Blog posts

Rethinking NICE Cost-Effectiveness Thresholds: Implications for the NHS and UK Industrial Strategy

There has been recent discussion about the need to revise drug pricing frameworks within the United Kingdom’s National Health Service (NHS), particularly amid the ongoing transatlantic trade frictions involving potential tariffs from the United States administration.

Elevating the cost-effectiveness threshold applied by the National Institute for Health and Care Excellence (NICE) by 25 percent from its established range of £20,000 to £30,000 per quality-adjusted life year (QALY) would increase access for NHS patients to innovative treatments that were previously excluded on grounds of excessive cost relative to their clinical benefits.

However, this change would also put increased pressure on the NHS budget. It is difficult to quantify the extra spending that might result from a wider range of drugs becoming available for use in the NHS through this change but any extra spending on these treatments would have to be matched by reductions in spending on other health services. Effective implementation would therefore require not only additional funding but also robust mechanisms for monitoring real-world effectiveness and ensuring that new treatments deliver value commensurate with their higher costs.

The government would also need to consider any benefits that might occur from increased investment in research and development in the UK by global pharmaceutical companies. From a trade and industrial policy perspective, revising the NICE cost-effectiveness threshold would have broader implications for the UK’s position in global pharmaceutical markets. A more permissive pricing environment may enhance the attractiveness of the UK as a destination for clinical trials, research, and early market access, reinforcing the government’s ambition to establish the UK as a “science superpower.”

But it could also be perceived internationally as a shift towards higher healthcare costs, potentially complicating trade negotiations that involve intellectual property protections, market access, and pricing transparency. The Department for Business and Trade would need to balance these considerations carefully, ensuring that any change supports the competitiveness of the UK life sciences sector while maintaining affordability and equity within the NHS.

Hence, this is not a straightforward issue and the Department of Health and Social Care, the Department for Business and Trade, and the Treasury may all have differing views about the relative costs and benefits of the change. Ultimately, the decision will depend on the government’s political and economic priorities and its assessment of the relative importance of the competing costs and benefits.

The importance of coding Long Covid in electronic medical records

As the world continues to grapple with the aftermath of the COVID-19 pandemic, Long Covid has emerged as a significant public health challenge. Characterised by persistent symptoms like fatigue, brain fog, shortness of breath, and joint pain lasting weeks, months or even years after an infection, Long Covid affects millions globally. Yet, one major hurdle in understanding and addressing this condition is its under-recording in electronic medical records (EMRs).

Accurate coding of Long Covid in EMRs is essential for studying its epidemiology, improving patient care, and managing its impact on healthcare systems and on societies. Electronic medical records are at the core of modern health systems and have largely replaced the more traditional paper-based records used by healthcare providers for many decades. Electronic medical records are used to track patient diagnoses, treatments, and clinical outcomes. When Long Covid is not properly coded, it becomes difficult to use this data to carry out these tasks. Accurate coding using standardised systems such as SNOMED enables researchers and healthcare providers to:

  • Track Prevalence and Trends: Consistent coding allows us to estimate how many people are affected by Long Covid, identify demographic patterns, and monitor changes over time.
  • Study Risk Factors and Outcomes: Properly coded data helps researchers pinpoint who is most at risk and how Long Covid impacts long-term health.
  • Optimise Healthcare Resources: Understanding the true burden of Long Covid helps health systems allocate resources, plan specialised clinics, and train clinicians.
  • Support Policy and Funding: Reliable data informs public health policies and justifies funding for Long Covid research and treatment programs.

Without accurate coding, Long Covid remains under-represented in the data that shapes healthcare decisions.

