The PA Consulting Group were commissioned to undertake a review of PbR tariffs and how they impact on cancer services, and how they could be best developed to support cancer services. Key findings and priorities within the report were used to inform the Cancer Reform Strategy. A copy of their full report Ensuring PbR supports delivery of effective cancer services has been made available for information purposes. The Department is currently considering the recommendations in the report.

Changing times Sustaining long-term performance against ‘Call Connect’ for NHS ambulance services aims to provide ambulance services with performance improvement tools and best practice examples. Its key purpose is to provide trusts with working solutions that aid sustainable performance improvement against the clock start measurement of ‘Call Connect’, and helps to enhance the delivery of service to patients through improved quality of care.

Visions for care in strategic health authorities is a briefing from the King’s Fund that provides a thematic summary of some of the key features of the nine SHA plans in response to the Darzi Review, for the North West, North East, Yorkshire and the Humber, West Midlands, East Midlands, East of England, South East Coast, South Central and South West.

Themes emerging are identified as:

• Waiting times
• Patient Choice
• Commissioning
• Shifting care from hospitals to community settings
• Primary care and community services
• Long term conditions, care co-ordinators and direct payments
• Centralising care
• Care pathways
• Public health

The next leg of the journey: How do we make High Quality Care for All a reality? is the NHS Institute’s review of the outputs of the Next Stage Review.  It focus’ on the the ‘how’ of executing and delivering the anticipated changes, not on the ‘what’ of the specific proposals. It describes recent evidence and experience in healthcare regarding execution of large scale change, and provides critical recommendations of things to consider as we move on from the current milestone.

High quality care for all: NHS Next Stage Review final report (Executive summary) is the final report of Lord Darzi’s NHS Next Stage Review. It responds to the 10 SHA strategic visions and sets out a vision for an NHS with quality at its heart.

As part of the Next Stage Review, A high quality workforce: NHS Next Stage review considers the future of the NHS workforce. The main findings are in the final report of the review. This document explains in more detail how each of the findings will be taken forward.

Our NHS, our future: the contribution of healthcare scientists provides examples of the potential contribution that scientists can make to the local Next Stage review process, to developing and setting up services within the primary care setting and to ensuring that the quality, service and safety of services are maintained. It fits in with the Modernising Scientific Careers agenda led by the Chief Scientific Officer, is a key work programme within the Department of Health designed to ensure flexibility, sustainability and modern career pathways for healthcare scientists, fit to address the needs of future NHS.

The Report of the National Patient Choice Survey, England - January 2008 gives the final results of around 72,000 responses to the eleventh national patient choice survey commissioned to assess the implementation of choice at PCT level. The series of surveys, monitor patient awareness of choice and recall of having been offered a choice of hospital for their first outpatient appointment. They were designed to provide a national overview of choice and summary results at PCT level and generally have an effective response rate around 30%.

The main findings of the January survey are:

• The percentage of patients recalling being offered a choice of hospital for their first outpatient appointment was 46% in January 2008, compared with 44% in November and 48% in the March 2007 survey
• 43% of patients were aware before they visited their GP that they had a choice of hospitals for their first appointment, up from 41% in November and 29% in the May/June 2006 survey.
• 63% of patients who were aware of choice recalled being offered choice, whereas 34% of those not aware of choice recalled being offered it, compared with 61% and 32% respectively in the November survey.
• 67% of patients were able to go to the hospital they wanted, with a further 23% having no preference and 7% unable to go where they wanted, compared with 65%, 25% and 7% respectively in November 2007.
• 80% of patients were satisfied with how long they had to wait from the time their GP referred them to when they saw the hospital.
• Hospital cleanliness and low infection rates were selected most often (by 76% of patients) as an important factor when choosing a hospital.

Provisional headline findings of the March 2008 survey are:

• 47% of patients recalled being offered a choice of hospital for their first outpatient appointment, compared with 46% in the January survey.
• 43% of patients were aware before they visited their GP that they had a choice of hospitals for their first appointment, up from 42% in January.
• 68% of patients were able to go to the hospital they wanted, with a further 22% having no preference and 7% unable to go where they wanted.

Back on May 21st we wrote about the North West contribution to the Darzi Review Healthier Horizons for the North West. The review has seen each of the nine Strategic Health Authorities (SHAs) publish their visions for better healthcare during May and early June 2008. The vision documents from outside the North West can be found using the following links.

