Website of the Department of Health

More operations

...extra capacity for elective surgery...

As a start, substantial investment will see more than a quarter of a million additional patients on waiting lists treated next year, helping to secure more rapid treatment for NHS patients and reducing the backlog of people waiting for treatment, so that the NHS has the room for manoeuvre to begin to offer real choices for patients.

The purpose of this investment is to enable Primary Care Trusts - working in partnership with Strategic Health Authorities, Trusts and social services - to assure delivery of targets for reducing waiting times by:

The money will be used to create extra capacity for elective surgery by expanding existing NHS facilities, developing diagnostic and treatment centres, by re- designing existing services to function more efficiently and by paying for NHS patients to be treated in other NHS facilities, private facilities or abroad. The NHS will also need to ensure that spending plans reflect the consequential costs for social care and community health services of providing care to the increased number of patients who will need support and rehabilitation after their operations.

This substantial expansion in activity will make substantial in- roads into waiting lists and put the NHS in a strong position to make rapid progress towards NHS Plan targets. By April 2003 the maximum waiting time for inpatient treatment will have fallen from 18 months today to 12 months. This will be an important staging post to further substantial reductions in waits by 2005, with a maximum six month wait and an average waiting time of seven weeks for a hospital operation.

More choice

The aim, set out in the NHS Plan, is to establish systems to ensure that patients who need hospital treatment will be supported through a series of choices which give them much greater influence over their own care.

By 2005 all patients and their GPs will be able to book hospital appointments at both a time and a place that is convenient to the patient. Patients and their doctors will be able to consider a range of options. This might include local NHS hospitals, NHS hospitals or diagnostic and treatment centres elsewhere, private hospitals, private diagnostic and treatment centres, or even hospitals overseas. They will be able to compare different waiting times at different hospitals and across different specialties. GPs and referring consultants will be able to book appointments online. The point is that by then, at the point of referral, the patient will be able to choose the hospital and waiting time that is convenient for them.

The resources we now have available mean that we can make a start next year to introduce this new system whereby patients choose the hospital rather than hospitals choosing the patient. Many patients may choose not to exercise a choice. Many will prefer to wait at their local hospital. Some will prefer to travel to get faster treatment. But the important point is that for the first time, it will be the patient's choice. And that choice will no longer be between waiting longer for treatment or paying for treatment.

We will start with patients who have been waiting longest for treatment. This new initiative will begin next year to open up the options, to tackle some of the highest priorities and to pilot new approaches. The initial focus in 2002 will be on opening up new opportunities for people who are waiting too long for heart surgery; with a number of pilots for other surgical specialties in London, the North East, North West, Midlands and the South.

In the light of these pilots, further schemes will be rolled out, with the aim that by 2005, as pledged in the NHS Plan, all patients will not only have rapid access to treatment, but will also be able to choose where that treatment is carried out. As waits are reduced across the country, most patients are likely to opt for local treatment, but the NHS will continue to give them the freedom to be cared for elsewhere if they prefer.

In implementing the initiative, local systems to support patient choice will need to enshrine a set of key principles to embed choice within the core NHS principles set out in the NHS Plan.

Principles

Free NHS Care - Wherever it is provided care will be provided free at the point of delivery, on the basis of clinical need, not ability to pay.

Clinical Priority - Treatment will be offered on the basis of clinical priority. All patients will continue to be offered treatment at their local centre on the basis of their clinical priority, within the guaranteed maximum waiting time. While the NHS works towards the 2005 waiting guarantees, where possible those who experience longer waits will also now be offered the choice of treatment elsewhere.

Safe and High Quality Care - Wherever patients choose to be treated, they and their doctors should be confident that the care will be high quality, with access to clear information about the clinical performance of the hospital to which they are being referred, as this becomes available.

Guaranteed Waiting Times - There will be reduced waiting times with guaranteed maximum times that will fall year on year.

Choice - Any patient for whom it is appropriate and who in the first instance, who has waited more than six months or longer will, if possible, be given the choice of going to another hospital - NHS, private, elsewhere in the country, or managed abroad - to ensure that they are treated quickly or treated in a hospital that better suits their needs and preferences. Over time, we will offer choice, not just to the longest waiters, but ever closer to the time of referral.

Information - Patients will be given easy access to the facts they need to take an informed decision about their care. Patient Care Advisors will discuss choices with patients and provide them with the information they need.

Predictability - Patients who have waited more than six months will be contacted to discuss options and to agree a date for treatment. They will have clarity and certainty about their time of treatment.

