For 2005 appeared to start pretty swimmingly. Waiting times were falling, clinical results were improving, facilities were much better and there were new contracts for consultants and family doctors. The biggest pay re­organisation of them al – known as Agenda for Change – was
proceeding steadily, if a little late.

Then in July some uncomfortable facts emerged. It was confirmed that after six years of record real terms growth, the NHS had overspent. Not by much in the big picture of things, but the net £250m overspend in England presaged worse to come. The service is currently projecting a deficit close to three times that and the health ­department is planning on the assumption that 2006 will be at least as bad as 2005.

This truly shameful loss of financial control has created famine amid a feast. Patients in some parts of the country are made to wait longer for treatment. Clinics are closed to balance the books – although in practice still fail to do so.

With that came a botched step on the path to reform. Again in July, ministers ill advisedly agreed to the shotgun merger of primary care trusts and strategic health authorities when these were in practice starting to happen organically anyway.

On top of that, the service’s top management told more than 200,000 staff in primary care trusts that while it could not tell them whether they would shortly be employed by the private sector, by general practitioners, by themselves, by a local authority, by some new “social entrepreneur” or by some new part of the NHS, the one thing about which they could be certain was that their future employer would not be their current one.

The result of these twin moves has been instability and uncertainty, with huge numbers of health service staff worrying about their next job rather than getting on with their current one.

Added to that, huge sums – 35 per cent of all the growth money on the department’s figures, more according to most people’s suspicions – has disapeared into extra pay with far too little to show for it in terms of modernised work practices or extra productivity.

None of this is to say that the NHS is not getting better. It is. But it needs to show far more improvement by 2008 when current record rates of spending growth will moderate. The reorganisation feels too much like rearranging the deckchairs on the Titanic.

The challenges for 2006 are large. Financial control must be re- established. A new regulatory system is needed to oversee the emerging market for suppliers, along with a new failure regime to cope with its inevit­able consequences. Providers from the independent sector need reassurance – by deeds, not just words – that the government genuinely sees them as long-term partners in the market.

Chief executives need a change of mindset that drives them to save to invest rather than overspend. They must then use that approach to achieve the productivity gains so badly needed if the government is to stand a chance of getting the maximum wait from GP to an operation down to 18 weeks by 2008.

And, as patient choice and payment by results kick in, ministers and the department need not just to hold their nerve, but to drive ahead with reform as some services close and others open.

There is no guarantee that the government’s current strategy will work. It contains paradoxes – a requirement for co-operation among healthcare providers along with a demand for competition.

But the recent experience of Scotland, Wales and Northern Ireland – where just as much extra money has been invested for even less apparent result – shows that just pouring new wine (more money) into old bottles (an unreformed service) does not work.

The current reforms may not succeed. What is certain is that tried half-heartedly they will fail. So they need to be seen through, with lessons learnt and adaptations made on the way. It is the year for living dangerously in the NHS.

http://news.ft.com/cms/s/3b76fa2e-79a2-11da-8d99-0000779e2340.html

The survey shows that in two (11%) out of the 19 Regional Genetics Centres which responded, women who suspect they may carry the BRCA genes are waiting up to 9 months for their first appointment with a geneticist. Nearly a third of responding Centres (32%) have more than a 6
month wait.

Women in five Centres (26%) are waiting between 1-2 years for their test results to come through, despite a Government White Paper issued in 2003 stating that by 2006 diagnostic genetic test results should be available within 8 weeks of the test taking place.

CancerBACUP identified 23 Regional Genetics Centres in the UK that carry out genetic testing. The Centres are serviced by 16 Molecular Genetics Laboratories which test the gene samples.

The survey also shows that only 6 out of 12 (50%) Molecular Genetics Laboratories who responded are currently testing 100% of the BRCA genes, despite NICE guidance in 2004 that the whole gene should be looked at. Advances in technology and government funding have made 100% testing now possible where previously only 60% testing was available in many Laboratories.

Centres are also required to carry out re-testing of samples to ensure women previously tested for 60% of the BRCA genes are now tested for 100% of it. Two laboratories (17%) say that it will take two years to clear the backlog.

CancerBACUP’s survey shows that there are also variations in the way Centres communicate with women about the retesting. Although women gave their consent to retesting at the time of their original BRCA test, this could have been several years ago. The survey shows that seven Centres (37%) are seeking renewed consent before they re-test, while five (26%) are not. A survey of patients in the London area carried out by UCL shows that a significant amount of women (40%) would prefer to give renewed consent before retesting takes place.

CancerBACUP is calling for women to be made aware that all Centres are offering 100% testing of the genes, and that all Centres will give them the option of having their genes retested within a reasonable timescale.

“It is vital that genetic testing Centres offer the same standard of service throughout the UK”, says Dr Andrea Pithers, CancerBACUP Genetic Information Project Manager. “We would like to see all women being informed that testing 100% of their BRCA genes is now available for everyone, in order to give them the choice over whether they would like to be retested. It’s also important that Centres speed up the time it takes to give women their test results. Although many of the Centres say they will meet the government targets on this by 2006, our survey shows that some have a long way to go to achieve it.”

James Mackay, Consultant Genetic Oncologist, said: “This conference is a great opportunity to discuss the important issues around what the needs of women who may have a genetic disposition to breast cancer are. While the survey offering a snapshot of former patients’ opinions showed that 40% of women would like to be re-contacted before their genes are retested, only half of the women asked remembered that they had given consent for testing in the future if technology improved.”

http://www.cancerbacup.org.uk/News/Press/Pressreleasesstatements/2005/32905125

The figures, from a survey of 182 English councils, also show men were two-and-a-half times more likely to die on their own than women. It is estimated that 3.5 million people aged over 65 live alone in the UK.

“Thousands of older people across the country not only live, but also die, alone, uncared for and often in poverty” claims MP Paul Burstow.

Local authorities have to carry out funerals for people who die alone, without any friends or family who would otherwise finance and make the arrangements.

The Lib Dem research found that the 182 councils carried out 11,004 such funerals between 2000 and 2004. Projecting these figures for the 266 councils responsible for arranging these funerals suggested there were around 16,083 such deaths during this period.

Almost three-quarters (72%) of the funerals were for men – compared to 28% for women.

The Lib Dems said that this trend was the same over the five years for which they collected data.

Isolation and loneliness
The report – Dying Alone: Assessing isolation, loneliness and poverty – found women who died alone were likely to be between the ages of 75 and 80 – almost 10 years older than men.

It said that although the figures represented only a “snapshot” of provision across England, they painted “a stark picture of isolation, loneliness and in many cases impoverishment”.

The Lib Dems are calling for a more concerted approach to tackling isolation, particularly in the elderly.

Mr Burstow, a member of the Commons Health Committee, said: “These figures are a sobering reminder that thousands of older people across the country not only live, but also die alone, uncared for and often in poverty.

“Being cut off from friends, family and neighbours undermines all quality of life. It is an indictment of society that too many people are left to fade away, unable to make ends meet and lonely on the fringe of our communities. We all have a responsibility to look out and care for vulnerable neighbours, friends and relatives, not just at this time of year.”

