HEALTH SERVICE SYSTEM REFORM

KEY POLICY INITIATIVES 2005-2008

INTRODUCTION

This document was put together by North East London Strategic Health Authority to assist local NHS organisations and their partner agencies make sense of the NHS policy jigsaw.  It is not a comprehensive list of all NHS policy and guidance, but outlines some of the key elements of the health service system reform agenda.  Given the constant change that the NHS is experiencing, it will almost certainly be out of date by the time you read it, but hopefully it will provide a useful starting point in setting out the plans for modernisation of the health service and priorities for the NHS to 2008.  It is reproduced with the Strategic Health Authority’s kind permission

Section A.

Public Sector Reform: National Targets, Local Delivery

Section B.

Improving the Health of the population: Reducing Health Inequalities

The Wanless Reports,  Choosing Health: Making Choices Easier

Section C

Managing Long Term Conditions

Section D

Patient Choice and Commissioning in the New Environment

Patient Choice, Choose and Book,  Payment by Results,  Practice Based Commissioning 

Section E.

Patient and Public Involvement

Section F.

Creating Capacity

Capacity Plans for General and Acute Services, Involvement of the Independent Sector,  Treatment Centres,  Capital Developments 

Section G. 

Modernisation

Section H.

Workforce Development and Pay Modernisation

Agenda for Change, European Working Time Directive, Improving Working Lives, The New Consultant Contract, The GMS Contract,  Dentistry, Pharmacy

Section I.

Foundation Trusts

Section J.

Healthcare Commission

Section K.

Improving Information, Communications and Technology 

 1.      Government Framework of Principles for Public Sector Reform

 The vision for the health service set out in the NHS Plan (July 2000) is to offer prompt, convenient, high quality services, which treat patients as partners. The delivery of this vision is shaped by the Government’s framework of principles for public sector reform; namely: 

• High national standards and clear accountability;
• Greater local ownership and innovation: devolution of responsibility;
• Increased flexibility for frontline staff;
• Greater choice for patients helped by greater diversity of provision.

2.         NHS Improvement Plan: Putting people at the heart of public services (June 2004) 

At a national level, the NHS Improvement Plan sets out the Government’s plans for the modernisation of the health service and priorities for the NHS to 2008. It supports the ongoing commitment to a 10-year process of reform first set out in the NHS Plan, and signals three major shifts: 

• Putting patients and service users first through more personalised care;
• A focus on the whole of health and well-being, not only illness; and
• Further devolution of decision-making to local organisations.

2.1       The Next Four Years to 2008 

Investment in the NHS will rise to £90 billion per year by 2007/08. In   return for this investment, the Improvement Plan says that the NHS will offer the following: 

• By 2008, no one will have to wait longer than 18 weeks from GP referral to hospital treatment, with quicker access in priority areas i.e. cancer;
• From December 2005, patients will be able to choose hospital care from 4 or 5 providers;
• By 2008, patients will have the right to choose any healthcare provider that meets the Healthcare Commission’s standards and can provide care within the maximum price that the NHS will pay;
• Patients will be given more access to a wider range of services in primary care;
• Electronic prescribing will improve the efficiency and quality of prescribing;
• In every care setting the quality of care will continue to improve, with the Healthcare Commission providing an independent assurance of standards; patient safety will be a top priority;
• People with complex long-term conditions will be supported locally by a new type of clinical specialist, the community matron;
• Major investment in services much closer to home will ensure much better support for patients who have long-term conditions;
• There will have been further progress in tackling the biggest killer diseases, with a 40% fall in death rates from heart disease and stroke, and a 20% fall in death rates from cancer by 2010, compared to 1997 levels;
• The NHS will develop into a health service rather than one that focuses primarily on sickness and will, in partnership, make in-roads into smoking, obesity and other major cause of disease, with a drive to reduce health inequalities;
• Local communities will have greater influence over local services and local priorities;
• PCTs will control over 80% of the NHS budget;
• All NHS trusts will be in a position to apply for foundation trust status
• More staff will work in the NHS and they will be encouraged to work more flexibly; and
• There will be incentives for healthcare providers to offer care that is efficient, responsive, of a high standard and respectful of people’s dignity.

