Blog posts

The Hidden Cost of Cheaper NHS Contracts: Losing Community Trust

NHS budgets are under considerable pressure. It is therefore unsurprising that many NHS Integrated Care Boards (ICBs) In England will aim to prioritise price in contract awards, But this approach is a significant threat to community-centred healthcare. While competitive tendering is a legally required, an excessive focus on costs in awarding NHS contracts risks overshadowing key factors such as established community trust, local expertise, and the long-term impact on continuity of care. This shift towards cheaper, often external, commercial providers threatens to cut the links between communities and their local health services. The argument that competitive tendering is solely about legal compliance, and not cost, is undermined by the very nature of such tendering, which by design encourages the lowest bid. This approach risks eroding the social fabric of local healthcare provision, where established relationships and understanding of specific community needs are essential.

Established local healthcare organisations – such as general practices and GP Federations – deeply rooted within their regions – possess an invaluable understanding of the intricate web of local health needs, existing healthcare networks, and the importance of continuity of care. This knowledge, developed over many years, allows these local healthcare providers to deliver care that is not only clinically effective but also culturally sensitive and responsive to the unique circumstances of the populations they serve. Distant, commercially driven firms, regardless of their operational efficiency, are unlikely to have this nuanced understanding. The potential exclusion of these local providers, who have built strong relationships with the populations they serve, could disrupt established care pathways, diminish the social value inherent in community-based healthcare, and ultimately lead to a fragmentation of services that undermines a holistic approach to patient care.

It is essential that ICBs adopt a more balanced and holistic approach to commissioning; one that transcends the narrow focus just on financial efficiency. This approach must recognise and value the long-term impact on community well-being, the preservation of essential local expertise, and the safeguarding of established relationships between healthcare providers and patients. A wider definition of ‘value’ needs to be adopted, one that includes social value, rather than simply financial cost. A system that truly prioritises patient outcomes and community health must consider the benefits of local knowledge and continuity of care, thereby ensuring that commissioning decisions are guided by a commitment to the long-term health and well-being of the communities they serve.

Why Indirect Costs on Research Grants are Essential for Universities

In recent days, there has been discussion about the “overheads” or “indirect” costs that universities add on to the cost of research projects. This has been driven by a decision by the US government to reduce the indirect costs of research on grants awarded by the US National Institutes of Health (NIH) from the current 60% to 15%. Comments from people such as Elon Musk has suggested these costs are wasteful and can therefore be easily cut from research grants. In this blog, I make the case for retaining a fair amount of indirect costs on research grants.

Without the indirect costs that universities receive on government research grants, universities would struggle to provide the essential support and infrastructure required for high-quality research to take place. While direct research costs (such as staff salaries, laboratory equipment, travel and consumables) are essential, they are only part of the funding needed. Research relies heavily on a wide array of indirect resources that ensure long-term sustainability, efficiency, and the proper functioning of universities.

Indirect costs include funding for essential services, such as maintaining research facilities and buildings, providing IT infrastructure and support, managing financial systems, and ensuring compliance through administrative and monitoring processes. Without adequate funding to cover these areas, research projects would be more difficult to complete successfully.

To address this challenge and ensure that universities receive adequate funding beyond direct project expenses, the UK government introduced the Full Economic Costs model. The Full Economic Costs model is designed to fairly and transparently allocate funding that covers the full range of costs associated with research activities.

Under this system, universities are able to recover a more realistic portion of the actual costs incurred in hosting and conducting research, helping to bridge the gap between the direct funding provided by grants and the true expenses they face. This model recognises that indirect costs, although not always visible at the project level, are vital to the successful completion and long-term sustainability of research projects.

The issue of indirect cost recovery is not unique to the UK. In the United States, for example, universities receive indirect cost reimbursements through a negotiated rate with federal agencies, but this system now also faces scrutiny over transparency and fairness. Comparisons like these highlight the importance of continually refining models such as the Full Economic Costs model to ensure they remain fair value for governments, taxpayers and universities.

The successful delivery of research projects relies on more than just securing grants for individual projects. It requires a support system that includes well-maintained buildings and other facilities, appropriate technology, efficient administrative processes, and skilled personnel; all of which are sustained by indirect funding.