Labour Government response
A Department of Health spokesperson came out with the usual claptrap and said there had been substantial funding increases for social services, and investment in schemes to help vulnerable people live independently in recent years.

Between 1998 and 2003 there had been an increase of 44% in the number of households receiving intensive home care.

In addition, the Commission for Social Care Inspection had been given powers to monitor quality and standards of care provided by all agencies providing personal care for people in their own home.

The spokesperson said: “We are doing a great deal to ensure the elderly receive the care and support they need to live safely in their own homes.”

http://news.bbc.co.uk/1/hi/health/4564166.stm

The Lib Dems and charity Counsel and Care called the figures “shocking” as Social Care inspectors failed one in five elderly homes in England on the standard of their food last year.

Parliamentary questions put down by Lib Dem MP Paul Burstow revealed that 250 homes missed the standards by a wide margin, and about 1,800 more narrowly.

Rigorous
Mr Burstow and the charity are calling on a celebrity chef to step forward and campaign for better food for the elderly in the same way Jamie Oliver did in his campaign for improved school meals.

A spokesman for the Department of Health said care home residents should always have nutritious, attractively presented, meals and that social care inspectors were rigorous in ensuring standards were met.

This summer celebrity chef Paul Rankin said he would push for improvements in the quality of food served to the elderly in the UK’s residential care homes.

He called for money spent on food in homes to be increased from an average of £18 to £28 a week and for more healthy menus to be introduced.

He became involved after a friend who owns a nursing home in Belfast asked him to help out with the catering.

http://news.bbc.co.uk/1/hi/health/4563392.stm

The move poses a problem for construction group Skanska, the preferred bidder for the scheme, and will sound warning bells for companies that have profited from building large infrastructure projects under PFI, including Balfour Beatty and Amec.

Pressure has mounted on big PFI hospital projects because of the government’s new “payment by results” system. It means that hospitals are paid only for the work they do and for the patients who choose to go to them, not through block contracts. As a result the forecasting of the financial flows that underpin the 25 to 40 year agreements involved in PFI deals has become much more risky.

That, in turn, has raised doubts about whether the schemes, where the costs are largely fixed once a deal is signed, are affordable. Doubts have also emerged about the need for “mega hospitals” now that technological advances have made it possible to treat patients outside the hospital and often at lower cost. Health department officials have already challenged the need to build “monuments on long-term leases”.

Once again the Labour govt is moving the goal posts in the middle of the game and is suffering as a consequence.

Senior NHS executives and Treasury officials say PFI may still work for smaller schemes in the £100m to £300m range, particularly where an entire facility is not being rebuilt.

But question marks are growing over the larger projects. The health department denied there was a specific review under way, saying PFI was under constant review to ensure it delivers value for money.

But a spokesman said: “A number of PFI schemes are reaching a critical moment in their contracting process, and are, therefore, being subjected to the sort of detailed scrutiny that the public would expect in a major procurement. This does not mean there is a freeze on hospital PFI projects.”

The department said it had recently given the go-ahead to a £193m project in Portsmouth and a £129m one in Oxford. But it has asked the trust that runs Barts and the Royal London “to reconsider its plans to ensure the scheme is both affordable and meets local needs”.

As part of that, it should “consider further the inclusion of the Barts element”, which involves a new cardiac and cancer centre.

The trust yesterday insisted its scheme was affordable and had the full backing of local health authorities.

Doubts over the PFI hospital projects have coincided with a dispute between the health department and Monitor, the foundation trust regulator, over who should sign off another big scheme – a new 1,200-bed hospital in Birmingham.

Work was meant to start in July 2005. But questions about financing and affordability have delayed it. The capital cost of the hospital has been put at £696m by the health department.

http://news.ft.com/cms/s/65bafc90-7650-11da-a8a9-0000779e2340.html

But the Department of Health said local health services had the funds to provide adequate maternity services.

“It’s quite astonishing how often that temporary closure turns into a long term closure” says Belinda Phipps of the National Childbirth Trust.

Birth centres are smaller than hospital units, and are not run by consultants. They focus on ensuring births are as natural as possible.

They account for about two per cent of births in the UK. But they are sometimes under- used. The NCT says GPs often do not give women the confidence to try them. There are around 100 such centres across the UK.

The NCT said in November that six units were under threat. But it now says centres in Dover, Petersfield, Fareham, Southport, Devizes, Malmesbury, Wakefield, Guisborough and Romsey are under threat, or had recently been closed. Birth centres in Grampian are also threatened with closure, they suggest.

Some centres have been closed temporarily, but the NCT says there are fears they will not re-open.

Belinda Phipps, chief executive of the NCT, said: “With Christmas coming up we’ve seen a sudden increase in the numbers that are closing – theoretically temporarily, but it’s quite astonishing how often that temporary closure turns into a long term closure and once they’re gone they’re gone, and it’s very difficult to get that sort of service back.

“The NHS requires them to be in place, but if they’re not we really worry that they won’t ever come back.”

The NCT warns the government’s plans to improve maternity services – as set out in the National Service Framework for Children, Young People and Maternity Services – will be jeopardised unless the government backs community-based birth centres.

Ms Phipps added: “We know that access to birth centres helps to increase normal birth rates, giving women with a straightforward pregnancy a better chance of giving birth without drugs, forceps or emergency surgery.”

But she added: “Many women are not being encouraged to consider the full range of choices for birth. As a result, birth centres in some areas appear unpopular, underused by women and unsupported by the local community.

“We fully support government pledges to increase choices for women over where and how they have their baby. Yet their worthy aims are being undermined by the short-term financial difficulties of NHS trusts.

“We are urging the government to consider the needs of the modern day “Mary and Josephs” and support community birth centres.”

But a Department of Health spokeswoman said: “Of course, expectant parents will be able to access maternity services over the festive period.”

She added: “Record investment in the NHS means that local primary care organisations and hospitals have the resources to deliver high quality maternity services.

“It is up to local service providers to decide how best that extra investment can be spent to meet the needs of their local communities.”

And a Scottish Executive spokeswoman said: “We do not recognise these claims at all. Our commitment to community midwife units is well documented and this is set to continue.”

http://news.bbc.co.uk/1/hi/health/4552422.stm

The call comes as interim findings of a joint survey, released today, reveal that over a third of trusts surveyed do not routinely follow government guidelines on the management of C. difficile infection in their hospitals.

The survey aimed to provide more information about C. difficile and the measures trusts have in place to deal with the infection.

The agencies are publishing interim findings now, as winter is when the prevalence of C. difficile tends to be highest. More detailed findings will be published in spring 2006.

The two organisations say trusts should:
* Ensure that their policies on antibiotic prescribing are informed by current guidelines on best practice, and that these policies are properly monitored. Current guidance states that trusts should have up-to-date guidelines for treating specific infections, policies to reduce inappropriate administration of broad-spectrum antibiotics*, and regularly monitor antibiotic usage through audit and feedback to prescribers.
* Review their procedures and capacity to isolate patients with C. difficile. The isolation of patients is an effective method of rapidly controlling the spread of infection.
* Ensure that they understand the criteria for testing and reporting samples of C. difficile, and that they comply with the scheme for mandatory surveillance introduced last year. This requires that all NHS trusts report to the HPA the number of cases of infection caused by C. difficile diagnosed in patients 65 years of age and older.