3.         National Standards, Local Action-Health and Social Care Standards and  Planning Framework-2005/06-2007/8 (July 2004)

 This Department of Health document describes a further shift, which   moves away from a system that is mainly driven by national targets, to one in which: 

• Standards are the main driver for continuous improvements in quality;
• There are fewer national targets;
• There is greater scope for addressing local priorities;
• Incentives are in place to support the system; and
• All organisations locally play their part in service modernisation.

3.1       Four national priority areas are highlighted, each with specific national targets and timescales, as follows; 

3.1.1       Improving the health of the population (by 2010) 

• Increasing life expectancy at birth in England to 78.6 years (men) and 82.5 years (women);
• Reduce mortality rates from heart disease/stroke/related diseases- by 40% (people under 75), from cancer-by 20% (people under 75), from suicide-by 20%;
• Reducing health inequalities-by 10% (from a 1997-99 baseline) as measured by infant mortality and life expectancy at birth; and
• Tackling the underlying determinants of ill health and health inequalities by reducing adult smoking rates to 21% and 26% (routine/manual groups), halting the rise in obesity among children under 11, reducing the under-18 conception rate-by 50%.

3.1.2       Supporting people with long-term conditions (by 2008) 

• Offering a personalised care plan for vulnerable people most at risk; and
• Reducing emergency bed days by 5%, through improved care in primary care and community settings, for people with long-term conditions.

3.1.3       Access to services (by 2008) 

·        No-one to wait more than 18 weeks from GP referral to hospital treatment;

·        Increasing the participation of problem drug users in drug treatment programmes by 100%; and

·        Increasing year on year the proportion of drug users successfully sustaining or completing treatment programmes.

3.1.4       Patient/user experience (by 2008) 

• Securing sustained national improvements in NHS patient experience, ensuring involvement in their healthcare, choice of provider, and focus on black and minority ethnic groups;
• Improving the quality of life and independence of vulnerable older people, by supporting them to live in their own homes where possible-increase by 1% annually-in 2007 and 2008, and increase % of those supported to live at home to 34% of the total of those being supported at home or in residential care; and
• Achieving year on year reductions in MRSA levels, expanding to cover other health care associated infections as data from mandatory surveillance becomes available.

4.         National Service Frameworks and National Institute for Clinical Excellence (NICE) Guidance 

           National Service Frameworks (NSFs) are long-term strategies for improving specific areas of care. They set measurable goals with set time frames. The rolling programme of NSFs was launched in 1998.   

NSFs and NICE guidance are integral to a standards-based system. They have a key role in supporting local improvements in service quality. Organisations’ performance will be assessed not just on how they do on national targets, but increasingly on whether they are delivering high quality standards across a range of areas, including NSFs and NICE guidance. 

           National Standards, Local Action, states that NSFs and other national strategies will continue to be developed where needed, and should be considered as part of the developmental standards. The NHS and Local Authorities will be required to demonstrate that they are making progress towards achieving the levels of service quality described in the NSFs and national strategies. 

4.1             Current NSFs 

• Paediatric Intensive Care (1999)
• Mental Health (1999)
• Diabetes (1999)

• Coronary Heart Disease (2000)
• Older People (2001)
• Renal-Part 1 (2004)
• Renal-Part 2 (2005)
• Children, Young People and Maternity Services (2004)

Other published guidance includes the NHS Cancer Plan and the National Strategy for Sexual Health and HIV. 

           The NSF for Long Term Conditions is due early 2005.

Further Reading

www.dh.gov.uk/publicationsandstatistics/publications/publicationspolicyandguidance/fs/en

 1.      National Agenda 

1.1           The Wanless Reports 

1.1.1       Securing Our Future Health: Taking A Long-Term view (2002) 

           In 2001 the Chancellor commissioned Derek Wanless to examine future health trends and to identify the key factors which will determine the financial and other resources required to ensure that the NHS can provide a publicly funded, comprehensive, high quality service available on the basis of clinical need and not ability to pay.  The report ‘Securing Our Future Health: Taking a Long-Term View’ set out an assessment of the resources required to provide high-quality health services in the future. It was based on first catching up, and then keeping up with other developed countries, which had moved ahead of the UK over recent decades. This report illustrated that: 

• There was a considerable difference in expected cost depending upon how well health services in England became more productive and how well people became fully engaged with their own health;
• Resources were needed not only to satisfy short-term objectives, i.e. access to services, but also to invest in improving supply, by building the capacity of the workforce, improving information technology support and renewing premises, and to invest in reducing demand by enhancing the promotion of good health and disease management;
• Many of the benefits of engaging people in living healthier lives occur in the long term but there are also immediate and short-term benefits when demand for health services can be reduced, i.e. acute services where capacity is severely constrained.

