Ambitious and charming, Lucy Camilla Siddiqi made an immediate impression on David Blunkett when they met at a dinner party hosted by a mutual friend last year.

Mr Blunkett, still Home Secretary at the time, must also have been intrigued at Mrs Siddiqi’s job as the director of a firm offering DNA tests for a fee. Today his relationship with that firm, DNA Bioscience, is at the centre of a growing controversy that could force him from the Cabinet for a second time in a year.

Now Secretary of State for Work and Pensions, Mr Blunkett already has reason to rue the friendship he forged with Lucy Siddiqi and her husband, Tariq, that night. The Surbiton couple introduced him to Sally Anderson, a 29-year-old estate agent at Annabel’s nightclub in Mayfair.

Ms Anderson dated the minister over the summer, then sold her account of their time together for a reported £50,000 this autumn. At first it seemed the story, while embarrassing, was mainly personal. But Mr Blunkett’s relationship with Lucy Siddiqi and the firm of which she is a director proved to be the more damaging.

Mr Blunkett knows better than most how marketable DNA testing will become, having fought and won an access battle to see a son, William Quinn, he had had to prove was his. Indeed, the firm was founded by a man, like Mr Blunkett, desperate to establish the paternity of a child born to a former partner.

Avi Lasarow, a South African, set up DNA Bioscience because he was frustrated trying to find affordable paternity tests. The firm, nominated this week for a prestigious business award, employs a small team in offices near St Paul’s, London.

Sometime in the first few months of the year, the firm hit on the idea of asking Mr Blunkett to join it as a non-executive director. Sources close to the firm say there was never any intention to use the former home secretary to win influence over government contracts. They hoped Mr
Blunkett’s presence would appeal to lawyers, the bulk of the firm’s clients.

Mr Blunkett took up the job with DNA Bioscience on 21 April of this year and was pictured posing with Lucy Siddiqi and other members of the firm.

Then on 6 May, just a day after Labour’s general election victory, the Sheffield MP resigned his post when he was made Secretary of State for

But DNA Bioscience’s motives for wanting Mr Blunkett are less interesting than his reasons for wanting to join the company. Perhaps the most curious aspect of the appointment is its timing in April 2005. For months it had been common knowledge that Tony Blair intended to call a poll in May and bring Mr Blunkett back to the Cabinet if Labour won re-election.

So why did Mr Blunkett take the post with DNA Bioscience when he knew that, in all likelihood, he would have to resign almost immediately?

Other questions have been raised. How did Mr Blunkett come to possess a 3 per cent share in the company? And doesn’t it constitute a clear conflict of interest, given his present position as a cabinet minister?

That was brought into question after Ms Anderson sold her story. She claims Mr Blunkett often talked about the business with the Siddiqis during evenings they spent together at Annabel’s.

“They were quite open about discussing the business of the DNA company and what David could do for them,” she has been reported as saying. “I didn’t pay much attention to much of it because it was so boring.

“Some weeks later, David told me he had made a number of important introductions for Tariq which had greatly boosted the business. I could tell this was the case because David was always going on about all the favours Tariq owed him. At one point he even offered to get Tariq to buy me a house, saying, ‘Tariq will do it; he has lots of money and he owes me big time’.”

But Mr Blunkett’s friends will point out that Ms Anderson was paid to tell her story and, in any case, has failed to provide evidence of any wrongdoing. Yet her testimony has been used to paint a picture of a former minister’s deepening interest in the business.

DNA Bioscience, through a partner firm, DNA Diagnostic Centre, performs tests in court custody cases for the Department for Constitutional Affairs.

The firm has also been granted “preferred bidder” status by the Child Support Agency, a body for which Mr Blunkett is now responsible.

So far, he has been able to reject demands for an inquiry, claiming that he scrupulously followed the rules. He says he told the most senior civil servant in his department about his shares and included them in the register of MPs’ interests.

The stake, on which he is reported to have made a paper profit of £280,000 after a stock market float in the new year, is being held in trust for his sons. But, crucially, his denials of wrongdoing have related only to his shareholding in the firm. And Mr Blunkett broke anti-sleaze rules just by taking up the appointment as a director without seeking clearance from the relevant watchdog.

He ignored Section 5.29 of the rules of the Ministerial Code (A Code of Ethics and Procedural Guidance for Ministers). Published by John Major in the early 1990s, the rules were tightened after growing fears at the speed with which former Conservative ministers were taking lucrative public sector jobs. Lord Wakeham, for example, became of director of NM Rothschilds merchant bank six months after he left Cabinet despite having awarded it a multimillion-pound contract when he was energy minister.

To deal with potential abuse, Lord Nolan’s report on standards recommended creating the Advisory Committee on Business Appointments to regulate the flow of former ministers and civil servants taking jobs in the private sector. Now the independent watchdog approves most
appointments but occasionally suggests former ministers delay starting work to ensure they could not be accused of improper behaviour.

The committee’s advice is voluntary but the need to seek it is not. This is explicitly stated in Section 5.29: “On leaving office, ministers should seek advice from the independent Advisory Committee on Business Appointments about any appointments they wish to take up within two years of leaving office.”

The code sets out that while it is in the public interest that former ministers should be able to move into business life, “it is equally important there should be no cause for any suspicion of impropriety about a particular appointment”.

As we report today, Mr Blunkett, deliberately or inadvertently, overlooked Section 5.29. Tony Nichols, the clerk to the committee told The Independent on Sunday: “David Blunkett did not seek the committee’s advice about DNA Bioscience.” Lord Maclennan, who is on the seven- member committee, also confirmed Mr Blunkett’s failure to consult. “It is advisable that former ministers should seek our advice,” he added.

A source close to the committee said: “Given all Mr Blunkett had been through with an official inquiry into his conduct as a minister leading to his resignation, it is extraordinary that he was not punctilious in following the rules subsequently.”

Mr Blunkett is believed to be the first minister to have failed to seek the committee’s advice since it was set up 10 years ago. That failure is all the more extraordinary given that he had been explicitly reminded of the rules by the committee’s chairman, Lord Mayhew, just a month before he took up his position on the board of DNA Bioscience.

Correspondence obtained by The Independent on Sunday shows Mr Blunkett was reminded about the rules on 21 December 2004. Lord Mayhew restated the guidelines on 2 March 2005 after Mr Blunkett had started working for a lobbying firm, Indepen.

Mr Blunkett wrote back to Lord Mayhew on 3 March 2005 insisting his failure to register the appointment had been a “misunderstanding”. He added: “It was my belief that I should seek your advice if I had any doubt about the nature of the employment and its connection with my role as a government minister.

“My apologies for not realising that, on a voluntary basis, I should have consulted you, irrespective of this.”

Yet a month later, Mr Blunkett became a non-executive director of a firm bidding for government work but, for the second time and despite warnings, failed to abide by a key tenet of the Ministerial Code. Unless Mr Blunkett can offer a convincing explanation of why he ignored the rules, the Prime Minister may struggle to save his friend for a second time in 12 months.

The exposure of Mr Blunkett’s failure to abide by the rules brought condemnation from the Tories. Chris Grayling, the shadow Leader of the House, said: “There now needs to be an urgent inquiry into Mr Blunkett’s conduct in relation to his business interests. There are just too many questions gone unanswered for it not to be looked at properly.

“Mr Blunkett’s position is now increasingly untenable. I really don’t see how he can carry on as a cabinet minister given all that’s gone on in recent days.”

Mr Grayling has written to both the Cabinet Secretary, Sir Gus O’Donnell, and the Prime Minister, demanding they investigate the breach.

Mr Blair faces particularly acute embarrassment over the affair since he is the final arbiter of how the Ministerial Code is to be applied. If he treats Mr Blunkett leniently it will fuel demands for immediate reform of the rules on sleaze.

Sir Alistair Graham, the chairman of the Committee on Standards in Public Life, has already voiced irritation with Downing Street for failing to make a promised change to the rules that would mean alleged breaches would be investigated by an independent body.

http://news.independent.co.uk/uk/politics/article323345.ece

If PFI was to be retained “it needs to be updated”, said Sylvia Wyatt, project manager for the confederation’s Future Healthcare Network. That could involve shorter contracts that would turn out more expensive as capital was amortised over a shorter period.

Alternatively, approaches closer to Lift, the programme in which the National Health Service has launched joint ventures with the private sector to rebuild primary care and community premises, could be tried.

Under these long-term partnerships, buildings for which there is an immediate need are constructed or refurbished, with others added as the need arises.

The survey showed trusts felt they had benefited from PFI but the negotiating process was costly, bureaucratic and time-consuming and rarely produced good design, while the resulting contracts were too rigid, she said.

Growing numbers were having to be recast in the course of the deal or altered within 18 months or two years of being completed, both of which were costly.

“The big bang solutions don’t work very well. It’s bad enough trying to predict what the price of fuel will be in 30 years let alone what healthcare will look like.