Questionnaires were sent to directors of infection prevention and control. Responses have been received from 118 of the 173 trusts (68%) in England. The survey showed:
* Thirty eight per cent of trusts surveyed said they do not have restrictions in place to prevent the inappropriate use of antibiotics, which would help to minimise the risk of C. difficile infection.
* Over a third of respondents reported that they are unable to routinely isolate patients with C.difficile infection. Only 11% of trusts said they have a ward that can be used for isolating patients with C. difficile.
* Less than half of trusts surveyed use the same recognised definition of an outbreak. Forty percent reported that, in the event of an outbreak, they do not routinely follow guidance, which recommends that they should inform the consultant in communicable disease control.
* Most of the trusts surveyed also reported that they do not routinely inform the relevant authority that is responsible for monitoring their performance i.e. the strategic health authority, or Monitor in the case of NHS foundation trusts.
* Two-thirds of respondents felt that the reported incidence of C. difficile infection has increased in their trust during the past three years.
* A quarter of trusts reported they had closed wards in the past 12 months due to cases of C. difficile.

Responses confirmed that cases of C. difficile are not confined to older people: 41% of trusts estimated that one out of ten cases affected people under the age of 65.

Respondents thought that the most practical measures to reduce the incidence of infection from C. difficile were: improved prescribing of antibiotics (55% of trusts); isolation of patients (39%); clean environments (32%); and improved hygiene (19%).

Over two thirds of trusts thought that the prescribing of antibiotics and the lack of facilities for isolation represented the greatest challenges to controlling infection.

Despite concerns that the severity of the infection has increased in the past few years, most of the trusts surveyed do not routinely collect clinical data on patients with the infection. Sixty-five per cent of trusts reported that they do not routinely record information on deaths from C. difficile.

Marcia Fry, Head of Operational Development at the Healthcare Commission, said “This survey reflects the views of the trusts of their own arrangements for managing C. .difficile. It is deeply worrying that a significant number of trusts are not managing to implement existing guidance on C. difficile. We recognise that these outbreaks are not easy to control, but trusts must do more to ensure that they have systems in place to protect patients from this potentially lethal infection. We and the HPA will be working with them on this.”

Professor Peter Borriello, Director of the Centre for Infections at the Health Protection Agency, said “Although we are concerned to see that guidance is not implemented in a uniform way among trusts, the results of this survey will help us to improve our surveillance of C. difficile and learn more about how trusts treat patients and tackle outbreaks. This will then inform the way in which we work with trusts to protect patients”

The Healthcare Commission and the Health Protection Agency will incorporate learning from these interim findings, and the final report, into their respective programmes of work.

For example, the Healthcare Commission will take into account trusts compliance with procedures for the control of infection in its annual health check on NHS trusts and its assessment against the expected hygiene code, the legislation for which is going through the House of Commons.

http://www.healthcarecommission.org.uk/NewsAndEvents/PressReleases/PressReleaseDetail/fs/en?CONTENT_ID=4022047&chk;=n0pJM/

It also emerged that Mr Bliar “freelanced” to strike the deal, on Friday night and early yesterday, without speaking directly to his Chancellor, Gordon Brown, at all.

The disclosures, again confirmed by Treasury officials, threatened to open up a fresh and damaging rift between the two men. Under the deal, which followed 17 hours of intensive talks, Mr Bliar promised to surrender a further £1.7 billion of the rebate first secured by Margaret Thatcher in 1984, on top of a previous offer to hand back £5.5 billion.

In return, he secured only a vague promise that the EU would “review” the controversial Common Agricultural Policy after Jacques Chirac, the French president, refused to give ground on the contentious issue of farm subsidies.

The deal provoked a storm of protest from opposition parties. William Hague, the shadow foreign secretary, said: “Seldom in the course of European negotiations has so much been surrendered for so little.”

However, a more serious blow came when the Treasury confirmed that the money being handed over as part of the EU deal, which covers from 2007 to 2013, would have a direct impact on future government spending plans. Officials said there would be between £1 billion and £2 billion a year less than was currently being budgeted for to spend in Britain between 2008 and 2011.

This is the time frame for spending on areas such as health, education, law and order, and transport, which will be formally decided in the three-year spending review planned for the summer of 2007.

“The size of the spending envelope for these years will be reduced,” a Treasury official said.

Asked whether Mr Bliar and Mr Brown had any direct contact in the hours leading up to the deal, the official replied: “No, they didn’t.”

The disclosure is further evidence of the disintegrating working relationship between Mr Bliar and Mr Brown. The EU future funding deal is a particularly sensitive subject because, soon after it comes into operation, Mr Bliar is expected to step down, with Mr Brown taking over.

Mr Bliar was under pressure to secure a deal in Brussels to seal Britain’s six month presidency of the EU, which ends on January 1, and help reinforce his political legacy as a pro-European.

The Prime Minister insisted that the deal secured Europe’s economic future, providing vital new funding for the latest – and poorest – EU member states.

“This is an agreement that allows Europe to move forward,” Mr Bliar told the BBC. “It allows us to demonstrate the right solidarity with the new member states. For those of us who have championed enlargement, this is an important point. And, it has been extremely difficult. It has taken difficult compromises on behalf of everyone. I think it removes one major obstacle to Europe in moving forward in the right, modernising direction, and I’m pleased to have been able to reach agreement.”

However, Mr Hague said: “This is a poor deal for Britain, for the EU, and for the developing world.

“The Government has spectacularly failed to achieve any such guarantees – merely vague promises – of a process of reform, in exchange for which they have surrendered £7 billion in Britain’s rebate alone. Those vague promises have come with a very high price tag.”

The agreement, which followed marathon sessions of talks in Brussels, was brokered with the help of Angela Merkel, the new German chancellor, who acted as go-between in talks with Mr Bliar and Mr Chirac.

In total, the budget package is worth €862 billion (£584 billion), an increase on the €849 billion limit that had been proposed by the Prime Minister when the summit began on Thursday.

http://telegraph.co.uk/news/main.jhtml?xml=/news/2005/12/18/nblair18.xml

Tens of thousands of family homes are sold each year to pay for the cost of long-term care – but many families that should receive help from the state do not.

Ann Abraham, the health service ombudsman, produced new checklists after becoming increasingly frustrated at the haphazard approach taken by many health authorities. She issued her first damning report into the scandal of misapplied means tests nearly three years ago. Yet despite further criticism since then, she still has cases waiting to be reviewed correctly by health authorities.

Ms Abraham found in February 2003 that many elderly infirm patients have been forced to pay for care that should have been funded by the state. This happened because their health authorities failed to assess their case properly. Ms Abraham ordered a review of all cases back to 1996.

The general rule is that, if the care someone needs is personal, such as help with dressing, they must pay for it themselves. If medical care is needed, the NHS should pay.

