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1. Summary and Purpose of the Report

1.1. The Committee has previously endorsed a collaborative approach to the conduct of health scrutiny and the evolving nature of the work programme of the Committee.

1.2. A programme of reviews of services, developed in consultation with key stakeholders has been agreed. Other health issues raised with the Committee by members or other key stakeholders, which are additional to the formal review programme also need to be addressed to support the delivery of an effective overview and scrutiny function.

1.3. In addition members of the Committee have previously indicated a wish to see how the work of the Committee is progressing.

1.4. This paper outlines the next steps in support of development of an effective overview and scrutiny function, taking account of the:

_ the views expressed by members

_ overview and scrutiny of Health Guidance (OSC Guidance)

_ draft regulatory framework for Patient and Public Involvement Forums (P& PIFs)

_ draft requirements for referral to the Independent Reconfiguration Panel (IRP)

1.5. The Committee has previously noted the complexity of the health landscape within its area. This point and the diversity of the population served is reflected in the Overview and Scrutiny of Health Guidance, which notes that there needs to be a variety of routes through which issues or concerns about health services can be raised with scrutiny committees.

1.6. Building on the fact that there are a number of different options open to the Committee in deciding how to address a particular issue the framework set out below provides a process through which the Committee can consider a range of health issues and respond to improve health services. Points to consider when setting of priorities of the Committee have also been included.

2. Next Steps: Designing the work programme

2.1. The OSC Guidance recommends that the Committee produces an annual overview and scrutiny plan that:

_ is discussed and shared with local health bodies

_ identifies priorities for a given period

_ includes capacity for the Committee to respond to formal consultation and issues raised by P & PIFs

2.2. This paper fulfils this recommendation and incorporates the collaborative approach to health scrutiny that the Committee has already been established. The paper will be circulated to all partner organisations for comment once the view of the Committee has been ascertained. Suggested improvements to the approach will be reported to the Committee.

2.3. In order to enable health scrutiny to have the maximum impact in influencing and improving the health of local people the OSC Guidance suggests that priority is accorded to:

_ issues where a distinct and positive impact can be made through the scrutiny function

_ topics that are timely and relevant but not under review elsewhere

_ health inequality considerations

2.4. Where an issue is already subject to performance management or other monitoring activities this should be used as a resource to inform the Committee's understanding of the problem in hand. Where appropriate the Committee may also wish to access other sources of intelligence regarding a particular topic. This may include feedback from the communities affected or their local representatives, patient groups or the voluntary sector. Similarly the Committee may wish to take account of in-house performance reviews where relevant.

2.5. The approach outlined in this paper will enable the members of the Committee to be confident that reviews and other investigations undertaken complement rather than duplicate other scrutiny or monitoring activities. In some instances the introduction of new arrangements for providing services to local people may mean that the Committee adjusts the agreed work programme in relation to a particular topic area.

2.6. The framework proposed also provides flexibility in the way in which the Committee discharges the overview and scrutiny function and seeks to use the resources available as effectively as possible. It is suggested that the programme of reviews is supplemented by two additional strands of work. These fully reflect the commitment of the Committee to partnership working and acknowledge the different forms of activity that support the scrutiny function. The proposed strands of work are:

_ Reviews of health services. These may be thematic across a health system or focus on a particular service. The review programme will provide the Committee with an overview of specific health topics, cross cutting service providers and identifying opportunities for improvement. As such they will complement existing performance management and other monitoring activities (e.g. best value reviews).


_ Health Inquiries. Members have identified a number of issues that they consider require further investigation by the Committee, including access to GPs, access to chiropody services and delayed discharges. Some of these concerns are already subject to regular performance monitoring, others require further investigation to determine any further action open to the Committee to improve the delivery of a particular service. Additionally partner organisations such as district councils may wish to draw a particular issue to the attention of the Committee.


_ Response to formal consultation. These will focus on issues of substantial service development or change. There will be a variety of approaches to determine the response of the Committee to consultation, shaped by the topic in question. There should be `no surprises' in the issues raised with the Committee for a formal response. The Committee should therefore have advance notice from the NHS regarding items which may be the subject of formal consultation.

2.7. Underpinning each of these strands of work will be the commitment of the Committee to take a challenging but constructive approach to health scrutiny, bringing together evidence and people's experience to drive forward improvement in health services to local populations.

2.8. A model for reporting progress against each of the three work strands identified is included at Appendices 1-3.

3. Defining the Work Strands

3.1. Reviews of Health Services

The first programme of these reviews will focus on Children and Young People. This topic for review was supported in the consultation with key stakeholders regarding the Committee's approach to health overview and scrutiny. A rolling programme of work has been identified across four specific areas:

_ looked after children

_ the health of school age children

_ mental health services for children and young people

_ therapy services for children


The first of these reviews `Looked after Children' is already underway and is due to report back to the Committee in December. The second topic area, `school age children' is intended to commence shortly.