The Challenges of Coding Long Covid

Despite its importance, coding Long Covid in EMRs faces many challenges:

  1. Lack of Standardised Coding: The ICD-10 and SNOMED codes exist but their use is inconsistent. Many clinicians may not apply it, either due to unfamiliarity or because symptoms don’t neatly fit into a code’s description.
  2. Symptom Overlap and Complexity: Long Covid presents with a wide range of symptoms that overlap with other conditions like chronic fatigue syndrome or fibromyalgia. Clinicians may code individual symptoms (e.g., fatigue) rather than linking them to Long Covid, fragmenting the data.
  3. Confusion with other medical problems. Where patients have other long-term medical problems – such as chronic lung disease or cognitive impairment – new symptoms may be be assumed to be of these conditions rather than from Long Covid.
  4. Limited Clinician Awareness: In busy clinical settings, Long Covid may not be recognised or prioritised, especially if patients present with vague or multisystem symptoms. Lack of training on Long Covid’s diagnostic criteria exacerbates this issue.
  5. Under-reporting by Patients: Some patients may not seek care for persistent symptoms, or their concerns may be dismissed, leading to no record of Long Covid in EMRs.

These barriers lead to underestimation of Long Covid’s impact, which in turn limits research and resources needed to improve diagnosis and treatment.

The Consequences of Under-Coding

When Long Covid is not properly documented, the consequences ripple across patients, providers, and systems:

  • For Patients: Misdiagnosis or lack of a formal Long Covid diagnosis can delay treatment, leaving patients struggling without validation or access to specialised care.
  • For Research: Incomplete data hinders epidemiological studies, making it harder to understand Long Covid’s long-term effects or develop evidence-based treatments.
  • For Healthcare Systems: Without clear data, hospitals and clinics can’t plan for the growing demand for Long Covid care, leading to strained resources and inequities in access.
  • For Public Health: Policymakers rely on EMR data to justify funding and programs. Under-coding obscures the scale of the problem, potentially stalling progress.

Solutions to Improve Coding

Addressing the under-coding of Long Covid requires a multi-pronged approach:

  1. Standardised Coding Protocols: Healthcare systems should promote the consistent use of ICD-10 and SNOMED codes. Clear guidelines are also needed for when and how to apply these codes. Future iterations of coding systems could include more specific Long Covid codes to capture its diverse presentations.
  2. Clinician Training: Educating healthcare providers about Long Covid’s symptoms, diagnostic criteria, and coding practices is essential. Continuing medical education (CME) programs can bridge knowledge gaps and encourage proactive documentation.
  3. Technology and AI: Natural language processing (NLP) tools can analyse unstructured EMR data, such as clinician notes, to flag potential Long Covid cases that might otherwise go uncoded. Integrating these tools into EMR systems could improve case identification.
  4. Patient Awareness: Public health campaigns can encourage patients to report persistent symptoms and advocate for themselves, ensuring their conditions are documented.
  5. Research and Collaboration: Partnerships between health systems, researchers, and policymakers can drive the development of better diagnostic and coding frameworks, informed by real-world data.

Conclusions

The under-recording of Long Covid in electronic medical records is more than a technical issue. It is a barrier to understanding and addressing a condition that affects millions of people globally. Accurate coding is the foundation for robust research, effective patient care, and informed public health strategies. By prioritising standardised coding, clinician education, and innovative technologies, we can shine a light on Long Covid’s true impact and pave the way for better outcomes.

For healthcare providers and clinicians, the message is clear: document Long Covid deliberately and consistently. For patients, it is about advocating for your health and ensuring your symptoms are recorded. And for health systems, it’s about investing in the tools and training needed to make electronic medical records an effective tool in managing Long Covid at patient, healthcare provider and national levels.

Empowering medical students to manage polypharmacy

Polypharmacy, commonly defined as the concurrent use of five or more medications, is a growing challenge in modern healthcare, especially among older adults with multiple long-term conditions. While advances in medicine have improved disease management, they have also led to an unintended consequence: a rising medication burden that can harm patient well-being.

