Project: London is a clinic of Medecins Du Monde (UK) which aims to support migrants that need help accessing healthcare.  It has just  published its second annual report the Project: London report and recommendations 2007: Improving access to healthcare for the community’s most vulnerable.

The report finds no evidence of health tourism, with patients had been in the UK for an average of 3 years before accessing care from Project: London. Migrants are no more likely to have expensive, complicated medical needs than anyone else. It also identifies difficulties for pregnant women in accessing proper care. Although they were entitled, nearly 70% of the women had no access to care, a situation which puts both mother and child in jeopardy, and must be addressed as a matter of urgency.

Proposed changes to NHS access for migrants are unlikely to be cost effective because:

• Lack of GP access means no chance of preventing diseases
• Lack of GP access means no chance of early and affordable treatment of diseases – including those which are contagious
• Lack of GP access is likely to lead to increased pressure on already burdened A&E department.

Regeneration in European cities: Making connections is a study of successful urban regeneration schemes in mainland Europe to draw lessons for the UK from the Joseph Rowntree Foundation.

It compares regeneration at Norra Alvstranden in Gothenburg; Kop van Zuid in Rotterdam; and Roubaix in Metropolitan Lille making comparisons with similar places in the UK (Gateshead, North Southwark, and Bradford).

An extensive literature review identifies where the UK might learn from Europe. Each case study:

• sets the context;
• assesses actions and achievements;
• looks at benefits for vulnerable groups;
• sets out the main elements of the scheme;
• includes reactions from UK partners; and
• outlines implications for UK policy.

Each year, the Government decides how much to raise benefits and tax allowances. The basis for these upratings is rarely debated, yet has major long-term consequences for the relative living standards of different groups and for public finances. The impact of benefit and tax uprating on incomes and poverty from the Joseph Rowntree Foundation considers the implications of present uprating policies, which mean that some parts of the tax and benefit system are uprated by earnings growth, other parts by prices and some not at all.

The impact of continuance of these polices over the newxt 20 years will be a doubling of the child poverty rate alongside a substantial gain to the public finances. Some of this budgetary gain may be needed to meet other demands – of an ageing population for example – but the cost falls disproportionately onto poorer groups and could be raised more fairly.

New statistics from the NHS Information Centre

• Expenditure on health
• NHS stop smoking statistics
• Hospital outpatient statistics
• Diagnostic waiting times

Individual responsibility for health and self-care are key themes in recent health policy development in England. The King’s Fund have addressed the issue with three papers:

• Paying the Patient: Improving health using financial incentives identifies programmes based on both positive and negative incentives, finds that financial incentives are effective in encouraging people to perform clearly defined, time-limited, simple behavioural tasks, and also in encouraging participation in lifestyle programmes.However, healthier behaviour is not maintained and financial incentives are not effective when the behaviour change required is complex, for example, giving up smoking.
• Low-income Groups and Behaviour Change Interventions: A review of intervention content and effectiveness considers interventions targeted specifically at low-income groups, this paper asks which interventions are effective in getting people to quit smoking, eat healthily and exercise. It reveals that the most frequently used techniques are providing information and encouraging people to set goals, which can be particularly effective at changing behaviour in disadvantaged groups.
• Using Information to Promote Healthy Behaviours looks at the theory and selected evidence of interventions in practice, and what this can tell us about the role of information in behaviour change programmes. Information-based health campaigns are a major part of the government’s health promotion strategy. A £75 million marketing programme has recently been announced to encourage healthy behaviour in children. This paper looks at the theory and selected evidence of interventions in practice, and what this can tell us about the role of information in behaviour change programmes.

Two more papers are due in the Kicking Bad Habits series before a final report is drafted.

Individual Budgets and the interface with health: a discussion paper was commissioned by CSIP as a stand alone piece of work to capture the issues and learning from the Individual Budgets pilot regarding the interface between Individual Budgets and Health. A “think tank” session was organised with key stakeholders from the Cabinet Office, Department of Health, In Control and Individual Budget pilot sites to discuss these emerging issues and any relevant activity.