NHS East of England

Towards the best, together: A Clinical Vision for our NHS, now and for the next decade

NHS East Midlands

From Evidence to Excellence - our clinical vision for patient care

NHS South Central

Towards a healthier future: A ten year vision for healthcare across NHS South Central

NHS South East Coast

Healthier people, excellent care: A vision for the South East Coast

NHS South West

The Draft Strategic Framework For Improving Health In The South West 2008/09 To 2010/11

NHS North East

Our vision, our future, Our North East NHS: A strategic vision for transforming health and healthcare services within the North East of England

NHS West Midlands

Investing for Health: Step 2: Delivering our clinical vision for a world-class health service

NHS Yorkshire and Humber

Healthy Ambitions

Report and analysis of the experience of patients in black and minority ethnic groups examines variations in the self-reported views of NHS patients from different ethnic groups across a range of healthcare settings, and the work was undertaken jointly by the Department of Health and the Healthcare Commission. Results include data from the national surveys of patients published by the Healthcare Commission up to and including 2006/07. The key points from the latest release are:

• Results show a range of variations between black and minority ethnic (BME) groups and their white British counterparts. Where differences do exist, most are negative, indicating that BME groups are less likely to report a positive experience. But many areas show no difference and a few show a positive difference.

• Patients from the Asian and Chinese/Other groups were less likely to give positive responses.

• Results for Black patients were more mixed, although slightly less likely to give positive responses compared with the White British group.

• Patients from the White Irish group were more likely to give positive responses compared with the White British baseline, across many questions.

• BME groups tended to be less positive about questions relating to ‘access and waiting’ or to ‘better information and more choice’.

• The largest number of differences were seen in the primary care and outpatient surveys. There were relatively few differences for results in the community mental health survey. This is consistent with previous HCC variations reports.

Public perceptions of privacy and dignity in hospitals is research, conducted by Ipsos MORI, involved 2,000 interviews with members of the public across the country. It was designed to explore perceptions towards privacy and dignity in hospitals, with particular emphasis on the importance of single-sex accommodation. Key findings are that cleanliness and staff attitudes are the most important factors for patients to feel they are treated with privacy and dignity in hospital.

The NHS Next Stage Review has been led locally by clinicians in each NHS region. Seventy-four local clinical working groups, made up of some 2000 clinicians, have been looking at the clinical evidence and engaging with their local communities. They have developed improved models of care for their regions to ensure that the NHS is up to date with the latest clinical developments and is able to meet changing needs and expectations.

NHS Next Stage Review Leading Local Change sets the context for these local visions and the principles which will guide their implementation.

Changing for the Better provides best practice guidance on provide clear guidance for patients, the public and NHS staff on the processes underpinning changes to acute NHS services arising from the NHS Next Stage Review.

New statistics from the NHS Information Centre

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

The National education and competence framework for advanced critical care practitioners describes:

• the role of an advanced critical care practitioner
• how the role should function within the critical care team
• the benefits of introducing the role in clinical practice
• a national framework of education and competence

More than one in four adults admitted to hospitals, care homes or mental health units are suffering from malnutrition, the Nutrition Screening Survey and Audit of Adults on Admission to Hospitals, Care Homes and Mental Health Units has found. Women and the elderly were at greatest risk, says the report from the British Association for Parenteral and Enteral Nutrition (Bapen). More than 11,000 patients were screened for signs of being under-fed and 28 per cent were found to be malnourished.

It recommends:

• Screening should be undertaken in all institutions and repeated at interval according to care setting, using accurate and reliable instruments
• Results of screening should be included in care plans.
• Nutrition advice and nutrition support teams should be routinely available.
• Strategies to detect, prevent, and treat malnutrition should be in place in all care settings, including the community, where most malnutrition originates.

Patients will be able to choose where they are treated from any provider meeting Healthcare Commission standards from 1 April, but Free Choice at the Point of Referral a King’s Fund’s briefing on the latest official data finds the policy has some way to go before it is likely to drive improvements in the quality of hospital services.

One of the ambitions of free choice is to create incentives for hospitals to drive up quality standards as they compete for patients, but official data shows that:

• use of ‘Choose and Book’ — the computer system designed to facilitate choice — whilst increasing still falls short of the government’s target, with only 50 per cent of referrals from GP to hospital being made using the system
• although increasing numbers of patients say they remember being offered a choice of hospital by their GP since the policy began in 2006, the proportion is still only 45 per cent
• of those 45 per cent, only 27 per cent said their GP gave them a booklet containing comparative information on hospital performance to help them make a decision.

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.

Trends in children and young people’s care - Emergency admission statistics 1996-2006 for children and young people aged 0 -19 years over the period 1996/97 to 2006/07,  including information on trends for:

• different age groups
• selected consultant specialties most likely to be involved in the care of children and young people
• emergency admission methods
• length of stay in hospital

Extensively discussed in the mass media Choice at referral: guidance framework for 2008/9  provides best practice guidance and information for referrers, providers and commissioners on how the roll-out of free choice in elective care in 2008/9 will operate.  It is supplemented by the Impact of Free Choice policy in Choose and Book R4.0.