Our recent study published in Clinical Practice explores how reframing polypharmacy as a chronic condition can empower future doctors to manage it more effectively. For example, polypharmacy substantially increases the risk of adverse drug reactions (ADRs). This underscores the urgent need for a shift in how we approach medication management.

Traditional medical education focuses on treating individual diseases, often leading to prescribing cascades where one drug’s side effect triggers another prescription. This cycle complicates care and worsens outcomes. We designed a three-phase educational intervention for final-year medical students. The program included interactive workshops that introduced polypharmacy risks, diagnostic tools, and case-based learning using electronic health records (EHRs) and clinical decision-support systems (CDSS). Simulated patient consultations and medication reviews with pharmacists to identify drug interactions and propose deprescribing strategies. Finally, debriefing sessions and reflective diaries help to integrate insights into future practice.

The intervention yielded significant improvements. Students’ confidence in recognizing polypharmacy as a primary diagnostic issue jumped from 32% to 86% and their knowledge of diagnostic tools increased from 3.1 to 4.7 out of 5. Standardized patient satisfaction scores also rose from 3.5 to 4.8, reflecting better communication and patient-centred care. Reflective diaries revealed a shift toward holistic thinking, with students better equipped to identify drug-induced symptoms and collaborate with multidisciplinary teams.

By teaching polypharmacy as a chronic condition, this model equips medical students with the skills to break prescribing cascades, enhance patient safety, improve quality of life for patients and reduce healthcare costs. The study’s small sample size limits generalisability but it offers a promising blueprint for updating medical curricula. Future research should explore the long-term impact of such new educational models on patient outcomes and clinical decision-making. Integrating patient feedback and real-world testimonials could further enrich this approach.

As healthcare evolves, empowering clinicians to manage medication burden proactively is essential for improving quality of life. This innovative training is a step toward a more holistic, patient-centred approach in medicine.

Citation: Conte, A.; Sedghi, A.; Majeed, A.; Jerjes, W. Reframing Polypharmacy: Empowering Medical Students to Manage Medication Burden as a Chronic Condition. Clin. Pract. 2025, 15, 142. https://doi.org/10.3390/clinpract15080142

What makes a good doctor – and who gets to decide?

What Makes a Good Doctor? This is the question that Waseem Jerjes and I explore in the Journal of the Royal Society of Medicine. It is a key question that underpins the architecture of medical education, clinical practice, regulation, and professional identity.

It cannot be answered by regulators, educators, or employers in isolation. It must be answered together – by doctors and patients – revisited throughout a career, and adapted as society and the profession change. Without that shared reflection, the danger is not simply disillusionment, but the erosion of the moral foundations of clinical work.

As we enter an era when diagnosis will increasingly involve artificial intelligence and when performance metrics reward volume over value, reclaiming this question as a professional one is imperative. The integrity of our institutions – and of the practitioners within them – depends on reimagining excellence in inclusive, relational terms.

A good doctor is not a flawless technician or a fixed archetype. They are someone who questions assumptions, listens deeply, and adapts with humility to the needs of patients and society. Until our systems are designed to allow such physicians to thrive, we risk losing not only their presence, but their purpose.

Talking to Patients About Weight-Loss Drugs

The use of weight-loss drugs such as GLP-1 receptor agonists (e.g., semaglutide, tirzepatide) has increased rapidly in recent years. These drugs can help some people achieve significant weight reduction, but they are not suitable for everyone and require careful counselling before starting treatment. By discussing benefits, risks, practicalities, and  uncertainties, clinicians can help patients make informed, realistic decisions about their treatment.

Key points to discuss with patients

1. Indications and eligibility
These drugs are usually licensed for adults with a specific BMI. They should be used alongside lifestyle interventions such as dietary change, increased physical activity, and behaviour modification.

2. Potential side effects – some can be serious
Common adverse effects include nausea, vomiting, diarrhoea, and abdominal discomfort. Less common but more serious risks include gallstones, pancreatitis and visual problems. Patients should know what to watch for and when to seek urgent medical advice.