The Report of the Office of Health Economics Commission on NHS Outcomes, Performance and Productivity identifies that the collection and use of outcomes measures in the NHS is both practical and essential.   In order to do so effectively the report makes the following recommendations:

• Measurement of patient outcomes and use of that information to drive better commissioning of services should be made an explicit element of the Government’s vision of “world class commissioning”.

• Mortality and survival data should be collated and published for all condition/treatment areas at the same time as collection of other outcomes data is initiated. Data on casemix must be collected, so that the crude mortality/survival data can be adjusted for the casemix treated. Confidence intervals should be estimated and reported to permit comparisons to be made over time and between providers.

• For elective surgery, condition-specific measures should be collected beforeand after surgery simultaneously with the generic EQ-5D for all NHS patients undergoing common procedures.

• Measurement of mental health outcomes in secondary care should be reinvigorated with collection of HoNOS data being incentivised in addition to mental health providers being reminded of its mandatory nature as part of the Mental Health Minimum Data Set. Routine collection at annual intervals of the CORE-OM measure for all patients receiving community based mental health services be piloted in a range of NHS Trusts at the earliest practical opportunity in 2008/09.

• Research is required to identify a generic measure of health related quality of life that is suitable for application to mental health patients as well as recipients of other kinds of health care.

• The practicality and value of collecting and using measures of outcomes for COPD patients should be piloted by a range of commissioners and their secondary and primary care providers, commencing in 2008/09. The preferred disease specific measure is either the Chronic Respiratory Disease Questionnaire (CRDQ) or the St George’s Respiratory Questionnaire (SGRQ).

• For colorectal cancer patients, mortality data (1 year and 5 years after diagnosis) should continue to be monitored and assessed as an important but partial measure of health service productivity in this disease area given its relatively high rate of mortality. But at the same time instigation in 2008/09 of pilot programmes of routine use of the EORTC QLQ-CR38 instrument to measure outcomes in colorectal cancer patients simultaneously with the EQ-5D or an SF- series generic measure should be undertaken.

• Collection of data about the wider benefits from health services by addition of questions on patients’ experience of care to the patient questionnaires used to measure health outcomes. Aspects covered should include: access, care co-ordination, autonomy, choice, communication, confidentiality, dignity, quality of amenities and support for carers.Further research is needed into the relative values of the wider benefits referred to in recommendation 8 and by compassion with health outcomes.This should be commissioned during the course of 2008/9.

• Information on wider benefits is already collected in national patient surveys. Building on its ‘customer experience information’ project, the Department of Health should work with its counterparts in Northern Ireland, Scotland and Wales on a UK-wide stock-take of patient surveys in process and planned, and then use this as the basis for discussion with all the interested parties how to co-ordinate those surveys in future.

• After a short period of research to identify the most practical way of collecting such data, including working days lost, measurement of productivity effects should be commenced for patients being treated for mental health problems, diseases of the nervous system and diseases of the musculo-skeletal system should be identified.

• Modification of existing national surveys of a sample of the general population should be investigated as one way of collecting at a general level data relevant to the wider societal impacts of health care interventions, including impacts on carers.

• Health care professional bodies, including the Royal Colleges, should explicitly and actively support the collection and use by their members of patient outcome measures, including the provision of training in their collection and use for both existing and new clinicians.

• Training in understanding and using outcome measures should be provided to NHS commissioner and provider managers.

• Investment should be made in IT and appropriately trained staff to enable user-friendly information collection, collation and analysis of outcome measures.

• The NHS should, commencing as early as possible in 2008/09, pilot, monitor and evaluate explicit incentives to collect, collate, analyse, feedback and use patient outcome measures. Initially at least this would not be extended to rewarding providers for the measured levels of outcomes achieved, although that could be considered once experience with use of outcomes measures has accumulated.

• There should be an expectation that within 5 years (i.e. by the end of 2012/13) routine measures of patient outcomes comprising the impact of an NHS intervention in terms of patient survival, quality of life, and experience of care, are collected for the majority of NHS activity. Within 10 years it should be the exception rather than the rule to find an area of NHS activity that is not assessed and actively managed according to the outcomes achieved.