1.1.2       Securing good health for the whole population: Final report  (February 2004)

 In 2003, the Prime Minister, the Chancellor and the Secretary for State for Health asked Derek Wanless to provide an update of the challenges in implementing the ‘fully engaged’ scenario set out in his 2002 report ‘Securing Our Future Health’. 

The report ‘Securing good health for the whole population’ focused on: 

·        The prevention and the wider determinants of health in England and the cost effectiveness of action that can be taken to improve the health of the whole population and to reduce health inequalities;

·        The consistency of current policy with the public health aspects of the ‘fully engaged’ scenario, and concludes that activity underway ‘could well put the NHS on course for the solid progress scenario’ (part way between the current position and fully engaged) but a step change will be required ‘to move us to a fully engaged path’;

·        The need to strengthen public health policy making, through explicit and quantified objectives, which are mainstreamed within the NHS and across Government; and

·        The urgent need to build the knowledge base to enable the development of much more effective public health delivery systems. 

1.2         Choosing Health: Making healthy choices easier (November 2004) 

The DH White paper ‘Choosing Health’ builds upon and addresses the issues from the Wanless reports.

 1.2.1    Choosing Health-Core Principles 

‘Choosing Health’, sets out a new approach to public health, based on three core principles: 

• Informed Choice-that people want to be able to make their own decisions about choices that impact on their health and have trustworthy information to help them do so. Two exceptions cover responsibility for children too young to make informed choices themselves, and special arrangements for cases where peoples choice impacts harmfully on others i.e. exposure to second hand smoke;
• Personalisation-to tackle health inequalities by tailoring support to individual lives, with services and support personalised, and provided flexibly and conveniently; and
• Working Together- the establishment of effective partnerships across communities to ensure that healthier choices can be made-including local government, NHS, business, advertisers, retailers, media, faith organisations, voluntary sector, and others.

1.2.2   Choosing Health-Priorities for Action 

• Reducing the number of people who smoke;
• Reducing obesity and improving diet and nutrition;
• Increasing exercise;
• Encouraging and supporting sensible drinking;
• Improving sexual health;
• Improving mental health.

1.2.3    Choosing Health-Proposed Initiatives 

Initiatives and timescales proposed in the White Paper are summarised in Table 1 below:       

     Table 1

 1.         National Agenda

 1.1       National Standards, Local Action-Health and Social Care Standards and Planning Framework-2005/06-2007/08

           This identified ‘supporting people with long-term conditions’ as one of the four national priority areas (See Section A paragraph 3.1.2)

           The national target for this area is: 

• To improve health outcomes for people with long-term conditions by offering a personalised care plan for vulnerable people most at risk; and to reduce emergency bed days by 5% by 2008 (from expected 2003/04 baseline), through improved care in primary care and community settings for people with long-term conditions.

 1.2       Supporting People with Long-Term Conditions. An NHS and Social Care Model to support innovation and integration (January 2005)

          This announced further guidance on the way health and social services will deliver care to people with long-term conditions. It directs NHS organisations to: 

• Assign individual ‘community matrons’ to the most vulnerable patients with highly-complex multiple long-term conditions-3,000 community matrons to be in place by 2007 (See Section B paragraph 1.2.4);
• Establish multi-professional teams that can identify all of the people in their area with a single serious long-term condition, assess their needs as early as possible, and provide pro-active care before their condition deteriorates;
• Educate all people with long-term conditions about their health and encourage them to manage their own care more effectively.

1.3             Supporting People with Long-Term conditions: liberating the   talents of nurses who care for people with long-term conditions (February 2005) 

           This DH guidance supplements ‘Supporting People with Long-Term conditions’ (See paragraph 1.2 above), by summarising what Government policy means, specifically for nursing, and how individual professionals can improve care for people with long-term conditions. 

           It focuses on patients with the most complex needs and on the role of community matrons. 

1.       Offering Patient Choice 

1.1     National Agenda 

1.1.1   The Principles of Patient Choice

• Patients should be involved in decisions about their healthcare;
• The NHS should provide services that are responsive to patients’ needs;
• Funding should follow patients, rewarding services that patients value;
• Choice, supported by booking will drive cultural and behavioural change in health services.

