual needs. Models of intermediate care and "hospital at home" are demonstrating that unnecessary hospital admissions can be prevented and discharges planned in a timely and integrated way.


  51.  The Government is committed to helping everyone enjoy more years of healthy active life, as set out in the Saving Lives: Our Healthier Nation White Paper and The NHS Plan. This includes those who live with chronic medical conditions. An Expert Patients Task Force was set up in late 1999 under the Chief Medical Officer to design a new programme that would bring together the valuable work of patient and clinical organisations in developing self-management initiatives. These have been shown to improve outcomes in chronic illness. The outcome of this work and the recommendations are set out in a report — The Expert Patient — A New Approach to Chronic Disease Management for the 21st Century — published on 14th September. This heralds the Expert Patients Programme that between 2001 to 2007 will provide self-management training through the mainstream NHS.

  52.  Approximately 17.5 million adults in Great Britain live with a chronic disease and older people are particularly affected: up to three-quarters of over-75 year olds. The Expert Patients Programme will:

    —  build on the expertise of the world leader in this field, Professor Kate Lorig of Stanford University, California;

    —  draw on the expertise of patients' organisations in the United Kingdom;

    —  be mainly user-led;

    —  be integral to all local NHS Services through PCTs;

    —  involve partnership between NHS and patient organisations;

    —  be piloted from 2002-04; and

    —  be mainstreamed in the NHS between 2004-07.


  53.  The Department's Information Management and Technology Strategy is supporting the availability of shared Electronic Health Records to assist the continuity of care across different health sectors both in terms of agreed care pathways, and through access to individual patient records.

  54.  Telemedicine was part of the vision of the NHS Plan, and formed part of the Government's Information Management and Technology Strategy for the NHS, Information for Health, and its update Building the Information Core. In response to those documents, local health communities were required to produce local implementation strategies describing their plans for delivering the NHS Plan vision. This of course included statements on their plans for telemedicine, and earlier in 2001 local strategies were reviewed. There is, at present, very considerable variation, depending on the resources, priorities and imagination of local health communities, but broadly speaking it was encouraging to see that there was a generally fairly positive attitude and recognition of the potential for telemedicine.

  55.  Telemedicine is one of the components of the Electronic Patient Record (EPR) programme, which forms a core element of the strategy, and a number of sites are looking at ways of integrating telemedicine into their EPR development. The Department is also funding a number of Information and Communication Technologies demonstrators that include telemedicine projects. Reports on the results of these are due in March of 2002, which will be a good moment to take stock. There is also the work on pathology modernisation going forward, and again, a number of projects include telemedicine aspects.

  56.  In conjunction with the British Library the Department has set up the Telemedicine Information Service ( to act as a repository for NHS telemedicine initiatives. We will be reviewing this to see how effective it is, and how we can make better use of it to help NHS managers and clinicians better aware of what can be achieved.

  57.  A key issue with telemedicine and telecare is not the technology, which is in fact relatively straightforward, but the implications for clinical practice and the organisation of workflow processes to deliver healthcare. Re-engineering of health care services needs to be the focus for change, rather than telemedicine as such.

  58.  While many of the current Telemedicine projects are about links between health care establishments (eg Minor Injuries Unit connected to A&E specialist centre), there are also many potential applications for home monitoring, which should make it easier for patients to be at home rather than in hospital.

  59.  Although not often considered as being telemedicine or telecare applications, the highly successful NHS Direct and NHS Direct Online programmes are good examples of using information technology to deliver healthcare and health information which use the existing communications infrastructure. Their greatest impact has been in the way citizens and patients interact with the service. Major strategic projects such as EPR and Direct Bookings (both of which have telemedicine aspects) are also drivers for looking at the business processes within the NHS and developing the NHS telecommunications infrastructure.

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