Predicting COVID-19 Hospital Bed Occupancy: A Pragmatic Approach for Effective Healthcare Planning

Effective management of hospital resources was a critical component of the response to the COVID-19 pandemic. With fluctuating waves of infection and emerging virus variants, accurately predicting the demand for hospital beds has proven to be a complex but essential task. Our recent study, led by Derryn Lovett and published in BMJ Health Care Informatics, evaluates a pragmatic approach to forecasting COVID-19-positive hospital bed occupancy using simple, accessible methods.

Why Predicting Bed Occupancy Matters

During the COVID-19 pandemic, healthcare systems around the world faced unprecedented challenges, with surges in demand for acute care beds due to severe cases of the virus. The ability to predict future bed occupancy is vital for several reasons:

  1. Resource allocation: Effective forecasting helps healthcare leaders plan staffing, equipment needs, and additional capacity.
  2. Crisis management: Accurate predictions enable health systems to anticipate surges and manage overflow by opening additional care facilities when needed.
  3. Cost efficiency: Reducing over- or under-preparation minimizes waste of resources and ensures that patients receive timely care.

However, many prediction models require complex statistical knowledge, making them difficult to deploy at local or regional levels. This study sought to evaluate a simpler, more pragmatic model suitable for use by typical health system teams.

The Study: A Pragmatic Approach

The research focused on North West London (NWL) during two major COVID-19 waves, driven by the Delta variant in summer 2021 and the Omicron variant in winter 2021-2022. The model used observational data from community testing, vaccination records, and hospital admissions, with linear regression as the primary tool for prediction.

Key Data Sources:

  • COVID-19-positive test results from NWL’s Whole Systems Integrated Care (WSIC) dataset
  • Vaccination status by age group
  • Daily hospital bed occupancy reports

Model Design:

The team developed two models:

  1. Simple linear regression model: This model used the number of COVID-19 cases among unvaccinated individuals as the main predictor.
  2. Multivariable model: This model incorporated additional variables, such as age bands, recognizing that older populations are more likely to be hospitalized.

Both models accounted for a lag period between positive cases in the community and hospital admissions, allowing for predictions of bed occupancy several days in advance.

Results and Performance

The models were evaluated using mean absolute percentage error (MAPE), a measure of prediction accuracy.

Key Findings:

  • Accuracy before the Omicron wave: The multivariable model performed well, with a MAPE of 10.8% during the Delta-driven wave from July to October 2021.
  • Decline in accuracy during the Omicron wave: The accuracy of predictions deteriorated significantly during the Omicron wave, with MAPE rising to over 110%.
  • Age band considerations: While the multivariable model generally outperformed the simple model, it also faced challenges such as multicollinearity—an issue where variables are highly correlated, leading to unstable predictions.

The rapid spread and distinct characteristics of the Omicron variant, including its lower severity and higher transmissibility compared to Delta, likely contributed to the reduced model performance. The study highlights the importance of continually monitoring prediction errors and adapting models as needed.

Practical Applications

The study demonstrated that even relatively simple models can provide useful predictions during stable periods of a pandemic. Importantly, the predictions generated by the model were shared with healthcare leaders twice a week and used in planning discussions to manage resources effectively.

Key Lessons for Future Pandemics:

  1. Monitoring and adaptation: Prediction models require ongoing monitoring to detect shifts in accuracy and adapt to changing epidemiological conditions.
  2. Collaborative decision-making: The integration of model outputs into strategic meetings allowed for proactive responses to surges in demand.
  3. Scalability: The simplicity of this approach makes it scalable and deployable in other settings, particularly when more sophisticated models are not feasible.
The study also highlights that modelling the impact of COVID-19 was simpler in the initial phases of the pandemic. This was largely due to the uniform susceptibility of the population, as there was no prior exposure to SARS-CoV-2 or any available immunisation. However, as the pandemic progressed, modelling became more complex due to factors such as:
  • Changes in population immunity: Prior infections and vaccination led to varying levels of immunity within the population.
  • Emergence of new variants: The appearance of new SARS-CoV-2 variants with different characteristics (such as the Delta and Omicron variants) further complicated the modelling process.
  •  Changes in government interventions: Public health measures implemented by governments, such as lockdowns and mask mandates, also influenced the spread of the virus and needed to be accounted for in the models.
These factors collectively made modelling more challenging later in the pandemic. The study highlights the need for models that can adapt to these complexities and accurately predict the impact of COVID-19.

