Website of the Department of Health

18 April 2002

1. Extending Choice for Patients - Information and Advice on Establishing the Heart Surgery Scheme was issued for consultation on 6 March 2002.

2. This letter:

(i) - responds to questions raised during consultation (Annex A);
(ii) - sets out the revenue allocations to support revascularisation in 2002/3003;
(iii) - reports on progress in establishing the scheme (see below).

3. Details about the allocation of the increased funding of £100m to support the scheme have now been issued. A copy of this advice is attached at Annex B.

4. It has been agreed that revascularisation plans for 2002-3 will be finalised on a separate track from the main SAFF process. The timetable for this is:

By 1 May, StHAs to reconcile SAFF plans with cardiac centre proposals and allocations and resubmit plans to DsHSC

By 10 May, DsHSC, with the Heart Team, to assess plans and identify capacity needed from the independent sector

Commissioners and providers should bear in mind that, pending agreement on increased activity to be undertaken as part of the choice scheme, activity levels between now and July should have regard to the need to sustain a 12 months maximum wait; reduce maximum waits to nine month by March 2003 and offer choice to six months waiters from 1 July.

5. Since the advice was issued there has been a number of developments. A national advertisement to support the local recruitment of Patient Care Advisers was published in Health Service Journal and Nursing Times on 27 March and the number of expressions of interest has been promising. Sifting and interviewing of relevant local applications will be carried out by individual centres. The Heart Team will be sending each Centre details of expressions of interest and some further information on training days in the next day or two.

6. The tender document inviting private sector and overseas providers to bid for activity to support the Choice initiative was issued on 4 April. Copies of the document are available at www.doh.gov.uk/extendingchoice/index.htm. The capacity to be secured through the central tendering exercise will be identified in late May or early June, following the agreement by DsHSC and the Heart Team of activity plans submitted as part of the SAFF process for cardiac surgery.

7. For further information on this letter please contact:

- for allocations, Ken Cooper on 0207 972 1314 - ken.cooper@doh.gsi.gov.uk
- for the tender exercise, David Lewis on 0207 972 4834 david.lewis@doh.gsi.gov.uk
- for Patient Care Advisers, Maree Barnett on 0207 972 4831 - maree.barnett@doh.gsi.gov.uk
- for all other enquiries, Gavin Larner on 0207 972 4814 - gavin.larner@doh.gsi.gov.uk

DR ROGER BOYLE
NATIONAL DIRECTOR FOR HEART DISEASE

Annex A

Comments, Questions and Answers on Extending Choice for Patients - Information and Advice on Establishing the Heart Surgery Scheme

Question: When will patients be referred to other providers and how soon after referral will they be treated? It is important to ensure that patients are treated as quickly as possible and prevent patients who are on the receiving provider's waiting list from being disadvantaged.

Answer: Initially when the Choice scheme begins on 1 July there will be a need to secure prompt treatment dates for the significant numbers of patients waiting more than six months for treatment. After that point as Patient Care Advisers manage this initial volume of patients, they should increasingly be able to anticipate patients who are likely to wait more than six months and begin to plan their treatment with them well before the six month trigger point.

For patients who are referred to private providers under the initiative, the outline contract specification has been framed on the basis that patients will be treated within four weeks of referral. NHS providers who are treating patients from outside their own local populations will need to closely monitor their referral to treatment times.The National Cardiac Coordination Unit will be able to assist PCAs on the likely time of treatment offered by receiving trusts.

Trusts should not offer more favourable waiting times to patients referred in under the scheme than to their own patients and waiting times should be monitored to ensure this.

Question: On whose waiting list will transferred patients appear? Will centres offering capacity need to strip out transfers when reporting returns to the centre?

Answer: The Department of Health will issue guidance on reporting systems for waiting information as soon as possible.

Question: Is it the intention that all patients will be assessed using the scoring system for identifying patients suitable for treatment away from their "home" centre, set out in Annex C of the 'Extending Choice for Patients' advice document, or just those who are travelling?

Answer: All patients likely to wait six months or more will need to be assessed to judge whether they are clinically suitable for the scheme. Where the severity of a patient's condition means that they are unable to travel a significant distance or that no alternative local provider is able to take on the complexity of their treatment, the Patient Care Adviser will discuss the reasons with the patient. Such patients will be likely to be a priority for treatment at the local centre.

Question: How can we ensure that "borderline" cases are not sent back untreated because of different treatment thresholds in referring and receiving centres?

Answer: The scheme has been set up in a way that will allow the development of "mini-networks" of providers, of perhaps two or three centres, so that clinicians are able to develop a mutual understanding of each other's referral thresholds and minimise disagreement on suitability for treatment. The patient scoring system set out in Annex C of the advice document should assist in and inform this process. The Department of Health is developing guidance on standard referral information to support those Centres who do not already have systems in place. Clearly, any differences of opinion which do arise should be resolved before the patient travels for treatment.