“The model is 10 years old, and PFI hospitals were built on the assumption healthcare was going to be broadly the same for the next 30 years,” she said. With money set to follow the patient, patient choice, and more care being shifted to specialist treatment centres and primary care “that is not now the case”.

The criticisms follow warnings from senior health department officials that the NHS was building PFI “monuments” when more flexible buildings are needed.

The private sector was also getting disillusioned, Ms Wyatt said. In the late 1990s there were frequently six bidders to a project. In a number of Scottish cases, and at Whipps Cross in London and Plymouth in Devon there had been only one.

“There is a very real risk that private contractors could walk away from both individual PFI schemes and from major PFI healthcare developments unless the current process is streamlined to reduce the cost, both financially and in terms of time,” she said.

http://news.ft.com/cms/s/7bd51674-4819-11da-a949-00000e2511c8.html

As vets investigated how H5N1 influenza came to infect a parrot from South America, which is unaffected by this strain, the European Union, the world’s biggest importer of wildfowl, said it was ready to propose a temporary ban on imports.

The H5N1 virus – which has only so far infected those working closely with infected birds – can be lethal and of 120 confirmed cases, around 60 people in south-east Asia have died. Experts fear that a mutation of the H5N1 strain or a blend with a human flu could create a pandemic.

On Sunday, the Government announced that its “working hypothesis” was that a Surinam parrot in the Essex facility was infected with H5N1 by one of a second batch of birds from Taiwan.

However, Taiwan has not reported any domestic cases of H5N1. “The British authorities do not have solid evidence,” said Yeh Ying, deputy director of Taiwan’s Bureau of Animal and Plant Health Inspection and Quarantine, adding that speculation was “very dangerous and irresponsible”.

Bird flu factfile

And a Government vet admitted yesterday that he could not rule out the possibility that the facility, run by a commercial bird importer, had become contaminated by an earlier import. One or more birds in an earlier batch could have had a “subclinical” infection, so the birds appeared free of disease. However, as a result of the stress of quarantine, they could have excreted virus.

The facility is supposed to be disinfected or fumigated between batches but it is possible that contaminated droppings remained to crumble and release airborne virus that could have infected subsequent batches of birds from Taiwan and South America. “That is a possibility. All that is being investigated,” said the vet.

The Department for Environment, Food and Rural Affairs is checking a consignment of birds that arrived “some time ago” to trace how the infection became established.

“We are looking at what went into the quarantine before,” the vet said. “We are carefully checking our facts and cross-checking them. It is quite complicated because we are being faced with some conflicting reports.”

If an earlier batch had been contaminated, the Government vet said he would have expected other cases of bird flu to have become apparent by now, given the three- to five-day incubation period.

“We have absolutely no evidence that the quarantine period has failed,” he stressed, adding that “sentinel birds” – British hens susceptible to the virus kept in the quarantine facility – had not shown signs of avian influenza.

The chief vet, Debby Reynolds, has admitted that some of the Taiwanese birds had died in quarantine before Oct 16 and yet they were only now being tested. “There are quite a number of unanswered questions,” she added.

Yesterday, another senior Government vet said there was confusion about when samples from the birds were submitted for testing, which birds died and when they died. When asked why the Taiwanese birds were not tested when they died, he said: “I don’t know.”

http://telegraph.co.uk/health/main.jhtml?xml=/health/2005/10/25/nflu25.xml&sSheet;=/health/2005/10/26/ixhmain.html

Total numbers of permanent staff fell from 3,600 to 2,245 during the period.

Now the union – which is collecting anecdotal evidence that temps are being used to ‘plug gaps all over the place’ – is preparing parliamentary questions on the topic for health secretary Patricia Hewitt.

PCS DoH London branch chair Malo Harvey told HSJ that the number of temps has been rising since the cuts to permanent staff took effect last year.

He said the original explanation from the DoH was that numbers had been increased in the short term ‘to ease the transition’, but he said current evidence suggested temporary staff were ‘plugging gaps all over the place’.

A headcount by the union in the DoH’s New Kings Beam House in south-east London found 188 out of 500 staff – 38 per cent – were not on permanent contracts.

‘There are huge swathes where it’s full of consultants and temps,’ Mr Harvey added.

The union said its attempts to get accurate details from the DoH had been thwarted by changes in the structure of the department. ‘Personnel has been devolved into three different teams so official figures are either vague or some way short of our estimation,’ Mr Harvey said. ‘It’s possible that centrally they don’t honestly know.’

The union is preparing to ask Ms Hewitt, through an MP on its parliamentary panel, to provide a complete breakdown by rates and periods of contract of all agency staff, contractors and consultants. It will also ask her what steps the DoH is taking to reduce the number of temporary staff.

In August, in response to a request under the Freedom of Information Act, the DoH told HSJ it did not have ‘accurate figures’ about temporary staffing, but said ‘work is continuing to capture the information’.

The DoH revealed that spending on outside consultants in 2004-05 had risen to £12.8m from £10m the previous year while the staff salary calculated over January to March 2005 was £95.2m, compared with £110.7m in the same period in 2004.

http://www.hsj.co.uk/nav?page=hsj.news.story&resource;=3506946

At the end of November all NHS trusts will have to offer patients the choice to go elsewhere for a MRI or CT scan if they have waited longer than 20 weeks. However, the Department of Health has yet to make a decision on whether this will apply to foundation trusts.

A spokesperson for independent regulator Monitor said foundation trusts would not be expected to meet the target because it was not set down in the DoH’s target framework National Standards, Local Action.

Network chair Sue Slipman criticised the government for ‘undermining’ the strength of the legally binding contracts under which foundation trusts now operate.

She told HSJ: ‘The government can’t keep introducing in-year change and expect foundation trusts to be efficient and effective.’

She warned the DoH that they were ‘undermining the potential success of the system they created’.

Ms Slipman said the constant barrage of new targets set in-year is damaging foundation trusts’ performance and making it difficult for them to carry out business plans.

Last month the DoH issued guidance setting out how, from November, providers should offer alternatives to patients waiting over 20 weeks for CT or MRI scans.

Trusts will also be expected to offer a choice of alternative provider to patients waiting over 16 weeks for all types of scans from April 2006, with a maximum waiting-time target of 20 weeks.

The letter, sent by the DoH’s national implementation director Matthew Kershaw to acute and primary care trust chief executives, urges trusts to offer patients the choice of an Alliance Medical scan.

In July 2004 the government awarded a five-year, £80m contract to the company and secured an extra 130,000 scans per year. But in its first year only half the scans bought, just 65,000, had been used.

However, according to Alliance Medical, the company has now carried out 90,000 operations on behalf of the NHS.

Alliance Medical managing director Jonathan Walsh told HSJ ‘patient throughput is now very high’. He said the company had scanned 8,500 patients in October.

‘It is not our responsibility to find patients,’ said Mr Walsh, but he added that ‘the continuing focus on patients waiting over 20 weeks and the choice target means we are now almost completely full and can’t do any more scans than we are doing’.

A DoH spokesperson said: ‘Discussions are still taking place and the decision will be clarified before choice of scan commences on 30 November.’

http://www.hsj.co.uk/nav?page=hsj.news.story&resource;=3507076

Fewer than half of doctors and 63% of nurses always wash their hands with antiseptic gels between patients, says the report. In some parts of the country only a third of hospitals have cleaners at night.

The findings by the Patients Association, which cover England’s 28 strategic health authorities, will be a blow to Patricia Hewitt, the health secretary, who has made tackling MRSA and other hospital acquired infections a top priority. In May Hewitt announced a code of practice for hospitals to ensure that hygiene standards are met.

Katherine Murphy, director of communications at the association, said: “Washing your hands properly is not complicated. We now have alcohol foams and gels that are very easy to use.

“Another basic step is ensuring that wards are clean, but our report showed that in some hospitals there is no access to cleaners in the evening. This is not acceptable. What happens if there is a blood spillage after 7pm?”

MRSA is now so rife in hospitals that in 22 of the 28 health authorities questioned babies less than one week old have been found with the bug.

The infants could have contracted MRSA from their mothers, from other patients or from doctors and nurses. While most of these babies would have been carrying the bug in their noses or on their skin without it causing harm, they are at risk of it developing into an infection.

Hewitt’s warning to hospital managers followed the Patients Association’s Clean Hospitals Summit in April at which the actress Leslie Ash, star of Men Behaving Badly, criticised the government for failing to keep hospitals clean. Ash fell victim to MSSA, a variant of MRSA.

At the two-day event the association set hospital trusts a “100-day challenge” to improve standards. At the end of August, when the 100 days were up, it carried out an investigation to find out if improvements had been made.

The full results will be published at a follow-up conference in London next month.

The study also showed that hospitals are overcrowded. In 58% of hospitals bed occupancy was in excess of 95% and in 90% of hospitals the rate was above 85%. Government guidelines advise managers that it should be no more than 82%.