Limitations and Future Directions

While the study’s pragmatic approach offers many advantages, several limitations should be addressed in future research:

  • Accounting for prior infections: The current model did not include the protective effect of previous COVID-19 infections, which could improve accuracy.
  • Vaccine efficacy variability: Incorporating dynamic estimates of vaccine efficacy based on variant-specific data and individual factors could enhance predictions.
  • Geographic granularity: Future models could explore more localized predictions by accounting for differences in prevalence and hospital capacity across regions.

Additionally, as COVID-19 testing availability changes over time, alternative data sources, such as primary care or emergency department data, may be required to maintain reliable predictions.

Conclusion: Balancing Simplicity and Accuracy

Our study highlights the value of pragmatic, data-driven models in supporting healthcare system resilience during pandemics. While more complex models may offer greater accuracy, the simplicity and accessibility of this approach make it a valuable tool for rapid response scenarios. The findings underscore the importance of collaboration between research teams and healthcare providers to develop, implement, and refine predictive models tailored to real-world needs.

As we continue to navigate the challenges of COVID-19 and prepare for future health crises, pragmatic prediction models will remain an essential component of effective healthcare planning and delivery.

Reference: Lovett D, Woodcock T, Naude J, et al. Evaluation of a pragmatic approach to predicting COVID-19-positive hospital bed occupancy. BMJ Health Care Inform 2025;32:e101055.

What is the difference between primordial prevention and primary prevention?

Primordial prevention and primary prevention are both crucial strategies for promoting health, but they operate at different levels. Primordial prevention aims to address the root causes of health problems and improve the wider determinants of health. It focuses on preventing the emergence of risk factors in the first place by tackling the underlying social, economic, and environmental determinants of health. This involves broad, population-wide interventions such as:

  • Policies that promote healthy food choices: Think about initiatives like taxing sugary drinks to discourage unhealthy consumption, or providing subsidies for fruits and vegetables to make them more accessible.
  • Urban planning that prioritises well-being: This could include creating walkable neighborhoods with safe cycling routes, ensuring access to green spaces for recreation and relaxation, and designing communities that foster social connections.
  • Social programs that address inequality: Initiatives aimed at reducing poverty, improving education, and promoting social justice can create a more equitable society where everyone has the opportunity to thrive.

In contrast, primary prevention focuses on individuals or groups who are already exposed to risk factors. It aims to prevent the onset of disease by managing those existing risks. This involves measures like:

  • Vaccinations: Protecting individuals from infectious diseases such as polio or measles.
  • Long-term conditions: Reduce the risk of developing long-term conditions such as heart disease through interventions such as encouraging people to take preventive drugs like statins.
  • Lifestyle changes: Encouraging healthy habits like regular exercise, a balanced diet, and avoiding smoking.
  • Health education: Providing information and resources to empower people to make informed choices about their health.

Essentially, primordial prevention works “upstream” by creating a healthier society where risk factors are less likely to develop, while primary prevention works “downstream” by managing existing risks before they lead to disease. Although primordial and primary prevention operate at different levels, they are interlinked. For example, successful primordial prevention can reduce the burden on primary prevention by creating an environment where fewer people are exposed to risk factors and where general health and well-being are improved.

What are the implication of “Make America Healthy Again” (MAHA) movement?

There are many positive elements in the “Make America Healthy Again” (MAHA) movement that would be beneficial for public health. This would include improved physical health through promoting exercise, better nutrition, reducing rates of obesity and managing chronic diseases. Exploring ways to make healthcare more affordable and accessible by the US population is also important as is recognising the importance of mental well-being, reducing stigma, and increasing access to mental healthcare services.

Another key area is environmental health. This could include cleaner air and water, reducing pollution, and addressing climate change. The USA also suffers from high rates of drug addiction and this needs addressing through prevention, treatment, and harm reduction strategies. These would all be positive steps for public health in the USA (and countries that replicated these approaches). But it is also that the MAHA movement does not undermine effective public health interventions such as vaccination or promote drug treatments for which there is no evidence of benefit and which could be harmful.

