But she added that some “very difficult” decisions would be needed in parts of the NHS where “too many services are being delivered from too many different places in a way that is very expensive and very inefficient”.

This would mean “reorganising services, reconfiguring hospitals, doing more treatment and diagnostics in the community, in primary care centres and community hospitals”.

Two separate surveys yesterday showed more than three-quarters of NHS chief executives saying that the areas with the worst financial problems could not solve them without the redesign and closure of services.

The NHS Confederation, which represents health authorities and trusts, said this left the government facing “a stark choice between continuing financial instability and tough political decisions”, even before the implementation of its more radical policies. These in-cluded giving patients a choice of hospitals and “payment by results”, in which hospitals were paid for the number of patients they treated, not through service level contracts.

Ms Hewitt acknowledged that politicians would have to argue the case. Changing medical technology and redesigned services would produce better patient care, and the service could not “do everything, or as much as we are currently doing, in acute hospitals”, she said.

Three-quarters of the NHS is in financial balance. But Ms Hewitt’s admission points to a controversial series of rationalisations, reconfigurations and possibly the closure of some hospitals in Sussex and Surrey, west London, the home counties to the north in Hertfordshire, and in parts of Hampshire, Kent, Lancashire and Yorkshire and possibly in Wiltshire. These are all areas where there are structural underlying deficits as well as current overspends.

Few hospitals are likely to close. But many more could lose accident and emergency departments and the full range of procedures as services are concentrated on fewer sites and in some cases moved out of the hospital entirely. Despite admitting the need for serious structural change in some areas, Ms Hewitt confirmed she was further extending the “payment by results” system, which is currently used for waiting list cases.

This will mean the system is applied to accident and emergency, urgent operations and outpatients. Officials said for a typical district general hospital that would mean about 60 per cent of its income would depend on levels of activity, not on block contracts.

Ms Hewitt insisted that “payment by results” was not causing the NHS’s financial problems, but making them transparent. Some hospitals and areas had failed to redesign activity to get best value and match finances, she said, in effect borrowing from others for years. This practice had to stop.

Dr Gill Morgan, chief executive of the NHS Confederation, said politicians needed the courage to let managers “take difficult decisions that will benefit patients in the long term”. This meant getting away from a fixation with hospital buildings and focusing instead on the services delivered. “Loss of beds does not necessarily equate to a decline in services.”

Dr Morgan called for historic debts to be restructured. However, Department of Health finance officials said debts would have to be cleared, not written off.

http://news.ft.com/cms/s/dc740782-8e10-11da-8fda-0000779e2340.html

On Thursday, Ms Hewitt will issue the first rulebook for NHS managers in an attempt to eliminate the financial deficits threatening to destabilise reform plans for hospitals and primary care services. She is expected to say that financial management must have a higher priority than clinical objectives during the coming year, a shift expected to enrage medical staff.

Ms Hewitt is determined to eliminate the “handout culture” she thinks may have been responsible for a quarter of trusts veering into the red in 2005/6. Their half-year accounts forecast overspending totalling £948m by the end of March. Many have resorted to emergency measures to cut spending, such as postponing operations until the new financial year, freezing staff vacancies and withholding tax and national insurance payments.

The health secretary will issue the “Business Arrangements” manual explaining how NHS finances should be controlled during 2006/7, when her reforms are due to create unprecedented instability in the service. She will say: “Excellence in financial management is the prerequisite for high quality sustainable services.” Trusts will have to say goodbye to “a culture of balance sheet adjustments and handouts” that allowed hospitals to tolerate inefficiency on the assumption that the NHS would bail them out.

The rulebook will make it clear that strong financial management has moved from the bottom of Ms Hewitt’s list of priorities to the top. Until this year, hospitals could fairly accurately predict the number of patients they would be expected to treat. They agreed contracts with local primary care trusts guaranteeing most of the income they needed to do the work. Patients can now choose, however, from a menu of at least four local NHS trusts where they are entitled to free treatment. Consequently, hospitals can lose income if they do not attract enough patients.

The fee they get for each attendance is also being priced differently. A national tariff was set last April for all non-emergency operations. If a hospital spent more than the norm for a particular procedure, it lost money on every patient treated.

The government had already warned trusts that this system of payment by results would be extended in April. Ms Hewitt will set a national tariff for every hospital activity, except critical care for a tiny minority of the most seriously ill patients.

In a new twist, Ms Hewitt will also create incentives to keep patients out of hospital if they can be cared for better, or more economically, by GPs and healthcare staff in the community. The rulebook will explain how “practice-based commissioning” will give GPs some control over the services available to their patients.

Ms Hewitt disputes reports suggesting that the NHS is in crisis in 2005/6, and the rulebook may explain how trusts can build up small surpluses as a cushion for the years after 2008 when the Treasury intends to reduce the pace of NHS growth.

A survey of trust chief executives by the Health Service Journal found that 63% of acute hospital trusts have been forced to close wards to reduce outgoings, 75% have frozen recruitment and 26% are planning to withhold tax payments until the new financial year. Yet 37% still expect to be in deficit. The Department of Health said the poll was unrepresentative.

http://www.guardian.co.uk/frontpage/story/0,,1692810,00.html

It announced that its Appraisal Committee is now recommending three drugs as “options for people with Alzheimer’s disease of moderate severity only”.

Andrew Dillon, NICE Chief Executive and Executive Lead for the appraisal, said: “People with Alzheimer’s will now get these drugs when they can help them most. Patients and those who care for them will be able to feel more confident about gaining benefit from them.”

Last year’s draft guidance was widely condemned and NICE received an unprecedented response from doctors and campaigners calling for a rethink.

In the draft, NICE accepted that donepezil, rivastigmine, galantamine and memantine – known as cholinesterase inhibitors – could alleviate the symptoms of Alzheimer’s, but said they were not cost-effective for NHS use.

The drugs cost £2.50 a day, and carers say they help them cope with people with Alzheimer’s because they reduce the symptoms which make care more difficult.

The fourth drug, memantine, is not being recommended as an option.

The Alzheimer’s Society estimates some 72,000 people have mild Alzheimer’s in the UK, with around 309,000 in the moderate to severe category.

Neil Hunt, of the Action on Alzheimer’s Drugs alliance, said: “We welcome the fact that Nice has acknowledged the effectiveness of drug treatments”.

However he said the draft placed “severe restrictions” on access to the drugs.

He said sufferers in the later stages “benefit enormously” from Ebixa (memantine), while withholding treatment in the early stages was “unethical”.

The watchdog says the recommendations are subject to consultation, and until then the 2001 guidance is still in force. The original guidance for donepezil, rivastigmine, and galantamine recommends their use for all patients with treatment stopping when they no longer have an effect.

When the guidance is published – it should be in July 2006 – it will apply to newly-diagnosed patients only.

http://news.independent.co.uk/uk/health_medical/article340389.ece

More than two-thirds of chief executives said the NHS would not be facing such severe financial problems if it were not for ‘inflexible government targets’ such as the four-hour accident and emergency wait.

And 99 per cent agreed that Agenda for Change and the consultant and GP contracts were not costed effectively by the Department of Health, and that this has had a big impact on the financial state of the NHS. Eighty-six per cent agreed strongly with the proposition.

One respondent to our survey of mental health, acute and primary care trust chief executives said: ‘In 30 years I have never experienced such chaos and paralysis and I hold ministers and the DoH absolutely responsible.’

Another said: ‘The DoH is responsible for negotiating Agenda for Change and the consultant and GP contracts so it should be accountable for the financial consequences,’ he added.

Another asked: ‘Who in their right mind would ever give their staff a pay award before agreeing what the productivity improvement will be?’

The ‘short-term nature’ of NHS targets was singled out for criticism by one, and another said: ‘The government has put too many changes in place at the same time without considering the impact on the service. Targets are set nationally; locally we try and meet these and then we get the blame when the targets and funding don’t balance.’

NHS Confederation policy director Nigel Edwards agreed that targets were costing trusts more than expected. ‘Some places have discovered that they are experiencing diminishing returns in meeting the targets. One strategic health authority has told me that it cost £15m just going from the 95 per cent to 98 per cent A&E; target, and it cost one trust £1m alone.’

Only 39 per cent of chief executives believed that the calibre of finance directors is a major factor. One senior figure said the government was wrong to blame management failings for the financial crisis: ‘If it is a failure of management, the system put these managers there, they appointed them and are responsible for holding them to account.’

Chief executives also blamed the introduction of the private sector for the problems: 66 per cent said the policy had destabilised parts of the NHS.

SHAs accused of piling debts on ‘bad apples’
Debts are being heaped on trusts by some strategic health authorities so the financial crisis can be put down to a ‘few bad apples’, King’s Fund chief economist John Appleby has claimed.

Questioning the credibility of SHA projections to the Department of Health, Mr Appleby said some authorities ‘centralised’ their deficits because the pressure to present a reasonable picture to the government was ‘immense’.

‘The reality is that most, if not all organisations are suffering to some degree financially. If you have got 10 hospitals in an area and they all have a deficit of £2m that could look worse than if you have two with a £10m deficit each,’ said Mr Appleby.