1.1.2   The NHS Plan places a key emphasis on extending patient choice

1.1.3   Building on the Best: Choice Responsiveness and Equity in the   NHS (December 2004)

This DH document was published after a national public consultation on patient choice. One of the strongest messages from the national consultation was that people wanted improvements in the quality and accessibility of information as an essential prerequisite to making informed choices about their health and healthcare. Table 2 below lists the key priority actions from Building on the Best:  

Table 2

1.1.4   Better information, better choices, better health: Putting information at the centre of health-DH (December 2004) 

           This DH strategy document builds on the commitments set out in ‘Building the Best’. It provides a framework to develop resources nationally and locally that meets everyone’s needs for information and sets out a three-year programme of action detailed in Table 3 below: 

Table 3

2.       Choose and Book

 2.1     National Agenda

 2.1.1   What is Choose and Book?

From December 2005, patients needing elective treatment will be offered a choice of 4-5 hospitals once their GP has decided that referral is required. These could be NHS trusts, foundation trusts, treatment centres, private hospitals or practitioners with a special interest operating in primary care.

As well as choosing where they are treated, patients will be able to choose the date for their treatment aided by an electronic booking programme.  

           In the meantime, from August 2004, all patients waiting longer than 6 months for an operation are being offered a choice of an alternative place of treatment. This is called ‘choice at six months’. 

2.1.2   Choose and Book Policy Framework-DH guidance (August 2004) 

This guidance sets out the detailed Policy Framework for December 2005, and notified the requirement for PCT level plans for implementation of Choose and Book to be submitted centrally by October 2004.

 3.        London

 3.1      The London Patient’s Choice Project 

           London has been one of nine pilot sites for Choice. It first looked at cataract surgery and patients waiting more than 6 months were offered alternative places for almost immediate surgery. The project has now expanded to cover orthopaedics, general surgery, ENT, urology and gynaecology. NE London has been taking part in the London project. 

SHAs and NHS trusts are working together on the following essentials of choice: 

• Having a clear estimate at any one time about how many patients are eligible for Choice;
• Ensuring treatment has been agreed and commissioned with alternative hospitals; and
• Ensuring that patients are transferred efficiently when they accept alternative care.

4.       Payment by Results 

4.1     National Agenda 

4.1.1   The NHS financial reforms were announced in ‘Delivering the NHS Plan’. The budget settlement of 2002 announced the largest ever sustained increase in NHS funding over 5 years, averaging 7.4% real growth per year and on course to match European average by 2008.  

4.1.2   Reforming NHS Financial Flows: Introducing Payment By Results (2002) 

          This DH consultation paper set changes to NHS Financial Flows and the introduction of the new financial system Payment by Results, as part of the drive towards greater consistency and transparency in the NHS. 

           Payment by Results:

• Is a tariff-based system for payment to Trusts, by PCTs, for activity they have undertaken, and adjusted for case mix (instead of being commissioned through block agreements);
• Is based on a standard national price tariff, which creates a level playing field;
• Enables PCTs to concentrate on quality and quantity rather than price
• Pays NHS Trusts and other providers, fairly and transparently for services delivered;
• Rewards efficiency and quality in providing services, and encourages productivity;
• Supports greater patient choice and diversity;
• Encourages activity for sustainable waiting time reductions; and
• Enables transfer of activity from secondary to primary care.

4.1.3   Payment by Results: Preparing for 2005 (2003)

           This DH document identifies the key decisions needed for implementing the next stage of Payment by Results. It outlines how it would apply to NHS Foundation Trusts from April 2004 and to all Trusts from April 2005.

 4.1.4   Scope of Payment by Results for 2005/06: Important Announcement (January 2005) 

           This DH letter notified SHAs of the decision to amend the phasing in of Payment by Results by: 

• Introducing a new step to the process, with non-electives, outpatients and A&E deferred by one year; so that

• Elective care only be included in 2005/06; and
• 90% of hospital care to be covered by 2008/09 (as per the overall implementation timetable).

5.       Practice Based Commissioning

 5.1        National Agenda

 5.1.1       What is Practice Based Commissioning? 

GP practices are one of the main determinants of health care utilisation, and with their central co-ordinating function, they often have a major influence on what care a patient receives and how a patient exercises choice.  

