May 24, 2013

Without integrated care we risk another Mid Staffs, warns minister.

The UK government has set out ambitious plans to fully integrate health and social care in England within five years, in a new blueprint hailed by ministers as a landmark moment in the future of the NHS.

The coalition government has pledged to establish new integrated care arrangements in every area of the country by 2015, with a view to fully integrating healthcare and social care by 2018.

The government said that the move to accelerate integrated care across England was essential to stop the NHS from, “buckling under the pressure,” of an ageing population with increasingly complex healthcare needs and ongoing financial pressures.

The government’s vision will be supported by the first concrete definition of integrated care and support, developed by the charity National Voices, and the introduction of new ways to measure patients’ experience of integrated care by the end of 2013.

The announcement comes after the UK Labour Party proposed to merge the budgets for health and social care and mental health services in England, when it launched its own flagship integrated care policy in January.

Responding to the announcement, Chris Ham described integrated care as “the central challenge that defines modern healthcare.”

He said, “To meet the needs of an ageing population and transform services for the growing number of people with long term conditions, it is essential that coordinating care and support becomes the core business of everyone working in the NHS and social care. So today’s announcement is an important statement of intent.”

BMJ 2013;346:f3152

Editor’s commentary.

As a seasoned observer of the healthcare scene, it never ceases to amaze me how often statements of the obvious are launched, and often relaunched, as if they were profound new insights. So this latest announcement of the importance of integrated care represents yet another rediscovery of something some of us understood to be necessary many moons ago.

I have long thought that adult social care services and community healthcare services should be brought together within one organisation as was the case in Northern Ireland with their Health and Social Care Boards to secure integration at community level. But what about integration between hospital and community care? The US HMO model seems to me to provide the answer here so we need somehow to combine these models. Only in this way will the challenge of the ageing population and the increasing prevalence of chronic diseases be met within a realistic resource envelope.

 

Paul Walker, May 2013

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May 21, 2013

Researchers have pinpointed a catalytic trigger for the onset of Alzheimer’s disease

Researchers have pinpointed a catalytic trigger for the onset of Alzheimer’s disease – when the fundamental structure of a protein molecule changes to cause a chain reaction that leads to the death of neurons in the brain.

For the first time, scientists at Cambridge’s Department of Chemistry have been able to map in detail the pathway that generates “aberrant” forms of proteins which are at the root of neurodegenerative conditions such as Alzheimer’s.

They believe the breakthrough is a vital step closer to increased capabilities for earlier diagnosis of neurological disorders such as Alzheimer’s and Parkinson’s, and opens up possibilities for a new generation of targeted drugs, as scientists say they have uncovered the earliest stages of the development of Alzheimer’s that drugs could possibly target.

The study, published today in the journal PNAS, is a milestone in the long-term research established in Cambridge by Professor Christopher Dobson and his colleagues, following the realisation by Dobson of the underlying nature of protein ‘misfolding’ and its connection with disease over 15 years ago.

The research is likely to have a central role to play in diagnostic and drug development for dementia-related diseases, which are increasingly prevalent and damaging as populations live longer.

“There are no disease modifying therapies for Alzheimer’s and dementia at the moment, only limited treatment for symptoms. We have to solve what happens at the molecular level before we can progress and have real impact,” said Dr Tuomas Knowles, lead author of the study and long-time collaborator of Professor Dobson.

“We’ve now established the pathway that shows how the toxic species that cause cell death, the oligomers, are formed. This is the key pathway to detect, target and intervene – the molecular catalyst that underlies the pathology.”

In 2010, the Alzheimer’s Research Trust showed that dementia costs the UK economy over £23 billion, more than cancer and heart disease combined. Just last week, PM David Cameron urged scientists and clinicians to work together to “improve treatments and find scientific breakthroughs” to address “one of the biggest social and healthcare challenges we face.”

The neurodegenerative process giving rise to diseases such as Alzheimer’s is triggered when the normal structures of protein molecules within cells become corrupted.

Protein molecules are made in cellular ‘assembly lines’ that join together chemical building blocks called amino acids in an order encoded in our DNA. New proteins emerge as long, thin chains that normally need to be folded into compact and intricate structures to carry out their biological function.