Since the first report was issued, tens of thousands of cases have been reviewed. But Ms Abraham criticised the Government once again in December last year, as half of the reviewed cases she had looked at had been mishandled. As you can see from the timeline above, the Department of Health (DoH) has failed to cover itself in glory on this issue.

Astonishingly, the ombudsman said this week that it still has more than 500 cases waiting to be reviewed again by Britain’s 28 strategic health authorities (SHAs).

A spokesman for the ombudsman said: “What worries us is that the authorities are still doing it wrong. We have compiled our own checklist, and the DoH has sent it out to SHAs because we want as many people to know about them as possible.

“We want the SHAs to take responsibility for the Primary Care Trusts (PCTs) doing the work. To make sure they have a robust system to assess all cases they need to take responsibility and not think ‘well, the ombudsman will pick it up if it all goes wrong’.

“We want the SHAs to get a firm grip on what’s going on. We don’t want to get involved in batting cases backwards and forwards with the SHA and PCT. We want them to understand what is going wrong, so that it can be sorted out. Not all PCTs have problems; the performance we would describe as patchy.”

The ombudsman’s checklist covers 12 points on the process of the review, and five points on the decision itself.

The process checklist includes an “audit of attempts to gather records said to be not available” and records of deliberations of the review panel at the first and second stage of the care assessment.

The checklists will be available on the ombudsman’s website, at www.ombudsman.org.uk, so that those involved in the process can see what stages their review should go through.

The spokesman added: “It is not for the ombudsman to issue guidance to those responding to individual requests for retrospective care funding in cases. That is for the department.

However, the checklists are consistent with existing good practice advice and the ombudsman hopes that these tools will be of assistance to SHAs and PCTs when planning and conducting care assessments and reviews, and communicating recommendations and decisions.”

A spokesman for the DoH, said: “These checklists are internal ombudsman investigation tools, which emphasise good practice and minimum standards in review and decision-making, based on the ombudsman’s work across the country.

“The checklists represent a new way of working on behalf of the ombudsman’s investigative team, and are intended to streamline the review process and disseminate knowledge gained. They have not been compiled in relation to any specific incidences of poor practice in PCTs.”

Jonathan Ellis, policy manager at charity Help the Aged, said that progress in these review cases has been “extremely slow, and clearly extremely frustrating for people in these situations, and for people on the verge of entering care”.

Mr Ellis stressed that those about to find themselves ensnared in the care system would be unsure who was going to have to pay for what until these issues were resolved.

He added: “The DoH over the last nine or 10 months has been working on a new national framework for continuing care, and they are pinning a lot of hopes on that. It will introduce greater consistency among the 28 SHAs. The work on that is ongoing.

“But as a matter of urgency, the reviews should be resolved. It is scandalous that people are still waiting for a conclusion.”

Sandra Gidley, the Liberal Democrat spokesman for older people, said that the cases that end up with the ombudsman are just “the tip of the iceberg”.

She added: “The scale of the problem is much bigger than the figures suggest. The people who bother to go to the ombudsman are those with the energy to pursue the matter vigorously.

“But it’s a battle in itself to get through the initial process.”
http://telegraph.co.uk/money/main.jhtml?xml=/money/2005/12/17/cmcare17.xml

They found a third of the hospitals visited achieving the highest standards in cleanliness across the board. But two-thirds were not, with mental health hospitals performing particularly poorly out of those in the sample.

Dividing the hospitals into four bands, the Commission found:
* High standards of cleanliness were being achieved in a significant proportion of organisations with 33 hospitals in band one.
* But too many hospitals failed to perform as well as they could with 44 being in band two, indicating they have room for improvement.
* There was evidence of systemic problems in the 23 hospitals that were in bands three and four, indicating that cleanliness was unsatisfactory for an environment in which clinical care is being provided.
* Standards were markedly poorer in NHS mental heath hospitals visited. These made up all six hospitals in band four, indicating serious and widespread problems, plus 18 of the 22 hospitals in bands three and four.

Simon Gillespie, Head of Operations at the Healthcare Commission, said: “ We have found some excellent performance. It is a myth to say all our hospitals are dirty.

“Among the highest scores were hospitals of all types. This shows that Healthcare managers can achieve the highest standards, and all should on behalf of patients. Nevertheless, the findings show that too many hospitals are failing to perform as well as they could. And some have particularly poor standards of cleanliness.”

He added: “Concern about cleanliness has been driven by the prevalence of hospital associated infections and the assumption that poor hygiene is contributing to this.

“If a hospital has dirty and poorly maintained facilities, patients will have little confidence that it can implement the more sophisticated precautions that are needed to prevent infection. It is not unreasonable to expect hospitals to aim to be at the higher spectrum of standard on cleanliness. Our results suggest that this should be achievable.

The Commission carried out the inspections in response to heightened public concern about the cleanliness of hospitals.

It aimed to:
* provide a snapshot of cleanliness in different types of organisation
* send a strong signal that poor standards of cleanliness are not acceptable
* identify next steps for healthcare organisations and national policy makers.

Until now the main information sources on cleanliness have been Healthcare Commission surveys of patients and data from the government’s patient environment action teams, the latter collected by self-assessment at a time agreed in advance.

Commission inspectors looked at: 37 NHS acute hospitals (72 wards and 64 outpatient areas, including 29 A&E; areas); 33 NHS mental health and community hospitals; 11 independent acute hospitals (18 wards and 11 outpatient areas); and 17 independent mental health hospitals (21 wards and two outpatient areas).

The Commission chose the hospitals by using data to identify a selection of apparent poor performers and some good performers. It aimed to get a better understanding of good practice, as well as identify poor practice.

Items looked at included medical equipment, beds, sinks, bedpans and toilets. Inspectors also looked at outpatient departments, and where appropriate A&E; department areas, for spillages, blood, general stains and debris and dust.

The Commission acknowledges that there are differences in the environmental priorities between a clinical environment such as an acute surgical ward and an environment such as a mental health ward.

But the Commission says mental health service users should have the same rights as other healthcare services users to be cared for in safe and clean environment

The Commission also looked at the management and systems in place for cleaning. It found that good management of cleaning services were crucial to delivering good standards. Nearly all the sites inspected indicated that they have a housekeeper role in their cleaning services. They also reported that they regularly audited their cleaning services, reported back to staff and had schedules for cleaning.

All hospitals inspected by the Commission received detailed individual results to help them make improvements.

The Commission will now use the information collected to carry out further inspections of the hospitals rated as performing poorly to ensure that the actions agreed with local management have been implemented successfully.

The Commission will emphasise cleanliness as a priority in its “spot check” inspections under the new annual health check for NHS organisations.

The Commission will work with the Department of Health and National Patient Safety Agency to ensure that the data collected each year on cleanliness in hospitals is consistent and available.