‘It implies something about who is to blame. If you have just a couple of hospitals with big deficits you can start to say it’s bad management. If every hospital had a deficit it would send out a different message. The finger could start to point upwards in the system.’

http://www.hsj.co.uk/nav?page=hsj.news.story&resource;=4047199

The fast-track system was negotiated with the Criminal Records Bureau by the Department of Health in summer 2002 against a backdrop of crippling delays in criminal record check during the CRB’s first year of operation.

Under the system, new employees can be cleared to start work if they do not appear on the Protection of Children Act 1999 (POCA) list of people banned from working with children.

The list – maintained by the Department for Education and Skills on behalf of the DoH – contains names of people deemed unsuitable to work with children on evidence referred to either the health or the education secretaries by employers.

Like ‘list 99′ – the list of teachers with a ban or restrictions on working with children – the POCA list of NHS employees is not cross-referenced with criminal record information. Instead, an enhanced CRB check of individuals is carried out, which would include the sex offender register and local police information checks. But staff applying to work for the NHS can start work before the checks are completed.

Information is not usually sent to trusts until at least one month after the person has started work. And in some areas where local police systems ‘are not adequately resourced’, trusts can wait four to six months for reports, according to NHS Employers senior business manager Gordon Fleck.

Mr Fleck said there was ‘a possibility’ that a known sex offender could fall through gaps in the system. However, he said NHS Employers would like the fast-track system to continue until new legislation introduces a universal barring and vetting scheme for all NHS staff in about a year’s time.

‘In the light of recent events, we will have to look at whether staff should be allowed to start work before full CRB information is available,’ said Mr Fleck. ‘But our response has to be balanced with consideration of whether it’s feasible to expect employers and employees to wait months between appointment and starting work.

‘Look at what happened when the DfES said all staff must be cleared following the Soham inquiry – it led to such a backlog that schools remained closed at the start of term and kids were running around the streets – it was nonsense,’ he said.

The role of list 99 has hit the headlines in recent days after education secretary Ruth Kelly admitted that the DfES had allowed sex offenders whose names were on the list to work in schools.

Asked about checks on potential employees to detect sex offenders, health secretary Patricia Hewitt said the NHS will be ‘strengthening them even more’ in line with new legislation set to be discussed in parliament next month.

http://www.hsj.co.uk/nav?page=hsj.news.story&resource;=4047103

Almost two-thirds said they had been forced to close wards to bring their finances under control and nearly half said they had postponed building work.

The questionnaire survey by the Health Service Journal was sent to more than 500 chief executives, of whom 117 replied. More than one in three (37 per cent) said they were heading for a deficit by the end of the financial year.

The findings came after ministers announced yesterday that a further 18 hospitals had been approved to apply to become NHS foundation trusts, which enjoy greater financial freedoms.

However, the RCN said the financial crisis in the NHS was deepening and foundation trusts were hardest hit, with more than half overspent.

Government figures published before Christmas showed NHS trusts were heading for an overall deficit of £620m, half the figure calculated by the RCN.

Barbara Tassa, chair of the RCN public policy committee, said: “Patients are suffering and nursing posts are being lost because of the deficits crisis in the NHS and this is unacceptable. “The Government has repeatedly said that action taken by trusts to balance their books would not affect patient services. This is now clearly not the case.

“We are seeing a situation which is deteriorating. We have real concerns about the stability of NHS finances, especially in view of the roll-out of reforms such as patient choice and payment by results.”

NHS chief executives blamed the Government for the high level of debt, saying inflexible targets on cutting waiting times, costly pay awards for consultants and GPs and the growing use of the private sector had put the NHS in jeopardy.

The NHS Confederation, which represents trusts and health authorities, said deficits were falling as measures taken to cut costs, such as shutting wards, began to take effect. Gill Morgan, chief executive, said: “It is worse at the moment because of the Government’s highly ambitious programme [to cut waiting lists and modernise services].

“In many places, the NHS tried to run faster but you can only run faster for so long. There was pressure on pay and higher activity. Now people are taking action to bring the deficits down. What you are seeing in terms of shut wards are the symptoms of efforts to achieve financial balance.

“It will get better financially towards the end of the financial year but it will get worse for patients.”

A health department spokesman said: “We simply don’t recognise the picture being painted. Improving financial management does not mean compromising care. The needs of patients are always paramount. Across the country, patients know their local NHS has new buildings, equipment, more doctors and nurses and faster access to care.”

Andrew Lansley, the shadow Health Secretary, said: “Patricia Hewitt has been in denial over the consequences of NHS financial deficits, any problems she has blamed on local decision-making. It is time for her to take responsibility for the consequence of the Government’s polices.”

http://news.independent.co.uk/uk/health_medical/article339579.ece

Almost half of hospital trust managers said that building and refurbishment projects were being delayed, while many trusts were also having to make staff redundant and to introduce recruitment freezes.

The Times understands that the Prime Minister is to order a shake-up of ministers and top civil servants, such is the concern in Downing Street about perceived NHS disarray. It follows six years of unprecedented rises in NHS funding.

Mr Blair wants a new junior minister to fend off criticism of the Government’s faltering reform programme and to sell NHS modernisation both to the public and Labour MPs. The health service is braced for even starker financial shortfalls from 2008, when the current round of annual funding increases will stop.

The poll of trust executives, conducted by Health Service Journal, comes as nursing leaders also give a bleak warning of massive NHS deficits. Their research suggests that health service debts in England will hit £1.2 billion this year, putting up to 4,000 jobs at risk.

The new minister, who will be charged with promoting the reform agenda in the media, is expected to be imposed on the Department of Health in a reshuffle due within days. The jobs of Jane Kennedy, the Minister for quality and patient safety, and Rosie Winterton, the Minister for health services, are both at risk. The Times understands that a number of senior bureaucrats will also be moved in an attempt to speed up the pace of delivery.

It is hoped that the MP will be a more effective deputy to Patricia Hewitt, the Health Secretary, who has struggled to explain the benefits of reforms and had to revise plans to reform primary care trusts. The uncertainty surrounding unforeseen knock-on effects of the Government’s reforms emerged when ministers decided to review the £1.2 billion redevelopment of Barts and the Royal London hospitals.

The last-minute decision, taken after more than six years of project planning, prompted 1,000 doctors to write to The Times earlier this week. They gave warning of the serious impact on cancer and cardiac services for London if the project was downscaled.

Evidence of serious financial problems is supported by 75 per cent of hospital chief executives who said that patient care would be affected by cash shortfalls. The warning comes despite assurances from Ms Hewitt that any cuts should only affect administration.

The Royal College of Nursing (RCN), which has been tracking the level of deficits and the impact on staff and services during 2005, confirmed that patient services and treatments were now being disrupted. It found that cost-cutting measures — including freezing job vacancies and use of agency staff — were now having a “direct and detrimental” effect on patients, with operations cancelled, appointments postponed and beds closed.

According to documents obtained under the Freedom of Information Act, a total of 81 NHS trusts in financial difficulties have been investigated by KPMG, the acountant. This is far more than the Department of Health acknowledged when it announced the “turnaround teams” of accountants before Christmas. It said that 50 trusts with financial problems would be visited.

The disclosure, and the full list of trusts visited, was obtained by Accountancy Age. They include 20 out of the total of 28 strategic health authorities, 29 primary care trusts, and 33 hospital trusts.

A Department of Health spokeswoman last night defended the NHS reform programme.

She said that the RCN’s predictions were “back of-an-envelope calculations”, adding that the “turnaround teams” would help to address financial problems centred on a small number of trusts.

http://www.timesonline.co.uk/article/0,,2-1995718,00.html

If the NHS merely gets the sort of growth in expenditure that the Treasury-commissioned Wanless report in 2002 said was likely to be needed – between 4.4 and 5.6 per cent a year in real terms – health and social care would take between 40 and 80 per cent of all the extra spending available, depending on just how fast total departmental spending grew.

If NHS spending were to carry on growing at the 7 per cent average annual real-terms rate that it has been rising by since 1999, it would take more than 60 per cent of all the available extra cash, even if the government raised overall departmental spending by as much as 3 per cent a year: a significantly faster rate of growth than Gordon Brown is likely to countenance.

If total departmental spending rises by an annual average of 2 per cent in real terms, 7 per cent growth for the NHS would take all the available money, leaving nothing at all for other government departments.

The illustrative figure for annual growth in departmental spending after 2008, used in the pre-Budget report, was 1.9 per cent.

For Patricia Hewitt, the health secretary, that means she faces a fierce battle against her cabinet colleagues to ensure that NHS spending gets somewhere near the 4 per cent-plus growth suggested by the Wanless report. For other ministers, it means they will have to argue hard to prevent health scooping the pot.

One factor that might move in favour of the other departments is that the Treasury is understood to be rerunning the Wanless model, presumably in the hope it can be used to justify somewhat slower growth in NHS spending.

However, one of Sir Derek’s main assumptions was that spending could be lower if the NHS became more efficient. Much of the evidence to date is that its higher levels of spending since 1999 have not been matched by higher productivity.

Part of the NHS’s problem is the steep increase in spending since 1999, amounting to roughly a doubling in real terms by 2008, by when it will account for close to a fifth of all government expenditure. As a result, even relatively moderate rises in spending take a large slice of the total cake.

The biggest problem for the NHS, however, is the government’s string of other priorities and pledges.