MRSA is now so prevalent in wards that babies of less than one week old have been found with the bug in 90% of hospitals. Last week two newborn babies had to be put in isolation at St James’s University Hospital, Leeds after they were found to be carrying the MRSA bug.

In February a two-day-old baby became the youngest victim to die in hospital from MRSA. Luke Day had been born healthy, weighing 7lb 7oz. But he died just 36 hours later at Ipswich hospital in Suffolk. Microbiologists said that a doctor or nurse was the most likely source of the infection.

Last December 14-week-old Connor Bull became one of the youngest known MRSA victims when he caught the infection at Leeds General Infirmary. Claire Wilkinson, his mother, had to scrub down before she could touch him. He fought off the infection after 19 weeks in intensive care.

Mark Enright, an MRSA expert at Imperial College London, expressed his disappointment at the failure of hospitals to take basic measures to improve hygiene.

“If we are not even delivering on improved hand washing and cleaning of hospitals then we are not really doing very much in the fight against MRSA,” he said.

Professor Hugh Pennington, a microbiologist and expert in hospital acquired infection, added: “This confirms that MRSA is a problem that affects babies and young children and not just older people and patients who have had a lot of surgery.”

The Department of Health said: “We expect hospitals to enforce strict standards of hygiene and cleanliness. All National Health Service trusts now have directors of infection control and teams to ensure good practice is followed.”

http://www.timesonline.co.uk/article/0,,2087-1827838,00.html

Key points
* From April 2006, PCTs will be given devolved budgets to commission NHS dental services in an attempt to redress the chronic shortages in some areas.
* Burnley, Pendle and Rossendale PCT has a plan to recruit dentists to the area, including working with Liverpool University dental school.
* Nationally, there are concerns that dental initiatives will get lost in the quagmire of PCT reconfigurations and that the new target-led dental contract will drive many dentists into private practice.

It was almost inevitable that the single biggest shake-up in NHS dental services comes as the health service is undergoing another seismic reshuffle of the organisational furniture.

With around six months to go until primary care trusts in England are given devolved budgets to commission comprehensive NHS dental services, those very PCTs are in the throes of major mergers. With so much on their minds, PCTs may find the rebirth of NHS dentistry in April 2006 a difficult one.

Last month Liberal Democrat health spokesman Steve Webb told his party conference that many dentists were threatening to quit the NHS because of new contracts, which pay on the basis of the number of procedures carried out.

The fears are echoed by the British Dental Association, which says dentists will be put under pressure to carry out as much work as possible to maintain incomes, leaving little time for health promotion.

In July the influential Commons public accounts committee said key milestones had been missed in reforming dentistry – including the planned introduction of a new base contract, which was postponed by six months and was due for publication this month.

However, the final version of the contract is now not expected until January, and there is also a separate active consultation on patient charges. PCTs are currently in discussion with the Department of Health about how much money they each need to be allocated to commission sufficient dental services.

Too much, too soon

The public accounts committee said it was ‘extremely concerned’ that PCTs were required to take over managing new contracting arrangements ‘without ensuring they had the necessary expertise and resources’.

And it is not as if the challenge to make the English mouth a nicer place is going to be easy. Notwithstanding the stereotypical view from across the Atlantic that the UK is a nation beset by bad teeth, a DoH survey in June revealed that nearly a quarter of under-threes had severe decay in their front teeth.

Of these more than half had five or more teeth affected. Coupled with the rising rates of obesity in under 16s, experts fear this marks a reversal in the trend of improvements in youngsters’ oral health in the last 30 years.

But the DoH is claiming major dental victories. The target for 25 per cent of all dental practices to be working under personal dental services – salaried dentists’ contracts – has already been surpassed. Over 30 per cent of dentists are moving to PDS pilots, which means there are now over 6,000 dentists in 2,200 practices working on this basis. The DoH has increased dentistry funding by 19.3 per cent, which equates to £250m over two years.

Dental undergraduate places are to be increased by 25 per cent from this month, creating an extra 170 student places a year.

The DoH is also engaged in a three-month consultation on replacing the current 400-plus dental charges dentists can levy with a system that will divide costs into three bands, ranging from low to high levels of required treatment.

It says the new system – known as the statement of financial entitlements, which will set in stone nationally determined payments for dentists – will be more transparent and easier to use for patients. It will also be more straightforward for receptionists and practice managers, who usually bear the brunt of patients’ billing queries. The department says it will be consulting the BDA on the new pay rates in the next few weeks.

Under the new contract providers will agree to supply a given number of units of dental activity (UDAs) and there will be a formula for calculating how many units each dentist or practice should provide. This formula will be based on the number of courses of treatment they carried out from October 2004 to September this year, less 5 per cent. This reduction represents half of the 10 per cent drop in activity the DoH says is evident across the country as a result of ‘new ways of working’.

Allocating funds

Dentists’ minimum contract values and associated UDAs will be sent to dentists and PCTs by the end of November. Indicative dental budgets for PCTs for 2006-07 will be sent to PCTs for validation in November.

From April 2006 PCTs will have funds directly allocated to them to commission primary dental services to meet local needs – either from dental practices, dental companies or by providing salaried services themselves. The new contracts will be longer-term agreements replacing the open-ended nature of the current arrangements with an agreed level of service.

The challenge for PCTs is managing the change, keeping dentists on board and then setting up the management infrastructure to operate local commissioning – at the same time as they are undergoing painful and potentially destabilising mergers.

Major tasks include ensuring that contractors comply with patients’ charges regulations, compliance with National Institute for Health and Clinical Excellence guidelines, including recall guidelines, setting up in-house complaints systems and putting clinical governance in place.

PCTs are most likely to apply the Healthcare Commission’s framework for clinical governance in dentistry. The framework standards describe the quality healthcare organisations will be expected to meet. They are organised in seven domains designed to cover the full spectrum of healthcare as defined in the Health and Social Care (Community Health and Standards) Act 2003:
* safety;
* clinical and cost effectiveness;
* governance;
* patient focus;
* accessible and responsive care;
* care environment and amenities;
* public health.

It is up to dentists to comply with these requirements, but PCTs are already working with them on clinical governance activities – ensuring significant event audit, adverse incident-reporting and continuing professional development. The clinical governance scheme launched in July in Kent, Surrey and Sussex deanery, which delivers postgraduate dental education in the area, has over 100 practices signed up.

Quality assurance in the new system will be monitored through the dental reference service at the Dental Practice Board. This is the statutory body that administers NHS general dental services and is accountable to the DoH and National Assembly for Wales. The General Dental Council, the equivalent of the General Medical Council, will not be directly involved.

As of August this year, the DoH says it has recruited over 850 of a promised 1,000 new dentists, including some from Poland and India. It has also ‘brought back’ additional capacity from existing dentists.

‘Burnley, Pendle and Rossendale PCT covers the former mill towns of Lancashire, where there are ‘hot spots’ of poor NHS dental coverage but where, for historic reasons, no more than half the population were ever registered with a dentist.

The PCT suffered setbacks last winter when five dentists in two practices decided to opt out of providing NHS care because they were unhappy with the new contract proposals, leaving 7,300 patients without a dentist.

Another blow came when plans to create capacity for 10,000 extra patients in Burnley with premises for six new NHS dentists were rejected by town councillors. Despite planning officers supporting the proposal of private company Independent Dental Holdings, the councillors rejected the plans. They were concerned about the impact on parking and other amenities.

Five-pronged policy

However the PCT has devised a five-pronged dental policy to create nearly 20,000 new dental places within three years.

It focuses on holding onto and expanding existing practices, attracting new dentists and setting up a relationship with Liverpool University dental school so that students are brought into dental surgeries within the PCT to act as assistants. The idea is that young dentists will get practical experience and also realise the area is a nice place in which to live.

The PCT has led the development of dental therapist courses at further education colleges in Blackburn and Lancaster. Once trained, those therapists will be able to carry out minor procedures and provide health promotion advice.

The PCT is also providing guaranteed emergency dental treatment in liaison with NHS Direct. ‘We can guarantee almost immediate access to a dentist in an emergency. It might be that a patient would go to a neighbouring town but access would be pretty quick,’ says a spokesperson.

Dentist and former DoH dental policy adviser Raj Rattan has first-hand experience of the impact of changes when PDS schemes are rolled out.

‘PCTs will need to work closely with local dentists and build relationships based on trust and mutual respect,’ says Mr Rattan. ‘For those dentists who wish to retain their commitment to the NHS, the challenge is one of change management. Dentists will need to decide how they can best serve the interests of their patients and whether the proposed new arrangements will help or hinder them. The time has come for us to think differently. We will not be able to overcome tomorrow’s challenges with yesterday’s mind-set.’

Why dentists aren’t smiling

Lester Ellman, chair of the British Dental Association’s general dental practice committee, doubts whether a comprehensive service can be provided by April 2006. He is sceptical about the government’s claims to be on target to recruit almost 1,000 new dentists. ‘You hear stories about a dozen dentists being recruited from [continental] Europe in one area and being so disappointed with what they saw that they all went home on the next plane,’ he says.