Continuity - Patients who travel for treatment will be supported by NHS staff to ensure that their travel, accommodation, assessment, treatment and aftercare are managed as smoothly and easily as possible. There will be appropriate support for a relative or carer.

Long term commitment to the NHS - The Government will continue to invest in NHS staff, equipment and buildings so that within a few years, shorter waiting times will be available to all patients at their local hospitals.

Efficiency - Whether treatment is local, public, private or abroad, the NHS will continue to seek the best possible value from NHS resources that is consistent with patient choice and prompt and high quality treatment.

Extending Choice for Patients - Heart Surgery

As the first stage in the initiative we have developed proposals to extend patient choice and dramatically cut waiting times for heart bypasses and angioplasty. We are starting with heart disease because this is an area in which the NHS is already demonstrating real progress in expanding capacity and cutting waiting times, it is of real concern to patients and relatives and because clinical teams want to move forward faster to secure a better deal for patients awaiting surgery.

The United Kingdom has historically low levels of provision for heart surgery, particularly in some of the areas where it is needed most. At the time of the publication of the National Service Framework for Coronary Heart Disease in March 2000, there were nearly 1,100 patients waiting more than 12 months for treatment. Today that has fallen to 560. By April 2002, when the maximum waiting time for all other operations will be 15 months, no patient will wait more than 12 months for a heart operation.

At the same time a number of factors has been putting increasing demand on cardiac surgical capacity. As the population ages, more people in the country are at an age where they are at risk of heart disease and demand for heart surgery is rising accordingly. Changing surgical techniques and improved surgical skills mean that the NHS is now able to treat safely patients who might not have survived surgery in the past. A growing number of urgent cases means that more bypasses and angioplasties are being carried out as emergency cases, meaning the less urgent cases are sometimes pushed back on the waiting list. With the ability to intervene in more complex cases, operations can take more time than they used to, again slowing the rate at which NHS surgeons can work through their waiting lists.

Nevertheless, waiting times have been falling. With substantial increases in the revenue funding available to the NHS for heart surgery and the hard work of dedicated clinical teams, the NHS has been making increased use of its current capacity to carry out surgery. It has also been paying for significant numbers of patients to be treated in private hospitals in England. As a result the NHS secured an extra 4,800 heart operations for patients over the last year. In addition, the CHD Collaborative has been pioneering new ways of working in all parts of the NHS which deal with coronary heart disease, to help ensure faster care that respects the needs and concerns of the individual patient. This programme will roll out nationally from April 2002.

For the medium to longer term, the Government has already begun to make substantial capital investment in new and expanded heart surgery facilities. Over the past two years £60m has seen a new specialist surgical centre begun at Wolverhampton, and renewal and expansion at Papworth, Bristol and South Tees. This month we announced a further £170m for new hospitals in Liverpool and Blackpool and expanded and modernised facilities in South Manchester, Central Manchester, Southampton, Leeds, Plymouth and Sheffield. That investment programme will continue over the next five years and beyond to ensure that, increasingly, the NHS is able to offer all heart patients fair access to the surgical services they need in a local unit and in an acceptable time. The current historic inequalities in provision in some parts of the country will be eradicated by this investment programme.

At the current pace of change, set out in the NHS Plan, this investment would secure a six month backstop for surgery by 2005 and a three month maximum wait by 2008. A growing number of patients will benefit from much faster treatment than these backstops. However we need to do more for the minority of patients still experiencing long waits. While they may be classified as 'routine' by the system, for any individual needing heart surgery, such a classification must be difficult to understand as they and their families try to deal with the discomfort, pain and anxiety of their disease. So we must to do better than the NHS Plan targets if that is possible.

Patient views

We know that heart patients are keen to explore other options. In one survey, more than 90% of the public said that they would be willing to travel to a different local hospital for treatment. More than three quarters were willing to travel to another hospital in a city close by. Just under a third said they were willing to travel to another part of the country or abroad. For heart patients, the figures are a little lower, but one recent survey suggests a majority of patients who have waited more than six months for surgery would wish to travel elsewhere for their treatment.

Some patients already travel for treatment because of shortages of surgical capacity in the areas in which they live. Some patients in Liverpool currently travel to Scotland to be treated more quickly and patients in the South West of England and the West Midlands frequently travel to London for their surgery. There is good experience to build on in successfully and safely treating patients in different parts of the country.