Education spending is pledged to be higher as a share of gross domestic product at the end of this parliament than the start.

Labour is committed over time to spending an extra 0.2 per cent of gross domestic product on international aid. It is pledged to halve child poverty by 2010, and the Institute for Fiscal Studies has calculated that requires an additional £1.4bn a year to keep on track.

Government spending will also need to rise faster than currently forecast if it maintains the pension credit’s link with earnings after 2008. That is even before the government addresses the recommendations of the Turner report on pensions, although the increases it recommends start to have a real impact only from 2011, after the next spending round.

John Hawksworth, head of macroeconomics at PwC, the professional services firm, argues that the government is also likely to have to spend more than currently planned to deliver its early years and childcare strategies.

He has warned that if the government sticks to these priorities and pledges, and gives the NHS anything like a 4 per cent increase, “that does imply a big squeeze on spending growth in other departments”.

Nigel Edwards, director of policy for the NHS Confederation, which represents health authorities and trusts, said the presentation clearly showed the Treasury was worried about the NHS’s productivity, given the large amounts of extra spending that have been injected in the past five years.

It also showed that the NHS needed to prepare for growth rates of only 3 to 4 per cent in real terms, and quite possibly slightly less, after 2008.

Mr Edwards said: “Even to get to 3 to 4 per cent the Treasury has to be prepared to give health and social care about 40 per cent of all the extra growth money. That is the most we [in the health service] have ever had since 2000, and it may want to give something less.”

That slowdown from the current 7 per cent growth rate will occur just as the full effects of Agenda for Change – a huge pay and grading deal for all NHS staff other than doctors – is working through in full.

Further cuts in junior doctors’ hours are also taking effect, and the NHS is having to meet the costs of installing the NHS’s £6.2bn information technology programme, which has costs for hospitals and primary care trusts over and above those of the central programme.

“That means it is going to be very tough,” Mr Edwards said.

http://news.ft.com/cms/s/0572120a-86ff-11da-8521-0000779e2340.html

Perhaps more worryingly, there was only limited evidence of plans for service redesign and improvement necessary to achieve improvements in sexual health generally, and only 30% mentioned targeted planned investment in sexual health, despite the Government’s additional £250m local funding for 2006/7 and 2007/8.

The report, published by Brook, fpa, MedFASH, National AIDS Trust and Terrence Higgins Trust found:
– Only 52% mentioned abortion services, and of those that did, it was primarily in the context of improving access for teenagers. Government statistics show that women in their twenties are most likely to seek an abortion.
– More than 50% failed to mention HIV, the fastest growing serious health condition in the UK, and nearly 50% did not mention planned work on reducing gonorrhoea diagnoses – which is another Government health target. Gonorrhoea is the second most common bacterial STI in the UK.
– Over 40% failed to mention tackling sexually transmitted infections (STIs) in general, and the same number made no mention of contraception services. Sexual health in the UK is currently amongst the worst in Western Europe, and we have the highest teenage pregnancy rates.
– One third of PCTs made no mention of plans to achieve the 48 hour access target for GUM services. Yet around one in three people remain sexually active whilst waiting for an appointment, driving up new infection rates.
– Almost a quarter (23%) of PCTs did not mention increasing the uptake of Chlamydia screening among15-24 year olds despite a 223% increase in new diagnoses between 1995 and 2004. One in 10 sexually active young people is now estimated to be infected with Chlamydia.

The charities are urging the Department of Health and the NHS to accord sexual health improvement top tier priority status for PCTs, and to ensure adequate funding to support this. They also want to see a radical shift in thinking about the delivery of sexual health services, and better, more consistent planning.

Said Anne Weyman, Chief Executive of fpa “We are extremely dismayed that despite the public health White Paper, despite the targets, and despite the considerable extra investment that is coming to them in 2006, too few PCTs appear to be planning to take serious advantage of the chance to improve our appalling record on sexual health.

”Sexual health remains too far down the list of local health priorities and is overshadowed by the pressure on PCTs to achieve financial balance.”

During August and September 2005, an audit was undertaken of two PCT LDPs from each of the 28 Strategic Health Authority (SHA) areas, giving a possible sample of 56 LDPs.

79% of PCTs were able to provide LDP data for analysis, either published on their website or provided directly when requested. This gave a final sample of 44 LDPs, which represented PCTs from across England in both urban and rural areas, with varying levels of prevalence of HIV and poor sexual health. The remaining PCTs were unable to provide data on their 2005 – 2008 plans.

National Sexual Health Targets And Investment
In order to address the deterioration in sexual health and the growing pressure on associated services, the Department of Health has committed to a Public Service Agreement (PSA) target in England for 2005 – 2008. PSA targets are agreed with HM Treasury and articulate national ambitions and objectives for public services.

The target refers to the following aspects of sexual health which should be reflected within Local Delivery Plans:
PSA 11a: reduction in the under 18 conception rate by 50% by 2010;
PSA 11b: 100% of patients contacting Genito Urinary Medicine (GUM) clinics to be offered an appointment within 48 hours by 2008;
PSA 11c: Decrease in rates of new diagnoses of gonorrhoea by 2008;
PSA 11d: Increase in the percentage of people aged 15-24 accepting chlamydia screening by 2007.

PCTs are required to submit data related to the target as part of the LDP process.

The charities are recommending the Department of Health and the NHS:
– Establish sexual health improvement as a top tier priority for the NHS for which PCTs should be specifically accountable.
– Support PCTs to make a radical shift in thinking about the delivery of sexual health services and implement significant service redesign. This should include the sharing of best practice where PCTs and other agencies have implemented successful changes.
– Ensure adequate investment within sexual health services to achieve the improvements which are urgently needed.
– Support PCTs to increase capacity and skills in sexual health service commissioning, planning and service delivery.

Oliver Wright
Terrence Higgins Trust
http://www.tht.org.uk

http://www.medicalnewstoday.com/medicalnews.php?newsid=36169

While he said he believed “passionately” that in vitro fertilisation, his specialism, should be available on the NHS, he was “completely in agreement with the idea that people might pay something towards that”.

The Labour peer and face of TV programmes such as Making Babies was asked for his thoughts on the Government’s controversial plans for the NHS, which focus on the role of primary care trusts.

He told ITN: “I really do not feel that any political party has actually been absolutely candid about the basic problem. Nobody has really costed where we’re going to be politically in ten or 15 or 20 years’ time.

“The escalating and spiralling cost has to be met somewhere. I’m not sure it’s going to be easy to meet it from taxation entirely. I think we need to be looking at different systems for funding as an augmentation.”

Citing problems including the rising cost of drugs, he added: “This Government has done a tremendous job in really trying to increase the budget of the NHS.

“But you can see the effect is, although the NHS has improved, there are still hospital trusts that are in serious deficit and that’s not just bad management. It’s much more than that, it’s a deeper problem.”

Most hospital trusts are struggling “very significantly”, Lord Winston added. And he said that he was “not convinced” that planned market-based reforms to the NHS would deliver the necessary cash to improve the situation.

Lord Winston went on to say that taking control of the NHS away from politicians could have the benefit of bringing stability to health policy.

http://www.thisislondon.co.uk/news/articles/PA_NEWA16965371137314986A0?source=PA%20Feed

The resulting longer waits are leaving many patients with reduced chances of surviving cancer, the report said. The Department of Health agreed an urgent capacity expansion was needed.

Report author clinical oncologist David Dodwell said despite substantial funding increases over the past five years, shortages of radiographers, physicists and other specialist staff caused long waiting lists.

“Radiotherapy services in the UK are inferior to those in most developed countries and indeed many poorer countries,” he said quoting earlier research. “Unfortunately the here and now of this is in terms of radiotherapy capacity in the UK in many centres in the UK is a real problem.”

This meant there was a long delay between referral and treatment starting, leading to reduced survival chances for certain cancers, Dr Dodwell said.

Cervical cancer patients’ chances of survival were cut by longer waiting times for radiotherapy, he said.

And the chances of tumours recurring in head and neck patients waiting more than six weeks for post-operative radiotherapy rose three-fold, he added.

While breast cancer patients have a 60% greater risk of relapse if delay between surgery and radiotherapy exceeds eight weeks.

Dr Dodwell said department managers found themselves “between a rock and hard place”, having to juggle competing priorities and pressures while balancing the rights of patients.

There needed to be a national debate on how to prioritise treatment and tackle waiting lists at a national level, he added.

National Director for Cancer Professor Mike Richards said demand for radiotherapy had increased in recent years which was why trainee numbers had doubled.

“The National Radiotherapy Advisory Group will shortly be making recommendations to ministers on future capacity requirements.

“We agree that expansion of radiotherapy capacity is urgently needed – we have already done a lot but need to do more.”

‘National crisis’

A survey in 2003 by the Royal College of Radiologists, which represents radiologists, found around 70% of patients waited longer than a month to start treatment.

The college said despite a slight improvement in equipment and staffing levels since then, over half of patients still waited more than a month.

The college’s registrar Dr Michael Williams said: “Continued and sustained investment in all the elements that go up to make the NHS radiotherapy services is required if the UK is to have a modern service able to deliver the best treatment to patients in a timely way.”

Richard Evans, of the Society of Radiographers, said of his members were frustrated that they could not provide the quality of care they would wish.