• The NHS should work with the ONS Centre for the Measurement of Government Activity to ensure that the health outcomes data used by the NHS can also used by ONS in its periodic assessments of NHS productivity and, subsequently, in the National Accounts.

Working for a healthier tomorrow from Working for Health identifies ten key challenges:

• The economic costs of sickness absence and worklessness associated with working age ill-health are over £100 billion a year
• The evidence base supporting the business case for investment in the health and well-being of their employees is inadequately understood by employers
• Lack of appropriate information and advice is the most common barrier to employers investing in the health and well-being of their employees.
• The importance of the physical and mental health of working age people in relation to
  personal, family and social attainment is insufficiently recognised in our society.
• GPs often feel ill-equipped to offer advice to their patients on remaining in or returning to work. Their training has to date not prepared them for this and, therefore, the work-related advice they do give, can be naturally cautious.
• The current sickness certification process focuses on what people cannot do, thereby
  institutionalising the belief that it is inappropriate to be at work unless 100% fit.
• There is insufficient access to support for patients in the early stages of sickness, including those with mental health conditions. GPs have inadequate options for referral and occupational health provision is disproportionately concentrated among a few large employers.
• The scale of the numbers on incapacity benefits represents an historical failure of healthcare and employment support for the workless in Britain.
• Detachment of occupational health from mainstream healthcare undermines holistic patient care.
• Existing departmental structures prevent Government from fully playing its part in meeting the challenges set out in this Review.

It also makes 10 recommendations:

• Government, healthcare professionals, employers, trades unions and all with an interest in the health of the working age population should adopt a new approach to health and work in Britain.
• Government should work with employers and representative bodies to develop a robust model for measuring and reporting on the benefits of employer investment in health and well-being. Employers should use this to report on health and well-being in the board room and company accounts.
• Government should initiate a business-led health and well-being consultancy service,
  offering tailored advice and support and access to occupational health support at a market rate, geared towards small business.
• Government should launch a major drive to promote understanding of the positive
  relationship between health and work among employers, healthcare professionals and the general public.
• GPs and other healthcare professionals should be supported to adapt the advice they provide, where appropriate doing all they can to help people enter, stay in or return to work.
• The paper-based sick note should be replaced with an electronic fit note, switching
  the focus to what people can do and improving communication between employers,
  employees and GPs.
• Government should pilot a new Fit for Work service based on case-managed,
  multidisciplinary support for patients in the early stages of sickness absence, with the aim of making access to work-related health support available to all – no longer the preserve of the few.
• When appropriate models for the Fit for Work service are established, access to the service should be open to those on incapacity benefits and other out-of-work benefits. This should integrate with with employment and skills programmes and Pathways to Work should cover all on incapacity benefits as soon as resources allow.
• An integrated approach to working-age health should be underpinned by: the inclusion of occupational health and vocational rehabilitation within mainstream healthcare.
• The existing cross-Government structure should be strengthened to incorporate the
  relevant functions of those departments whose policies influence the health of Britain’s working age population.
• The existing cross-Government structure should be strengthened to incorporate the
  relevant functions of those departments whose policies influence the health of Britain’s working age population.

Person or place-based policies to tackle disadvantage? Not knowing what works from the Joseph Rowntree Foundation looks at the effectiveness of policies introduced by the Labour government since 1997 to encourage employment, education and reducing income disadvantage, focusing on policies that explicitly take account of people and places.

It finds that person and place-based policies have mostly developed separately and often in isolation from each other. This separation does not reflect the relationships between places and the poverty and disadvantage of people who live in them.

Key findings

• Most policy interventions, whether person or place-targeted, had small, favourable impacts. In the rare cases where information on expenditure was available, costs were generally offset by savings to the Exchequer.
• Both forms of intervention had significant positive impacts on particular aspects of education results and employment. However, it was not possible to determine whether person or place-based policies were better, as they tended to have different objectives that prevented direct comparison.
• Some interventions had negative consequences for the average participant or detrimental effects on some groups of participants.
• It was rarely possible to explain properly how policy interventions worked or why they failed, because the way they were intended to work.
• Evaluators judged policies to have the greatest impact if they delivered individually tailored support to the most disadvantaged people with minimal complexity. The evaluators considered policies successful if they reflected local needs and priorities and were shaped by active engagement with stakeholders, including end users.