He also says home-grown dentists’ disaffection is not simply a matter of pay comparability with the private sector. ‘It’s the workload they are worried about rather than the pay itself. A recent Inland Revenue study revealed the average pay for a private practice dentist isn’t that much higher than an NHS one. One of the reasons people go into private practice is that they have more time with patients – that’s the luxury they have and that is why people move away from the NHS.’

He adds: ‘The BDA is in talks with the DoH to make sure dentists who work for PCTs do not get swamped because it’s not just being set up as an illness service. It’s about health promotion as well. It’s a well-known maxim that £1 spent on prevention is worth £50 of treatment.’

The BDA is also concerned about technology, which Mr Ellman says is ‘nowhere near as advanced as IT in the rest of primary care’.

It is also worried that the patient-charging proposals will prove a disincentive to dentists and patients. ‘As it stands, the step between charging at band 1, which is £15, and band 2, which is £41, might be a disincentive as some will see it as an enormous jump.

The BDA says it has not seen much evidence of work on ensuring quality and good governance at PCT level. ‘I’m worried about the possibility of making a pig’s ear of all this – just as we are setting up NHS dentistry PCTs are going to be merged and re-arranged,’ says Mr Ellman. ‘I work with the three central Manchester PCTs, where people will be fighting to save their jobs, and not giving 100 per cent of their thoughts to setting up dental services. They might not have a job in six months’ time.’

Dentists are also worried that many aspects of their new work life are at present enshrined in draft or consultation document form.

Mr Ellman explains: ‘We really haven’t even got any concrete figures in terms of funding available for PCTs. There have been some veiled threats of funding being stopped if dentists don’t hit targets, which is not really what we want to hear. These things may be driving people away from working in the NHS.

‘Dentists are small businesses and all this uncertainty about potential global income is making planning impossible. It could be driving people into the private sector.’

Scarborough unfair

In February last year the seaside town of Scarborough saw scenes reminiscent of food queues in poverty-stricken former Eastern bloc countries.

Over 3,000 residents, some of whom had not consulted a dentist in years, queued for hours to register with a newly opened practice.

Dutch dentist Aria Van Drie was recruited to the practice in New Queen Street by Medimatch, but within two weeks the practice was closed after it was revealed that she was the subject of criminal proceedings in the Netherlands.

While there were no concerns about her dental skills, Ms Van Drie decided to resign. She said coverage had undermined confidence in NHS dentistry.

Concerns about overseas dentists treating patients were compounded when it was revealed that Ms Van Drie’s Greek colleague Irene Tsanidou was not registered to practise in the UK.

More than 18 months on, two new dentists have been recruited. Scarborough, Whitby and Ryedale primary care trust dental practice modernisation manager Helen Stokell is proud of the progress that has been made.

She says the PCT had set up its own three-year action plan and is well-placed to provide a comprehensive NHS service from next year.

‘We had very low dental registration levels in the PCT and we decided we needed to get over 11,500 patients signed up by 2006. In the last 18 months we have registered 8,000 new patients, so we are well on the way to meeting the target.’

She adds that dental provision would be given a major boost if lobbying for a new dental school at Hull York Medical School is successful.

http://www.hsj.co.uk/nav?page=hsj.news.story&resource;=3414783

The review is required as the NHS moves to much more market-like mechanisms for care delivery, with competition between hospitals, between hospitals and primary care providers, and between public, private and voluntary sector operators.

Chris Ham, professor of health service management at Birmingham University, said the development of the market had run ahead of policies on how it should be regulated.

He said: “At the moment there is a quality regulator in the Healthcare Commission. Foundation trusts are regulated by Monitor, but ordinary NHS trusts, insofar as they are regulated, are regulated by the health department. The department is the price regulator because it sets the tariff.

“But beyond that there is absolute confusion about who should be dealing with failure, with monopolies, mergers and acquisition and with competition policy. It is a dog’s breakfast.”

Professor Ham said the inspection and the “licence to trade” regime differed for public and private health providers. He said the likelihood that joint ventures would develop between private operators, foundation trusts and, potentially, GP practices meant clearer regulation was needed.

His comments came as Bill Moyes, chairman of Monitor, said the days when most providers were state-owned, and the health department could regard itself as a holding company – able to “bark orders and instruct” – were ending.

Instead the department should see itself chiefly as “the headquarters of a major insurance company” that was in charge of £100bn and whose job “was to get the best possible care it can for that money”.

Speaking at a King’s Fund conference on the issue, he argued that there should be a clear split between an economic regulator and a separate inspector overseeing quality. Separation would remove the risk that the quality of care might be compromised, he said.

The review will be welcomed by private sector operators, which have long complained about the differing inspection regime they face.

A main question, however, will be who sets the highly complex NHS price list used to pay both NHS-run and private providers.

Professor Ham said that theoretically that should be set as independently as possible. But it remained the chief tool by which the government could control the cost of NHS care. “I suspect that will make the department very reluctant to let it go,” he said.

http://news.ft.com/cms/s/20aaea88-403c-11da-8394-00000e2511c8.html

Health Direct highlighted this issue nearly 12 months ago when the then Labour Health Secretarty John Reid claimed on November 21st 2005 “Sexually transmitted disease is reaching epidemic proportions amongst young women and requires a government response on the scale of the 1980s.”

Britain’s sexual health is in rapid decline: in the last decade cases of gonorrhoea and HIV have more than doubled, syphilis is resurgent (up 1500%), and the number of sexually active people under 25 infected with chlamydia is now thought to number just under half a million.

One of the country’s most senior Genito-Urinary clinicians, Professor George Kinghorn, tells Panorama that it amounts to “a public health crisis”.

With extensive access to patients and staff at the GUM (Genito-Urinary Medicine) clinic in Sheffield, Panorama revealed how the STI (sexually transmitted infection) epidemic is overwhelming Britain’s sexual health service.

Across the country, waiting times are at record levels, with many clinics forced to turn away patients. Gill Bell, the Nurse Consultant in Sexual Health Advising in Sheffield, explains how it has become “the survival of the fittest”.

Panorama followed the story of several patients seeking treatment to assess the other costs, including the poignant case of 24-year-old Sian, who developed Chlamydia over two years ago and has been struggling to get pregnant ever since.

The BBC camersa were with her in the operating theatre when her surgeon, Bill Ledger, discovers that her tubes are blocked with adhesions; and with her when she learns – just hours afterwards – whether she will be able to conceive naturally again. Professor Ledger estimates that 100 women a year, in Sheffield alone, are undergoing such operations.

http://news.bbc.co.uk/1/hi/programmes/panorama/4334310.stm

For many patients, such extra costs coincide with a loss of income and patients can end up in debt because of their disease, the charity said.

More than 41,000 women and 300 men are diagnosed with breast cancer each year in the UK.

“As a result of my double mastectomy I have spent hundreds on getting to hospital – I have even had to buy a car”. said Jean Williams from Inverurie, Aberdeenshire, who has spent £12,200

Almost a quarter of those surveyed identified travel to hospital and parking as the highest extra financial cost linked to their cancer.

An equal number said their highest extra cost was linked to improving their diet or using complementary therapies.

Many patients feel that special foods, massage or aromatherapy are necessary expenditure as they can aid their recovery.

‘CANCER COST ME £5,000′
Cath Sorsby, 57, from Sheffield, was diagnosed with breast cancer in 2003. She underwent a mastectomy and a course of chemotherapy, but also dealt with further surgery after she developed an infection, and pneumonia.

She was unable to return to her job as a teacher. And she says she faced many unexpected costs.

“I lost two-and-a-half stone after my first operation, so I had to buy a whole new wardrobe which was costly, even though I spent the minimum. “I also suffer extremes of temperature, which has meant we’ve spent double on additional electricity and gas. And we had to employ a carer for three months, and have to have a cleaner because I can’t do it. We also had to have our bathroom adapted because I can’t climb into the bath. Cath added: “These sorts of costs are a real burden.”

One in six said the cost of prescriptions was the highest bill they faced, while one in seven said heating, electricity and gas bills were their most expensive cost.

These additional payments had an impact on women’s home lives, the survey found. A quarter said they had to cut back on food shopping or bought cheaper food, and half had to cut back on buying clothes or haircuts.

Three in five patients said they had fewer days or evenings out, while others reported being able to have fewer treats such as takeaways or meals out (54%)

Breast cancer patient Jean Williams from Inverurie, Aberdeenshire, said she had spent £12,200.

She said: “As a result of my double mastectomy, I have spent hundreds on getting to hospital – I have even had to buy a car.

“And due to the nature of my operations, I’ve spent thousands on complementary therapies including reflexology, aromatherapy and massage, otherwise I am in lot of pain.”