           At present, with the possible exception of prescribing, this impact comes without any need for practices to consider how they are using health service resources and often without the financial ability to secure better and more innovative services for their patients. 

Practice based commissioning is consistent with the principles of greater devolution, and the right to hold a budget meets this aim and recognises the important role that GP practices play in commissioning services for their patients and local populations. 

5.1.2   The New NHS (1998)  

This White paper stated that ‘over time, the Government expects that…PCTs will extend indicative commissioning budgets to individual practices for the full range of services’ 

5.1.3   The NHS Improvement Plan (2004) 

           Indicated that from 2005, GP practices that wish to do so will be given indicative commissioning budgets. 

5.1.4   Practice Based Commissioning: Engaging practices in commissioning-DH (October 2004) 

           This publication sets out proposals for involving GP practices in commissioning health care services, and highlights that changes in the NHS mean that practice based commissioning will assume greater importance in the system overall offering the following benefits: 

• More efficient use of services;
• Greater involvement of front line doctors and nurses in commissioning decisions;
• A greater variety of services, from a greater number of providers, in settings closer to home and more convenient to patients.

5.1.5    Practice Based Commissioning-DH (December 2004) 

           Based on the paper outlined in paragraph 5.1.4 above, this document provides guidance on Practice Based Commissioning and provides a framework for local implementation. It highlights the additional positive outcomes of Practice Based Commissioning as follows: 

• Increased support of clinician-to-clinician dialogue about improving services and developing care processes;
• Early and continuing involvement of practitioners in service development; and
• An additional set of levers to aid the active management of the market in the context of Payment by Results and Foundation Trusts.

The paper covers guidance on the following issues: 

• What is meant by the right to an indicative budget;
• How it is anticipated Practice Based commissioning will develop;
• Risk-sharing, budget-setting and arbitration; and
• How the DH will support Practice Based Commissioning.

No targets are highlighted for Practice Based commissioning, other than the right of practices to hold an indicative budget from April 2005, and the DH aspiration that all practices will be involved in Practice Based Commissioning by 2008. 

1.       National Policy 

1.1       The NHS Plan (July 2000) 

Described a vision for the 21^st century, with services designed around the needs of patients and improved health, particularly for the poorest people in our society. 

1.2       Health and Social Care Act 2001, Section 11  

           This places a duty on all NHS organisations to make arrangements to involve and consult patients and the public. NHS organisations were already required to consult on substantial variations and developments to services, but Section 11 places wider duty (a legal requirement since January 2003) to involve and consult patients and the public in the ongoing planning of services, developing proposals, and in decisions that may affect the operation of services. ‘Strengthening Accountability’-DH policy and practice guidance (February 2003) was issued to help the NHS to carry out this new duty. 

1.3       Building on the Best: Choice, Equity and Responsiveness-DH national consultation document (December 2003) 

            Launched to give staff, patients and the public an opportunity to tell the Government what choices they would like to be able to make about their health and health services. 

1.4       Involvement to Improvement - Commission for Health report (February 2004)

This described what the Commission had found out about patient and public involvement (PPI) from more than 300 inspections of NHS organisations and from its own research into the topic, as follows: 

• That organisations are getting better at some aspects of PPI such as providing information for patients and undertaking exercises in obtaining feedback from patients, but that not as much was being done to ensure that patients, carers, service users and the public influence decision making;
• That PPI is not part of everyday practice, and tended to be found in pockets of good practice which were not shared across organisations or picked up at strategic level; and
• That PPI is not yet having a major impact on policy and practice despite the plethora of PPI initiatives.

1.5       Getting Over the Wall-DH report (October 2004) 

Aimed at helping the NHS shift the focus of its PPI work from process to outputs and outcomes. The document provides examples of how results from patient and public involvement activity can influence service planning and development in the NHS to deliver real improvements for patients. 

1.6      National Standards, Local Action 

           Identifies patient/user experience as one of four national priority areas. The framework emphasises the importance of improving the whole experience of individuals, with particular attention to tailoring services to patients with long-term conditions (section…refers), promoting independence for older people and supporting self care and the ‘expert patient’.