3.2. Health Inquiries

The introduction of the `Health Inquiries' strand of work recognises that there may be opportunities to influence and improve some aspects of health services without recourse to a full review. In addition there needs to be an open and accessible route through which partner organisations can draw the Committees attention to a particular health issue.

It is intended that P & PIFs will have the power to refer to the Committee:


_ issues of concern relating to the provision of health services in a particular Trust

_ issues of concern relating to the discharge of Section 11 of the Health and Social Care Reform Act.


The approach suggested extends this option to include other partner organisations as defined in the original consultation paper. This includes Hampshire district councils, NHS bodies, voluntary and independent sector providers and organisations that are representative of social care service users and carers.


Where inquiries raised with the Committee are already subject to monitoring or other performance management activities the action taken should be focused on the local resolution of inquiries through appropriate sign-posting to the agency best placed to respond.


The issues raised and action taken would be reported to the Committee at each meeting, providing a `litmus test' of the performance of health services across the Committee's area which will complement and not duplicate other monitoring activities.


If an issue cannot be satisfactorily resolved then the Committee will be able to consider other options for further action, including referral to the relevant responsible agency or P & PIF (when established) or inclusion in the formal review programme.

3.3. Response to Formal Consultation

Each local NHS body has a duty to consult the Committee on any proposals it may have under consideration for any substantial development of the health service in the area of the Committee's local authority, or on any proposal to make any substantial variation in the provision of such service(s).

This duty to consult the Committee is additional to the duty placed upon NHS bodies to consult and involve patients and the public as an ongoing process under section 11 of the Health and Social Care Act.

Any proposals for service change should be discussed with the Committee at an early stage, in order to agree whether or not the proposal is considered substantial. At this point there should also be discussion about how consultation will be undertaken. This latter discussion should include agreement about the length of time the consultation will last and methods to be used taking into account local needs.

In determining if a proposal is substantial, the Committee should consider the impact of the change of patients, carers, and the public who use, or have the potential to use a service. This may include issues such as the acceptability of the proposed change to service users or the impact that proposals may have on other heath services. Account should be taken of:

_ Changes in the accessibility of services for the people using the service in question

_ Clarity about the improvements to be achieved for people using the service in question. This should include changes in the way in which services are delivered.

_ Change that is based on clear evidence and organisational best practice

_ The extent to which service users, the public and other key stakeholders had contributed to the planning and delivery of the service in question (Section 11). Particular regard will be given to the involvement of `hard to reach groups' where this is appropriate.

_ Evidence that the views of the public and key stakeholders were considered and responded to appropriately.

_ Impact of the proposal on the wider community and other services. This may include consideration of issues such as economic impact, transport issues and regeneration

_ Whether the proposal is in the interests of health services in the area of the Committee


Whilst it will be for the Committee to determine how it wishes to respond to formal consultation the Guidance suggests that weight is given to the way in which the NHS has discharged its statutory duty to effectively involve and consult all key stakeholders under section 11 of the Health and Social Care Act.

4. Independent Reconfiguration Panel

4.1. Any referral made to the Secretary of State by the Committee or, until 1 December 2003, by a Community Health Council may be referred by the Secretary of State to the Independent Reconfiguration Panel (IRP).

4.2. The IRP was set up in April 2003 and consists of one third health professionals, one third health service managers and one third patients/citizens representatives. It is an advisory body only, the final decision on any contested proposal resting with the Secretary of State.

4.3. The proposed structure and function of the IRP has now been drafted and can be accessed on www.doh.gov.uk/irp

4.4. Cases referred for consideration by the panel will probably relate to:

_ substantial or significant changes in the pattern of service delivery

_ widespread and consistent stakeholder disquiet not resolved by any other means

_ cases where all other options for mediation have been exhausted.

4.5. The IRP will seek to respond to a referral in eight weeks and will place particular emphasis on the way in which the NHS has involved and consulted local people at all stages.

4.6. Any referrals from the Committee will be examined to ensure that there is clarity regarding the grounds for the objection and action taken to resolve these locally. This reinforces the need for responses to formal consultation to follow a clear set of criteria to inform decision making by the Committee.

4.7. The full draft document produced by the IRP is appended at Appendix Four.

Recommendations

1. The proposal for developing the three strands of work defined section three of this paper is endorsed by the Committee.

2. A standing item is included in each Committee agenda to report back to members on progress with:

_ The programme of reviews undertaken by the working groups on behalf of the Committee.

_ Inquiries received and action taken. This should include an indication of the source of the inquiry and comments on any response received and will enable the Committee to identify good practice as well as issues that merit further investigation.


_ Information on any proposals to vary or develop NHS services. This will alert the Committee and others key stakeholders to planned changes and enable consideration to be given to the need for formal consultation as well as providing the Committee with an up-date on existing consultations.

3. Feedback on the approach adopted by the Committee is invited from all partner organisations. Comments received will inform the review and development of the overview and scrutiny plan.

4. The Committee regularly assesses the inquiries received and the programme of reviews to ensure that work undertaken is able to improve and influence health and health services in its area.