A “Make America Healthy Again” movement, if built on a foundation of evidence-based public health principles, a commitment to health equity, and a focus on both individual and systemic changes, could be a powerful force for improving the health and well-being of Americans. However, it’s essential that such a movement avoids the pitfalls of promoting misinformation, undermining proven interventions like vaccination, and pushing unproven or harmful treatments.

Blood Biomarkers for Alzheimer’s Disease: What do they mean for the NHS?

The Challenge of Diagnosing Alzheimer’s

Alzheimer’s disease (AD) is a leading cause of death in the UK as well as affecting nearly a million people. Currently, the diagnostic pathway for AD is based on clinical symptoms that emerge late in the disease, often after 20 years of progressive accumulation of intracerebral pathological AD features.  When memory, mood, or personality changes are noticed, individuals or their family usually seek advice from a general practitioner, who may perform some cognitive tests along with some general blood tests.  If cognitive decline is suspected, the patient is often referred to a memory clinic or to Old Age Psychiatry Clinics within Mental Health Trusts for further evaluation, aimed at confirming cognitive decline and ruling out reversible causes.

The Promise of Blood Biomarkers

Recent advances in blood-based biomarkers hold promise for transforming AD identification and care.  These biomarkers have shown similar sensitivity and specificity to positron emission tomography (PET) scan and cerebrospinal fluid (CSF) tests in specialist settings.  If reliably predictive blood tests were to become available at low cost in primary care, this could be transformative for AD identification.

The NHS and Blood Biomarkers

The UK’s National Health Service (NHS) is exploring how to adopt and integrate these innovations into its care model.  Initiatives like the Davos Alzheimer’s Collaborative (DAC) International Initiative, the AD RIDDLE study, and the UK’s Blood Biomarker Challenge aim to pilot real-world implementation and validation of blood-based biomarkers, with hopes of integrating them into the NHS within the next few years.

The Future of Alzheimer’s Care

Blood-based biomarkers have the potential to revolutionize early detection of Alzheimer’s disease, making diagnosis more accessible and affordable.  This could lead to earlier intervention and better outcomes for patients.  With a focus on affordability, accessibility, and robust post-launch monitoring, an Alzheimer’s care framework that is more effective, equitable, and capable of transforming the lives of those affected by the disease can be created.

Read more in our article in the Journal of the Royal Society of Medicine.

Why has prescribing of antidepressants increased over the last 30 years?

In a recent post on the platform X, Elon Musk claimed that antidepressants were over-prescribed. In many countries, the prescribing of antidepressants has increased significantly over the past 30 years. During the 1990s, public health campaigns aimed at reducing the stigma surrounding depression encouraged more people to seek treatment. This contributed to a rise in antidepressant prescriptions in countries such as the UK.

Additionally, antidepressants – particularly selective serotonin reuptake inhibitors (SSRIs) – are now widely used not only for depression but also for other conditions such as anxiety disorders, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and chronic pain. This expanded range of indications has been a significant factor in their increased use in recent decades.

One concern regarding antidepressant use is their potential toxicity and their role in suicide. SSRIs are generally considered safer than older antidepressants, such as tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs), which are more likely to be associated with fatal overdoses.

Because of their better safety profile, doctors are more willing to prescribe SSRIs than the older antidepressants. Their relative safety has made SSRIs the preferred choice of drug for many doctors and is also a factor in the increased prescribing of antidepressants.

Antidepressants do play an essential role in managing depression and some other mental health conditions, but over-prescription may occur in some cases due to system-wide barriers like limited access to psychological therapies. Addressing the wider determinants of health is also important. This would include areas such as poverty, housing and access to green spaces and other leisure facilities.

The increase in antidepressant prescribing in the UK has sparked debate about whether they are being over-prescribed. However, antidepressants are a clinically effective option for moderate to severe depression and are now used for a broader range of conditions, such as anxiety disorders and chronic pain. Ensuring a balanced approach, where pharmacological and non-pharmacological treatments are accessible and appropriately used, remains a key goal for improving mental health care in the UK and elsewhere in the world.

Using Mobile Apps for Diabetes Self-Management: A Review of Patient Perspectives

Diabetes is a chronic disease that affects hundreds of millions of people worldwide. Self-management is crucial for people with diabetes to maintain their health and prevent complications.  Mobile applications have emerged as promising tools to help people with diabetes self-manage their condition. Our recent article in the journal BMJ Open – What are the perceptions and experiences of adults using mobile applications for self-management in diabetes? A systematic review – reviewed some of the the research literature in this area to obtain patient perspectives on these apps.

