Tag: NHS

The NHS needs urgent support as we enter the most challenging period of the pandemic yet

On Friday 17 December, a record number of Covid-19 cases (93,045) was reported in the UK.  Unfortunately, the recently identified Omicron variant has proven to be considerably more infectious than previous variants. Vaccines are also less effective against Omicron, with two doses of the vaccine providing only limited protection from symptomatic Covid-19 infection. A booster (third) dose increases protection but not to the level seen against other variants.

Although the clinical severity of Omicron-linked cases is still to be fully determined, the sheer volume of cases will lead to greater pressures on all sectors of England’s NHS. This comes at a time when the NHS in England is already struggling to cope with existing demands, whilst also trying to manage the enormous backlog that has built up since the start of the pandemic in early 2020.

With the NHS now tasked with substantially increasing the number of Covid-19 vaccines available, we are entering a very challenging period, juggling; the increased rollout of Covid-19 vaccinations, a surge in Covid-19 cases, usual winter pressures, such as seasonal respiratory infections and other urgent medical problems, and maintaining rapid access to care for people with suspected cancer.

Other important areas of work also need to continue. This includes childhood vaccinations, mental health services, and community care for vulnerable patients. Inevitably, much of the elective work that the NHS does will have to be deferred, leading to yet further increases in NHS waiting lists for specialist care. There will be less capacity to defer elective NHS care in general practices, leading to further frustrations from patients, if access to primary care services is curtailed.

Unfortunately, due to these challenges a deterioration in health outcomes will occur. It is not always easy to separate out urgent from non-urgent medical problems. If people are asked to defer seeking care, some patients will inevitably suffer delays to their diagnosis.

It is essential that access to primary care services is maintained during this challenging time. Unfortunately, many community healthcare providers are already suffering from long-standing workforce shortages that cannot be easily addressed. Ideally, expanding Covid-19 vaccination capacity would be in addition to, rather than in place of, these services. But this requires rapid planning at national and local level, and a willingness to give local clinicians the autonomy to develop their own solutions without the bureaucratic hurdles that are often the hallmark of the NHS.

The continued waves of infection the NHS has faced since the start of the pandemic have taken a considerable toll on the physical and mental health of NHS staff. The largest wave of infection yet, from Omicron, will add further to this toll. As well as the direct risks from Covid-19, an infection that has disproportionately affected healthcare workers, the mental health of NHS staff has also been adversely affected; with high levels of problems such as stress, burnout and post-traumatic stress disorder. This in turn has led to high levels of absence due to illness, which further compounds the pre-existing shortages of staff. Recognising the impact of working during the pandemic on healthcare professionals is essential, as are initiatives to improve the well-being of staff.

The NHS is entering one of its most challenging phases – probably more challenging than the previous two large Covid-19 waves in March 2020 and January 2021. The public need to understand that the NHS urgently need support. In the worst-case scenario, this could mean the NHS being placed on an emergency footing for several months if there are very high numbers of Omicron cases and the reduced effectiveness of vaccines lead to a prolonged increase the number of severely ill patients in need of NHS care.

A version of this article was first published in The House Magazine.

Lancet Commission on the Future of the UK’s NHS

I would like to thank the Lancet for giving me the opportunity to contribute to their Commission on the Future of the NHS. I fully support the recommendation for a strong and sustained increase in NHS funding to address the current weaknesses in the NHS. For me, the most striking data in the Lancet Commission on the Future of the NHS was this figure, taken from Securing a sustainable and fit-for-purpose UK health and care workforce, showing the changes in the number of NHS GPs and consultants per 1,000 people between 2008-18. Note the decline in GP numbers compared to the increase in consultant numbers. Although we hear a lot from NHS managers and politicians about the need to shift the focus of the NHS to the community, staffing statistics do not support this. The reality is that NHS primary care funding and workload need to reflect staff levels, not meaningless rhetoric.

Figure: Numbers of GPs and hospital consultants across the UK per 1000 people, 2008–18

Covid-19 in London

The Covid-19 situation in London is now very serious, with the number of Covid-19 cases doubling in the past to week to around 50,000. Infection rates are highest in the North-East of London, with increases seen all across the city.

The number of hospital patients with Covid-19 has increased to around 3,000 compared with around 1,600 one month ago. The number of patients requiring ventilators has increased by 100 over the last week to around 360. There are also pressures on other parts of the NHS, such as GP, mental health, and community services.

The new strain of SARS-CoV-2 is now becoming the most commonly identified strain in London and the South-East of England. It appears to be more infectious than other strains, and this will drive up the number of cases, people requiring hospital treatment and deaths.

The latest statistics show how rapidly the situation can change. From a period around one month ago, when case numbers were falling and NHS pressures were sustainable, we are now on a trajectory of rapidly increasing cases, hospital admissions and deaths in London.