5. A work programme is produced detailing how each of the three strands of scrutiny will be progressed in the period 31 March 2004. This will include the officer lead for different area of activity.

5. The criteria set out in section three are adopted to guide the formulation of the Committees response to formal consultation. The appropriateness of these criteria will be regularly reviewed to ensure that they reflect best practice.

6. A rolling programme of briefings for members is established, based on issues raised with the Committee.

Section 100 D - Local Government Act 1972 - background papers

The following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extent in the preparation of this report.

NB the list excludes:

Published works

Documents which disclose exempt or confidential information as defined in the Act.

File Location

APPENDIX ONE

Health Review Committee APPENDIX TWO

Sample Inquiry Report

Attachment A

Health Review Committee

Briefing Note: Access to GPs

Summary and Purpose

This briefing note has been prepared at the request of a member of the Health Review Committee to clarify arrangements for enabling patients to obtain timely access to GPs.. It sets out:

· The national targets for access to a GP or other primary care professional

· The role of the Primary Care collaborative in supporting practices make progress towards these targets

· The definitions applied to the targets

· The current position in Hampshire as reported by the Health Authority

· A short note on the new contract for GPs and the changes that will result from the implementation of this contract.

The purpose of this briefing is to provide members with information on the issues that will have implications for the ease with which local people can get an appointment with a GP or other health professional.

National targets for access to a GP or other primary care health professional

The NHS Plan set out that, by 31 December 2004, all patients will be able to see a primary care professional within 24 hours and a GP within 48 hours, if they wish to do so. This target applies to permanent and temporary residents registered with a practice.

The choice remains with patients to decide if they wish to be seen at a time more convenient to them outside these timescales or wait longer to see a preferred GP or health professional.

Specific funding has been allocated to support the delivery of target. In 2002/03 the primary care access fund was increased from £84.5 million to £168 million. This is allocated to PCTs on a weighted capitation basis. It is expected that this finding will be used to

· Achieve the 24/48 hour access in primary care

· Increase capacity and extend services in primary care

· Manage demand in primary and secondary care (e.g. through `walk-in' centres, integrated nursing teams, training for GPs with a special interest).

Monitoring on progress is conducted quarterly and the expectation was that, at March 2003, 90% of patient would be seen in accordance with the target.

Role of the Primary Care Collaborative

The Primary Care Collaborative (PCC) is the vehicle through which the national development team is seeking to improve services to meet the targets. The work of the collaborative focuses on three areas

· Access to primary care

· Coronary heart disease

· Improving capacity

The approach adopted by the PCC is based on a model of continuous improvement through small rapid cycles of change, commonly known as the plan, do, study, act cycles. Essentially this is about helping practices work smarter not harder.. The aim is not only to improve the quality of systems but to enable participants to develop quality improvement skills which can be deployed elsewhere.

In a report of progress in its first two years of existence, published last November, the PCC reported

· 2000 practices, covering 11.5 million patients were involved in improvement work

· early results indicating a fourfold reduction in the mortality of patients with coronary heart disease in PCTs

· a 60% reduction in the average wait to see GP in participating practices

· a 50% reduction in waiting time to see a nurse in participating practices

· the setting up of new ways of working across primary and secondary care, reducing overall waiting times and improving the patient experience.

Definitions applied to targets

· `a GP' means any GP. It is not a named GP nor is it necessarily a GP at the registered practice, although the latter is desirable.

· `within 48 hours' is within two normal working days, following the day that the request was made by the patient.

· `a primary care professional' refers to any health professional who is a member of the practice or wider local primary care team.

· `within 24 hours' means by the end of the following normal working day

· `patients' means those registered with a GP.

· `to see' means face to face contact

Current position in Hampshire

The year end position in the Hampshire and Isle of Wight Strategic Health Authority area was

· access to a health professional (including GPs) within one working day -89.5%

· access to a GP within two working days- 78.9%

The new GP contract

There are a number of changes taking place in primary care that will have an impact on the services available to local people. One of the main influences will be the new GP contract which should be in place by April 2004.

The contract will include arrangements for work load management and improved quality relating to:

· Services to be provided by all practices. Termed essential services these will cover the management of patients with treatable illness, care of the terminally ill and care of patients with chronic diseases.

· Additional services. These cover six areas: cervical screening, contraceptive services, vaccinations and immunisations, child health surveillance, maternity services and minor surgery procedures. Practices may opt out of providing these services in some circumstances (e.g. workload pressures).

· Enhanced services. These may be either essential or additional services delivered to a higher standard or an extra specialist service such as a minor injury service.

Where practices choose to opt out of providing services PCTs will be responsible for ensuring that patients access is not compromised.

In addition practices may also choose to opt out of providing out of hours cover.

The obligation for providing out of hours care will be transferred from local practices to PCTs . Where practices choose to opt out of providing this care, or are not able to meet mandatory standards, PCTs will be responsible for providing these services directly or commissioning alternative providers. This change will come fully into effect from December 2004.

Health Review Committee APPENDIX THREE

Consultations currently underway