Research  from the  National Institute of Health Research presenting the organisational characteristics shared by emergency departments by identifying three factors that are strongly associated with shorter waiting times, Organisational factors that influence waiting times in emergency departments (summary) identifies the following key findings:

• Waiting times are a key performance target for emergency departments, with all hospitals aiming to treat and either admit, discharge or transfer people within four hours of arrival.

• Two significant factors that influence waiting times are the size of the department and the seriousness of cases entering the department.

• Three other important factors which are associated with shorter waiting times are:
  • lower levels of sickness absence among nursing staff
  • lower expenditure on non-pay items (such as medical equipment, clinical investigations and processes)
  • a more participative leadership style by the lead consultant.

• Together these five factors account for more than a third of the variation in average waiting times between emergency departments. However, more research is needed to establish ‘cause and effect’ – i.e. whether these factors are responsible for lower waiting times or vice versa.

• Practitioners cite a range of working practices which they believe improve waiting times, such as more co-operative working within the emergency department and better co-ordination with primary and secondary care services. A participative leadership style may help promote such working practices.

• While waiting times have an impact on patient satisfaction, it is important also to understand and address the other factors that influence quality of patient care.

The Right Result? Payment by Results 2003-07 details how Payment by Results (PbR), has been embedded across the NHS and has helped hospitals to be more business-like.  It should start to deliver the significant increases in productivity and efficiency across the NHS that the policy was designed to achieve.The PbR policy was introduced by the government four years ago and is a system of paying hospitals nationally set prices for the number of patients and types of conditions they treat. It is designed to encourage hospitals to treat more patients, more efficiently without compromising quality of care.

This Audit Commission report finds that under PbR most hospitals have improved their financial management and now have a better understanding of how much it costs them to treat patients. The impact on the NHS in terms of efficiency and activity has been smaller than expected, however, and PbR seems to have contributed to positive trends rather than driven them.

The report sets out a number of priorities for future development of the policy that need to be addressed if PbR is to deliver further improvements:

For Primary Care Trusts

• Further develop commercial, legal and contracting skills, identifying gaps in line with the developing World Class Commissioning competencies, to improve their ability to operate in the PbR environment.

• Ensure that 2008/09 contracts contain appropriate incentives and penalties to support appropriate, high quality care, for example, readmissions targets, and that information requirements are clearly specified and enforceable. Progress against these targets should be reported regularly.

• Adopt a robust yet proportionate approach to monitoring and challenging provider activity and costs under contract, prioritising investment in practice level information systems so that practices can engage in the planning and monitoring of hospital activity.

• Actively monitor provider actions in response to the Audit Commission’s PbR data assurance audits, and use the findings from these audits to supplement existing information on potential data quality issues.

For Acute NHS Trusts

• Ensure that robust information and reporting systems are in place that meet all internal and external requirements within the minimum reporting deadline of 30 days following the end of the month, and that local information systems are in place to complement SUS as necessary.

• Embed and promote service-line management and reporting, paying particular attention to the use of surpluses and how this will be managed within the organisation.

• Understand the costing data they require to manage the business, and invest in improving internal costing systems, considering the business case for introducing patient level costing systems where appropriate.

• Prioritise the implementation of the OPCS-4.4 classification system for procedures, to improve coding internally and to support the introduction of HRG4.

• Engage in discussions with commissioners about changing patient pathways, demand management and use of local flexibilities, such as unbundling the tariff into its component parts.

For the Department of Health

• Identify and explicitly prioritise the changes that will be most effective in achieving policy objectives, and ensure that the development programme for addressing these priorities is realistic, properly resourced and communicated to stakeholders.

• Ensure that timely guidance, support and direction continues to be provided to both commissioners and providers in a balanced way, including more effective mechanisms for receiving and providing feedback, particularly in relation to contract and information issues.

• Review and address the perceived limitations of SUS in supporting PbR, ensuring there is a clear vision for NHS data and organisations’ responsibilities that is shared by NHS Connecting for Health and the Information Centre for Health and Social Care, and that the expectations of the NHS are consistent with this vision. Additional steps should be taken to ensure that guidance from these bodies is consistent.

• Invest in information systems to capture and report on community services and support the development of an appropriate payment mechanism.

• Monitor usage of the new standard contract and reinforce the move toward a consistent approach to contracting across the NHS, providing guidance as appropriate to ensure that balanced, fair contracts, that support nationally agreed principles, are negotiated.