The Commission will build on the evidence for best practice. It will use these results in its more detailed longer-term study of healthcare associated infection that it will undertake early in 2006. The study will enable further analysis of the association between performance on cleanliness and the prevention and control of infection.

http://www.healthcarecommission.org.uk/NewsAndEvents/PressReleases/PressReleaseDetail/fs/en?CONTENT_ID=4021832&chk;=OVjS7C

For more than six years the NHS has received record spending increases. Expenditure has doubled since 1997. This year it will reach £76bn in England alone. Yet, having overspent last year by £250m, the current projection for this year is a £650m deficit – even allowing for alleged surpluses in those parts of the service that have not lost financial control.

NHS finance directors cite the usual list of cost pressures. These undoubtedly exist. Three big, and already generous, pay deals have all come in way over budget, to the tune of hundreds of millions of pounds.

The service has had to put more into pensions. It is possible that the health department has underestimated the cost of hitting waiting time targets.

But cost pressures are not a one-way street. A 7 per cent cut in the price of branded drugs means the overall pharmaceutical bill should barely rise this year, against its regular 10 to 13 per cent cash increase.

So the real reason for the deficit lies deeper. Bob Dredge, a former head of financial reform at the Department of Health and now a senior finance fellow at Keele University, sums it up in one word: culture.

The NHS has a statutory duty to balance its books: making neither a surplus nor a deficit. So there is no incentive to save to invest. Indeed there is every reason not to, as those that do make surpluses risk having to lend them to overspenders.

In addition, NHS finance directors have invented accounting tricks to achieve the book-balancing require-ment: transferring capital spending to revenue which slows developments, putting off paying bills, and even using “unofficial” brokerage: an organisation with a surplus will lend it to a neighbour in deficit for, literally, 24 hours on book balancing day, so both are in exact balance.

The result has been that while the books appear to balance, there are big “underlying deficits” that do not show in the accounts. And the department is ignorant about their scale. The overspend “has not been sudden”, Richard Douglas, the health department’s finance director, said last week. “It has been below the surface for at least the last year or two.”

Until now, the star system that rates the performance of hospitals (and thus of chief executives) has put little emphasis on financial management. NHS trusts have been allowed to overspend by up to £1m before losing a star.

“I’ve heard NHS chief executives say, ‘If I’m going to be £1m over, I might as well be £5m over’,” Mr Douglas said. The chief executive moves on, and the big overspenders get a rescue package.

“That’s how you can go entirely out of control,” Mr Douglas said. “£1m over for each of 600 NHS organisations puts you £600m down the swanee.”

Until this culture changes, the NHS will continue to break its budget. The introduction of foundation trusts might adjust the culture. As free-standing organisations, they do have an incentive to save to invest, as they retain their surpluses. If they overspend over time, they will go bust, with their boards and executives fired.

The department now says it wants to start introducing foundation trust disciplines into the health service more generally. However, that will not stop an overspend quite likely to be bigger this year than last. Nor will it keep NHS staff or keep clinics and hospitals open.

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An email from the office of Sir Liam Donaldson, the chief medical officer, has warned that junior ministers’ statements on spending proposals will not be honoured if they have not previously identified and agreed the source of the money to pay for them.

The cutbacks will undermine schemes that ministers see as a way of saving the NHS billions of pounds by changing people’s lifestyles.

Written by Donaldson’s chief of staff, the email tells officials that Richard Douglas, the NHS director of finance, “has imposed an embargo” on all new unfunded spending.

It suggests ministers’ announcements should be ignored: “Commitment to spend by virtue of an announcement (including ministerial announcements) is not considered a commitment in this context,” it says.

Last month Caroline Flint, the public health minister, announced a programme to deal with alcohol problems at an early age. The health department has not said which programmes are at risk, but the email tells officials that unless a contract is completely signed off, with all finances agreed, the investment should be halted.

It warns that “entering into new contracts on contravention of the embargo” will “commit a criminal offence”.

Many in the public health field have pointed out that changing people’s lifestyles is vital to avoid the bankrupting of the NHS.

Almost seven out of 10 people are classified as overweight or obese, one in ten women under twenty five is thought to be carrying clamydia, one in four smokes, while alcohol consumption is also climbing.

Meanwhile, a health service quango has turned down requests to fast-track approval in England and Wales for a cancer drug that has been approved for use in Scotland for more than a year.

The National Institute for Health and Clinical Excellence (Nice) is under pressure to carry out a special analysis of Arimidex after trials revealed it outclassed Tamox-ifen, the current standard treatment.

Cancer specialists believe Nice is stalling because the health department has insisted it should carry out a large, simultaneous study into Arimidex and two similar hormone-based anti-cancer drugs. Doctors would rather a single study was carried out which could result in faster approval.

It is thought Arimidex could be suitable for treating 75% of the 32,000 women a year in the UK who contract breast cancer. It would cost £68 a month per patient and the total cost to the health service would be about £20m a year.

Joanne Rule, chief executive of the charity CancerBACUP, said: “Reform of the system is a life-and-death issue for cancer patients. We have to speed up the way new cancer treatments are assessed.”

The health department said: “We are currently reviewing spending plans for the year against available resources.”

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There is still no service- level agreement between local PCTs and the trust – and there is unlikely to be one for the rest of the financial year – but agreement has been reached for the routine operations to restart.

Local PCTs, led by Crawley, originally intended to commission 5,000 routine treatments from other hospitals. Around half of an initial tranche of 3,000 have been carried out.

But it is now possible that some patients waiting for operations will return to Surrey and Sussex in the next few weeks. New referrals will also be made to the trust and normal elective work will resume there from the end of the month.

Crawley PCT said the final cost of the 3,000 transfers is likely to be £5m – which it admits is more than the cost of doing the work at Surrey and Sussex.

Surrey and Sussex Healthcare trust chief executive Gary Walker said: ‘The trust needed to reduce its costs to live within its means. In doing so, it had to reduce capacity which has led to the transfer of patients.

‘Given the high cost to transfer these patients, the trust and the local PCTs have been working together since September to ensure that there are no further transfers.’

The reprovision resulted in the temporary closure of theatres at Crawley Hospital and a loss of potential income for the trust, which was £31m in the red at the end of the last financial year.

Crawley PCT said the work had been carried out at a number of other sites, including Dartford, Sidcup and Chichester.

Some work was done at Redwood diagnostic and treatment centre in the grounds of the East Surrey Hospital – part of the trust. The treatment centre is privately owned but all capacity is contracted to the NHS.

Crawley MP Laura Moffatt said she had opposed the reprovision from the start, but it had been put forward as a short-term way of saving money.

Some patients had been unhappy with being offered treatment up to 40 miles away, but Crawley PCT said it had supported them with transport arrangements.

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By November, the battle for NHS funding for Herceptin for women with a certain aggressive form of early-stage breast cancer was all over the media and being discussed in parliament. The publicity culminated in a dramatic order from health secretary Patricia Hewitt that if a clinical case can be made in these cases primary care trusts should fund the drug.

This is despite the fact that its use for this purpose has not been approved by the National Institute for Health and Clinical Excellence – and some say its efficacy is unproven.

However, for an NHS wrestling the twin beasts of enormous deficits and major reorganisation, the effects could be dramatic.

According to the Department of Health, about 5,000 of the 35,000 women diagnosed with breast cancer in the UK every year have the aggressive form containing the protein HER2, for which Herceptin can be prescribed.