What are the benefits of using mobile apps for diabetes self-management?

Our systematic review explored the perceptions and experiences of adults with types 1, 2, and gestational diabetes using mobile applications for self-management.  The review included 24 qualitative studies that interviewed or surveyed people with diabetes who used mobile apps for self-management.

We found that people with diabetes generally have a positive view of mobile apps for self-management.  App features that were particularly valued included:

  • Monitoring blood glucose, diet, and exercise
  • Receiving reminders about blood glucose checks, medication, and mealtimes
  • Learning about the interrelationship between blood glucose, diet, and exercise

What are the challenges of using mobile apps for diabetes self-management?

We also identified several challenges that people with diabetes face when using mobile apps for self-management. These challenges include:

  • Uploading excessive information
  • Monitoring device incompatibility
  • Episodic app crashes
  • Telephone handling issues

What are the implications of this research?

We concluded that mobile applications are promising tools to help people with diabetes self-manage their condition.  However, it is important to address the challenges that people with diabetes face when using these apps. We also recommended that future research should:

 

  • Include healthcare professionals (HCPs) to get their views on the apps
  • Explore the long-term usage of mobile apps
  • Evaluate the role of AI in providing interactive support for self-management

Conclusion

Mobile apps have the potential to improve diabetes self-management. By addressing the challenges and incorporating the recommendations of this research, we can develop apps that are truly beneficial for people with diabetes.

Tackling Drug Shortages: An Urgent NHS Priority

The NHS in the UK is grappling with a worsening crisis, drug shortages, as we discuss in our recent article in the British Medical Journal. These shortages have doubled since 2022, with supply disruptions affecting vital medications like antibiotics, diabetes treatments, and hormone replacement therapy. The implications for patient safety and healthcare services are profound, making it imperative for the UK government and the NHS to address this challenge .

Why Are Drug Shortages Happening?

The root causes of these shortages lie in both global and local factors. Disruptions in international supply chains — driven by the COVID-19 pandemic, geopolitical conflicts like the Ukraine war, and rising energy costs — have hampered the production and transport of essential pharmaceutical ingredients. Domestically, the NHS faces challenges such as manufacturing inefficiencies, logistical delays, and regulatory hurdles.

Brexit has also compounded the problem, introducing new trade barriers, customs checks, and currency depreciation, which have made importing medicines more costly and time-consuming. Moreover, economic measures like the Voluntary Scheme for Branded Medicines Pricing and Access (VPAS) have created financial disincentives for pharmaceutical companies to prioritize the UK market.

Impact on Patients and Healthcare Providers

The repercussions of drug shortages are far-reaching. For patients, unavailability of essential medications can lead to delayed treatments, reduced efficacy, and increased risks. For example, shortages of anti-epileptic drugs such as sodium valproate have heightened seizure risks for affected patients. Healthcare providers, meanwhile, face mounting workloads as they try to find alternatives, often dealing with stressed and anxious patients.

Pharmacists, in particular, bear the brunt of these challenges. Many have had to ration medicines or pay inflated prices, which are not fully reimbursed by the NHS. This financial strain comes at a time when community pharmacies are expected to play a larger role in easing the burden on GPs.

Solutions: Immediate and Long-Term Strategies

Addressing drug shortages requires a multifaceted approach:

Regulatory Reforms: Streamlining approval processes and easing restrictions on drug imports could help bridge the gap in supply. Aligning more closely with the European Medicines Agency could mitigate post-Brexit barriers.

Strengthening Supply Chains: Developing better forecasting tools and stockpiling strategies would help anticipate and respond to demand spikes. Investment in domestic pharmaceutical manufacturing, particularly for generic drugs, is also crucial to reducing reliance on global supply chains.

Support for Healthcare Providers: Allowing pharmacists greater flexibility in prescribing alternatives can prevent delays in patient care. Price concessions for scarce medications would also alleviate financial pressures on community pharmacies.

Patient-Centric Interventions: Providing online resources and national helplines to guide patients during shortages can help reduce anxiety and improve adherence to alternative treatment plans.