Under some conditions, however, proteins can ‘misfold’ and snag surrounding normal proteins, which then tangle and stick together in clumps which build to masses, frequently millions, of malfunctioning molecules that shape themselves into unwieldy protein tendrils.

The abnormal tendril structures, called ‘amyloid fibrils’, grow outwards around the location where the focal point, or ‘nucleation’ of these abnormal “species” occurs.

Amyloid fibrils can form the foundations of huge protein deposits – or plaques – long-seen in the brains of Alzheimer’s sufferers, and once believed to be the cause of the disease, before the discovery of ‘toxic oligomers’ by Dobson and others a decade or so ago.

A plaque’s size and density renders it insoluble, and consequently unable to move. Whereas the oligomers, which give rise to Alzheimer’s disease, are small enough to spread easily around the brain – killing neurons and interacting harmfully with other molecules – but how they were formed was until now a mystery.

The new work, in large part carried out by researcher Samuel Cohen, shows that once a small but critical level of malfunctioning protein ‘clumps’ have formed, a runaway chain reaction is triggered that multiplies exponentially the number of these protein composites, activating new focal points through ‘nucleation’.

It is this secondary nucleation process that forges juvenile tendrils, initially consisting of clusters that contain just a few protein molecules. Small and highly diffusible, these are the ‘toxic oligomers’ that careen dangerously around the brain cells, killing neurons and ultimately causing loss of memory and other symptoms of dementia.

The researchers brought together kinetic experiments with a theoretical framework based on master equations, tools commonly used in other areas of chemistry and physics but had not been exploited to their full potential in the study of protein malfunction before.

The latest research follows hard on the heels of another ground breaking study, published in April of this year again in PNAS, in which the Cambridge group, in Collaboration with Colleagues in London and at MIT, worked out the first atomic structure of one of the damaging amyloid fibril protein tendrils. They say the years spent developing research techniques are really paying off now, and they are starting to solve “some of the key mysteries” of these neurodegenerative diseases.

“We are essentially using a physical and chemical methods to address a biomolecular problem, mapping out the networks of processes and dominant mechanisms to ‘recreate the crime scene’ at the molecular root of Alzheimer’s disease,” explained Knowles.

“Increasingly, using quantitative experimental tools and rigorous theoretical analysis to understand complex biological processes are leading to exciting and game-changing results. With a disease like Alzheimer’s, you have to intervene in a highly specific manner to prevent the formation of the toxic agents. Now we’ve found how the oligomers are created, we know what process we need to turn off.”

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May 20, 2013

Up in Smoke: Reasons to Kick Your Habit

In recent years, general attitudes towards smoking have changed a great deal. Increased awareness of smoking’s effects on your health and government legislation have seen cigarettes and accompanying advertising messages all but eradicated from public sight. This has cast the smoker in an unfavourable light – now they carry with them a habit that is deemed not only detrimental to their own health but anti-social too.

Within this environment, there is a lot more pressure upon the smoker to give up and, it seems, an increased inclination to do so. Of those that remain addicted to smoking in the UK, 63% possess the desire to quit. Unsurprisingly, the main reason given for this disposition is concern over health and the gloomy prospect of premature death.

Kicking the Habit

Despite nearly two-thirds of smokers having a desire to quit, the vast majority remain addicted as relapse rates for those that attempt to give up are very high. Many smokers have tried to give up at least once but have failed because their dependence on cigarettes is so hard to kick.

The addictive element is nicotine, and all smokers have built up a physical dependence to this drug, such that abstinence from it will cause a multitude of unpleasant withdrawal symptoms. These include nausea, headaches, anxiety and extreme cravings that are at their worst within the first 12-24 hours of quitting, making this the most common period for relapse.

Think of Your Health

For those who bite the bullet and endure that difficult first day, there are so many statistics borne from reliable sources that suggest quitting smoking will make your life much better. Within three days you should already start feeling better.

Within just 20 minutes of stubbing out your final cigarette, your body’s blood pressure and pulse rate will return to normal. Inside 48 hours the nicotine in your body will have disappeared and your quest to escape the drug’s vice-like grip will become that much easier. The 72 hour mark will see your breathing improve significantly as the bronchial tubes start to clear, so your energy levels should improve and physical exertion will become easier.