Tackling health inequalities: 2007 Status Report on the Programme for Action provides a review of developments against the data since the publication of the Programme for Action in 2003. It considers progress against the Public Service Agreement (PSA) target, the national headline indicators and against government commitments. The report shows:

• Further slight narrowing of the infant mortality gap, little change in the gap in male
  life expectancy and a widening of the gap in female life expectancy since 2003–05.

• An encouraging picture on the cross-government indicators, with long-term progress in reducing child poverty and narrowing inequalities in housing quality, educational
  attainment and uptake of flu vaccinations. Cancer and circulatory (heart) disease
  mortality, child road accident casualties and teenage conceptions show a narrowing of
  inequalities in absolute terms (but not in relative terms); other areas, for example
  smoking, show a general reduction in prevalence but no narrowing of the gap between social groups

• Most departmental commitments set out in the Programme for Action and due for
  delivery by the end of 2006 have been wholly or substantially achieved.

Why the NHS is the sick man of Europe by James Gubb of the think tank CIVITAS argues that market-based reform in the NHS is being crushed by central direction and will fail if this pressure continues. It recognises that the NHS’s ideals of universal and comprehensive health care are admirable, but suggests the delivery mechanism is not.

The report compares the NHS with health systems in countries such as France, Germany, Switzerland and the Netherlands which it states succeed in delivering much higher standards of health care than the NHS for all. The key difference between the NHS and these health systems is that the state is not cast as either the main funder or provider of health care, but effective regulator.

It suggests that rather than a tax based health system, social insurance is fundemental because it ensures the consumer - the patient - controls the purse strings, not the government and the health service is therefore much more responsive.

In each comparator country the following universal principles apply:

• All individuals are obliged to pay into a health insurance plan from a menu of insurers;

• Insurers are obliged to accept all the applicants that choose them;

• The government both defines the mandatory minimum package, and pays for/tops up for those on low incomes or with excessive health risks.

France and Germany achieve this direct from wages, the Netherlands and Switzerland through health premiums supported by subsidies for the less well off and sick.

Hit or Miss - women’s rights report from ActionAid shows that promises made by the world’s governments to tackle poverty are failing to deliver because the basic rights of women in the developing world are being ignored.  The report finds that women and girls formed the majority of the poor and hungry, and, in south Asia, women are getting a shrinking share of income as the economy continues to grow. Ten million more girls than boys miss out on primary school, while African women accounted for 75% of all young people living with HIV/Aids.

Following the the Ministerial Industry Strategy Group’s Longterm leadership strategy  for medicines to encourage joint working between the NHS and pharmaceutical industry it was recommended an interactive toolkit was developed to support this.  The strategy had three main themes

• Improving the relationship between the NHS and industry to support the better use of cost effective medicines
• Supporting the European Commission’s plans to improve the competitiveness of Europe through the High Level Pharmaceutical Forum
• The need to improve the effectiveness of medicines regulation.

The toolkit aims to:

• encourage NHS organisations and staff to consider joint working as a realistic option for the delivery of high-quality healthcare
• provide the necessary information and have easy access to the tools which will help to enter into joint working.

A selection of templates are also available.

The third quarterly report on NHS finance and service performance shows that the NHS is still on course for a £1.8 billion surplus for this financial year, with only seventeen trusts reporting a deficit. This surplus is about two per cent of the overall NHS budget.

In 2001, the Government published the National Sexual Health and HIV Strategy and one of the recommendations is the provision of more comprehensive and integrated sexual health services. One of the commitments in the strategy was to undertake an evaluation of different models of One Stop Shops. 

Evaluation of One-Stop Shop Models of Sexual Health Provision, which has just been published provides valuable findings and information for PCT commissioners and service providers considering an integrated approach as well as those already providing integrated services. 

It finds:

NHS Pay Modernisation: New contracts for general practice services in England (Executive Summary) from the National Audit Office notes that it has contributed to improved recruitment and retention of GPs, with numbers increasing from 26,833 to 30,931 since 2003. However, the contract has cost the Department £1.76 billion more than it originally budgeted for.