Urgent action is needed to control the Covid-19 pandemic on London, protect its population and reduce pressure on the NHS. This requires everyone to strictly follow the local Tier 4 rules. In particular, mixing indoors with people from other households should be avoided.

Most transmission of infection occurs indoors and it is stopping mixing of people from different households in indoor settings that is the key to breaking chains of infection. Other measures, such as wearing face masks in public spaces and good hygiene, are also essential.

We do now have one vaccine for Covid-19 licensed for use in the UK. We urgently need other vaccines to be approved for use; along with a massive increase in supply of vaccines and mobilisation of the NHS to deliver vaccines to the population on a speed and scale not previously seen in the UK.

Table: London boroughs by highest number of COVID-19 positives per 100k population.7–day rolling rate by specimen date – ending Dec 17. The table is from @UKCovid19Stats.

What are the priorities for the NHS during the period when tight Covid-19 restrictions are in place?

People in many areas of the United Kingdom will be living under tight Covid-19 restrictions for the next few months. In London and the South-East of England, for example, this means being placed under Tier 4 restrictions.

For the NHS, there will be two main priorities during this period. The first will be to rapidly implement the Covid-19 vaccination programme. This is our best hope of bringing the pandemic under control and allowing life to start to return to normal. But success requires working on a speed and scale not seen before for any public health programme in the United Kingdom. Adequate supplies of vaccine must be secured and the infrastructure put in place to administer vaccines rapidly to tens of millions of people.

The second priority will be to ensure that people with non-Covid illnesses receive the care they need. This will be very challenging in the middle of a pandemic. We have already seen a large backlog of NHS work build up in 2020. The NHS must ensure that people receive the healthcare they need at this difficult time; whether this is in general practice, mental health, or hospital settings to prevent a rise in ill-health and deaths from non-Covid related causes.

Health outcomes in the UK: how do we compare with Europe?

In an article published in the British Medical Journal, I discuss the health outcomes achieved by the NHS in the UK and how these compare with other European countries. Health outcomes in the UK have improved substantially since the NHS was established in 1948. The NHS also performs well in many international comparisons on measures such as efficiency, equity, and access.

Despite these achievements, however, problems with health outcomes remain. Moreover, other European countries have also improved their health outcomes in recent decades, often at a faster rate than the UK. Consequently, the UK now lags behind many other European countries in key health outcomes in areas such as child health and cancer survival.

I conclude that new health policies in the UK should help the NHS to focus on improving health outcomes and that politically expedient schemes that are not evidence-based – such as extended opening hours in primary care – should be abandoned. Continued progress is also needed on wider determinants of health such as poverty, housing, education, employment, and the environment.

Public Health and Primary Care in England: What does the future look like?

I spoke at a joint training day for primary care and public health registrars in London on the topic of Public Health and Primary Care in England: What does the future look like?

The key points from my presentation were:

  • Some new NHS investment – but investment is very low by historical standards
  • Will the new models of healthcare delivery deliver the £22 billion efficiency savings the Treasury expects?
  • What impact will contractual changes have? Junior doctors, consultants, GPs, public health consultants
  • Can primary care attract and retain enough doctors?
  • What impact will cuts in public health budgets have on health improvement programmes and on careers in the specialty?

My presentation can be viewed on Slideshare.

Is there still a role for smaller hospitals in the NHS?

A paper published in the British Journal of Hospital Medicine asks the questions “Is there a role for smaller hospitals in the future NHS?”

The NHS is challenged by rising demand as a consequence of a population with more complex conditions and the rising costs of paying for that care. Inefficiencies resulting from fragmented primary, secondary and social care services highlight the need for greater coordination and continuity to improve patient outcomes at lower cost. Financial constraints can drive health system review, providing impetus to modify health service delivery within the NHS to maximize value and better align with the needs of our population.

The Naylor (2017) review calls for urgent rationalization of the NHS estate to meet the mandate of the Five Year Forward View. Smaller acute hospitals could be seen as a potential starting point for reconfiguring health services in England. However, local change is not always welcome and the perceived loss of services is often met with staunch political and public opposition.

The NHS Chief Executive Officer, Simon Stevens, has expressed his support for smaller hospitals. In the Five Year Forward View, smaller hospitals have an opportunity to once again be at the centre of defining patient pathways. This will require some change in provision of services. Gaining local public and clinician support will be crucial and small hospital leaders must be visionary. Support programmes such as the New Cavendish Group and New Care Models programme will be increasingly important in helping to ensure that smaller hospitals remain part of the fabric of the English NHS.

DOI: https://doi.org/10.12968/hmed.2017.78.8.424

How well does the NHS Health Check Programme reach under-served groups?

