A.  INTRODUCTION

  A.1  Clinical Solutions welcomes the opportunity to respond to the Health Select Committee's inquiry into health inequalities.

  A.2  Clinical Solutions is the world's leading provider of decision-support software for clinicians. We have designed and provided the computer programmes which underpin NHS 24 and NHS Direct, as well as in healthcare services around the world—in Australia, New Zealand, Norway, Scotland and the United States. All of our products have been delivered to the NHS on time, and on budget.

  A.3  We are committed to constructive working with the Government and the NHS to help communities tackle health inequalities and believe that technology has the potential to make a significant contribution. Experience has shown us that new technologies, such as clinical decision support software, and telehealth and telecare systems, can transform the quality and accessibility of health services and deliver improvements in information and care for patients.

  A.4  Clinical Solutions' response focuses on two of the inquiry's major themes:

—  The extent to which the NHS can contribute to reducing health inequalities

—  The ways in which improved access to primary and urgent care services can assist the NHS in tackling health inequalities

B.  EXECUTIVE SUMMARY

  B.1  Health inequalities are caused by a wide variety of factors, many of which are outside the control of the NHS and social care services. However, inequalities in health outcomes are exacerbated by the problems those in deprived communities encounter in accessing health services.

  B.2  The greater integration of primary and urgent care services—such as NHS Direct, GP out-of-hours services, walk-in centres and Accident and Emergency (A&E) departments—can help improve access to health and social care services for those in deprived communities. We share the NHS Next Stage Review's aim of establishing a single telephone number for urgent care services in order to provide a universal and consistent access point for patients.

  B.3  Walk-in centres, in particular, have—and should continue to—play a role in making healthcare services more accessible to hard-to-reach groups. By their nature, walk-in centres provide services more convenient and less intimidating than traditional primary care services, as well as providing drop-in access to health services for patients unregistered with a GP.

  B.4  With the burden of long-term conditions relatively higher in deprived areas, any strategy for tackling health inequalities must also put in place effective plans for their management, which fully harnesses the potential of telecare and other forms of health-related technology, coupled with the support and knowledge of health professionals. The Department of Health's Whole System Demonstrator pilots—currently ongoing—will provide valuable experience to inform the health inequalities strategy.

  B.5  Tackling health inequalities requires commissioners in Primary Care Trusts (including practice-based commissioners) to recognise and imitate the variety of healthcare models now working successfully across the country, and—in particular—to fully utilise the potential for technology both to deliver improved access to healthcare services for those in equal need, as well as to deliver cost savings to the NHS.

C.  THE ROLE OF THE NHS IN REDUCING HEALTH INEQUALITIES

  C.1  Inequalities in health outcomes are caused by a wide variety of personal, socioeconomic and environmental factors. These include employment status, the quality of housing, the environment more generally, education and genetic factors attached, for example, to race.

  C.2  Although many of these factors are outside the control of the NHS and social care services, it has long been recognised that the availability of good healthcare varies inversely with the needs of the population served.[251] This reinforces and exacerbates the differences in health outcomes caused by the factors outside the control of the NHS and social care.

  C.3  Any effective strategy for tackling health inequalities must therefore ensure that health services deliver—at the least—equal access to health services for those in equal need. Indeed, this view has been underscored recently by the Secretary of State for Health, who explained in a speech of 12 September 2007 that, "we must improve access to decent healthcare for people from deprived areas".[252] In addition, the NHS Next Stage Review noted, in its interim report, that a comprehensive strategy for reducing health inequalities must, "ensure fair access to NHS services for everyone".[253]

  C.4  In order to ensure fair access to primary care services, a proportionately greater effort needs to made in deprived areas vis-a"-vis areas less deprived: evidence suggests that a significantly higher proportion of people living in deprived areas report putting off a visit to see their GP because of inconvenient hours[254]; whilst areas with significant black and minority ethnic populations report high levels of inappropriate access to urgent care services—such as A&E departments—because of a lack of awareness of other points of access to primary care.[255] This results not only in a poorer standard of care, but is also cost-inefficient: each attendance at an A&E department costs, on average, £87, compared to an average consultation cost at a walk-in centre of just £27.[256]

D.  SIMPLIFYING ACCESS

  D.1  This evidence of inappropriate use of urgent care services in deprived areas underlines the need for a simple way to access them. To this end, we welcome the commitment contained in the NHS Next Stage Review's interim report to explore, "the introduction of a single three-digit number in addition to the emergency services number 999".[257] As the supplier of the software which underpins NHS Direct—through which nurses assess the level of care needed by a patient and direct them to the most appropriate service—we see at first-hand the great potential for savings to be made by the integration of telephone healthcare services with GP out-of-hours services and other urgent care settings in this way. Indeed, in Australia, we have assisted in realising this potential (see case study, below).

Case study: GP Assist

  Our GP Assist service provides out-of-hours support to GPs throughout the state of Tasmania. All out-of-hours calls by patients are routed through our GP Assist centre, staffed by a small team of doctors and nurses.

  Here, assisted by our CS Teleguides™ software, they provide advice and support to callers and arrange the most appropriate care for them—including, where appropriate, a GP going to their home. Of all the calls made to GP Assist, just 7% end up being referred to a local out-of-hours GP, and almost three-quarters (73%) result in reassurance or advice being delivered over the phone. The caller's GP is provided with a full report the next day. This has had a secondary benefit of encouraging GPs to remain in rural communities, safe in the knowledge that they will be called upon out-of-hours only when absolutely necessary.