In the first two years of the contract, productivity has fallen by an average of 2.5 per cent per year. GPs are working on average seven hours less per week than in 1992, partly because of the removal of the responsibility for out of hours care. While the number of consultations with patients has increased, these are not in proportion with the increase in costs. Primary Care Trusts’ spending on GP services has however now started to level off.
The largest overspend of the contract was due to an underestimation of the amount that GPs would earn from the pay for performance scheme, the Quality Outcomes Framework (QOF). While there is evidence that the QOF has improved consistency in the quality of care, it is too early to say if overall patients’ health has improved as a result.

In 2005-06 the annual average pay of a GP partner was £113,614, an increase of 58 per cent since 2002-03. GPs report, however, that over the last year their pay has stayed the same or decreased. GP partners have taken more profit from the practice as pay while the average salary for GPs they employ increased by only three per cent in the first two years.

The report found that nurses are delivering more practice work leaving GPs to spend more time with more complex cases. The proportion of consultations undertaken by practice nurses increased from 21 per cent to 34 per cent between 1995 and 2006. GPs now spend more time with each patient, an average of around 12 minutes compared to 8 minutes in 2002-03.

The report concludes that Primary Care Trusts have not made use of all the levers in the new contract. Money for new local services has not led to improvements such as increased opening hours and some of the most deprived areas remain under-doctored. Some 40 per cent of GPs believed that aspects of the contract had not helped tackle health inequalities.

The report recommends that the Department develop a strategy for yearly negotiations on the QOF and the QOF should be based more on health outcomes. Primary Care Trusts should provide more services based on local need and review the number and skills of staff employed to commission and performance manage GP services with the aim of improving local commissioning.

A report from the think tank the Taxpayers Alliance suggests the bill for public sector pensions is of growing concern for taxpayers facing huge bills for underfunded and over-generous pensions. In December 2007, the TaxPayers’ Alliance (TPA) revealed that there are almost 3,700 retired civil servants with retirement benefits worth £1 million. In the second paper of our public sector pensions series, they look at the generosity of pension arrangements in the NHS in England and Wales.

In £1 Million NHS pensions using information obtained from the NHS Business Services Authority Pensions Division, TPA researcherscalculate the extent of the taxpayers’ pension commitments. The findings are:

• There are almost 8,500 retired NHS employees (including GPs) in England and Wales with retirement benefits worth £1 million.
• The total value of these retirement benefits is almost £8.5 billion (up to £337 per household)

‘Better Care: Better Lives: Improving outcomes and experiences for children, young people and their families living with life-limiting and life-threatening conditions’ aims to improve the care and support given to children in England with life-limiting or life-threatening condition and their families. The strategy calls on commissioners, service providers, voluntary sector partners – to improve the experiences of young people and their families by:

• improving data sources

• building stronger joint working arrangements

• developing better needs assessments and support regimes

• tackling inequalities

• encouraging the delivery of care in the most appropriate setting.

To access this video you will be required to give some details about yourself to HealthExecTV.

David Stout, Director of PCT Network at the NHS Confederation, shares his vision for World Class Commissioning and its potential to transform health services and drive improvements in health outcomes.

He advises on how Trusts can step-up their current approaches in World Class ways - for example, planning for the longer term needs of the population through more effective public engagement and techniques such as risk stratification.

In particular, Mr Stout defines the role of the NHS Confederation and how they are supporting PCTs in their transition.

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The World Class Commissioning initiative provides a major opportunity for Trusts to transform care services and develop new ways of maximising the value of limited healthcare budgets.

While Trusts wait for the WCC Assurance Framework, there are many ways to start planning the transition to World Class Commissioning. Evidence-based analysis of population requirements, how money has been spent and how other organisations are approaching commissioning is a key starting point.

In this interview, Andrew Beale, Executive Director of Matrix Knowledge Group consultancy, discusses how evidence-based analysis can help Trusts to better understand their current position, population healthcare patterns and to maximise the benefit of their investments within the available resources.