A study from my department published in the journal BMC Health Services Research assessed how effective the NHS Health Check Programme was in reaching under-served groups.

Cardiovascular disease (CVD) is the leading cause of premature mortality and a major contributor of health inequalities in England. Compared to more affluent and white counterparts, deprived people and ethnic minorities tend to die younger due to preventable CVD associated with lifestyle. In addition, deprived, ethnic minorities and younger people are less likely to be served by CVD prevention services. This study assessed the effectiveness of community-based outreach providers in delivering England’s National Health Services (NHS) Health Check programme, a CVD preventive programme to under-served groups.

Between January 2008 and October 2013, community outreach providers delivered a preventive CVD programme to 50,573 individuals, in their local communities, in a single consultation without prescheduled appointments. Community outreach providers operated on evenings and weekends as well as during regular business hours in venues accessible to the general public. After exclusion criteria, we analysed and compared socio-demographic data of 43,177 Health Check attendees with the general population across 38 local authorities (LAs).

Using Index of Multiple Deprivation, the mean deprivation score of the population reached by community outreach providers was 6.01 higher (p < 0.05) than the general population. Screened populations in 29 of 38 LAs were significantly more deprived (p < 0.05). No statistically significant difference among ethnic minority groups was observed between LAs. Nonetheless some LAs – namely Leicester, Thurrock, Sutton, South Tyneside, Portsmouth and Gateshead were very successful in recruiting ethnic minority groups. The mean proportion of men screened was 11.39% lower (p < 0.001) and mean proportion of 40–49 and 50–59 year olds was 9.98% and 3.58% higher (p < 0.0001 and p < 0.01 respectively) than the general population across 38 LAs.

We concluded that community-based outreach providers effectively reach under-served groups by delivering preventive CVD services to younger, more deprived populations, and a representative proportion of ethnic minority groups. If the programme is successful in motivating the under-served groups to improve lifestyle, it may reduce health inequalities.

Changes in the Roles of Health Care Professionals in Primary Care in England’s National Health Service

In an article published in the Journal of Ambulatory Care Management, Dr Sonia Kumar and I discuss the change in the roles of doctors and other health professionals in England’s NHS. Primary care in England has seen a slow but steady expansion in the roles and numbers of non-medical health care professionals over the last 50 years. In the next 5 to 10 years, the use of non-medical professionals will expand rapidly in primary care, with currently unknown consequences for patient outcomes and England’s NHS. Doctors in England will find their traditional professional autonomy slowly decreasing as they increasingly work in multi-professional teams; and the education and professional development of our medical students and doctors need to change to reflect these new ways of working.

A further challenge (and opportunity) for doctors arises from the rapid advances we are seeing in information technology. Through the Internet and Web sites such as NHS Choices, patients in the United Kingdom now have easy access to medical information. We are also now seeing developments in artificial intelligence (AI) leading to alternative routes for accessing medical and health promotion advice. For example, the NHS has now begun trialing AI-based “chatbots” that will be used to offer health advice to patients when they contact the NHS telephone advice line (NHS 111) for medical advice. If these trials are successful, we may see a rapid development in the capabilities and use of AI-driven health chatbots in England and elsewhere.

NHS England’s plan to reduce wasteful and ineffective drug prescriptions

I published an article in the British Medical Journal in August 2017 on NHS England’s plan to reduce wasteful and ineffective drug prescriptions. In the article, I explain why national rules on prescribing are a better approach than the variable local policies being implemented by clinical commissioning groups (CCGs, the NHS organisations responsible for funding local health services).

The National Health Service (NHS) in England must produce around £22 billion of efficiency savings by 2020. A key component of the NHS budget in England is primary care prescribing costs, currently around £9.2 billion annually. Inevitably, the NHS has begun to look at the drugs prescribed by general practitioners to identify areas in which savings could be made; ideally without compromising patient care or worsening health inequalities. This process was initially led by CCGs, focusing on drugs that are either of limited clinical value or which patients can buy from retailers without a prescription (referred to in England as ‘over the counter’ preparations).[1]

However, this local-based approach is flawed.[2] Firstly, CCGs have no legal power to limit the prescribing of drugs by general practitioners. As CCG policies on restricting prescriptions are not backed by statutory guidance, this will inevitably lead to variation between general practitioners in the use of the drugs that CCGs are proposing to restrict, thereby leading to ‘postcode prescribing’. It also raises legal issues in that if there is a complaint about a refusal to issue a prescription, it will be the general practitioner who will have to defend any complaint made by the patient and not the CCG. Each CCG carrying its own evidence review, public and professional consultation, and developing its own implementation policy also results in duplication of effort and is a poor use of NHS resources.[3]

NHS England has now launched its own consultation process to identify areas where ‘wasteful or ineffective’ prescribing can be reduced.[4] However, although a national process is better than local processes, NHS England has not stopped CCGs from continuing to roll-out their own restrictions on prescribing, even though some of these will inevitably conflict with the guidance produced by NHS England when it completes its consultation process.