3. Loss of muscle mass as well as fat
Treatment often leads to loss of both fat and lean tissue (muscle). Reduced muscle mass can affect strength, mobility, and metabolic rate. Encourage resistance exercise and adequate protein intake to help maintain muscle.

4. Long-term safety and unknowns
While clinical trials show substantial short- to medium-term benefits, we do not yet have decades of safety data for newer agents. Patients should be aware that some long-term effects remain unknown.

5. Need for sustained treatment
For many, continued use is required to maintain weight loss. This raises issues around cost, availability, and the practicality of long-term therapy.

6. Likelihood of weight regain after stopping treatment
Most people regain much of the weight lost when medication is discontinued unless lifestyle measures are sustained.

7. Impact on mental health and eating behaviour
Changes in appetite can be beneficial but, rarely, may lead to problematic eating patterns. Monitoring for disordered eating is important.

8. Contraindications and drug interactions
Caution is needed in people with a history of pancreatitis, certain gastrointestinal diseases, or relevant endocrine tumours. Review other medications for potential interactions.

9. Monitoring requirements
Ongoing follow-up is essential to assess weight, metabolic health, nutritional status, muscle mass, and side effects.

The NHS Emergency Care Plan underestimates the role of general practice

I welcome the Government’s commitment to expanding urgent care provision in community settings. This approach has the potential to ease pressure on emergency departments and enable ambulance services to focus more effectively on patients who require rapid assessment and conveyance.

However, as I discuss in the BMJ, the current Emergency Care Plan underestimates the central role that NHS general practice can and should play. Primary care is often the first point of contact for patients with urgent needs, and with appropriate support, it can manage many conditions effectively without referral to other parts of the system. There is also a risk that investing in a wide array of separate interventions—such as urgent treatment centres, community response teams, and virtual wards—without clear coordination could further fragment care. This may reduce continuity, lead to duplication, and ultimately result in less efficient use of NHS resources.

Direct investment in NHS general practice—particularly at a time when many GPs are underutilised or struggling to find substantive roles—would strengthen clinical capacity where it is most needed. Enhancing the ability of general practice to manage both acute presentations and long-term conditions more effectively would support whole-system resilience and reduce downstream demand across urgent and emergency care.

Balancing Patient Safety and Human Rights: Implementing the Special Allocation Scheme in Primary Care

The Special Allocation Scheme (SAS) aims to protect NHS staff and other patients from individuals who are violent, aggressive, or pose a serious threat, while at the same time ensuring that these patients continue to receive essential primary care services in a secure environment. The decision to refer a patient to the Special Allocation Scheme is a significant one and rightly requires careful clinical and ethical consideration. However, in practice, such decisions often need to be made rapidly and under stressful or unpredictable circumstances, such as following a serious verbal or physical assault on a member of staff.

Updated guidance from NHS England and the additional requirements introduced by some Integrated Care Boards (ICBs), including the need for written confirmation that all alternative approaches have been considered, are well-intentioned. These measures are designed to ensure that referrals to the Special Allocation Scheme are proportionate, lawful, and respectful of patients’ rights; particularly for those with protected characteristics under the Equality Act 2010, or those with complex health needs and vulnerabilities. Such safeguards are important to prevent inappropriate exclusion from general practice services and to maintain fairness and transparency in the use of this scheme.

Nevertheless, there is a risk that these requirements could prove challenging to implement, particularly in urgent situations where staff safety is at risk and swift action is needed. Primary care teams already operate under considerable time, clinical, and administrative pressures, and the addition of further bureaucratic steps, however well-meaning, could inadvertently delay appropriate referrals or discourage practices from using the Special Allocation Scheme even when it is clearly warranted. This could, in turn, compromise the safety of staff and other patients, undermining the purpose of the scheme.