Not all options will be appropriate for all patients. For some the nature and severity of their illness will mean that the safest option is for them to be treated locally rather than to travel. Others may prefer to stay with a particular clinical team with whom they have built a trusting relationship. Others will wish to stay in close contact with friends and family at home. A significant number will need treatment urgently and will continue to be seen in a matter of days or weeks. But for patients who do wait and where it is possible for other options to be offered, it is right that there should be a choice about where they are treated.

We know that there is scope to use capacity elsewhere and we know where some of that is now - in London, elsewhere in the United Kingdom, in the private sector and overseas. The time is now right to put in place the funding needed to harness that capacity to the needs of NHS patients, and to open up real choices for those patients who currently have to wait for too long.

The NHS will need to prepare for important practical and cultural changes in the way that they relate to patients who are waiting for heart surgery. The initiative calls for a new kind of dialogue with patients, with their clinicians and other advisers enabling and supporting patients in decisions about their own treatment. The National Director for Heart Disease, Dr Roger Boyle, will be working with cardiologists and surgeons in the NHS to discuss the clinical and other practical implications of this new referral system.

How the system will work for patients

From July 2002, all patients who are on a waiting list and who have been waiting more than six months for a heart operation will be contacted by their hospital to discuss the options for treatment:

Other patients already on the list will be offered the same options if their wait continues for six months or longer. For new patients who join the list from July 2002 onwards, the referring cardiologist will explain the new arrangements and again the patient care advisor will contact them within six months if the patient is still waiting. For patients who choose not to travel there will remain a backstop maximum 12 month wait at their local centre.

All patients who need to be seen more urgently will continue to be seen in a matter of days, weeks or months, depending on how clinically urgent their operation is. For patients who need to travel, support will be put in place to ensure strong links and continuity of care with their 'home' hospital, so that after surgery they can return home knowing that their records, medication and aftercare will be carefully managed by their local hospital and family doctor. When patients do travel, it will only be on the basis that both doctor and patient are confident in the standard of care delivered in the unit where the operation will take place.

Managing the New System

In the proposed system, commissioners would contract with NHS surgical centres, on the basis that:

To provide this choice, the trust, in consultation with the hospitals which refer patients to it in the cardiac network, would need to subcontract with other NHS and private providers, in line with its patient choices, through a central clearing system.

Funding will be available to enable cardiac centres to continue with planned expansion and develop to the maximum their own capacity to treat local patients. NHS surgical centres and private sector hospitals who have the capacity to carry out more surgery or who feel they can extend their capacity quickly and efficiently would be invited to submit bids to the central clearing system to treat additional patients, subject to agreed quality requirements, so as to provide choice to those patients who are likely to wait more than 6 months at their local centre. This will enable a pool of additional options to be identifed nationally and 'reserved', so that these can be offered as choices to those patients. The networks of commissioners and hospitals will have the funds to be able to support the choices of those patients who decide to take up one of these options. So local centres will have the funds either to provide treatment locally or to enable patients who have waited six months or more to be treated elsewhere if they choose.

We would expect relationships to develop between referring centres and those hospitals which are likely to prove most convenient for their patients, and that strong clinical links will develop between them. However where patients prefer, perhaps because of personal or family circumstances, to be treated at a greater distance, that too will be arranged through the clearing house. An important feature of the arrangements will be the need for clinical leadership of the clearing house arrangements, to help facilitate good communication between clinical teams and ensure that the clinical elements of transfer arrangements will work smoothly in all circumstances.

We recognise that patients and their relatives will also want the reassurance that there will be suitable arrangements to help them with travel where necessary, and to ensure that a relative or friend is able to accompany the patient if they are to be treated at a considerable distance from home. There are examples of successful existing schemes on which to build, and we shall want to explore with patients and relatives what kinds of information and support will best support these new treatment options.

Overseas Options

Overseas providers will also be invited to put forward bids to treat NHS patients. In selecting potential providers we will need to satisfy ourselves that the standards of care offered are at least equivalent to those in the United Kingdom. As with all arrangements where treatment is contracted to another hospital, we will need to develop seamless links between the referring NHS hospital and the overseas provider. And we will be looking for arrangements which take full account of patients' needs (such as smooth travel to and from the United Kingdom, availability of English speaking staff and translators and appropriate support for patients while overseas).

The overseas package of care is likely to include travel, surgery and a period of postoperative care. And there will need to be suitable arrangements to enable a relative or friend to accompany the heart surgery patient. We shall wish to explore these issues in more depth with patient organisations and relevant NHS bodies.