“Significant improvements have been made in recent years, however we agree with the authors that the fundamental need to see a significant increase in radiotherapy capacity remains.”

Clara Mackay, director of policy at support charity Breast Cancer Care, said the study confirmed mounting evidence of a national crisis in radiotherapy.

More staff were clearly needed, she said, but this will take time so in the meantime everything possible to keep waits down had to be done.

She added: “The priority must be to ensure that all cancer patients get the treatment they need, when they need it. Government must make it a priority for this to happen.”

Dr Lesley Walker, director of cancer information at Cancer Research UK, said it was investing to improve radiotherapy treatments.

“But without more action to ensure Britain has the required numbers of radiologists and radiographers… patients will not receive the best available care, which is what we should all be working to provide.”

John Baron, Shadow Health Minister, said: “It is unacceptable that ministers still have no plans to monitor and reduce radiotherapy waiting times, which we know are lengthening.

“The government’s cancer targets are focused on the front-end of the patient pathway, and so later stages of care – including radiotherapy – are struggling to keep up.”

http://news.bbc.co.uk/1/hi/health/4606756.stm

1. Besides cost savings, the Government has stated that the main aim of these reforms is to strengthen PCTs’ commissioning function, as larger commissioning organisations, similar in size to old Health Authorities, will have increased bargaining power, and can be better aligned to local authority services. However, before discussing in detail the likely impact of the Government’s proposal to restructure PCTs, it is important to note that PCTs were established only three years ago, at considerable cost to the taxpayer. A return to structures which are similar in size and function to previous Health Authorities raises important questions about why the shortcomings now being identified by the Government, including increased management costs and dilution of bargaining power, could not have been easily anticipated and addressed before PCTs’ introduction three years ago. As we discuss later in this report, all restructurings are hugely disruptive, and to introduce a large scale reconfiguration of NHS organisations only three years after the last root and branch reform of NHS organisations points to an ill thought-out approach to policy-making.

2. We are appalled at the continuing lack of clarity about whether or not PCTs will eventually divest themselves of their provider functions. This announcement was first made at the end of July, together with a firm timetable for its implementation, which was withdrawn in October. Various ministerial announcements have failed to clarify the position, and even our witnesses, drawn from the senior ranks of the NHS, could not agree about whether or not these changes would eventually happen, with many appearing genuinely bewildered. As far as we can see, the overall direction of travel in fact remains unchanged, and PCTs will ultimately divest themselves of provider services. We urge the Government to either confirm or deny this immediately.

3. We are deeply concerned that neither Lord Warner nor John Bacon were able to give us a confident assurance that NHS staff potentially affected by these changes would be able to retain their NHS pensions. The Government must provide clear information as to whether existing NHS staff who are transferred to other providers, particularly in the private sector, as a result of these changes will be able to retain their NHS pensions.

4. Perhaps most concerning of all is that these announcements about the future of PCT provided community services anticipate the outcome of the Government’s flagship consultation Your Health, Your Care, Your Say, which is supposed to shape the Government’s forthcoming White Paper on out-of-hospital care. For a Government to announce its intended direction of travel a full five months before its consultation on this subject comes to an end makes a mockery of the consultative process. Equally, if the Government is now committed to introducing changes to PCTs to a more relaxed, less prescriptive timescale, it is difficult to see why the announcement would not have been better made in a more measured, informed way, in the expected White Paper.

5. One of our witnesses argued that the Government’s handling of announcements surrounding Commissioning a Patient-Led NHS gives “a clear impression that the policy is being developed on the hoof”. We agree. In our view, the numerous announcements and retractions about the divestment of PCTs’ provider services, in advance of a White Paper consultation designed to canvass views on precisely this area, points to flawed and incoherent policy-making.

6. The consequence of this, which could have easily been predicted before the July announcements, has been the destabilization of a very valuable workforce whose support will prove essential to the implementation of the forthcoming White Paper. The insecurity and distraction that has been caused within NHS community health services demonstrates how damaging the repercussions of ill-thought through policy announcements can be, and we therefore recommend that the Department of Health carries out an immediate review of its internal systems to ensure that this does not happen again.

7. Although the stated aim of these proposals is to design a more patient-led NHS, evidence both from NHS bodies and from Patient and Public Involvement Forums confirms that patients and the public have not been adequately consulted. We find this unacceptable. If the Government truly believes in a patient-led NHS, it should have started its reforms with a patient-led consultation process, rather than the top-down process we are clearly seeing.

8. Even NHS officials who otherwise supported the proposals to merge PCTs have described the initial consultation process as “flawed”. In some cases, organizations were given less than a month, during the summer holidays when many key figures were absent, to put together proposals for far-reaching changes to local services. The timing also meant that many local MPs and councillors were unable to contribute to the process. We accept that organizational change causes extreme instability, and for this reason it is helpful if periods of uncertainty are kept to a minimum. However, this needs to be balanced against the time needed both to consult local stakeholders, most importantly NHS patients, and to design new organizational structures that are fit for purpose. Our evidence suggests that in this case the Government has got this balance very wrong, particularly as the White Paper has not yet been published.

9. The flawed nature of the pre-submission engagement makes the proper conduct of the formal three month NHS consultation starting on 14 December vital. The letter from John Bacon, Group Director Health and Social Care Services Delivery dated 30 November to SHA Chief Executives instructed them to “ensure that all options are presented fairly and given equal weight in your documentation” and said that “where there are sharply differing views on particular options, it would be desirable to engage the relevant PCT in preparing the document”. But it is not clear how the Department of Health has ensured this has happened as the consultation documents issued by SHAs did not have to be approved by the Department. The Department of Health should ensure that the consultation is fairly conducted by all SHAs, especially where the External Panel has required SHAs to consult on additional or different options than those originally considered in the pre-submission engagement. Not to do so would leave the Department vulnerable to allegations that the result of the consultation process was pre-determined and a sham.

10. Despite the Government’s repeated reassurance that this is not a ‘top down’ process, with change being imposed on local NHS organizations from central government, the evidence we have received from those working in the NHS at a local level suggests that it is exactly that. This is because, in their view, the most significant driver of these reforms is finance and so solutions that would best meet local needs are being overruled because they do not yield enough cost savings. Cost savings may be a legitimate and justified driver for reform, as we discuss later in this report. However, the Government must be explicit that this is its key objective. It is disingenuous to argue that these changes are being driven from the grassroots of the NHS when NHS managers have been told that the solutions that would best meet the needs of their local populations will not be adopted because they will not produce sufficient cost savings.

11. Another very serious concern raised in our evidence is that because of the uncertainty about the divestment of provider services, SHAs are having to design new organizations without a clear understanding of what their ultimate function will be. This could lead to the formation of organizations which are not fit for purpose, necessitating yet more reorganizations.

12. Because SHA senior managers are currently under threat of redundancy, not only are they having to draw up reconfiguration plans whilst ‘distracted by thoughts of self-preservation’, but also, in all likelihood, will no longer be in post next year to be held accountable for the reconfiguration decisions they have taken. We find this highly concerning. The Government should have taken this into consideration and planned its restructuring accordingly, first ensuring existing SHAs have an ongoing role in overseeing and being held accountable for their PCT reforms, and then changing the configuration of SHAs themselves, rather than reforming both types of organisation in tandem, threatening both the quality of, and accountability for, these reforms.

13. We are pleased that Lord Warner has given us a commitment to publish all information submitted to the external panel as soon as possible. It is essential that the external panel’s responses are made public also. We also note that the Secretary of State has promised that all proposals that have not been subject to extensive local consultation will be rejected. From our evidence alone, it would appear that insufficient consultation has taken place in several areas, and we urge the Government to make clear at the earliest opportunity to make clear which proposals have been rejected.

14. In the light of our evidence, we believe that further steps must be taken to ensure that what remains of the formal consultation process in respect of changes to PCTs is as transparent and inclusive as possible, offering patients and other local stakeholders a genuine choice over how their local health services are structured. To achieve this, the Government must publish all documents submitted to its external panel as soon as possible; furthermore Ministers must ensure that all formal consultation is conducted in a fair and unbiased manner.

15. The evidence is clear: the distraction caused by these reconfigurations will set back the development of PCTs’ core functions, which include commissioning services, providing community health services, and protecting public health, by at least 18 months. We consider that imposing a further structural change on organizations that are only three years old, at a time when pressure on those very organizations to perform well has never been higher, is ill-judged in the extreme.

16. There are also well-founded concerns that patient care will suffer as a direct result of the distraction caused by these reforms, and our evidence suggests that the destabilising effects are already being felt across the NHS, with clinical staff moving from community hospitals to the acute sector because of uncertainty over their future roles. It is highly ironic that while a key plank of Government health policy is now to move services away from the acute sector and strengthen community health care services, the uncertainty generated by these mismanaged policy announcements is having precisely the opposite effect, causing a drift of staff away from community health services back to the acute sector, which is now perceived as more stable. That some of these outcomes could, with more rational and coherent planning, have been predicted and avoided, makes the Government’s actions in this area even more indefensible.

17. We strongly support the Government’s desire to improve commissioning in the NHS, but believe that this should have been addressed before, or at least at the same time as powerful incentives were being introduced which strengthened the provider sector. The fact that it was not has given rise to an uneven balance of power in the NHS that may now prove difficult to redress. We are pleased that the Department of Health has acknowledged this, and we hope that in future it will make efforts to ensure that the wider impacts of its policies are considered at a system level to avoid such a situation arising again.