Charity Breast Cancer Care puts the annual cost to the NHS of each patient’s treatment with Herceptin at £21,800, which has led the DoH to calculate that the drug could cost the service ‘about £100m’ a year.

How can this extra cost be absorbed? Many PCT managers recoil from the notion that there is a cost point at which they must say that these citizens’ lives are simply too expensive to save – or at least prolong. They say, however, that their duty is to apportion funds for a financial year, accounting for treatments on the basis of the needs of their entire population.

A central aim of the current reconfiguration of primary care is to strengthen commissioning and planning, but effective long-term strategic thinking is hampered by DoH diktats in the middle of the financial year to spend money that has long since been allocated (and in many cases exceeded).

At least two strategic health authorities estimate that the cost to each of them of funding Herceptin for the remaining six months of the financial year is around £2m.

Many senior managers are furious about the situation, but fears over job security engendered by the PCT reconfiguration mean that even fewer than usual are willing to make a stand against political interference.

And ministerial visits to PCT chief executives at the centre of the row have produced some dramatic turnarounds: North Stoke, for example, changed its mind about funding Herceptin within 48 hours of Ms Hewitt’s decision to drop by and visit it.

One senior manager describes the political ‘interference’ in difficult local decisions over Herceptin funding as ‘outrageous’ – and they are not alone in their view.

‘Herceptin is a highly promising but very expensive drug, and its case for treating early-stage cancer is as yet unproven,’ says David Lock, head of law firm Mills and Reeve’s health department and a former government minister. ‘From the patient’s perspective it could be a lifesaver, but should NHS bodies be bounced into prescribing it for those who might benefit, in advance of clear proof?’

Mr Lock’s concerns were echoed during a special parliamentary debate in early November. MPs of all parties called on Ms Hewitt to put money behind her October statement that PCTs must fund Herceptin if the clinical case is made.

Labour MP for Staffordshire Moorlands Charlotte Atkins, a member of the Commons health select committee, said she was delighted with Ms Hewitt’s decision.

But, speaking during the parliamentary debate, she said the government should not expect cash-strapped and over-burdened PCTs ‘effectively’ to take on the role of NICE in a ‘highly charged, emotive atmosphere’. She said extra funding should be more available to fund individual cases such as the one in Somerset that precipitated the debate in the media and then parliament.

‘Trusts cannot say “we will invest this money now to save it over the next five or six years,” because each PCT has to stay within its budget year on year,’ said Ms Atkins. ‘I have suggested to the secretary of state that in the short-term such cases should be funded not by the PCTs but by the NHS Bank.’ She argued that the cost of Herceptin will come down over the next 25 years and therefore ‘the NHS Bank should fund the drug over 25 years and reimburse PCTs accordingly’.

However, there is only so much cash in the system – and most of it has been spent before it is even available. Eastern Birmingham PCT chief executive Sophia Christie is adamant that she will not bow to political or media brow-beating, but stick to the decisions already taken. And these have been based on meeting the commissioning requirements of the whole population.

‘The [commissioning] network [for Birmingham and Solihull, which she chairs], after proper debate at the beginning of the financial year, did not decide to prioritise Herceptin as it remained unlicensed [for this use], its case has not yet been proven, and the view was taken on balance that this intervention was not the most cost effective. We need to take into account all the evidence and make proper commissioning decisions based on firm evidence – otherwise what is it PCTs are being asked to do?’ she argues.

Ms Christie adds that her network calculates that funding the drug would cost Birmingham and the Black Country SHA over £2m for the six months to the close of the current financial year.

However, she says the anger felt among PCTs focuses on process rather than cost. ‘That money can only be found mid-year by cutting something like specialist child services, cardiac, other cancer services or long-term conditions,’ she says. ‘Having said we must spend the money, will the secretary of state tell us which of those services she is happy for us to cut?’

A recent report by leading European health economists argues that health economies must take a more cautious approach. Ghent University’s Mattias Neyt argues in the journal Annals of Oncology that countries will have to be ‘prepared to reallocate resources, get rid of other treatments that are no longer cost effective and drive a hard bargain over the cost of the drug,’ if they are to stand the financial strain this ‘expensive’ drug would put on them.

Inevitably the government sticks to its mantra that the NHS has had ‘record amounts of funding’. However, responding to a question about whether the DoH would provide emergency funding to PCTs to fund Herceptin, health minister Jane Kennedy said: ‘If PCTs are having specific cost problems they should speak to their SHA’.

City and Hackney PCT chief executive Laura Sharpe said that her organisation put aside £25,000 at the beginning of the year specifically for funding Herceptin, should the need arise. However, it has already agreed to fund one patient at a cost of £24,000, and an additional case is looming on the horizon.

Ms Sharpe argues that NICE should assist the NHS in the very difficult decisions that have to be made. ‘It should be saying this intervention is more effective for population gain than that – it’s a rationing debate that we don’t have at the moment and cases like this just show how desperately it’s needed,’ she says.

Meanwhile, PCTs in Manchester and Leicestershire, Northampton and Rutland have announced that they will fund the treatment according to strict criteria. But according to Mr Lock, the legal system has always backed the right of health organisations to refuse treatments on the grounds that they reached a fair decision based on the needs of their whole population – to whom they have a statutory obligation.

Choice may lie at the heart of government policy. But in the case of Herceptin, the interplay between funding and the patient voice has seldom been more complex – or painful.

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The decision is “a serious setback for the government’s flagship policy for reforming the NHS,” David Hunter, professor of health services management at Durham University, said yesterday. It may also mean further extension of the system, by which money follows the patient, would be delayed a second time.

“Payment by results” hospitals are paid a fixed price for each patient they treat, rather than agreeing activity and finance levels at the start of each year.

Hospitals that treat more patients get more income, creating the competition the government believes necessary to improve health service efficiency.

For most hospitals, payment by results applies only to waiting-list operations. Moves to extend the scheme last April to include out-patients and emergencies were put off until April 2006 amid fear of financial chaos.

Last night the health department said it still intended to broaden the system. Ministers would “not make final decisions on the details until after their preparatory work”.

Hint of a possible delay came as the King’s Fund health think tank warned the NHS’s financial problems would worsen unless the government formed a regime to deal with hospital failure.

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‘In many areas the basic model of service has changed little over many years, even though needs have changed and increased markedly,’ the report states.

NHS Confederation policy manager Jo Webber told HSJ that primary care trusts must keep sexual health services ‘in their minds’ despite the fact that ‘everything else is moving around’.

She warned PCTs against losing the partnerships they had built with local authorities on sexual health and added that there was still a lot of work needed to ensure that sexual health services were ‘locally responsive to local needs’.

The report says that it is imperative that the ‘extra £250m funding announced by the DoH for PCTs to help achieve improvements in sexual health is fully utilised’.

Terrence Higgins Trust deputy chief executive Paul Ward said the extra cash ‘must get to the front line’.

He called on the government to introduce a sexual health policy that would ‘expand capacity and redesign services as well as establishing community-based and community-led services’.