Patient Care Advisors

A central aspect of delivering the initiative successfully will be the sensitive management of the patient's journey through the various stages of his or her care pathway. Where patients are to be transferred to other hospitals, possibly some distance from home, the management of that transfer needs to be carefully co- ordinated. Patients and their carers will need information and support throughout the process. We envisage that for each tertiary centre and its cardiac network there will be a cardiac Patient Care Advisor to work for patients.

The Cardiac Patient Care Advisor will act as the patients' champion and their adviser on exercising choice about their care. Although they will sit within the cardiac networks in order to be close to the patients they are serving, they will be accountable to Patient Choice Trustees at a national level, who will include representatives of the British Cardiac Patients Association, the British Heart Foundation and members of the National Coronary Heart Disease Taskforce.

There will also be a need for support during the transfer process and surgery as well as ensuring patients are fully integrated into local support and rehabilitation networks post operatively without compromising existing patients or services. We want to explore further how this kind of support can best be offered. One option would be to invite centres who bid for the extra activity to offer this kind of support for patients and relatives as part of their package. The number of transfer patient co- ordinators required will depend upon local circumstances and the numbers involved.

What will be new for Patients?

For patients the initiative offers the prospect of real choice about where they are treated - for the first time in the history of the NHS. Their treatment will remain free at the point of delivery. If they have waited for more than six months at their local hospital, they will be given options to be treated elsewhere more quickly. They will be supported in making their choice by a patient care advisor and the doctors that they know, and will be helped at each stage of the patient journey by their own care co- ordinator.

What will be new for NHS Staff?

For clinical teams, the initiative will help to take some of the pressure off their own waiting lists and allow them to concentrate their efforts on patients who need to be treated urgently or near to their homes. We recognise that this may well have implications for case- mix and clinical outcomes for some centres, for example if they undertake a changed proportion of more urgent cases as a result of these changes, and the National Director for Heart Disease will be exploring these issues with the Royal College of Surgeons and the Society of Cardio-thoracic Surgeons.

The central clearing house to manage surgical capacity will need to be informed by a good understanding of the clinical practices and systems around the country. The Department of Health will ensure that expert consultant input is available to guide the work of the clearing house. For referring cardiologists and receiving surgeons, it will be important that strong links are established and maintained so that referring hospitals have trust in the arrangements at the receiving surgical centre and so that receiving centres have confidence in the clinical judgements of referring hospitals. The National Director for Heart Disease will be discussing these arrangements in detail with the relevant stakeholders, Royal Colleges and professional bodies.

In the light of the experience, the initiative will spread to other clinical areas and the Government will explore the scope for further significant reductions in waiting times for heart surgery in subsequent years. At the same time, the Government will continue to invest in surgical services across the country to ensure that all patients are given the choice of rapid access to treatment in a hospital near to where they live.

Issues to be Explored with Stakeholders

There are a number of important practical issues to be resolved, both nationally and locally, to ensure that the proposed initiative for heart surgery works to the greatest benefit of patients. The Department of Health will be liaising with the NHS, key professional bodies and patient representatives to discuss these issues over the coming weeks and months. Questions that we will be exploring include:

Other Surgery

The initiative for heart surgery marks the start of a wider initiative to improve patient choice and speed up treatment across the NHS. Other pilots will be developed over the coming months in London and in other parts of the country.

This will be an important staging post towards delivering the new system in 2005, in which all patients will be able to book a convenient time and place for their treatment at the time their GP or consultant refers them.

Patient Information

Good information will be essential to ensure that patients have genuine choice. All organisations that are providing additional treatment options to patients from other localities will be required to provide prospectuses describing their services and what they can offer for patients.

NHS Direct Online (see link below) will provide up to date and accurate information with which patients and their GPs can make informed decisions about treatment. The website will provide patients and their GPs with inpatient and outpatient waiting times by specialty and by consultant. Patients will also have access to information:

Next Steps

This document signals the direction for new relationships between patients and the NHS and between the NHS and its wider partners. A relationship where patients are in the driving seat. Where it's the patients' interests that come first and where there is more choice and more diversity within an NHS based on principles of need, not ability to pay.

There is more to do to flesh out these proposals and ensure they deliver the greatest benefit for patients. This document is therefore intended as a starting point for discussion: - nationally, on the heart surgery scheme, and within regions, as other pilots are developed.

We shall call an early summit, involving patients, clinicians, managers and partner organisations, to explore and help refine the heart surgery proposals. As the regional pilots are developed during 2002, they will need to be informed by similar dialogue.

This document is about opening up patient choice and we want to hear above all from patients how we can best shape these new developments to meet their needs.

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