Lesley Dileonardo, from Somerset, added: “Since being diagnosed, we have had the worry of extra costs plus losing my wage. The same costs are being paid out, but half the amount of money is coming into the household budget. The added worry of finances at a time like this is devastating.”

Stressful time

Peter Cardy, chief executive of Macmillan Cancer Relief, said: “Our survey has shown that patients see their spending levels rocket when they are diagnosed with breast cancer. Patients have to spend out on travel to hospital to receive their life-saving treatment.”

“But equally expensive is the cost of special diets and complementary therapies – it’s clear that patients want to help control their symptoms and improve their quality of life. It is appalling to think that at this very stressful time cancer patients are having to worry about their financial situation – it should be the last thing on their mind.”

Emma Taggart, director of policy and campaigns at Breakthrough Breast Cancer, said: “Being diagnosed with breast cancer and undergoing treatment is an upsetting time for many women without the added pressure of financial worries. Women tell us that this is a major issue and that there isn’t enough information out there. Greater awareness of how women can ease this pressure is key.”

There is no firm evidence that H5N1 has acquired the ability to pass easily from person to person. However, concern remains that the virus might develop this ability, or that it might mix with human flu viruses to create a new virus. It is this ability of avian influenza, to change and to mix, that has given rise to the fear of a new human flu pandemic.

“Most experts believe that it is a matter of when, not whether, another influenza pandemic strikes.” Getting ahead of the curve: A strategy for combating infectious disease. A report by the Chief Medical Officer. January 2002 (p44).

Avian influenza or ‘bird flu’ is a highly contagious disease of birds, caused by influenza A viruses. In birds, the viruses can present with a range of symptoms from mild illness and low mortality to a highly contagious disease with a near 100% fatality rate. The bird flu virus currently affecting poultry and some people in Asia is the highly pathogenic H5N1 strain of the virus.

As the virus can remain viable in contaminated droppings for long periods, it can be spread among birds, and from birds to other animals, through ingestion or inhalation.

All bird species are thought to be susceptible to avian influenza. Migratory birds such as wild ducks and geese can carry the viruses, often without any symptoms of illness, and show the greatest resistance to infection. Domestic poultry flocks, however, are particularly vulnerable to epidemics of a rapid, severe and fatal form of the disease.

There are many different subtypes of influenza A virus. The most virulent are called highly pathogenic avian influenza (HPAI) and can reach epidemic levels among birds. Of these, subtype H5, and more particularly subtype H5N1 currently, pose the greatest concern for human health.

Two other subtypes – H9 and H7 – have caused illness in people but neither has caused outbreaks in poultry as severe as H5N1-related ones.

According to the World Health Organization (WHO), there is mounting evidence that the H5N1 strain has a unique capacity to jump the species barrier and cause severe disease, with high mortality, in people.

How can bird flu infect people?

People are rarely infected with bird flu viruses. Those who have become infected have had close direct contact with infected birds. Historically, human infection with avian influenza viruses has usually caused mild conditions such as conjunctivitis (eye infection) and mild flu like symptoms.

More severe infections can lead to pneumonia, acute respiratory distress, viral pneumonia, and other severe and life-threatening complications.

The first documented cases of bird flu infecting people occurred in Hong Kong in 1997 and this was also the H5N1 strain of virus. Investigation showed that close contact with live infected poultry was the source of the infection.

H5N1 is able to infect people because it is able to cross the species-barrier. In human populations, where domestic pigs and wild and domestic birds live in close proximity with people, the mingling and exchange of human and animal viruses can more easily occur.

Person-to-person transmission

There is no firm evidence that the H5N1 strain causing the outbreaks in SE Asia has acquired the ability to pass easily from person to person or to sustain transmission.

So far, while some instances of spread from one person directly to another have been reported, these have been isolated one-off occurrences with no further spread to people, and the route of transmission remains unconfirmed.

Until mid-December 2003 — the start of the current outbreak in poultry — highly pathogenic avian influenza (HPAI) was considered a rare disease of birds.

The first documented cases of bird flu in people appeared in Hong Kong in 1997, when 18 people infected with an H5N1 virus strain were admitted to hospital, six of whom died. The source of infection in most cases was traced to contact with diseased birds on farms and in live poultry markets.

As of 17 October 2005, 117 reported cases of H5N1 infection in people have occurred in four countries, Thailand, Vietnam, Cambodia, and Indonesia. Sixty of these have been fatal.

The outbreak now concerning health experts is H5N1. It began in poultry in South Korea in mid-December 2003, and has affected birds in many countries in Asia, Russia, and most recently Turkey and Romania. It involves a variant of the same virus subtype as that associated with the 1997 Hong Kong outbreak.

EU and UK controls are in place aimed at preventing the occurence of bird flu in UK poultry. Nonetheless, it remains a remote possibility that bird flu could be introduced to poultry through the migration of wild birds, the importation of dead chickens for consumption, the illegal importation of live birds or the entry into the UK of a person who has acquired the illness in an infected area.

As a precautionary measure, the UK has banned imports of live chickens from the following countries (due to bird flu outbreaks in these countries):
Turkey, Romania, Russia, Kazakhstan, Thailand, Cambodia, China, Hong Kong, Laos, Indonesia, Vietnam, Pakistan, Malaysia, South Africa, and North Korea.

The European Commission (EC) has banned imports of all poultry, poultry meat products, and eggs from Thailand. The importation of ostrich and ostrich products from South Africa has also been banned, along with imports of other birds of the ratite family (a type of flightless bird). Other non-poultry birds, including pet birds accompanied by their owners, have also been banned.

In December 2004, the World Health Organization (WHO) stated:
“WHO and influenza experts worldwide are concerned that the recent appearance and widespread distribution of an avian influenza virus, influenza A/H5N1, has the potential to ignite the next pandemic.” World Health Organization, 8 December 2004

“Wherever in the world a flu pandemic starts, perhaps with its epicentre in the Far East, we must assume we will be unable to prevent it reaching the UK. When it does, its impact will be severe in the number of illnesses and the disruption to everyday life. The steps we are setting out today will help us to reduce the disease’s impact on our population.”
Sir Liam Donaldson, Chief Medical Officer, 1 March 2005

But what is a pandemic, and what causes it? We are used to epidemics of ‘ordinary’ flu, which occur seasonally, every year, around the world. An epidemic is a widespread outbreak of disease occuring in a single community, population or region.

A pandemic, on the other hand, occurs on a much greater scale, spreading around the world and affecting many hundreds of thousands of people across many countries.

There are three main groups of flu viruses: influenza A, B and C. Influenza B and C viruses infect people only, however, influenza A viruses have the ability to cross the species barrier and infect people, birds, and animals such as pigs and horses. Among people, influenza A is the source of most ‘ordinary’ flu epidemics and has caused all previous flu pandemics.

Experts fear that the H5N1 subtype of avian influenza A could trigger the next pandemic, for several reasons. Firstly, it has already demonstrated an ability to infect people and cause severe disease – one of the key characteristics of a pandemic strain. Secondly, the virus has the ability to mutate and acquire genes from viruses infecting other species.

Experts are concerned that the virus could either:
* adapt, giving it greater affinity for humans, or;
* exchange genes with a human flu virus, thereby producing a completely new virus strain capable of spreading easily between people, and causing a pandemic.

By necessity, if a new strain were to occur then few people, if any, would have a natural immunity to it.

Antiviral drugs

There is some evidence that recent H5N1 viruses are susceptible to a class of antiviral drugs called neuraminidase inhibitors, although they appear to be resistant to the alternative antiviral drug, amantadine.

The Government is expanding its stockpile of antiviral drugs against the contingency of a flu pandemic, whether due to an H5N1 or another new strain. On 1 March 2005, the Health Secretary announced the procurement of 14.6 million treatment courses of the antiviral, Tamiflu – enough to treat a quarter of the UK population, but they will not be delivered in full until December 2006.

The DH website provides further information on what the Government is doing to plan for an influenza pandemic as part of its overall contingency planning. The UK has had a national influenza pandemic plan since 1997 and was one of the first countries to publish a pandemic plan. The plan was updated and the revised UK Influenza Pandemic Contingency Plan was published on 1 March 2005.

The revised plan outlines the actions that Government and other authorities are taking to prepare for a possible pandemic, and the actions that different organisations would take in the event of a pandemic, to slow down the spread of infection and minimise disruption. The plan is currently being further revised and an updated version will be published shortly.

“This is a high quality plan, which shows that the UK continues to be at the forefront of preparations internationally for pandemic influenza. We hope that every country will develop their preparations to the same high degree.”Dr Asamoa-Baah, Assistant Director-General – Communicable Disease, World Health Organization

Vaccines

There are already several potential vaccines for protecting humans from infection with bird flu, at various stages of testing and production.

Vaccine manufacturers and institutions working to develop and produce bird flu vaccines are using several candidate virus strains based on H5N1, which have been made available by the World Health Organization.