In its consultation document, NHS England proposes restrictions on prescribing for a range of drugs. Stopping prescribing in some areas – such as homeopathy and herbal remedies – will not be controversial but will also not save much money. Some other drugs that NHS England is proposing to restrict, such as liothyronine, have limited evidence for their benefits but some patients do find them useful, and there will be resistance from patients and from some clinicians about the proposed restrictions on their use.

The two most controversial areas will be around NHS prescriptions for gluten-free foods, for which there was a separate consultation;[5] and NHS prescriptions for drugs available over the counter. In the case of gluten-free foods, these are essential for people with coeliac disease and although gluten-free foods are now much more widely available from retailers than in the past, many patients with coeliac disease continue to receive NHS prescriptions and will resist strongly any restrictions on the availability of gluten-free foods through the NHS[6]. For drugs available over the counter, for example treatments for headlice or hay-fever, many patients will be able to pay for them out-of-pocket. Some poorer patients though will struggle with the costs of buying such drugs.

NHS England is to be congratulated for launching its public consultation and not just leaving decisions about eligibility for NHS treatment to individual CCGs.[7] However, it needs to ensure that its recommendations are accepted by CCGs and that the restrictions on prescribing that some CCGs are trying to impose fall into line with national recommendations. NHS England also needs to make the necessary changes to the National General Practice Contract and to the NHS Drugs Tariff to ensure that any prescribing restrictions it imposes have a firm legal basis. If this is not done, it places general practitioners in the invidious position of being at clinical and legal risk if they adopt NHS England’s prescribing guidance when this is finally published, at a time when they are already under considerable workload pressure.[8,9]

Restrictions on prescribing and the reduced availability of drug treatments on the NHS will have adverse consequences. For example, there is a risk of unintended effects such as codeine-based analgesics being used in place of simpler analgesics like paracetamol or Ibuprofen if the use of the latter is restricted. We also need to ensure that prescribing restrictions do not affect patients with very serious conditions. For example, if restrictions are imposed on NHS prescriptions of laxatives because these are available to buy from retailers, this will impact on patients with cancer, in whom constipation is a common and distressing symptom.

There will also be a risk that poorer patients, who are less able to pay for their own medication, will suffer disproportionately from these restrictions, thereby exacerbating health and social inequalities.[10] Ultimately, however, politicians  and the public must understand that the financial savings the NHS in England needs to make are so large, they cannot be made without substantial cuts to the provision of publicly-funded health services; and without patients making a greater financial contribution to the costs of their health care.[11,12]

doi: https://doi.org/10.1136/bmj.j3679

1. North West London Collaboration of Clinical Commissioning Groups. Choosing wisely – changing the way we prescribe. https://www.healthiernorthwestlondon.nhs.uk/news/2017/06/12/choosing-wisely-changing-way-we-prescribe
2. Iacobucci G. Doctors call for national rules on OTC prescribing. BMJ 2017;356:j1442
3. Phizackerley D. National approach to OTC prescribing is needed. BMJ 2017;357:j1849.
4. NHS England. Items which should not be routinely prescribed in primary care: a consultation on guidance for CCGs. https://www.engage.england.nhs.uk/consultation/items-routinely-prescribed/
5. Department of Health. Availability of gluten-free foods on NHS prescription. https://www.gov.uk/government/consultations/availability-of-gluten-free-foods-on-nhs-prescription
6. Kurien M, Sleet S, Sanders DS, Cave J. Should gluten-free foods be available on prescription? BMJ 2017;356:i6810.
7. Iacobucci G. NHS to stop funding homeopathy and some drugs in targeted savings drive BMJ 2017;358:j3560.
8. British Medical Association. BMA responds to NHS England action plan on wasteful drug use. https://www.bma.org.uk/news/media-centre/press-releases/2017/july/bma-responds-to-nhs-england-action-plan-on-wasteful-drug-use
9. Majeed A. Shortage of general practitioners in the NHS. BMJ 2017;358:j3191.
10. Gleed G. Commentary: We’re under financial strain without prescriptions for gluten-free food. BMJ 2017;356:j119.
11. Toynbee P. Feet first, our NHS is limping towards privatization. The Guardian, 16 August 2016. https://www.theguardian.com/commentisfree/2016/aug/16/feet-nhs-limping-towards-privatisation-podiatry-diabetic-amputations
12. Iacobucci G. GPs urge BMA to explore copayments for some services. BMJ 2017;357:j2503.