 1.7       National Patient Surveys 

           The NHS Patient Survey Programme was introduced to: track changes in patients’ experiences on a year on year basis; provide information to support local quality improvement initiatives; and inform the national performance ratings and performance indicators for NHS Trusts and PCTs. Spring 2003-national standard patient surveys were conducted in acute and specialist trusts across England, and, for the first time, they were also conducted in mental health trusts. 

1.8       Patient and Public Involvement Forums 

           PPI forums have been established for every PCT and NHS Trust in England, and are independent forums with a role to represent the views of local patients and communities about the quality and development of health services provided and commissioned by local Trusts and PCTs. They have a role in monitoring and reviewing local healthcare services from a patient perspective, including seeking views of patients about the services they receive. They have legal powers to inspect premises where NHS services are delivered, and can make reports and refer matters of concern to the Local Authority Overview and Scrutiny Committees. (Paragraph 1.9 below refers)

            The national Commission for Public and Patient Involvement in Health (CPPIH), currently provides officer support for PPI forums through local support organisations, and is responsible for appointing members of Forums. This responsibility is due to pass to the NHS Appointments Commission when the CPPIH is abolished, and new legislation is put in place (future arrangements on support for PPI Forums are currently under discussion)

 1.9       Overview and Scrutiny Committees (OSC’s) 

           Since January 2003 Local Authorities with responsibility for social services have been responsible for reviewing the planning, provision, and delivery of health services. NHS organisations are required to consult their local OSC on any proposals to make significant variations to the provision of healthcare services. It is important that PPI Forums and OSCs work closely together to ensure that local people are effectively consulted about and involved in decisions about healthcare service developments or changes. 

1.10    The Expert Patient Initiative (launched 2001) 

A programme which aims to help people who live with long term conditions to become key decision makers in their own care. Patients receive training and support to help them take more control of their own health and treatment and to make effective use of health and social services. 

1.11    Copying Letters to Patients Initiative 

           An initiative set out in the NHS Plan, which stated that ‘letters between clinicians about individual patient’s care will be copied to the patient as of right’. The DH target for implementation was April 2004, but the significant culture change needed for compliance has been recognised, and the DH is now working with SHAs to ensure significant progress is made with this initiative during 2005/06

 1.12         Patient Choice

            Section D paragraph 1 outlines the national agenda for patient choice.

1.       Capacity Plans for General and Acute Services 2006/08

 1.1      National Agenda 

The Department of Health initiated a new capacity planning process to enable assessment to be made of capacity required to deliver the NHS Improvement Plan targets. The process commenced in April 2004, with an interim assessment submitted to the DH in June 2004, and a final submission in September 2004. The DH is in ongoing discussions with strategic health authorities in reviewing and finalising sector-wide plans. 

1.1.1    Capacity Planning Policy 

The capacity plans are framed around three key policy themes in the NHS Improvement Plan. 

·        Plurality: by 2008 independent sector providers will undertake 15% of NHS procedures, and patients will have a choice of treatment in the independent sector;

·        Further reduction in waiting times: by 2008 the maximum waiting time from referral to treatment will be 18 weeks (i.e. including outpatient, diagnostic tests and treatment); and

·        Development in the treatment of long-term illness: will deliver a 5% reduction in emergency bed days by 2008.

2        Improving Capacity-Involvement of the Independent Sector (IS)

 2.1      National Agenda  

With the central DH agenda supporting the involvement of the IS, SHAs and PCTs have been asked to consider how a new working relationship with IS providers could help health economies meet their access and performance targets.

2.2      Benefits of IS partnership 

• ‘Plurality and Diversity’ agenda to deliver wider Patient Choice;
• An opportunity to see radical change in Primary Care across the sector;
• An aid to meeting access targets, and addressing the long term conditions agenda, particularly in the Thames Gateway population growth boroughs;
• IS experience of providing diagnostics in Primary Care settings overseas;
• IS experience of working within agreed protocols and pathways which streamline patient flows;
• Catalyst for change; Speed of adopting new ways of working;
• Introduction of new capacity with higher service orientation-better patient experience;
• New workforce models which may attract and retain clinical staff; overseas recruitment possible;
• New ways of working using tele-radiology and remote reporting introduced quickly, reducing workload on local staff;
• More flexible approach to service delivery-opportunities to offer a wider range of services

 2.2.2       Risks of IS partnership   

• Revenue implications
• Challenge to the stability of existing teams if staff are attracted to work in IS