The UK’s National Institute for Biological Standards and Control (NIBSC) is one of several organisations worldwide participating in the development of a vaccine to combat H5N1.

Whether these will be suitable for use against a new pandemic flu strain depends on how much the pandemic strain may have mutated and changed from the original H5N1 virus strain used to create the vaccine.

If the virus should substantially change, it is unlikely that existing vaccines would be effective, and a new one would have to be developed. Whilst the existence of an H5N1 vaccine could speed up the production of an effective vaccine, work on creating a vaccine could only begin once the
new strain has been identified.

In addition, on 20 July 2005 the Department of Health invited manufacturers to tender for a contract to supply a limited amount of H5N1 vaccine. The move is part of work to prepare for and reduce the impact of a possible flu pandemic.

The Department proposes to purchase two million doses of H5N1 vaccine. This strategic stockpile could be used for research or as a first line of defence for priority groups, whilst a vaccine against the exact flu strain is manufactured. Experts will also be able to carry out further clinical studies on the H5N1 vaccine to learn more about how it works against the virus and how effective it could be.

http://www.dh.gov.uk/AboutUs/MinistersAndDepartmentLeaders/ChiefMedicalOfficer/Features/FeaturesArticle/fs/en?CONTENT_ID=4102997&chk;=OcYuEL

Four key findings have emerged:

* First, the early implementers of payment by results are, on balance, positive about the change (foundation trusts slightly more so than PCTs).

The new system offers a clearer framework for planning and managing their business. The greater level of financial risk inherent in payment by results has provided the impetus to strengthen planning, financial management arrangements, information systems and overall performance management.

In addition to this, payment by results has encouraged commissioners to focus on demand management and improving clinical pathways. Both PCTs and foundation trusts report greater clarity of roles and responsibilities; a positive change in culture and accountability and improved understanding of their business and local health economy.

However, there are still concerns about certain aspects of the policy, the speed of transition and the readiness of the rest of the NHS to implement the system. Even foundation trusts that are relatively efficient, with high bed occupancy and a low cost base are pursuing cost improvements and structural change in order to be financially viable under payment by results. This raises questions about the ability of less efficient trusts to make the much larger gains required.

* Secondly, in the first year, payment by results proved to be a more complex, time-consuming and challenging process for the early implementers than they anticipated. It requires investment of time and resources – the organisations in our sample spent approximately £100,000 each, equivalent to £50 million nationally.

It also requires clinical engagement, better planning and reporting arrangements, careful negotiation and close attention to detail. All this has meant that time and energy has been devoted to the system and its mechanics, and has not yet broadened into the expected concentration on quality of care and performance improvement. The majority of NHS bodies are only just beginning to use payment by results as a lever for change.
* Three factors have influenced the relative ease or difficulty of introducing payment by results:
o the underlying financial stability;
o the complexity of the commissioning environment; and
o the degree of preparation.

Those economies with an underlying historic deficit have found that payment by results tended to increase pressure and polarise organisational interests, leading to disputes. This is likely to increase going forward, given that the number of health bodies in financial deficit increased in
2004/05 in comparison to the previous year. Commissioners in complex economies have also found implementation more challenging.

In particular, some London PCTs struggled to manage payment by results when commissioning from the larger hospitals. They felt they lacked sufficient clout as commissioners to manage in the new environment and needed stronger strategic leadership, planning and joint working within and across health economies.

And while the early implementers have a good understanding of payment by results and its impact, those that shadowed the system in previous years and put the necessary capacity and systems in place in advance found it easier to harness payment by results to achieve their objectives.

* Finally, payment by results is exposing existing weaknesses in the NHS, in health economies and in individual institutions – underlying financial difficulties, inadequate financial management arrangements and problems with data quality. It has created instability and increased tensions between organisations.

Changes to the policy framework, late or unclear guidance and lack of attention to organisational development at the national level, particularly for PCTs, have exacerbated this. Overall, the potential risks that we identified in our earlier report have been confirmed by many organisations in the first year and will likely remain an issue throughout the transition period.

Analysis of provisional hospital activity data for 2004/05 shows little difference in activity growth or efficiency between foundation trusts and other acute trusts, although foundation trusts may have marginally improved their efficiency as measured by average length of stay. This suggests that the reported growth in activity across the NHS has been driven by initiatives other than payment by results (for example, national targets) and that expected efficiency gains have not yet been realised by the early implementers.

While it is too early to draw any definitive conclusions, there is little evidence at the system level that the new incentives have generated the positive behaviours intended.

However, the potential for payment by results to destabilise finances locally (either due to weaknesses in local arrangements or volatile activity levels) has certainly been felt. Payment by results is intended to increase risk in order to spur financial discipline and improvement. But there are valid concerns that the level of risk inherent in the current policy design, particularly given the pace of implementation and the size of the change agenda, is too great.

While national policy clearly states that all activity should be funded at tariff, a number of local variations were negotiated in 2004/05 to reduce financial instability, including the use of caps and floors on activity volumes.

While this dilutes incentives for improved productivity and stronger commissioning, the organisations involved maintain that there is little point in introducing payment by results in full if it is going to destabilise the local health economy and undermine patient services. This is especially true during the transition, while organisations are still strengthening arrangements.

There is an ongoing need to review the policy in light of the experience of the early implementers and, in particular, the approach to funding non -elective care. While there may not be a strong argument for caps on elective activity in an era of patient choice, if policy objectives are to be realised then the DH should consider alternative payment models for non-elective activity that provide incentives to control growth and enable individual bodies to better manage their risks, for example, funding capacity and paying for activity at marginal cost.

Not all of the concerns about payment by results can or should be addressed through changes to the policy framework – there are other mechanisms. The required improvements in data quality (particularly clinical coding) and the potential for ‘gaming’ or manipulation of the system for financial gain necessitate a robust framework to provide assurance on payments and behaviour and promote stability across the system. We are currently working with the DH and other stakeholders to develop such a framework.

Further, payment by results is being applied to organisations that are still developing and a clear mechanism needs to be in place to identify and deal with potential failure of either a service – for example, under payment by results a service becomes unviable and the trust wishes to close it, but the service is vital for emergency patients – or the entire organisation, where this will impact on access to and quality of patient care.

Meanwhile, the DH’s decision to defer full implementation of payment by results for non-foundation trusts until April 2006 has given trusts and PCTs more time to prepare during the current financial year, with the prospect of better risk management.

These potential advantages will be lost, however, unless trusts, and PCTs in particular, give a high priority to adequate preparation. Payment by results is as much about a change in culture as it is about incentives and payments. It requires a holistic organisational response.

Clinical engagement is particularly important and this takes time and effort. NHS bodies should actively seek to learn from the early implementers of payment by results and others that have relevant knowledge and expertise – the findings and case studies included in this report are intended to support this. NHS bodies should explore opportunities for collaboration (particularly across PCTs) in order to strengthen their capacity to manage in the new environment.

There also needs to be greater stability in the policy framework, with clear and balanced guidance communicated early. Although the tariff and overall policy design will inevitably be refined continually over the next few years, the instability of the national framework during 2004/05 and into 2005/06 created additional difficulties for foundation trusts and PCTs. Further large-scale changes will undermine planning and management in the new environment. The impact of these changes on NHS bodies needs to be assessed fully and likely changes should be communicated early.

Our key recommendations for NHS bodies and the DH are set out below. Additional recommendations are made throughout the report and a set of questions for boards to assess the readiness of their organisations for payment by results can be found in Appendix 1.

Recommendations

PCTs and trusts should:

* Review their arrangements in the areas of: organisational development, planning and analysis, data quality, partnerships, demand management and service redesign, contracting and monitoring in light of our findings and detailed recommendations . Boards should use the questions in Appendix 1.
* Ensure that there is a common set of expectations across the health economy locally, based on joint planning, agreement on high-level clinical pathways and a clear understanding of business arrangements (for example, reporting, monitoring and dispute resolution).
* PCTs should prioritise the development of robust local monitoring arrangements, recognising that the introduction of the Secondary User Service (SUS) and other developments under Connecting for Health (formerly the National Programme for IT) will not remove the need to have local arrangements in place for reporting and analysis.

Strategic health authorities should:

* Continue to review the financial impact of payment by results on each organisation and on the health economy as a whole and assess the preparedness of individual organisations in light of this report.
* Facilitate joint planning, skills transfer and organisation development across the health economy and support health economy-wide demand management and service redesign initiatives.