Looking Ahead

The drug shortages crisis underscores the need for robust policies that prioritise patient care and support healthcare providers. With timely interventions and strategic investments, the NHS can overcome these challenges and safeguard the health of the UK population. Building a healthier population through prevention and reducing demand for medications must also remain a long-term goal. Tackling drug shortages must be a priority for the NHS. Patients deserve reliable access to the medications they need, and healthcare providers need to certain that access to key drugs remains uninterrupted.

Staying health and making more effective use of the NHS in 2025

s we enter the new year, here are some tips on how to stay healthy and well and to make better use of the NHS in 2025:

1. Exercise regularly, aiming to include outdoor activities for sunlight exposure, which can help with physical fitness and improve mood, especially for those affected by Seasonal Affective Disorder (SAD).

2. Don’t smoke. Smoking is a major risk factor for diseases such as lung cancer and heart disease. Quitting smoking significantly reduces these risks.

3. Take-up the offer of any NHS vaccinations that you are eligible for. If you have young children, make sure they are also up to date with their NHS vaccinations.

4. Sunlight exposure may be limited in Winter, so consider vitamin D supplementation if you are in a group that this is recommended for.

5. Attend for NHS health screening appointments when invited.

6. Eat five portions of fruit & vegetables every day and eat plenty of high-fibre foods. Eating a nutritious diet is important for maintaining a healthy weight and reducing the risk of chronic diseases.

7. Limit your sugar and salt intake.

8. Limit your alcohol intake to a safe level.

9. Take time to improve your mental health; including by meeting regularly with friends and family. Mental health is just as important as physical health, and it is important to take steps to protect and improve your mental well-being.

10. Use the NHS app to book appointments, view your GP medical record and order repeat prescriptions.

11. Attend for appointments for medication reviews and for the management of long-term conditions when invited. This helps to ensure that your medication is up-to-date and that your condition is being managed effectively.

12. Be aware of the range of options for NHS care – including opticians, pharmacists, self-referral services (e.g. Pharmacy First, podiatry, IAPT, smoking cessation), and NHS 111.

13. Use the NHS electronic prescription service so that your prescription is sent directly to a pharmacy.

14. For queries about hospital care, contact the hospital Patient Advice and Liaison (PALS) team rather than your general practice. The PALS team is there to help patients and their families with any concerns or questions they have about their hospital care. The contact details are usually present on the hospital’s website.

15. Apply for online access to your hospital records if this is available

16. Check your own blood pressure. Blood pressure machines are now relatively cheap. In some parts of England, the NHS may be able to provide you with a machine. High blood pressure is a major risk factor for stroke and heart disease, so it is important to monitor your blood pressure regularly.

17. Take your medication as prescribed.

18. Get a good night’s sleep.

19. Reduce the risk of injury by wearing seatbelts and bike helmets, and driving or cycling safely

20. Listen to experts on health issues and not uninformed people on social media. There is a lot of misinformation about health issues circulating on social media, so it is important to get your health information from reliable sources, such as the NHS website or healthcare professionals.

21. Use telehealth options for accessing healthcare when appropriate, to save time and minimise exposure to potential infections.

22. Keep a well-stocked first aid kit and know how to use the basic items. This can be particularly useful for minor injuries and illnesses.

23. Keep your home safe. Falls and accidents are common during the winter due to icy conditions. Making your home slip-proof can prevent unnecessary hospital visits.

24. Keep Emergency Numbers Handy. Important contact numbers should be easily accessible, whether it’s on your fridge or saved in your phone.

25. Regular Hand Washing. Promote good hand hygiene, especially if interacting with vulnerable populations like the elderly or very young.

26. Ensure food is stored safely to reduce the risk of food-borne illnesses such as gastroenteritis.

27. Know the Signs of More Serious Conditions: Understanding the early symptoms of conditions like strokes, heart attacks, and other acute illnesses can save precious time in an emergency.

28. Improve indoor air quality. Try to keep up the air quality in your home and at work; for example, through ventilation.

29. Community Support. If possible, check on neighbours and family members who might be vulnerable during the winter months, whether due to age, health conditions, or social isolation.

30. Use of Over-the-Counter (OTC) Medication. Understand when to use OTC medications for minor illnesses and when to seek professional advice.

Let me know about any other suggestions for staying healthy.