February 2001

The Quince

Health Policy Analysis and Evidence-based Public Health

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February 2001

The Quince ...

Issue 39.

In this issue

Improving health in Wales – A plan for the NHS with its partners

NICE Guidance on Methylphenidate for Attention Deficit/Hyperactivity Disorder in Childhood.

Improving health in Wales – A plan for the NHS with its partners

The new NHS plan for Wales will, the Welsh Secretary for Health says ‘provide a sense of renewal and of purpose for the Service over the next ten years’.

The headline changes were the structural changes

Underlying the approach which the Plan adopts are three key characteristics

simpler for patients to use and understand.

accountable for the actions it takes and the services it delivers.

and have a stronger democratic voice in the way it is governed.

At the local level, the government intend radically to strengthen and develop the role of Local Health Groups (LHGs). LHGs will take on new responsibilities for commissioning and delivery of health care in their localities. Membership of LHGs will be extended to include representation from local authority elected members to strengthen democracy.

At the national level, and in order to achieve a Welsh NHS that tackles inequalities and provides the best possible service, the National Assembly will provide leadership, direction and oversight. This will allow the abolition of Health Authorities in Wales. The structure of the service will be simplified and made more understandable, more transparent, more accountable and more responsive to its users than ever before.

Trusts must become accountable servants of their local communities working in partnership with the National Assembly and local stakeholders/interests.

The Assembly will consult on proposals for the future management of the remaining Health Authority duties, including a regional capacity in line with evidence on service provision and use by patients.

The public health function will be overhauled and developed to meet the health and well-being challenges of the 21st century.

The new structure will enhance the democratic voice in Wales, by making the elected National Assembly directly responsible for our health services. Locally, the role of local government will be enhanced. New Partnership Boards will oversee the development and delivery of those community services in which both health and social services play a joint role. The retention of Community Health Councils in Wales will complement these developments and local government will continue to play a vital role within them. The assertion of the Assembly’s direct oversight, the development of LHGs; new accountabilities for Trusts and the closer integration of local government are all important elements in the renewed NHS for Wales.

The Plan also has some consideration of improving patient care. This is spelled out in terms of targets. The range of targets agreed for 2001/02 include:

All referrals deemed urgent by a cancer specialist should be seen within 10 working days of receipt of GP’s request for an appointment;

No patient needing routine cardiac surgery should wait more than 12 months for treatment;

The maximum waiting time for cataract surgery will be 4 months;

Restructuring of orthopaedic services to match best practice;

Achieve a sustained reduction year on year in the number of people waiting over 12 months for orthopaedic treatment, and the numbers facing outpatient waits of more than 6 months, aiming to reduce the number to nil by the end of 2002/03, subject to resource availability;

Increase by a minimum of 10% the number of hip and knee replacement/revision operations;

Deliver agreed reductions in long waits;

Trusts and LHGs should introduce, at a minimum, booking systems in two major outpatient specialties;

NHS Trusts should ensure inpatient or day case treatment booked admission systems are introduced in 2-3 specialties during 2001/02 and fully operational for the five largest specialties by March 2003

Each trust must produce by September 2001 a plan of action to introduce in 2002/03 seven day working in an area of service where it is appropriate and clinically acceptable to do so.

NICE Guidance on Methylphenidate (Ritalin, Equasym) for Attention Deficit/Hyperactivity Disorder in Childhood.

This is intended as a brief overview of the NICE guidance. Methylphenidate is recommended for use as part of a comprehensive treatment programme for children with a diagnosis of severe Attention Deficit/ Hyperactivity Disorder (ADHD).

Caution is required in the prescribing of methylphenidate for children and young people with epilepsy, psychotic disorders, or a history of drug or alcohol dependence.

Diagnosis should be based on a timely, comprehensive assessment conducted by a child/adolescent psychiatrist or a paediatrician with expertise in ADHD. It should also involve children, parents and carers and the child’s school, and take into account cultural factors in the environment. Multidisciplinary assessment, which may include educational or clinical psychologists and social workers, is advisable for children who present with indications of significant co-morbidity.

Treatment with methylphenidate should only be initiated by child and adolescent psychiatrists or paediatricians with expertise in ADHD, but continued prescribing and monitoring may be performed by general practitioners, under shared care arrangements with specialists. Careful titration is required to determine the optimal dose level and timing. The drug should be discontinued if improvement of symptoms is not observed after appropriate dose adjustment.

A comprehensive treatment programme should involve advice and support to parents and teachers, and could, but does not need to, include specific psychological treatment (such as behavioural therapy). While this wider service is desirable, any shortfall in its provision should not be used as a reason for delaying the appropriate use of medication.

Children on methylphenidate therapy should receive regular monitoring. When improvement has occurred and the child’s condition is stable, treatment can be discontinued at intervals, under careful specialist supervision, in order to assess both the child's progress and the need for continuation of therapy.

The remainder of the document has details on clinical need, technology, evidence, implications for the NHS, further research, implementation, clinical audit advice and a review of the guidance together with information for patients

The Full document and a summary of evidence will be available on the NICE website at http://www.nice.org.uk/nice-web/Cat.asp?c=11652

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