• Use the tariff as a policy lever to drive desired behaviours, rather than purely as a reflection of average costs, signalling likely changes to the NHS well in advance.

• Explore the use of separate payment streams in addition to the tariff, for example to reward quality or to fund capital costs, where this is necessary to provide the right incentives to NHS bodies.

• Carefully monitor the implementation of HRG4 to ensure that the additional complexity of the payment classification is warranted and is not undermining policy objectives.

From the Confederation of British Industry (CBI) comes ISTCs and the NHS: Sticking plaster or real reform.   The report emphasises the advantages of plurality of choice, benefits of contestability, enhanced infection control, and user satisfaction.  It also expresses concerns about the apparent withdrawal from further use and development of Independent Sector Treatment Centres on the  part of the government.  It makes the following 6 recommendations:

• Mechanisms of patient choice should be improved with information provided to patients directly
• GPs and PCT commissioners should be incentivised to refer patients to ISTCs
• Opportunities to co-operate should be explored by both NHS and ISTC providers and piloted
• Independent decisions on the NHS tariff and the NHS funding formula should be made
• Patients must be allowed to choose any accredited provider that meets NHS tariff costs
• The market should be regulated in an independent and transparent way.

Delivering Quality and Value: Consultant Clinical Activity 2005-06: Activity rates of consultants in five surgical and five medical specialties is a tool to enable acute trusts to benchmark consultant clinical activity in 10 specialties. Charts have been sent to individual trusts with the data for their own consultants. The methodology used this year is the same as previously and uses the methodology outlined in York University’s report: Measuring productivity of hospital consultants using hospital episode statistics in England (Executive Summary). This exercise will be repeated using HES data for 2006-07 and 2007-08.

Mental Health Act Commission Twelfth Biennial Report - Risk, Rights, Recovery finds that there are severe funding issues faced by providers of mental health services in that:

• Patients deemed to be a threat to themselves or others are being denied hospital beds while commissioners disagree with regard to funding.

• The Mental Health Act Commission has found practitioners are being told to delay sectioning people with urgent mental health needs until primary care trusts ascertain who should pay for their treatment.

• The problem is caused by high bed occupancy levels and the need for PCTs to balance budgets.

• This has encouraged PCTs not to detain patients who have travelled from other areas until the home PCT has agreed to pay.

Thse practices are unsuprisingly condemned in this report.

Mental Health Act Commission Eleventh Biennial Report (In Place Of Fear) questions whether all inpatient mental health services provide their patients with acceptable levels of security, care, or a sense of being treated as  someone who matters. It welcome the Government’s announced refocus on inpatient services and call for it to concentrate on building up these aspects, in place of the fear that many patients have of services and that many people have of mentally disordered people.  The importance of breaking such ‘circles of fear’ for Black and minority ethnic patients are particularly welcomed.

There is evidence that inpatient services are losing staff and resources to community
services, but that pressures on inpatient beds remain high. Over half of all wards are full or have more patients than beds, with staffing shortages and unpleasant ward environments undermining the therapeutic purpose of inpatient admission.

The report highlights the dangers inherent in devolved service commissioning for ensuring adequate levels of specialist provision, and note the vulnerability of mental health services as Trusts face financial crises.

The extension of patient ‘choice’ across health service provision should not be allowed further to disadvantage or ostracise patients who are unable to exercise choice because of their mental incapacity or because of legal powers of compulsion held over
their treatment.

Boundaries of current mental health law under stress, with discussion of about forty cases
in court, and a more general observation of legal powers being used in ways that may not have been intended by Parliament, often for pragmatic reasons where professionals are keen to intervene in what they perceive to be a person’s best interest or as measures of social order.

It also discusses aspects of the use of present mental health powers in relation to civil detention and police powers, including an extended discussion on the detention of mentally disordered offenders.We provide analysis of deaths of detained patients; seclusion incidents notified to the Commission; and Second Opinion activity during this period.

The report has a strong focus on measures to encourage and support the empowerment of all patients, including those without mental capacity to make certain decisions about their care.

It finally reviews the proposed future arrangements for monitoring detention of mentally disordered persons and suggest ways in which the forthcoming Mental Health Bill might be improved to ensure acceptability to mentally disordered persons and the effective protection of their rights.

Mental Health Act Commission Eleventh Biennial Report - Errata and Addendum

Summary of responses to the  ‘Options for the Future of Payment by Results: 2008/09 – 2010/11′ consultation put forward proposals for future developments in PbR including tariff setting, coding and classification, expanding the scope of PbR, and supporting health policies through financial reform.