To meet public service agreements and local delivery plan targets, both organisations call for much greater development in community health and care services.

They also want to see policy introduced in three key areas: strengthened sexual health promotion; improved access to sexually transmitted infection, contraception and abortion services; and better management of HIV.

BMA calls for neighbourhood diagnostics
Neighbourhood centres where patients can access diagnostics, outreach services and social services as well as GPs is a key proposal contained in the British Medical Association’s submission on the healthcare outside hospitals white paper.

The centres would also provide patients with extra clinical services and information on how to manage long-term conditions.

The BMA wants to see hospital doctors and public health professionals involved in practice-based commissioning. But it warns that ‘to be most effective, many specialist services will have to remain in the hospital setting’.

The association also warns that if private sector provision is increased there should be a ‘level playing field’ with existing providers.

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These include: money following the patient, with hospitals paid only for the work they do; foundation hospitals becoming free-standing organisations outside the direct control of the health department; the arrival of competing private providers; patients being given a choice over where they are treated; and moves to give family doctors shadow budgets with which to buy care.

The changes, combined with factors such as technological change and further cuts in junior doctors’ hours, threaten the viability of some hospitals.

A revamp of the way the health care market is regulated is also needed to cope with the changes.

Tony’s Cronies
Mr Corrigan is the husband of Hilary Armstrong, the government’s chief whip- who was castigated as a “shouting child” by teh Conservative leader David Cameron in PMQs yesterday. Corrigan was a special adviser in the health department for four years up to this year’s general election and played a key role in devising the changes. He replaces Ian Dodge, a civil servant who will return to the health department.

A Whitehall insider said: “Paul spent four years trying to get his head round this so he is probably four years ahead of everyone else in trying to understand its consequences and work out what needs to be done.”

The insider added that given the unrest on Labour’s backbenches over the health reforms, there was also a need for “a political take” on the whole reform process as well as a technical one: something that it was difficult for Mr Dodge, as a civil servant, to provide.

Since leaving the department, Mr Corrigan has worked as a consultant and published work warning that the government needs “a failure regime”, not just for hospitals but for primary care. Some family doctors may fail to attract sufficient patients in an era of patient choice, he has warned.

He also argued that family doctor practices are too small and need to be organised into bigger units so they can borrow money to provide high-quality diagnostics and much more care outside hospitals.

He argues that “size matters” in primary care if millions of episodes of care are to be successfully moved out of hospital. If the NHS fails to do that, he has said, it will be in trouble.

His appointment comes as some people are blaming the health service’s financial problems on the early stages of reform. For the first time this year, trusts are being paid for non- urgent surgery by numbers of patients, not a block contract.

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Conservatives and Liberal Democrats said hospitals were cutting patient services because health service finances were “spiralling out of control”.

The figures are a serious embarrassment for the Government, which has raised tax and National Insurance to finance record spending on the NHS, reaching £74.5 billion this year.

Miss Hewitt said the figures were being published to try to increase openness and to make clear that “inefficiency and poor financial management” were not acceptable.

She said the Government intended to ensure that the position at the end of the financial year would be “significantly better” than yesterday’s mid-year prediction.

Miss Hewitt said the teams would not compromise the service to patients. “They will focus on ensuring that organisations deliver the efficiency and quality improvements needed to achieve financial balance and better care,” she said. The figures are a personal embarrassment for Miss Hewitt, who faced criticism last week over the shortage of flu vaccines.

The British Medical Association, which represents doctors, welcomed the release of the figures and said it had been trying for some time to tell the Government about the health service debt crisis. It said that trusts were facing the biggest and most radical reform in health policy since the inception of the NHS. They needed support, not to be thrown in at the deep end and left to swim- or more likely sink.

The Liberal Democrats said Government reforms had created “massive instability” in the NHS. Steve Webb, their health spokesman, said that many hospitals were having to make swingeing cuts. A “roller-coaster” of NHS finances made it impossible to plan effectively.

Andrew Lansley, the shadow health spokesman, said that finances were spiralling out of control and the net deficit had more than doubled since last year. He said that much of the money had been “swallowed up in bureaucracy”. Since 2000, an extra £1.6 billion had gone on administrative staff. “Patients will bear the brunt of this financial mismanagement as front-line services are cut to balance the books.”

Sir Nigel Crisp, the chief executive of the NHS, said he expected the final deficit to be closer to £200 million, which would be covered by “savings elsewhere”.

He denied that the Government was planning a financial bail-out of trusts in difficulty. “Those organisations will have to repay any debt.”

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Health Direct warns that these “hit teams” will be extremely expensive as they are consultants from the private sector. not from any organisations with any medical specialiality but bean counters from McKinsey and PwC.

Hospitals and primary care trusts are being put under intense pressure to balance their books. It is embarrassing for the Government that the NHS runs at a deficit after a period in which it has been given huge budgetary increases.

Andrew Lansley, the Shadow Health Secretary, said: “NHS finances are spiralling out of control — the net deficit has more than doubled since last year . . . Patients will bear the brunt of this financial mismanagement as frontline services are cut to balance the books.”

Ms Hewitt published the figures in a written ministerial statement, which also announced that “turnaround teams” of financial and management experts would help to address the problems.

She emphasised that most NHS trusts, primary care trusts and strategic health authorities were managing their budgets successfully. At the same time last year, she said, the forecast was for a deficit of £499 million. The actual outcome was about half that.

NHS managers had told the Health Select Committee that the new contracts for consultants and GPs had cost almost £400 million more than expected. Agenda for Change, which deals with pay arrangements for other NHS staff, was also over budget, although by “nowhere near” the £900 million that has been reported.

Sir Nigel Crisp, chief executive of the NHS, said that he expected the figure would be reduced to £200 million by the end of the year. Richard Douglas, NHS director of finance, said that there was always a “degree of pessimism” within trusts at certain times of the year.

Paul Burstow, MP, a Liberal Democrat member of the committee, said: “The Government’s approach to reducing the deficits is to take even more money away from those local organisations in the red. This will be a recipe for chaos and cuts in local services.”

Jo Webber, of the NHS Confederation, which represents more than 90 per cent of organisations in the health service, said that it was sensible to agree a planned deficit of £200 million with strategic health authorities for this year. “We should not lose sight of the fact that NHS organisations and their staff are delivering real improvements in patient care — and most are doing that within budget,” she added.

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But Treasury officials and the NHS Confederation, which represents health authorities and trusts, fear this year’s overspend will turn out much worse than £200m. Treasury officials believe it could be “several hundred millions” higher.

The overspend appears to make a mockery of previous statements by Sir Nigel Crisp, the NHS chief executive, that health authorities and trusts needed to get into surplus over the next couple of years to provide an investment cushion beyond 2008, when the growth in health spending is expected to halve.

There is dramatic evidence of the severity of the problem in Suffolk and Surrey, where two primary care trusts have told staff and GPs that they might not be able to pay them for the last month of this year.

Some NHS hospitals, particularly but not exclusively in London and the south-east, are shedding staff and delaying admissions to reduce projected deficits.