The DH should:

* Continue to refine the policy framework in light of early experiences, avoiding increases in complexity, keeping large-scale changes in the policy framework to a minimum and communicating intentions well in advance, to enable the system to bed in.
* Focus on organisational development to support the implementation of payment by results over the period to 2008/09, particularly to strengthen commissioning, and commit to the timely release and communication of balanced guidance and tools to NHS bodies.
* Clarify its stance on the use of local risk management strategies that are not in line with national policy, but have been negotiated locally in order to promote stability, and review the design of payment by results for non-elective care.
* Develop a comprehensive and robust strategy and framework, which meets the needs of local and national stakeholders, to provide assurance on payments and behaviour under payment by results.
* Work with Connecting for Health to review arrangements for the education and training of clinical coders and prioritise the development of coding tools that are up to date and that support the provision of good-quality data.
* Develop a strategy to identify and address potential failure of services or organisations if they become unviable in the new environment, in order to safeguard access and patient care.

http://www.audit-commission.gov.uk/reports/NATIONAL-REPORT.asp?CategoryID=ENGLISH^574&ProdID;=B502F0FC-E007-4925-AD24-529C4889AD02&SectionID;=sect1#

Concerns were highlighted last week by the case of Sarah Ingham, aged 91, who lost three-and-a-half stone while in hospital. She was meant to be on a diet of purées and energy drinks to help her eat, but her family said they were forced to take food onto the ward because she was not getting her special meals.

Andrew Lansley, the shadow health secretary, said it was crucial that the NHS provided proper continuity of care. ‘Missed hospital meals are one illustration of a more general problem that no one person takes responsibility for observing patients and monitoring their progress, including nutrition,’ he said.

A new report from the European Nutrition for Health Alliance warns that one in 10 people entering a nursing home lose five per cent of their body weight within the first month, and more within six months. Up to 60 per cent of nursing home residents and 40 per cent of those admitted to hospital are malnourished.

Although in some cases that will be related to their medical condition, such as gastric diseases which prevent them absorbing nutrients, or depression which stops them wanting to eat, the charity Age Concern says it has received numerous complaints from people anxious that elderly relatives are missing meals.

‘We get complaints from the adult children of older people who have been in hospital about the food available,’ said Philip Hurst, policy officer for Age Concern.

He added: ‘We have had numerous examples of someone who is blind just having the food put in front of them and getting no help to eat it. Although they are in an unfamiliar place, they are not given the support or encouragement to eat, and it’s just recorded that they didn’t eat it, assuming they didn’t want it.’

http://politics.guardian.co.uk/publicservices/story/0,11032,1588135,00.html

Although Hewitt is promising limits to private-sector incursions into state care, the launch this week of new cooperatives of doctors to bring venture capital into the health service shows that something very important and dramatic is happening to British health care.

In place of the single NHS, we now have an increasingly decentralised health system, a proliferating network of service providers and independent treatment centres, and hospitals built and financed by private money. Companies have already been drafted in to run surgical clinics; some diagnostic services are now private; and new out-of-hours primary-care services are on their way.

With these plans, the Government has clearly signalled its commitment to extending the pro-market reforms begun under Conservative governments of the 1980s and 1990s.

The intention behind these reforms is not necessarily bad. Change in the NHS was, and still is, very much needed—as anyone who has worked in the UK health system will be all too aware. Decades of under-financing have left demoralised medical staff working in outdated buildings and struggling with inadequate equipment. Steep inequalities, both in access to services and health outcomes, persist throughout the country. And translation of research into practice remains shamefully slow.

These problems are, in part, a reflection of the diffidence of doctors and nurses in relation to leading much- needed reform. But it is also true— and critics of the Government’s reforms must recognise this— that there are simply too few incentives in the NHS to drive change and boost performance.

Providing market-style enticements for health providers to perform better has been a key part of Labour’s agenda for change. A raft of rapid reforms has brought in administrative targets, inspections (both of clinicians and hospitals), health-technology appraisals, payments on the basis of results, and the promise of autonomy for successful hospitals.

However, these incentives have so far failed to prove their worth. A report published last month by health-policy think-tank The King’s Fund examined whether the current system of incentives has improved care. So far, it has not.

Not only did the report highlight cases in which incentives have acted to inhibit, rather than promote, quality care, it also concluded that these strategies can in fact work against each other— for example, by reinforcing boundaries between institutions.

A wider public debate about when and how to use incentives to improve care is essential to ensure that undesirable outcomes are minimised.

But there is an issue of deeper concern. The Government’s ambitious programme of structural reorganisation has brought with it an increasingly fragmented health service. To prevent potential dissolution, the governing principles of health-service reform— universality and equity— need to be more firmly reiterated.

And while there have been numerous rhetorical references to preserving the principle that, regardless of provider, care must be free at the point of need, the Government has failed to make a clear statement of values that will reassure patients and health workers in different settings across diverse providers.

Reform of a health service that is failing to meet patients’ expectations should be an urgent government priority. Clearly, it is— and that is welcome. The view that there are too few incentives to encourage continuous improvements in care— and too many perverse incentives to stifle much-needed change— is plainly correct.

But Patricia Hewitt’s error, repeated over and over again by her predecessors in all governments, is to change the system based on ideology rather than evidence. No drug would be licensed without good data about its safety and efficacy. Yet Britain’s health system is freely turned upside down without any reference to evidence or any plans to study the controlled effects of these reforms.

This kind of haphazard policy-making risks the welfare of patients and the commitment of health workers. The Government’s latest proposals are untested and, therefore, irresponsible and potentially dangerous. Patricia Hewitt is playing fast and loose with the public’s trust. Until there is independent evidence of the effects of her policies, her programme of wide-ranging privatisation must be stopped.

http://www.thelancet.com/journals/lancet/article/PIIS0140673605675010/fulltext

The strategic authorities will respond to the consultation in the next few weeks. The Department of Heath aims for the number of trusts to fall to fewer than 150 – perhaps as few as 128.

Crisp said that cutting the number of trusts could save £250m over the next few years. “These funds can then be redirected straight to front-line services,” he added.

The reduction in the number of trusts will raise questions about their creation, a scheme that cost more than £63m.

However, the Government says it remains committed to these smaller health authorities, as they allow local communities greater power over their health services.

The proposed closures have attracted criticism from Alan Milburn MP, who was health secretary when the trusts were established. The MP is furious about plans to merge a trust in Darlington, his own constituency, with a larger County Durham authority. He told his local newspaper that the proposal was “ludicrous”.

The cuts are expected to result in thousands of job losses and the department has begun talks with civil service trade unions The department said last night: “We are committed to reducing the excess bureaucracy in the management of the NHS. It is far too early to be talking about the number of job losses. There will be a reduction in the number of top management teams and back-office units.”

http://www.telegraph.co.uk/money/main.jhtml?xml=/money/2005/10/09/cnhelf09.xml

The distance from his sick bed to the phone was only a few yards but for Steven Wiseman it might as well have been a mile. Crippled with pain, here was only one thing for it: he would have to crawl.

Inch by inch, gasping for breath and sweating heavily, the 30-year-old dragged himself across the carpet.

Wiseman’s worried fiancée, Kerry Robertson, was desperate. “He couldn’t stand up, the pain was just so much,” she said later. “It was easier for him to crouch down to speak on the phone.” His breathing was heavy and he sounded close to tears.

Finally, Wiseman was able to describe his symptoms to the nurse working for NHS 24, the government’s health service helpline. The nurse assured Robertson her fiancé just had a bad dose of the flu. She should give him some paracetamol and let him sleep.

Last week a fatal accident inquiry into the failings of NHS 24 heard how Wiseman’s situation deteriorated rapidly. When a doctor finally arrived at the family home in Laurencekirk, Kincardineshire, Wiseman was gravely ill. As he was being prepared for the ambulance he asked his fiancée — the mother of his two children — for a kiss. Then he asked the same from his mother. Seconds later, he died, the victim of streptococcal toxic shock undiagnosed by the call centre staff.

The story of Wiseman’s death was not the only sign last week of a Scottish NHS struggling to meet the most basic needs of its patients. On Friday, talks broke down between the Scottish government and Scotland’s dentists on moves to provide NHS dental care to every communityacross the country — a service once taken for granted but which is now an increasingly rare commodity.

In the past two years, thousands of Scots have been told by their dentists that they will no longer be treated on the NHS.

In a familiar sight in communities across the country, people have had to queue outside surgeries for the privilege of becoming a private fee-paying patient. Those who miss out, or who move to a new area and find the practices all full up, find themselves with no dental care.

Douglas Murray, 56, has been without a dentist for more than six months and has been refused by two surgeries in Brechin who are not taking new patients. When a tooth broke last April, he decided his best option was DIY dentistry. “When my tooth broke I tried around Brechin but nothing was doing,” he says. “I’ve been getting by with a tube of superglue ever since.”

In recent years arguments about improving Scotland’s health have been dominated by hospital waiting times and waiting lists. Jack McConnell, the first minister, has come under sustained criticism for failing to introduce reforms that have seen improvements in hospitals in England.

Bad publicity about dentists and NHS 24 are a timely reminder to McConnell and his ministers that Scotland’s health service is about more than just hospital treatment. Equally important are more routine demands — the pain of a lost filling in a tooth, or parent’s worry about a sick child in the middle of the night.