18. While larger PCTs may be able to wield greater bargaining power over the acute sector, research evidence demonstrates that increases in PCT size beyond populations of 100,000 patients do not necessarily generate substantial improvements in overall performance, and that optimal size for commissioning varies widely according to services being commissioned. Health Authorities were large commissioning organisations, and their size does not seem to have made them effective commissioners. Arguably, the introduction of Payment by Results may already be giving PCTs the levers they need to commission effectively from the acute sector, without the need for restructuring.

19. We recognise the need to improve commissioning skills within PCTs. However, we remain unconvinced that instigating large-scale structural reform in order to ‘retrench’ commissioning expertise in larger centres is the only, or indeed the best, way to achieve this. Equally, it seems illogical that, at precisely the time the Government has committed to improving NHS commissioning, it is currently planning to spend £250 million less per year on this crucial function, further depleting management expertise from an already under-managed health system. This is more likely to weaken rather than strengthen NHS commissioning.

20. In principle, we support the aim of improving joint working between the NHS and local authorities, both in respect of social services, and other crucial local functions including housing, regeneration and education services. However, we are concerned that these reforms, while offering an opportunity to better align some boundaries, may risk setting up new barriers in other areas, and may threaten existing joint working arrangements.

21. PCTs were established to ensure that decisions about the NHS were made locally. By reverting back to the more remote structures that were abolished only three years ago, this localism will be lost. At the moment, each of the 302 PCTs in England has several Non-Executive Directors; a Patient and Public Involvement Forum; and a Professional Executive Committee of key local clinicians. While these structures clearly have a cost, they were introduced to add value. It is not clear why the Government is now unwilling to meet the cost of securing an enhanced level of local input into the NHS, only four years after this was identified as a key aim of Government health policy in Shifting the Balance of Power. Whatever the size of future PCTs, it is essential that structures to ensure clinical engagement and, most crucially, patient and public engagement are retained at their current levels, covering each natural community.

22. Practice Based Commissioning is a crucial policy which underpins the Government’s proposals for restructuring PCTs, which the Government hopes will both strengthen commissioning and secure greater local engagement. However GPs, who will be responsible for implementing Practice Based Commissioning, have described a ‘woeful lack of information’ about the scheme, with key questions still unanswered. We therefore consider it highly unlikely that this system will be functioning effectively in all areas by the end of next year, and are concerned at the Government’s complacency and unwarranted optimism over the implementation of Practice Based Commissioning. We urge the Government to address this lack of information immediately.

23. The Minister’s view that Practice Based Commissioning as it is currently conceived will improve patient and public involvement in health care is not firmly based on any evidence. In fact, there is a significant gap in this area. We recommend that the Government places a specific requirement on all practice based commissioners to establish regular, formal arrangements for securing the input of their patients and local populations in the commissioning and provision of local services, just as PCTs and other NHS trusts are obliged to.

24. We are also concerned at the complacent attitude that the Government is displaying towards the very real possibility of Practice Based Commissioning introducing perverse incentives that could threaten patient choice and access to health care. It seems to us that these problems have not yet been fully anticipated or considered by the Government, which is worrying given that they hope Practice Based Commissioning will be universally implemented within a year. These potential problems need to be addressed before they arise, and to this end we recommend that the Government publish details of what actions it intends to take to counter these risks before Practice Based Commissioning is universally implemented next December.

25. Evidence from those working in the NHS suggests that PCTs are collaborating with one and other and, as a result, bringing about improvements without the need for large-scale reorganization. In our view, Lord Warner’s suggestion that improvements in PCTs have been “patchy” does not constitute a valid argument for imposing radical structural reform across the board, dismantling organisations that are performing well as well as those that are performing badly. A more rational, constructive approach would be to support the evolutionary changes that are already taking place.

26. As a senior NHS chief executive told us, there is no such thing as a ‘holy grail’ of a perfect size for a commissioning organisation. There is a clear trade-off between the increased bargaining power and better co-terminosity of larger organisations, and the enhanced local engagement of smaller PCTs. Practice Based Commissioning may achieve local clinical engagement, but will leave serious gaps in terms of patient involvement. In order to improve commissioning, PCTs need better skills and information systems. Restructuring is not necessary to achieve this.

27. Given our evidence that the majority of PCTs are already involved in successful collaborative working, we believe that the most effective way to improve commissioning is to allow PCTs to develop organically, enabling them to evolve into larger organizations where this clearly best meets local needs. A managed approach to sharing best practice should be adopted to ensure that the poorest performers learn from the expertise of the best performers, and support should be specifically targeted towards developing commissioning in the poorest performing PCTs.

28. We were very concerned to learn that, prior to the publication of Commissioning a Patient-Led NHS, there was no consultation with public health professionals at all about its potential impact on PCTs’ crucial public health function. In our view, debate about Commissioning a Patient-Led NHS has also given insufficient prominence to this. In order to safeguard local public health initiatives, we recommend that where PCTs merge leaving only one Director of Public Health, other consultants in Public Health are retained with responsibility for public health delivery, working with local authorities and local strategic partnerships. Further to this, steps must be taken to provide continuing support to community health professionals who play an equally important part in securing public health improvements.

29. The Government has downplayed the financial motivation for these reforms, concentrating instead on its aim of strengthening commissioning. However, our witnesses were clear that this was the key consideration in drawing up plans for reform, to the extent that plans which would better meet local needs were discounted because they did not yield sufficient savings. While achieving efficiency savings is a legitimate aim, this needs to be stated explicitly so that it can be subject to proper scrutiny.

30. In fact, the evidence to date suggests that this reconfiguration is unlikely to yield the savings the Government is hoping for. Figures put to us by PCT officials suggested that current proposals for reconfiguration might save between £60 and £135 million, well short of the target figure of £250 million. If proper clinical and patient involvement is to be retained, further local structures will need to be put in place at a sub-PCT level, which will generate additional costs. Equally, the costs of Practice Based Commissioning, which are at present unclear, will need to be taken into account. The NHS will also have to bear costs associated with redundancies, as well as the cost of reduced productivity over the next 18 months.

31. It is vital that NHS organisations deliver value for money. However, while the enhanced local perspective PCTs have brought to the NHS clearly has a cost, the benefits they have brought may well justify this cost. In addition to this, PCTs are currently responsible for spending 80% of the NHS’s £76 billion budget. At a time when PCTs’ commissioning role is crucial to the success of the NHS, it is a false economy to deplete the NHS’s managerial resources still further in an attempt to save only a fraction of that total amount.

32. Whether or not PCTs should divest themselves of their provider services is a huge question which is outside the scope of this short inquiry. However, inevitably our witnesses raised many important concerns about the divestment of PCT provider services, most notably that it would lead to fragmentation of services, and make joined-up care even harder to deliver. Equally, it is not clear whether sufficient alternative providers exist to provide a market in community services. We urge the Government to address these crucial questions in its forthcoming White Paper on out-of-hospital care. (Paragraph 181)

33. We were extremely concerned at evidence we received about proposals to tender out the commissioning function in Oxfordshire before the new PCT Board has even been appointed. When we put this to Lord Warner he reassured us that this would not be allowed to happen, and we are relieved to see that Thames Valley SHA has now reconsidered its plans. However, we believe that the idea of outsourcing commissioning represents a significant departure from current policy, which has the potential of reducing transparency about the disposal of public funds. Further consultation and discussion is absolutely crucial before the Government allows any PCT to proceed down this route.

http://www.publications.parliament.uk/pa/cm200506/cmselect/cmhealth/646/64611.html

Only 1% of those who responded to the largest survey yet carried out into the views of doctors on the national programme for IT in the NHS (NPfIT) rated progress as “good” or “excellent”.

Last June and July a poll by Mori showed that IT specialists in the NHS had a generally favourable impression of the NPfIT.

But a survey by research firm Medix between December 2005 and January 2006 shows that doctors are critical of and worried about the programme’s implementation.

The NPfIT is due to cost between £6.2bn and £31bn, but the NHS is facing funding pressures. The survey’s results also come against the backdrop of a 28-hour failure of the NHS data spine – the backbone of the NPfIT.

The Medix survey brought responses from 1,329 doctors – about 1.5% of the total in England. Only 1% of those who responded rated progress in the NPfIT as good or excellent. Seventy five per cent of GPs and 63% of other doctors rated progress as poor or unacceptable.

Three years ago 47% of doctors thought the NPfIT was a good use of NHS resources, but only 17% say that is the case now.

Hospital doctors were in general more supportive of the NPfIT than GPs. But only 45% of them were enthusiastic about the programme – down from 75% two years ago.

There was some good news for Connecting for Health, which is running the NPfIT: more than 50% of all doctors thought the programme would improve clinical care in the longer term.

But fewer than 50% thought the NPfIT an important priority for the NHS, and only 5% thought personal consultation with them had been adequate. There were also concerns about whether enough money would be made available to fund the programme and whether the confidentiality of patient records held on central and regional systems could be compromised.

Only 6% agreed with the statement that their trust had or was likely to have enough money to properly implement the NPfIT, including buying new equipment, training, consulting staff and managing process change.