A pragmatic and balanced approach is needed; one that upholds patient rights and ensures a fair process, while also enabling a timely and proportionate response to serious incidents. Ideally, the referral process should allow for immediate action in exceptional or high-risk situations, with more detailed documentation, justification, and review taking place once the immediate threat has been managed. Clear, practical protocols and access to legal or safeguarding advice may help practices navigate these decisions appropriately.

Support from ICBs and NHS England will be essential to help practices interpret and implement the requirements for referral to the Special Allocation Scheme in a consistent, safe, and effective manner. This should include training, practical guidance, and access to expert advice when needed. By doing so, we can ensure that the scheme continues to protect NHS staff and patients, while also respecting the dignity and rights of individuals who require care under difficult circumstances.

Reclaiming the primary care consultation for patients and clinicians: is AI-enabled ambient voice technology the answer?

Our recent article in the Journal of the Royal Society of Medicine discusses the potential role of AI-enabled ambient voice technology in healthcare and the implications for doctors and patients. While interest in ambient voice technology , particularly in primary care, continues to grow, evidence regarding its feasibility, acceptability and real-world impact in primary care remains limited. This includes data on cost, staff training and implementation (including integration with current electronic medical record systems).

Questions also remain about how ambient voice technology  handles complex consultations, including with non-native English speakers, and its broader integration into routine practice. As ambient voice technology  develops, further research is needed to assess its usability, acceptability, feasibility, cost-effectiveness and unintended effects on clinical interactions and decision-making. If demonstrated to be effective, ambient voice technology  could become a transformative tool in advancing the government’s 10 Year Health Plan for England.

Why after 35 Years of NHS plans, cure is still favoured over prevention?

The aims of the government’s 10 year health plan – such as the shift from prevention to cure – are not new and have been priorities in many other health plans over the last 35 years. The question we need to ask is why have previous plans failed in achieving these objectives?

The short-term electoral cycle prioritises funding for immediate, visible hospital crises over long-term strategies whose benefits are not seen for years. This is compounded by a health system that is designed to reward the treatment of sickness, not the promotion of wellness.

The persistent fragmentation between the NHS, public health and social care, and pressures from an ageing population and widening health inequalities have created a reactive environment where long-term strategic goals are perpetually sacrificed to manage immediate demands.

The UK government and NHS staff do not lack insight into what improves health. Unless we redesign the incentives, protect public‑health budgets and hold every department—not just the NHS—to account for population health, the next Ten‑Year Plan risks becoming another plan that does not improve the NHS or health outcomes in England.

Does Online Access to Medical Records Help Patients and Improve the Quality of Healthcare?

There was a lot of discussion in the government’s 10 year health plan about digital interventions such as giving people online access to their medical records. But does this improve healthcare delivery and clinical outcomes? This was the topic of our recent systematic review published in the journal BMJ Quality and Safety. We found that giving people online access to their medical records increased self-reported patient-centredness and improved some aspects of patient safety. But many questions about the benefits of online access remain unanswered.

The Good News: Empowering Patients

On the positive side, we found clear evidence that giving people online access to their medical records increased self-reported patient-centeredness. What does that mean in simple terms? Patients felt more involved, informed, and in control of their own care. This shift from a passive recipient to an active participant is a cornerstone of modern healthcare and is a significant win for patient empowerment.

We also found that this digital access improved some aspects of patient safety. While the full scope of this finding is still being explored, it suggests that when patients can review their own records, they may be able to spot potential errors or inconsistencies, acting as an extra layer of oversight.

The Reality Check: More to Learn

While these findings are encouraging, our review made it clear that the story is far from over. Despite the positive results, many questions about the broader benefits of online access remain unanswered. We still need more research to fully understand the long-term impact on overall clinical outcomes, patient-provider relationships, and potential unintended consequences.

The transition to a digital healthcare system is a complex one, and it’s important that we continue to base our decisions on robust evidence. While online access to medical records holds great promise for a more informed and empowered patient population, our work shows we are only at the beginning of this journey.