McConnell knows these are the kind of health issues that strike a public nerve. These current difficulties are about the fundamentals of providing a basic health service. As a result, the first minister knows that failing to bring NHS 24 and dental care under control will come at a heavy political cost.

The timing could not be worse. Just around the corner is the harsh Scottish winter, when the NHS comes under the greatest pressure, especially from elderly patients and those who fall ill with flu.

So how did two key pillars of today’s NHS come to develop such worrying cracks? Can NHS 24 cope with the expected surge in the number of calls this winter? Can Scots be assured that the haemorrhaging of NHS dentists will stop, and they can be assured of treatment? Is Scotland’s NHS safe in McConnell’s hands?

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Four years ago the NHS agreed to end direct recruitment from about 150, mainly developing, countries. But a loophole emerged as private agencies started recruiting nurses and hiring them out as agency staff to the NHS.

The latest figures from the Nursing and Midwifery Council show that more than 2,800 nurses and midwives from “banned” countries registered to practise in the UK in the year ending in March. Almost 1,000 registered from South Africa.

The attraction for nurses is clear. An experienced theatre nurse can earn £35,000 a year in Britain compared with £7,000 a year in South Africa.

A researcher called the MTA Medical recruitment agency in Johannesburg claiming to be a South African nurse responding to the company’s advertisement in a nursing journal and was told the agency had jobs at the Queen Victoria NHS Trust burns unit in West Sussex, and that “because of the terrible need I think they would probably waiver the moratorium”.

A Department of Health spokesman said: “The new code is in force but recruitment agencies and NHS trusts were given until December to allow them to make the changes to contracts to recruit domestically.”

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Nearly 100 people, including many staff, heard finance director Duncan Brodie warn that if the performance of the first five months of the year continued, the trust would end the year between £30m and £33m in deficit, pushing its accumulated deficit to more than £60m.

‘Our biggest concern at the moment is cash; we are experiencing real challenges in meeting our cash obligations to suppliers,’ he said.

The strategic health authority has helped with £35m emergency funding, but repayment of this is due to commence later this financial year.

The trust’s expected income for this financial year is £138m, although service-level agreements have yet to be agreed with primary care trusts.

Its expenditure could be as much as £175m, although a £10m cost-cutting programme, including theatre closures, restriction on the use of agency staff and sending electives elsewhere, is now in place.

But former deputy chair Robin Eve, who was ousted earlier this year, said the new board must be fearless in highlighting funding problems.

‘Realistically, this trust is facing a black hole,’ he said. ‘If this goes on we will be facing the closure of Crawley Hospital.’

Mr Davies said that the trust ‘would not be allowed to raze Crawley Hospital to the ground and put houses on it’.

New chief executive Gary Walker said the hospital had costs that are between £17m and £20m too high due to high administrative costs, the trust’s dependence on agency staff, and its relatively long lengths of stay.

But a £10m cut in costs would make the trust an efficient provider, even though it might still end up with a deficit of between £10m and £15m.

‘I have to get more work going through the hospital, which is difficult in an NHS that wants to do less in hospitals,’ he said.

‘Crawley Hospital is a major accident and emergency department next to Gatwick [airport]. There is no question that we won’t be there, but there will be many discussions on how much elective care we provide.’

Elective care ‘pays its way,’ he said. ‘Where I lose money, it is on emergency care because of the local payment by results system’.

Former chief executive Ken Cunningham was paid between £265,000 and £275,000 in his last year with the trust, accounts reveal. This included an ‘agreed compensation for loss of office’ – his base salary was £120,000-£125,000.

Anthony McKeever, who was acting chief executive after his departure, was paid £52,769 for his work from February 4 to March 31.

Mr Walker told the annual meeting he was being paid £115,000 a year.

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A Department of Health spokeswoman said the ruling would not pave the way for other women to claim the treatment.

Somerset Coast, Barbara Clark’s local PCT, agreed to prescribe the drug Herceptin, which has not yet been approved by the National Institute for Health and Clinical Excellence, to fight the early stages of breast cancer. The agreement was reached due to Ms Clark’s personal circumstances.

However, Roche, the manufacturers of the drug – which has already been prescribed to up to 40 women on the NHS – has not yet applied for a licence for its early use.

The DoH spokeswoman said that ‘the government cannot dictate when drug companies apply for licences’.

‘We must be sure that medicines are robustly tested and proved effective before they are made available to patients.’

She added that health secretary Patricia Hewitt has already made clear that once it had been licensed the drug would be ‘fast-tracked to NICE’.

Last month NICE submitted plans to the DoH on ways it could streamline its assessment process to ensure medicines are available as quickly as six months after they are licensed by drug companies.

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The trust is not itself in deficit and won three stars in the most recent set of ratings issued by the Healthcare Commission.

But it has been told to find efficiency savings of £3.3 million a year; has lost £1 million from the primary care trusts it serves; and has been asked to find another £1.65 million by Thames Valley Strategic Health Authority (SHA) to help other trusts in the area to balance their books.

Faced with this final demand, the trust announced last week that seven consultants, seven senior house officers and one specialist registrar could lose their jobs.

The British Medical Association stepped in to try to prevent the redundancies and has been in discussion with the SHA.

Jonathan Fielden, deputy chairman of the BMA consultants’ committee, said: “We have been saying for months that redundancies among medical staff were a risk. This is the first time it has actually been threatened.

“As far as we are aware, the last time consultant redundancies were threatened in the NHS was over the Tomlinson report into hospital provision and medical training in London, and that was more than ten years ago.”

If implemented, the cuts at Oxfordshire Mental Healthcare Trust, which runs the Warneford Hospital in Headington, Littlemore Mental Health Centre, Park Hospital for Children and three other centres, would reduced its medical staff by 20 per cent.

The announcement came as trusts across the country made plans to shed hundreds of jobs because of NHS cash problems. Despite the Government spending billions more on the service, some trusts have substantial debts, running collectively into hundreds of millions of pounds.

Others are in surplus. Normally cash is shifted around from trust to trust to help to balance everybody’s books. In this case, the Oxfordshire trust — which has broken even for the past five years — said that if required to find the £1.65 million the SHA was demanding it could do so only by cutting jobs.

The trust and Dr Fielden are hopeful that a settlement that would not involve redundancies is still possible. “But the threat is still there,” he said yesterday. “It validates what we have been saying for months.

“The news we are hearing from around the country is that the axe is being sharpened and many more jobs will go either directly or indirectly.

“A lot of trusts are planning to make redundancies by stealth. They will avoid direct redundancies where they can. Oxfordshire Mental Health Trust is one of many that is having its bank balances raided to help those trusts that are in deep debt, some to the tune of tens of millions of pounds.”

He said that it was sad that psychiatric jobs were under threat, as patients with mental illnesses were often the most vulnerable in society and would undoubtedly suffer if doctors lost their jobs.

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The shortage of new drugs is caused by tight financial controls and delays in approving medicines, says a report by the authoritative Karolinska Institute in Stockholm.

It claims that Britain’s National Institute for Health and Clinical Excellence (Nice) is “unable to cope” with the task of approving drugs, some of which take more than a year to enter use.

“The UK lags behind other EU countries in terms of the ability of cancer patients to access new cancer drugs,” says the research by Nils Wilking, an oncologist at the Karolinska, and Bengt Jonsson, an economist at the Stockholm School of Economics.

“The Czech Republic, Hungary, Norway, Poland and the UK were consistently identified as below average adopters of new cancer drugs.”

Professor Karol Sikora, consultant oncologist at the Hammersmith hospital, London, said the failings meant British patients needed to pay to receive the best medicines. “It is very sad that despite spending billions trying to improve cancer services we are still at the bottom of the league.

“We have a burgeoning bureaucracy with much growing inequity and persistent hidden rationing. The well off and the better educated simply get better care.”

The report, which will be presented to the European parliament this week, shows that survival from cancer is directly linked to access to the best medicines.

It finds that the lack of availability of drugs is the primary reason why cancer survival rates in Britain are relatively poor despite the government’s £2 billion cancer care plan.

Only 67% of patients survive one year after diagnosis in Britain compared with 81% in France and 73% in Bosnia-Herzegovina. Survival rates five years after cancer is detected are at 48% in Britain compared with 61% in France and 54% cent in Bosnia.

In addition to the shortage of Herceptin, Britain performs well below the European average for access to the new lung cancer drugs gemcitabine and vinorelbine. British patients dying from lung cancer would be more likely to be treated with gemcitabine if they lived in Greece, Hungary or the Czech Republic.

In addition, bowel cancer patients are less likely to be prescribed the new medicines oxaliplatin and irinotecan. A smaller proportion of British patients receive irinotecan than do sufferers in Hungary or the Czech Republic.

The report directly blames Nice for the failure to make cancer medicines available to British patients.

Once drugs are approved by the central EU regulatory body, the committee for medicinal products for human use, they should be available nationally within 180 days.

But the study found that it can take 18 months from European approval until a medicine is even considered by Nice. Its review can then take an additional 14 months.

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