More than 70% of GPs and 46% of other doctors thought that the advent of an NHS Care Records Service would weaken the confidentiality of patients’ records.

The Medix survey indicates that the mountain of opposition Connecting for Health will have to climb to make the NPfIT a success is becoming steeper.

Medix said, “It will now take extraordinary efforts toÉ overcome the distrust and cynicism that seems to have replaced early enthusiasm in the minds of many doctors.”

The findings raise questions about whether there should be a full independent review of the programme and its future direction. Public spending watchdog the National Audit Office is due to publish a report but it has been delayed twice and is more likely to look at the programme’s history than its future.

Family doctor Gillian Braunold, who represents GPs at Connecting for Health, said the survey’s results did not accurately reflect the views of most doctors. She said that as doctors become more familiar with the new technology, receive further information and see that the systems raise standards they will “get switched on”.

A spokesman for Connecting for Health said that confidence sometimes dips in the early stages of large implementations and “that is the phase we are in”. Greater familiarity will increase confidence, he said.

http://www.cw360asp.com/Articles/2006/01/10/213589/Costandprivacyconcernserodedoctors’confidenceinNHSplan.htm

Only 1% of those who responded to the largest survey yet carried out into the views of doctors on the national programme for IT in the NHS (NPfIT) rated progress as “good” or “excellent”.

Last June and July a poll by Mori showed that IT specialists in the NHS had a generally favourable impression of the NPfIT.

But a survey by research firm Medix between December 2005 and January 2006 shows that doctors are critical of and worried about the programme’s implementation.

The NPfIT is due to cost between £6.2bn and £31bn, but the NHS is facing funding pressures. The survey’s results also come against the backdrop of a 28-hour failure of the NHS data spine – the backbone of the NPfIT.

The Medix survey brought responses from 1,329 doctors – about 1.5% of the total in England. Only 1% of those who responded rated progress in the NPfIT as good or excellent. Seventy five per cent of GPs and 63% of other doctors rated progress as poor or unacceptable.

Three years ago 47% of doctors thought the NPfIT was a good use of NHS resources, but only 17% say that is the case now.

Hospital doctors were in general more supportive of the NPfIT than GPs. But only 45% of them were enthusiastic about the programme – down from 75% two years ago.

There was some good news for Connecting for Health, which is running the NPfIT: more than 50% of all doctors thought the programme would improve clinical care in the longer term.

But fewer than 50% thought the NPfIT an important priority for the NHS, and only 5% thought personal consultation with them had been adequate. There were also concerns about whether enough money would be made available to fund the programme and whether the confidentiality of patient records held on central and regional systems could be compromised.

Only 6% agreed with the statement that their trust had or was likely to have enough money to properly implement the NPfIT, including buying new equipment, training, consulting staff and managing process change.

More than 70% of GPs and 46% of other doctors thought that the advent of an NHS Care Records Service would weaken the confidentiality of patients’ records.

The Medix survey indicates that the mountain of opposition Connecting for Health will have to climb to make the NPfIT a success is becoming steeper.

Medix said, “It will now take extraordinary efforts toÉ overcome the distrust and cynicism that seems to have replaced early enthusiasm in the minds of many doctors.”

The findings raise questions about whether there should be a full independent review of the programme and its future direction. Public spending watchdog the National Audit Office is due to publish a report but it has been delayed twice and is more likely to look at the programme’s history than its future.

Family doctor Gillian Braunold, who represents GPs at Connecting for Health, said the survey’s results did not accurately reflect the views of most doctors. She said that as doctors become more familiar with the new technology, receive further information and see that the systems raise standards they will “get switched on”.

A spokesman for Connecting for Health said that confidence sometimes dips in the early stages of large implementations and “that is the phase we are in”. Greater familiarity will increase confidence, he said.

http://www.cw360asp.com/Articles/2006/01/10/213589/Costandprivacyconcernserodedoctors’confidenceinNHSplan.htm

It meant text longer than 255 characters entered by doctors into a patient’s medical record would disappear, causing potentially vital clinical information to go missing.

It is believed the error may have been affecting patients’ records for up to four years before it was spotted. In some circumstances the missing text re-attached itself to another patients’ medical records.

Officials at the National Services Scotland, which operates the system, found a solution for the problem last October. But furious doctors have warned patients may have unknowingly received potentially harmful treatment or drugs intended for someone else.

A letter sent to GPs highlighted the problem. It stated: “When you look at the encounter [entry] for the patient, the text truncates after the 255th character and the remainder of the entry is not visible.

“In very rare circumstances, the missing text can appear to re-attach itself to another patient’s record. This is a very unusual occurrence.”

GPASS is used by more than 904 GP practices across Scotland. The fault is believed to have affected mainly those operating “paper-light” systems, where doctors enter notes from consultations directly into the computer, meaning there is no paper back-up. There are believed to be around 100 paper-light practices in Scotland, each with thousands of patients.

Doctors claim this is not the first problem with the latest edition of the computer system, which has been in use in Scotland since April 2001.

Shortly after it was introduced, two patients in Glasgow were given the wrong prescriptions because of a printing error caused by the system. In one case, a 90-year-old woman was given a prescription which her doctor said could have been fatal had the patient not spotted the mistake.

Last night one GP, who asked not to be named, said: “There have been endless problems with this computer system. This latest one was potentially highly dangerous as important information about a patient’s medication or condition might have been cut out and given to another patient.”

Dr Michael Hendry, a member of the GPASS User Group, said a number of doctors were concerned about the safety of the system. He said: “This latest error had been a problem for practices that do not use paper notes and record everything on screen. I believe a small number of practices were affected, but a fix for the problem has now been sent out to all practices.”

A spokeswoman for National Services Scotland said “a small number” of practices had been affected as most still used paper notes. She added: “No information was actually lost and a fix has now been issued that re-attaches the missing data.”

The Scottish Executive has encouraged GPs to use computer systems as it attempts to modernise the NHS with electronic patient records.

SNP shadow health minister Shona Robison said: “The Executive needs to ensure the monitoring of GPASS and other electronic records are robust and pick up faults before they can do any harm.”

http://news.scotsman.com/health.cfm?id=32012006

There is an unprecedented cash shortage for hospitals in Wales. Most NHS trusts are millions of pounds underfunded and the news of ward closures, non-availability of services, job cuts and stubbornly high waiting lists are daily breakfast news to the people of Wales.

Already there have been public protest meetings at places as far afield as Withybush in Pembrokeshire and Blaenau Ffestiniog.

Meanwhile, Welsh Assembly civil servants nervously wonder how they are going to break the bad news that whole areas of West and South West Wales may be deprived of their ability to provide sophisticated critical care.

So why is Wales doing so badly and what has happened to the money?

In the days before devolution it only took a few nationalists to kick up a fuss for Whitehall mandarins to shovel money into Welsh health and education, keeping everything quiet so that, after Scotland, Wales’ health service was relatively well funded.

Now things have changed. Whitehall sends out Wales’ block grant which the Assembly then divides between health, education, transport, roads, et al.

While English ministers can plunder Treasury coffers for more funds for special projects in a less than transparent fashion, Wales is told to decide its priorities keeping within the block grant.

The Welsh NHS Confederation, not normally known for its sensationalist approach, has produced comparative health spending figures between Wales and England for 2005 to 2008. These make grim reading.

England’s health spending is set to increase at an annual rate of 9.3% while Welsh spending will fall behind at 4.1% which, allowing for inflation and increased demand, effectively means cuts.

What about policy? Our political masters and their civil servants in Cardiff Bay woke up in a cold sweat after devolution, realising that the old technique of stamping Cymru/Wales on English documents would no longer do.

The first attempt at health policy was an expensive reorganisation that created one of the most bloated health bureaucracies in Europe for a population of 3 million people.

Some 22 local health boards, each with 18 board members and innumerable employees with fancy titles and clipboards to match, now control the cash.

In 2003/4 the Assembly Government’s own figures showed there had been a 35% increase in NHS managers, none of whom can treat a single patient.

What about the doctors needed to develop the service?

Any keen, newly qualified consultant will be reluctant to come to a country where enthusiasm to improve patient care runs up against the dead hand of bureaucracy and a managerialist culture unwilling to involve front line doctors in planning the service.

It is no coincidence that the unfilled vacancy figures show that Wales has more than double the English consultant vacancy rate at 7.7% compared to England’s 3.3%, with particular shortages in cardiology, oncology, diabetic medicine, histopathology and psychiatry, which all have more than 20% vacancy rates.

Scotland, on the other hand, is viewed as a devolution success with close co-operation between doctors and health service planners, high levels of investment in the health service, good recruitment figures and short waiting lists.

Of course, the news is not all gloom and doom.

Rhodri Morgan and Health Minister Brian Gibbons have clearly signalled that Wales will not be joining England’s disastrous and hugely costly privatisation experiment.

The Alice in Wonderland economics of private finance initiative funding have been less enthusiastically embraced in Cardiff than they have on the other side of Offa’s Dyke.

Wales has also stayed out of England’s hugely expensive £6bn plus IT project Connecting for Health, designed to support market reforms. Like many other central government driven IT initiatives, this one is doomed to failure. Fortunately, Wales has pursued a more evolutionary approach to IT development with local hospitals developing their own systems.