Leaked letters from one Surrey PCT shows it is planning to admit no non-urgent patients for four months, until April 1, unless they already have a date booked for their operation. Harrow PCT has said the maximum six- month wait for non- emergency surgery will have to become the minimum. It and others are telling outpatients they will have to wait a minimum of 10 weeks for a non-urgent appointment.

The NHS Confederation said that although two-thirds of NHS organisations were in financial balance, they were all under pressure from three big pay awards: one for consultants, one for family doctors and another still being implemented for all other NHS staff.

Nigel Edwards, the NHS Confederation’s policy officer, said awards had cost far more than budgeted. But the worst overspends were also concentrated in certain parts of the country “where there are unresolved strategic issues”, he added.

These included Surrey and Sussex “where there are probably two to four too many hospitals but no one over the years has taken a decision to deal with that”. Hertfordshire has five hospitals “when it probably needs three” and the same applies in Avon and Gloucestershire where overspends are high and there is probably at least one hospital too many, Mr Edwards said.

Chris Ham, professor of health services management at Birmingham University, said some targets the health department has set, and which the NHS is hitting, have probably not been costed properly.

He added: “But when there are a relatively small number of NHS organisations – 30 to 40 – so out of control that they are running massive deficits, it does suggest there is a lack of the necessary financial management skills, or that chief executives, or their boards, are not taking financial discipline seriously enough.”

Andy McKeon, head of health at the Audit Commission, whose auditors since March have issued more than two dozen “public interest” reports warning of mounting financial difficulties at various NHS organisations, said the figures “do suggest that those people who have got into financial difficulties are finding it very difficult to get out and are getting into further difficulties. Some seem to be going further down rather than recovering.”

The commission has repeatedly warned that NHS financial management needs to be improved as it faces “unprecedented challenges” from the new market.

HEALTH SERVICE’S PROJECTED OVERSPEND
Actual deficit 2004-05:
NHS organisations: £219m
Foundation trusts: £37m
Together, approximately 0.3 per cent of NHS funding

Current projected overspend 2005-06:
NHS organisations: £623m
Foundation trusts: £20m
Together approximately 0.8 per cent of NHS funding

The potential deficit is made up from those organisations projecting a £948m overspend, offset by those projecting a £325m surplus. About a quarter each of NHS trusts and primary care trusts are projecting overspends. But 37 organisations, about 7 per cent of the total, account for two-thirds of the gross deficit of £948m

NHS spending has doubled since 1997 to £76.4bn in England this year. It will have almost tripled by 2008

Sources: Department of Health and Monitor, the foundation trust regulator

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A large number of acute trusts were also facing financial problems last year. Of the 84 ‘significant control issues’ – those which prevent or hamper plans to meet public service agreement targets or stay within resource limits – more than half concerned trusts’ financial position.

The statement of DoH resource accounts for 2004-05 details where the funding increases have gone in the NHS: £1.4bn was spent on additional staff (8,050 doctors and 11,160 nurses, midwives and health visitors), £0.8bn on additional prescribing and another £0.8bn on goods and services.

A further £1.2bn was used to fund training, research and capital infrastructure, including the construction of six new hospitals. And £2bn was spent on extra pay.

The report also reveals that the DoH underspent by £1.7bn in 2004-05. However this figure does not include the surplus or deficits of trusts and the performance of certain arm’s-length bodies.

The accounts of the arm’s-length bodies were all signed off with the exception of the NHS Pensions Agency, where issues relating to the management of student grants had arisen and ‘are being addressed’.

The report confirmed that NHS organisations incurred a deficit in 2004-05 of around £250m – less than 0.5 per cent of the NHS budget.

The report was written on 26 October, the day after health secretary Patricia Hewitt said community staff would continue to be employed by the NHS unless and until the PCT decides otherwise.

Nevertheless, the document still states that ‘changes to PCT service provision will be complete by 2008′.

The accounts also reveal the salaries of the top civil servants at the DoH (see below).

Salaries of the departmental board, 2004-05
Sir Nigel Crisp, chief executive of the NHS: £210-215,000
Sir Liam Donaldson, chief medical officer: £175-180,000
Sarah Mullally, chief nursing officer (to Sep 2004): £65-70,000
Christine Beasley, chief nursing officer (from Oct 2004): £125-130,000
John Bacon, director of delivery: £170-175,000
Sian Jarvis, director of communications: £130-135,000
Hugh Taylor, director of strategy and business development: £130-135,000
Richard Douglas, director of finance: £125-130,000
Stephen O’Brien, director of strategy (from June 2004): £125-130,000

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This is despite spending on health improvement and public health in Scotland rising from £26 million a year in 1999 to £240 million now. The total NHS budget for Scotland is about £8 billion a year.

The report on health changes between 1998 and 2003, published yesterday by the Executive, found that smoking among girls aged 8 to 15 had doubled and the number of 15-year-old boys who drank at least once a week had risen from 9 per cent to 15 per cent.

The Executive said yesterday that efforts to change the lifestyle habits of Scots would not succeed overnight and had to be judged over a 10 to 20-year period. A spokeswoman pointed to some chinks of light in the gloom, with rates of physical activity increasing and fewer people eating chips or consuming fizzy drinks.

Andy Kerr, Scotland’s Health Minister, insisted that work was being done to tackle Scotland’s health problems and said that since 2004 ministers had driven forward changes aimed at shedding the country’s “sick man of Europe” tag. “We know that Scotland is facing major issues such as rising obesity levels and increased alcohol consumption, particularly among women. It is also disappointing that smoking and alcohol consumption among 15-year-olds is on the increase,” he said.

The report showed that while fewer older Scots were smoking, there had been an increase in young smokers. The ban on smoking in all public places in Scotland comes into force on March 26 and ministers hope this will be a major factor in reducing smoking among the young.

The number of female binge drinkers increased from 16 per cent to 19 per cent and the number exceeding weekly recommended limits went from 15 to 17 per cent. The survey also showed the number of girls aged eight to 15 who smoked doubled from 3 per cent to 6 per cent but fell slightly among boys in the same age group.

The survey showed that approximately one third of men and women in Scotland still smoke despite the barrage of bad publicity over the years.

While physical activity in people aged from 16 to 74 increased, the survey also showed that obesity among men and women increased from 19 per cent to 22 per cent and 21 per cent to 24 per cent respectively. Type 2 diabetes, which is linked to the increase in obesity levels, went up in men from 1 per cent to 2 per cent with a smaller rise among women. Obesity among boys aged from two to 15 went up from 14 per cent to 18 per cent but in girls dropped slightly.

Recent figures from the Office of National Statistics showed that Scots could expect to die younger than people in the rest of Britain and Glaswegians died younger than people elsewhere in Scotland.

The lowest age for death for both men and women in 2002/04 was 69 in Glasgow and out of the ten local authorities in Britain with the lowest male life expectancy at birth, seven were in Scotland.

The SNP MSP Bruce Crawford called for a rethink on the extension of opening hours for pubs and clubs. “These hugely disappointing figures starkly underline the fact there is a drinking culture in Scotland which is only getting worse. Scotland is clearly not ready for up to 24-hour drinking,” he said.

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