  D.2  We would ask the Committee to consider the ways in which a single telephone point-of-access for urgent care services can contribute to tackling health inequalities by making primary care services more accessible in deprived areas.

E.  EXPANDING WALK-IN CENTRES

  E.1  Over the last few years, walk-in centres have also proved effective in enhancing access to primary care services for hard-to-reach groups, such as young men and homeless people.[258] A recent Department of Health-commissioned study found that 35% of people believe that to be able to walk into NHS health centres on the high street whenever you want would be a "big improvement"[259], and this need is even greater in deprived localities, where fewer GPs tend to work despite incentives designed to encourage them to do so.[260]

  E.2  The Department of Health has recently reiterated its view that increasing the number of routes into primary care—in part, through walk-in centres—increases the chances of delivering services at a time and a place which suits the needs of patients.[261] Co-locating walk-in centres and A&E departments in inner-city areas can also realise significant efficiency gains for the NHS, with the cost of an attendance at a walk-in centre (£27) comparing favourably with that of an attendance at an A&E department (£87).[262]

Case study: Tooting Walk-in Centre

  Situated in an inner-city area with a significant black and minority ethnic population, the Tooting Walk-in Centre—which uses the paperless software developed by Clinical Solutions—sits alongside the fully equipped A&E department at St George's Hospital in South London. Its location ensures that it eases pressure on the A&E unit: people visiting A&E with minor conditions are instead directed to the Walk-in Centre, and almost three in five visitors to the Walk-in Centre said that—if it did not exist—they would have gone to A&E or other local health services instead.

  E.3  We share the view of the Department of Health that the continued expansion of walk-in centres will help to tackle health inequalities, and we are particularly encouraged by the moves mooted in the Next Stage Review to create "health centres" combining both health and social care services.[263] Since the users of social care services are among the most vulnerable groups in society—and are more likely to experience the problems of housing and a lack of employment which are also contributory factors to health inequalities—the co-location of social care and health services will facilitate access for these groups to the NHS.

F.  LONG-TERM CONDITIONS MANAGEMENT

  F.1  Any strategy for tackling health inequalities must include as a core component ways in which long-term conditions may be tackled. There are clear links between deprivation and individual long-term conditions: a King's Fund study looking at admissions for Chronic Obstructive Pulmonary Disease (COPD) medical admissions in the UK between 2000 and 2002, for example, found that the rate of hospital admission for COPD rises as deprivation increases. Further analyses found that 31% of such admissions could be attributed to deprivation.[264] The Long Term Conditions Alliance estimates that three in five hospital beds are at any point occupied by people with long-term conditions[265], and in deprived areas this burden—other things equal—is likely to be considerably higher.

  F.2  We share the view of the Department of Health that the effective management of patients with long-term conditions in the community can diminish the number of emergency bed days considerably, and therefore result in an improved quality of care and improved health outcomes.[266] We are of the view that the more widespread use of telecare technology can help to deliver care of greater cost- and clinical-effectiveness. Call volumes to NHS Direct, for example, vary during the course of the day, affording nurses the opportunity to make outbound calls at times of low demand, in order to actively mentor, coach and help patients with long-term conditions to self-manage more effectively their conditions. With the advice nurses deliver over the phone complemented by decision-support software tailored to individual patients, technology such as this allows the needs of patients with long-term conditions to be addressed in a very precise way.

  F.3  As a key delivery partner in the Department of Health's Whole System Demonstrator pilot in Newham—which aims to show how comprehensive and holistic approaches to the care of patients with long-term conditions, making full use of electronic assistive technologies (coupled with the support and knowledge of a trained health professional) can deliver significant improvements in the quality and efficiency of care—we are actively involved in the development of such systems in deprived areas. We hope that the Department of Health will make full use of the results of the pilot in order to assist in its development of the strategy for tackling health inequalities.

G.  SUMMARY

  G.1  Tackling health inequalities requires commissioners in Primary Care Trusts (including practice-based commissioners) to recognise and imitate the variety of healthcare models now working successfully across the country, and—in particular—to fully utilise the potential for technology both to deliver improved access to healthcare services for those in equal need, as well as to deliver cost savings to the NHS.

  G.2  We hope the Committee finds this evidence of use, and we would be glad to submit further evidence if required.

January 2008

252   Alan Johnson, Speech to the New Health Network, 12 September 2007. Back

253   Department of Health, Our NHS: our future, 4 October 2007. Back

254   King's Fund, Inverse care law, 21 June 2001. Back

255   For example, the Bangaldeshi community in Tower Hamlets. Cited in Alan Johnson, Speech to the New Health Network, 12 September 2007. Back

256   Hansard, 1 November 2006, Col. 484WA. Back

257   Department of Health, Our NHS: our future, 4 October 2007. Back

258   Department of Health, Tackling health inequalities: consultation on a plan for delivery, 23 August 2001. Back

259   Department of Health, Our Health, Our Care, Our Say, 30 January 2006. Back

260   King's Fund, Inverse care law, 21 June 2001. Back

261   Alan Johnson, Speech to the New Health Network, 12 September 2007. Back

262   Hansard, 1 November 2006, Col. 484WA. Back

263   Department of Health, Our NHS: our future, 4 October 2007. Back

264   King's Fund, COPD medical admissions in the UK: 2000-01-2001-02, August 2004. Back

265   http://www.lmca.org.uk/pages/about_ltc.html Back

266   Department of Health, Our Health, Our Care, Our Say, 30 January 2006. Back