What are the Assembly Government’s plans for the future?

A recently published 10-year strategy for Welsh health called Designed for Life optimistically outlines the vision that by 2014 care will be delivered as close as possible to patients’ homes by shifting resources from hospitals to the community.

Unfortunately, in the present funding climate, it appears likely hospital services will be cut before community services can be developed. This will leave patients bereft of the services they need, particularly in rural Wales.

Indeed, implicit in the delivery of Designed for Life will be a wholesale reorganisation and rationalisation of the hospital services that will result in the closure of many a treasured local hospital, to provide expensive services at distant sites.

This represents a huge electoral gamble for politicians who still have raw memories of a labour candidate being unseated by an upstart anti-hospital closure doctor in Kidderminster.

So what can be done? A frank admission that the reorganisation has not worked out would be helpful.

The merger of local health boards into three regional offices together with localised GP commissioning and appropriate cuts in management costs is long overdue.

We need to build or convert centres within NHS Wales with ring-fenced beds for elective surgery, in order to get a grip on Wales’ unacceptable waiting lists.

This will reduce the need to send patients to England, for surgery in expensive treatment centres, far from family and friends, draining NHS Wales resources.

The obvious inequalities in global health funding between England and Wales urgently need to be addressed by Assembly politicians.

The electorate will not be pleased to discover that the price of devolution was a poorly funded and deteriorating health service.

Finally, policy makers and politicians need to realise that doctors and nurses in Wales cannot respond to current directives. These are dreamed up in Cardiff Bay with inadequate consultation, and handed down to the service alongside crippling financial straitjackets.

At present the professional advisory structure for NHS Wales, from the Chief Medical Officer all the way down is largely ignored.

Front-line doctors and nurses are keen to innovate and could develop practical solutions to get around funding difficulties if only they could share in planning and developing their service both locally and nationally.

We need to harness every available talent to get NHS Wales out of intensive care and back on to the ward.

http://icwales.icnetwork.co.uk/0100news/0200wales/tm_objectid=16562325&method;=full&siteid;=50082&headline;=welsh-nhs–in-intensive-care–name_page.html#story_continue

Hospitals and primary care trusts are heading for a collective deficit of £75m by the end of March and their cash position is so precarious that they may not be able to pay the wages or meet bills from suppliers. The warning came in a “public interest report” from Helen Thompson, the district auditor.

“I am concerned about the financial position of the Surrey and Sussex health economy,” she said. “Unless this deficit is effectively addressed, it is likely to impact on services provided to patients. There are an increasing number of organisations in deficit and in some the financial position has got substantially worse.”

Surrey and Sussex hospital trust lost £30.7m in 2004-05, Royal West Sussex lost £15.5m and Brighton and Sussex university hospitals lost £10m. Five other trusts in the counties had a combined deficit of £11.3m.

The health authority commissioned consultants to draw up a recovery plan, but the trusts are not likely to implement it without a more effective “performance culture”, the commission said.

Although some trusts are managing their affairs well, others show no tangible evidence of driving through the radical modernisation of services needed to improve their financial position.

“Some of the savings programmes in place are extremely ambitious and at high risk of failure due to their scale. Halfway through the current financial year, only 34% of the identified savings plans totalling £149m has been achieved,” Ms Thompson said. Previous reports from the commission have identified serious problems at individual trusts.

Last month it said the deficit at Queen Elizabeth hospital NHS trust in Woolwich, south-east London, would accumulate to £100m by 2008-09 unless the government restructured a crippling private-finance initiative (PFI) debt.

But the warning to Surrey and Sussex is understood to be the first to draw attention to the weakness of an entire NHS network.

Even if trusts can reduce their net deficit to £40m by the end of March, they face a cashflow problem, and will require external cash support worth £83m.

This is “the most immediate risk facing the economy”.

The commission warned that there will be even greater pressure if trusts do not achieve their financial recovery plans.

“Organisations need to be clear that continued overspending will generate real cash shortfalls and ultimately threaten both the supply of goods and payroll,” Ms Thompson said.

“We recognise that the financial position differs for individual NHS bodies, with some managing their finances well. However, our report will raise awareness of the health economy position and we encourage all organisations to review the recommendations in view of their own circumstances and devise action plans to address them.”

The health authority covering the two counties received a new chief executive in November when Candy Morris was seconded from the Kent and Medway health authority to take charge of a reorganisation.

http://www.guardian.co.uk/uk_news/story/0,,1680281,00.html

Under new terms of the general medical services contract, PbC engagement will become a ‘direct enhanced service’ – like the obligation to see patients within 48 hours.

It means practices will receive 95p per head of population to reimburse them for ‘clinical time’ spent on planning commissioning for their patient lists. They will also receive a further 95p per head for demonstrating they have reduced the number of patients going into secondary care in locally agreed clinical areas.

The NAPC was very influential in persuading ministers to reconsider giving indicative budgets to practices after Labour ditched GP fundholding in 1997. But this week the organisation slammed the new incentive to encourage GPs to ‘engage’ with PBC, which is included in new terms for GMS contracts from next financial year, negotiated by NHS Employers and the British Medical Association.

The NAPC says the incentive will set up a ‘national standard-based approach’ that will undermine the entire aim of the policy. Chair Dr James Kingsland said health minister Lord Warner and his former colleague John Hutton had both promised that there should not be a national standard run through primary care trusts ‘because the whole point of this was supposed to be creating drivers to get GPs to adopt an entrepreneurial outlook, encouraging different approaches around the country.’

He said the way the new incentive was being introduced would mean the ‘failed’ system of PCT-managed commissioning would prevail, and PBC would ‘sink’.

He added that he supported a small incentive to practices to kick-start their understanding of the budget and how competitive behaviour can drive up quality, but said if it was used to set up a centrally controlled system, then the whole policy was ‘doomed to failure’.

However, NHS Alliance chair Dr Michael Dixon said the £1.90 incentive – which his organisation had recommended – was a necessary sweetener to get some ‘very disaffected’ GPs on board.

Dr Dixon also welcomed the agreement not to raise the amount GPs can earn per quality and outcomes framework point in line with inflation. ‘I think it is quite right to say that after the big pay increases for GPs last year, we will go for that extra pound of flesh. It’s perfectly reasonable for the NHS to expect general practice to work for higher standards without extra cash in the QOF this year,’ he said.

NHS Employers lead GMS negotiator and Bradford South and West PCT chief executive Barbara Hakin said PCTs should be £300m better off on their GMS budgets in 2006-07 as a result of the QOF freeze.

She said PCTs should be able to save at least £1m each in the next financial year after the two sides agreed to maintain current prices attached to the QOF framework, which financially rewards GPs for achieving defined standards of care and services.

http://www.hsj.co.uk/nav?page=hsj.news.story&resource;=3989999

But an analysis of Department of Health data by the Financial Times shows that the government will miss its target without additional capacity and reform of the way the service operates.

On the health department’s own planning assumptions, to achieve a maximum wait of 18 weeks – from the first GP visit to an operation – the average wait will need to be about nine weeks.

That implies something like an average two week wait from GP to the outpatient visit, three weeks for diagnostic tests, which may include scans and investigative pathology, and then no more than a four week wait once a decision is made to operate.

At the moment, no data exists to measure how long that total wait is – chiefly because there are no national data on how long patients wait for diagnostics. In some parts of the country, however, patients can wait 26 weeks or longer for a scan- which would blow the 18 week promise clearly off course.

But published figures show that the average wait for an outpatient appointment is currently almost 7 weeks – more than three times longer than the two weeks that it will need to be by 2008.

That figure has been falling, down from 7.7 weeks in 2000. But it is falling so slowly that on current trends it will take 35 years to get down to an average two-week wait.

The longest waits for an in-patient operation have also been falling.

But in order to eliminate the relatively small tail of very long waits (more than six, 12 and 24 months) has meant that paradoxically, the average wait patients have faced at the time they get an operation has been going up in recent years, not down.

Since March 2000, the median wait for an operation has risen from 6.1 weeks to 7.4, a 20 per cent increase, when it needs to fall to an average of about 4 weeks if the overall 18-week target is to be met.

And while extra MRI scans and other forms of diagnostics are being installed in the NHS and bought from the private sector, health economists say there is good international evidence that the first effect of that may well be a rise in demand as patients who would not now be sent for a scan because the wait is so long become eligible for one.

In other words, the extra capacity could initially produce little or no fall in the overall wait for some forms of diagnostics, and possibly even an increase.

“What these figures show,” according to Alan Maynard, professor of health economics at the University of York, “is that of the three elements needed to get to the overall 18-week target, one is falling far too slowly, one is unknown but may well rise before it falls, and the third – the time spent on the waiting list before an operation – is actually going in the wrong direction.

“Unless something changes radically, the government is going to miss its target”.

To hit it will require “an unprecedented increase in productivity”, he said, when, on most measures, NHS productivity has been falling as large parts of the extra spending have gone into pay.

Professor Maynard said: “For both the consultants’ and GPs’ contracts there has been a big increase in pay but no matching increase in productivity.

“There is an argument to be had about whether the NHS needs to buy extra capacity from the private sector over and above the amounts already planned.

“But it clearly needs to organise services much more efficiently if it is to have a hope of hitting the target.”