Question: How will funding be provided for travel and accommodation, information systems, administrative and clerical staff, PCAs, and other support systems for the choice scheme?

Answer: The revenue allocations set out in this letter include resources for these elements of the scheme but they are not separately shown. This will allow commissioners and cardiac centres a degree of flexibility in the way that they use the funds to support the choice scheme locally. The costs of the overheads should be included in the contracts between providers.

Question: Will the £100m be ring-fenced to ensure local implementation of the national initiative?

Answer: The £100m is from a central budget, allocated for the purposes set out in Annex B and expenditure will be monitored.

Question: Will allocations match the demand in each area? Will allocations punish past achievement or reward poor performance?

Answer: Details about the methodology underpinning the allocation of funding are set out in Annex B. Briefly, they take account of population need and the need to expand services across the country in line with the rate of 750 procedures per million population nationally for CABGs set out in the CHD NSF goals.

Question: What will the funding arrangements be beyond March 2003?

Answer: The revenue allocations to StHAs are recurrent.

Question: Who will manage PCAs and to whom will they be accountable?

Answer: The Patient Care Adviser will be professionally accountable to the Director of Nursing in each trust. His or her day-to-day manager in the cardiac service in each trust will be a matter for local discretion, but should allow close working with the local cardiac service. The Patient Care Adviser will be accountable to the PALs at a local level for ensuring the scheme operates in the way intended. Patient Care Advisers will also have access to Patient Choice Trustees who will provide independent external oversight of the scheme. It is planned that the Trustees will guide development of the Patient Care Adviser role as well as considering any issues of principle and policy which need to be addressed and advising on the lessons learned from this cardiac surgery pilot for the wider roll out of patient choice. Equally, Patient Choice Trustees will be able to ask PCAs for information on the way the scheme is operating.

Question: Will PCAs be short term appointments?

Answer: The duration of appointments will be for local discretion but the scheme is expected to run for at least the next two to three years.

Question: Are PCAs going to be in place in sufficient time? Unless PCA appointments are done through internal postings and secondments, they are unlikely to be in place on time.

Answer: Initial responses to the national recruitment advertisements suggest a high level of interest in the posts across the country. Sifting and interviewing of relevant local applications will be carried out by individual centres and it will be for them to decide on the best way of filling the PCA posts. Obviously timing is tight, and in some areas it may be necessary to use internal postings and secondments in the short term to ensure the scheme is in place by July 1st. Annex C of the advice document sets out work that should be in hand now to prepare for the start of the scheme.

Question: If nine months is not a target, what is it?

Answer: The Priorities and Planning Framework actions on CHD for 2002-03 included the requirements: "Expand revascularisation capacity to maintain and improve on a 12 months maximum wait so that a growing number of patients are treated within 9 months. From July 2002, introduce choice of alternative provider for patients who have waited 6 months for revascularisation at their current provider." The £100m now available should enable StHAs to plan to offer a nine months maximum wait by April 2003, or better if possible. StHAs are asked to plan on this basis, or better, if possible. As the scheme is a pilot and it is not yet clear how many patients will wish to exercise choice, the 9 months maximum wait is not at this stage a public guarantee for patients.

Question: Why isn't there greater emphasis on cardiac rehabilitation in the document?

Answer: The revenue allocations set out in this letter include elements to cover rehabilitation costs. It will be the responsibility of Patient Care Advisers to ensure that patients are provided with prompt and high quality rehabilitation following surgery. The Department of Health is currently developing further advice on the provision of rehabilitation to support the choice initiative.

Question: Why should valve surgery normally be carried out within six months? How can services ensure that this is the case?

Answer: For many cases involving valves, there is the potential for these conditions to worsen over time. It is important that all patients with surgically significant aortic valve disease and all those with mitral regurgitation should be seen with six months. Services for and subcontracts for CABGs and other cardiac surgery should be planned to ensure that there is sufficient capacity for this to take place.

Question: Will commissioners have a say in the suitability of subcontracting with particular providers?

Answer: Subcontracts should be agreed in close consultation with local cardiac networks, including commissioners, taking account of the needs of local populations and patient preferences. In identifying suitable providers, the NCCU will work closely with local networks to ensure that commissioners and tertiary centres are content with the proposed arrangements.

Question: Is all capacity that is not needed to deliver a local nine month wait to be offered nationally, or could a trust take in fewer patients and offer local patients an eight or seven months maximum wait?

Answer: Initially, all capacity that a trust does not need to meet a nine months maximum wait for patients should be offered to the NCCU as a national resource. In order to allow trusts with significant levels of additional capacity to benefit local patients as well, the NCCU will be willing to discuss pragmatic arrangements with providers in these circumstances.

Question: Will there be in-year opportunities to revise capacity estimates upwards, for example, subject to the success of recruitment that is currently under way?

Answer: Yes, and it will be important to keep the NCCU up to date on capacity changes in order to enable this capacity to be used within the funding available for the scheme overall.