To receive an update from the Primary Care Trust on the Local Development Framework.

The Committee received an update on the Primary Care Trust’s Local Delivery Plan.

Mr Simon Hairsnape, Chief Executive (Acting) of the Primary Care Trust (PCT) gave a presentation on the Local Delivery Plan 2007/08 (LDP).

He commented first on the national funding picture noting that 2007/08 was the last of 3 years of significant funding growth (around 9% per year) which had brought funding roughly into line with European average investment of 9 % Gross Domestic Product. He explained the basis on which funding was allocated to PCTs and that Herefordshire had been allocated £233 million in 2007/08 (£1,309 per patient.)  This was to cover hospital services, community services, primary care (e.g. GP services) and prescribing.

The LDP, which had now been agreed with the West Midlands Health Authority set out the PCT response to national requirements and local targets.  Priorities for 2007/08 were:

·          Reducing waiting times from when a GP referred a patient for treatment to the start of treatment to 18 weeks by December 2008.  (This represented a significant contrast to the position where patients had had to wait 6-9 months for an out-patient appointment and up to two years for treatment.)   Herefordshire had opted to implement this early so that 90% of people would be treated within 18 weeks by December 2007.  It would require a huge increase in capacity and redesign of services to achieve the target

·          Reducing the incidence of healthcare acquired infections.  (Although the number of cases was not large in health terms there was an issue of public confidence in the system to address.)

·          Reducing health inequalities and promoting health and well-being (with particular focus on 48 hour access to Genito-urinary Medicine (GUM) clinics).  (Money allocated to the Health Promotion Service had been ring-fenced.  A joint Director of Public Health was to be appointed.)

·          Improving financial ‘health’. (Whilst Herefordshire’s financial position had generally been good it was again an area where it was important to ensure public confidence.)

He reported that following the requirement for the NHS to achieve financial balance in 2006/7 there was a requirement to achieve a national £250M surplus in 2007/8.  This was in the context of reduced growth from 2008/9 onwards and a requirement that cash releasing efficiency savings of 2.5% would be achieved for all services.

He also drew attention to the introduction of the system of payment by results which was based on paying nationally fixed ‘average’ prices for each episode of care rather than negotiating prices locally.  This aimed to reward productivity and efficiency in that if a hospital could attract more patients or provide care cheaper than the national tariff, they would gain.  It was also intended to play a key part in achieving other areas of system reform such as choice, and achieving the 18 week waiting time target from GP referral to the start of treatment.

He referred to the ‘Non-NHS Contracts’ for the delivery of long-term and palliative care through contracting with the private and independent sectors.

In relation to further system reform to increase choice and competition he commented on the national drive for greater ‘plurality’ of providers to increase capacity, drive competition, increase innovation and responsiveness to patients.

He also commented on the target that 80% of patients should report they were being offered a minimum of 4 choices by their GP when they are referred to hospital services.  Currently this was not something which appeared to be being met in Herefordshire with only 30% of patients claiming to be offered this level of choice.  Comparative information for patients to help them make choices was basic at this stage, often resting on GP recommendation.

In conclusion he stated that 2007/08 was another important year for the PCT with the Government’s expectation that national targets set out in 2000 would be met.  There would be organisational reform with the development of a Public Service Trust for Herefordshire and decisions on the management of provider services.  The PCT’s decision to seek to achieve the target of delivery of reducing waiting times from GP referral to the start of treatment to 18 weeks by December 2007 was also a challenge.  Whilst the financial position in Herefordshire had historically been reasonable there would still be some difficult decisions to take.  Improved public engagement was also an objective with a mismatch between the level of public satisfaction expressed with services, most people indicating that they were “generally satisfied” and the improvements that the PCT considered had been delivered.

In the ensuing discussion the following principal points were made:

·          The implications of seeking to reduce waiting times from GP referral to the start of treatment to 18 weeks by December 2007 were discussed.  Mr Hairsnape said that making sufficient capacity available was the key challenge rather than providing the finance in 2007/08.  An “unscheduled care” project was underway to seek to manage workload so that the capacity to undertake elective care was maximised.  However, the tighter financial circumstances expected in future years made it important that progress was made this year.  He added that if the PCT achieved the 18 week target and met its financial targets and public health targets it would be one of the highest performing PCTs in the Country.

·          It was asked how the PCT intended to finance the delivery of the target to reduce waiting times from GP referral to the start of treatment to 18 weeks by December 2007 and why it believed it could do so in 2007/08 given the difficulty in paying for operations it had faced at the end of 2006/07.  Mr Hairsnape said that once the waiting list had been reduced it did not need as great a level of resources to keep it at that level.  There were also potential financial gains in that once the shorter waiting time was achieved patients would seek to be treated locally rather than elsewhere.   He added that the principal reason for funding issues arising in 2006/07 had been that the PCT had had to pay £6.1 million in 2006/07 to the Strategic Health Authority to help offset financial pressures elsewhere in the NHS.  It was expected that at least a proportion of this money would be returned to the PCT particularly if it could demonstrate that it was performing well.

·          Mr Woodford, Chief Executive of the Hospitals Trust, confirmed that the 18 week target had the potential to benefit the hospital in that treating more patients would generate more income.  The Chairman of the Trust emphasised that achieving the target depended on the Hospital,  the PCT,  Social Services and the voluntary sector working working together.  To succeed the project would require that patients did not stay in the hospital or community hospitals longer than necessary but returned to home as soon as they could safely do so.

·          A question was asked about instances of patients being discharged and not subsequently being notified of aftercare appointments.  On behalf of the PCT it was stated that it was now the case that a lot of follow up appointments were no longer necessary.  Discussions had taken place with the GPs on this point to agree a policy.  What was important, however, was that if a follow up appointment was not required this was clearly communicated.

·          On behalf of the Hospitals Trust it was acknowledged that the hospital booking centre had been under pressure, in part because of the introduction of a new computer system.  Direct booking by GPs across all services would be rolled out by mid-summer which should reduce pressure on the centre.   The Chief Executive said that he would be pleased to look into any specific cases if the details were forwarded to him.

·          In response to a question about payment by results Mr Hairsnape confirmed that whilst the PCT was paid slightly more per patient than the average, reflecting the County’s demographic profile, with a higher number of older people, no account was taken of the County’s rurality, despite the PCT continuing to make the case to Government that delivering services in a rural County cost more.

·          Mr Hairsnape also commented briefly on the resources which had been put into NHS pay.  He acknowledged that these had been significant but had helped in addressing recruitment and retention difficulties.  He added that GPs were now delivering a wider range of services and that good performance was being rewarded.

·          It was asked whether the proposed increased levels of activity created the risk of an increase in the number of infections being acquired within the hospital.  Mr Woodford replied that there was a proven link between activity levels and infection rates.  Targets had been set to reduce the number of cases of MRSA and C. Diff.  In 2003/04 the hospital had very few cases and improving on that level was very difficult.  It was explained that all elective care patients were screened before entering the hospital.  Where cases were found the aim was to isolate those cases.  This was a challenge in a relatively small hospital with a small number of wards.  The ideal would be to achieve an occupancy level of about 85%.  Prescribing policy was also being changed recognising the link between some antibiotics and the spread of C. Diff.  It had to be acknowledged, however, that visitors to the hospital needed to heed notices about the need to take appropriate steps to preserve cleanliness such as washing hands in accordance with the instructions on the notices posted around the hospital.