The scale of the challenge is underlined by figures showing that to cut the NHS waiting list by 250,000, the service has undertaken more than 31m operations since 2000. In other words, the 14 per cent rise in non-emergency operations in six years has chiefly gone on keeping pace with demand, not cutting waiting lists or average in-patient waiting times.

That may imply that extra capacity is needed from the private sector, above the contracts announced but not yet advertised, for a second round of treatment centres.

Chris Ham, professor of health service management at the University of Birmingham, said: “The big risk is around diagnostics, where there is a real danger that as more becomes available demand will rise to fill the gap.

“But it is also clear that outpatient services need a major redesign – getting rid of inappropriate follow-up appointments, getting specialist GPs and physicians to do more outpatient work outside hospital, and thus freeing up more time in hospital for first outpatient appointments.”

Planning figures released by the Department of Health in September suggest a 10 per cent shortfall by 2008 in the number of outpatient appointments, a potential 10 per cent shortfall in operations, and up to a 19 per cent shortfall in scans and other diagnostic procedures.

The longer-term trends, however, suggest that those figures are an underestimate.

http://news.ft.com/cms/s/66f7c620-7cc6-11da-936a-0000779e2340.html

Patricia Hewitt, the health secretary, hopes to be able to announce this month that the government hit its target in December of having no one in England wait more than six months for an in-patient operation. But that measures only the time between the decision to operate and the operation taking place.

The government’s 18 week target for the NHS is much more ambitious. It covers the whole of treatment, from the first visit to the GP, any diagnostic tests that are needed and the operation.

At the moment, no data exist to measure the total wait from the visit to the GP to operation, as routine data are not collected on how long patients wait for diagnostic procedures, such as MRI scans and the more sophisticated forms of pathology.

In some parts of the country, however, patients can wait six months (26 weeks) or longer for a scan.

And published figures show that the average wait for patients who have actually had an operation has been rising in recent years, not falling. Since 2000, it has gone up by 20 per cent to 7.4 weeks.

Waiting times for a first out-patient appointment have been falling – but far too slowly for the government to hit its 18-week target.

In addition, there are fears that increasing diagnostic capacity may prompt more demand, so that waiting times for tests and scans could rise before they fall – something that has happened in other countries when capacity has been expanded.

“What these figures show,” said Alan Maynard, professor of health economics at York University, “is that of the three elements needed to get to an overall 18-week target, one [the outpatient wait] is falling far too slowly, one [the wait for diagnostics] may well rise before it falls, and the third [the time spent on the waiting list before an operation] is going in the wrong direction.

“Unless something changes radically, the government is going to miss its target.”

The figures are likely to fuel an ongoing debate within the department of health and No.10 Downing Street over how much extra capacity the NHS needs to buy in from the private sector, and how far NHS-run institutions and services can increase their own productivity to hit the target.

http://news.ft.com/cms/s/e39bddfa-7c9f-11da-936a-0000779e2340.html

Cancer can be expensive for patients, with many spending increased amounts on heating, special diets, prescriptions, travel and parking at hospital – particularly those undergoing long courses of chemotherapy or radiotherapy.

About two-thirds (66%) of the 58 patients surveyed said they worried about how they were going to afford Christmas this year, while 55% spent less on presents than usual, and 47% cut down on going out.

One in six (16%) borrowed money from friends and family, 13% have taken out a loan and 12% extended their overdraft.

Overall, 60% had to make cuts to their Christmas spending levels this year due to the high costs they shoulder because they have cancer.

Sally Strugnell, a 39-year-old breast cancer patient, said that her family could barely afford to get by over Christmas.

“We have really struggled with Christmas this year”, she said. “I haven’t been able to save up, or buy presents for friends or my husband. Cancer has robbed us of so much of our daily life that we were determined to have a normal family Christmas, make the best of what we could and enjoy ourselves.”

Over 700 people in the UK are diagnosed with cancer each day. More than one in three will be diagnosed at some time in their life.

Peter Cardy, chief executive of Macmillan Cancer Relief, urged patients to contact the charity line to find out about the financial help on offer.

“We know cancer patients can find it hard to make ends meet generally,” he said. “But when this is coupled with additional festive costs it can really break the bank, leaving many patients really anxious. Some have even cancelled Christmas.

Please call 0800 500 8000 for the Macmillan campaign line, or visit www.macmillan.org.uk/abetterdeal if you need any help now.

http://society.guardian.co.uk/health/news/0,8363,1674913,00.html

Cardiac catheter ablation, a procedure performed in day surgery which is more than 90% successful in curing an irregular heartbeat, will now only be available to a minority of high risk cases.

Around 50 patients in Oxfordshire and Buckinghamshire who had been referred to the heart unit at the John Radcliffe hospital in Oxford have been taken off the waiting list and told they cannot now have the operation on the NHS. The numbers will build up over the next year.

Consultant cardiologists at the hospital are dismayed at the decision. They have written to the trust’s chief executive, protesting that without the treatment hundreds of patients will need continuing medical help. Drug treatment helps only a third and has side effects.

The cardiologists say that classifying a small number of patients as high priority implies that the rest do not need the operation.

“We must stress that every patient placed on the ablation waiting list … has a disabling arrhythmia that results in debilitating symptoms that significantly impair their quality of life,” nine consultant cardiologists told the trust’s chief executive, Trevor Campbell-Davis, in a letter.

Withdrawing cardiac ablation – the insertion of a wire which locates and burns a tiny area of the heart causing the irregular rhythm – runs counter to recommendations in the government’s recently published national service framework for coronary heart disease, they say.

The Arrhythmia Alliance, representing patients with heartbeat irregularities, has written to the health secretary, Patricia Hewitt. It has been inundated with calls from distressed members about Oxfordshire’s new policy, it says.

This is “not an appropriate way to resolve the financial crisis which faces Oxford Radcliffe hospital NHS trust … far from saving costs, the cancellation of this procedure for hundreds of patients in Oxfordshire alone will ultimately cost the trust far more,” wrote its president, Professor John Camm. Patients will keep coming back to their GP and casualty units, and will incur losses of earnings and depression.

The crisis has been brought about by the under pricing of the procedure by the Department of Health, cardiologists believe. The department sets a tariff for every treatment, and cardiac ablation is set at £2,000 – but it costs Oxfordshire twice that. It means that Oxfordshire is making a loss on the procedures it carries out, and yet demand is so great that the trust has had to pay for many to be carried out in the private sector, to keep within the six-months waiting list target. Cardiac ablation costs £7,500 to £8,500 in the private sector.

“There is clear evidence that the main motivator for removing patients from the waiting list and denying new patient access to ablation treatment is the need to meet government six-month waiting list targets,” said one cardiologist.

“If Tony Bliar were to come to the John Radcliffe hospital today with his arrhythmia, he would be denied the treatment that he received 14 months ago. He would not satisfy the … ‘high-risk’ criteria.”

Evan Harris, the Liberal Democrat MP for Oxford West and Abingdon, has constituents whose ablation procedures have been cancelled. “It’s disgraceful that patients with serious cardiac conditions and troublesome symptoms are being wiped off an NHS waiting list in order to avoid hospitals breaching perverse political targets.”

Pointing out that Oxfordshire’s move followed close on the heels of the national service framework on heart disease that recommended cardiac ablation, Dr Harris said: “The financial crisis affecting the NHS across the country is now so acute that in the same year that ministers proudly announce new initiatives to treat important clinical conditions, NHS managers are furiously coming up with schemes to avoid providing those treatments.”

Oxford Radcliffe hospitals trust said in a statement that it has recently “been looking at how best to use its resources”. Following a review of cardiac ablation “some patients have been informed that they will no longer be eligible for this particular treatment”. It would still be available for those who were a clinical priority, it said.

http://society.guardian.co.uk/health/news/0,8363,1676577,00.html

Primary care trusts have to include the centrally contracted independent treatment centres, where they exist, on the choice menu.

They must also include private hospitals prepared to offer treatment at the NHS tariff if the existing range of NHS providers does not offer a large enough choice.

In practice, most primary care trusts have run tenders for private hospitals to be included. That has resulted in “most private providers who wanted to get on the menu, getting on the menu”, according to the independent sector’s trade body the Independent Healthcare Forum.

Not all independent providers are offering care in all specialities. It does mean, however, that “in most parts of the country there will be an independent sector choice”, the forum said.

A survey of more than 1,000 adults conducted for Nuffield Hospitals shows four out of five do not know that patient choice is arriving next week.

It equally shows that 60 per cent, given the choice, would opt for a private hospital, with only 18 per cent positively choosing an NHS hospital and 22 per cent saying they do not know.

The initially limited number of private facilities on offer means those figures are unlikely to be borne out in practice. But they imply that NHS- run hospitals, a quarter of which are forecasting an overspend for this year, face strong competition for waiting list patients.

A limiting factor may be that three quarters of GPs, in a smaller survey carried out for Nuffield, say they lack sufficient knowledge of the independent sector to advise patients on whether to go private.

But surveys by Bupa and others suggest patients perceive private hospitals have lower rates for hospital-acquired infections.

http://news.ft.com/cms/s/3b3a275c-79a2-11da-8d99-0000779e2340.html

In this 2006 we are about to witness a crunch year for the NHS with the rushed and dangerous policies of the Labour government about to be noticed by all the voters.