The long-term benefitsare even more note-worthy. By your ten-year mark as a non-smoker the risk of developing lung cancer will drop by half and the risk of you having a heart attack will be at the same level as someone who has never smoked.

Financial Cost

Okay, so the fact that giving up smoking will improve your health is hardly a revelation. However, if you don’t mind having heavy lungs, perhaps you have grown tired of having a lighter wallet.

Cigarettes have increased massively in price, especially in the last ten years. The government have hiked up tax exponentially not just as a measure to line their own pockets, but as a tool to incentivise people to quit.

If you pay for your cigarettes as and when you need them, the deficit that your habit is inflicting on your finances might not be as obvious. However, if you take just a few moments to ponder the cumulative sums of cash squandered upon the habit it can become mind-boggling. If you think of quitting smoking in terms of what you can spend with the money saved then you can provide yourself with quantifiable inspiration– this quit smoking calculator tells you exactly how much you’ve spent, and what luxuries you could have treated yourself to instead!

Smoking severely depletes your health and your wallet. Considered in combination and alongside the increasing perception of smoking as an anti-social habit, surely there is no better time to send your habit ‘up in smoke

Gavin Harvey is a personal trainer who loves to blog on all things fitness and health related.

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May 18, 2013

NHS to go digital with £260m investment – Comment from Fjord

The government is investing £260m in the NHS for hospitals to replace “outdated” paper patient notes and prescriptions with online systems. This is part of the move towards a digital public sector by 2018 and to make patient records available online by 2015.

Key points

  • Hospitals will be able to develop electronic prescription and patient system
  • This will enable medics from different departments to access patient information quickly and easily
  • This is also part of a bid to make the NHS safer after Jeremy Hunt revealed that 11 people died last year after being given the wrong medication

Mark Curtis, Chief Client Officer at Fjord, who are experts in creating digital services and have worked with numerous healthcare and research organisations including Harvard Medical School the leading service design consultancy, comments as follows :

“The new electronic system for the NHS is poised to address patient needs in a way that paper cannot, but it’s not as simple as just ‘going digital’ as doctors are increasingly disconnected with electronic health records (EHRs). Currently EHRs are not optimised to help doctors get a quick and accurate overview of patients’ health patterns and the NHS would do well to take a design-led approach to the digitisation of its system, building in feedback from doctors in order to make the service more usable and ultimately to aid the delivery of healthcare across the UK. Reports show that medication errors are not uncommon and with so much data now available, it’s no surprise that doctors are caught in a deluge of information. Through clear visual representation of complex data, this information can be understood and digested more easily, cutting down on human error. Our recent work with Harvard Medical School to develop an interactive paediatric growth chart shows that presenting patient data through visualisations makes it easier to understand and action healthcare decisions as a result. It will be interesting to see the digitisation of the NHS roll out and to see if it meets doctors’ requirements. Only involving both engineers and designers into the creation process, the NHS can create a useful and effective service.”

 

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May 18, 2013

Future options for the NHS

Notes from Health Matters seminars at Kings College London on March 1st 2013 and University College London on April 26th 2013

Near future: In the run up to the 2015 general election, the NHS is likely to have:

  • A large part of community services (and some hospital services) provided or managed by the private sector. Mental health services, of which 30% are currently provided by commercial or third sector organisations, are the shape of things to come.
  • Clinical Commissioning Groups struggling with rising demand and expectations, and shrinking budgets, with limited powers. Some CCGs will manage these pressures better than others, perhaps changing general practice as they do so, but others will fail to develop services or balance budgets.
  • Increased central efforts to manage (and micro-manage) the NHS, and promote service integration as a cost-saving exercise. Provider flux and unachievable targets will undermine these efforts, and top-down management will fail more often.
  • More public engagement with the NHS agenda, through both official channels (Health Watch, the Health & Wellbeing Boards) and unofficial ones (campaigns to preserve existing NHS resources & services). The tension between bottom-up accountability and political accountability will increase tensions within the NHS.
  • Further shrinkage of publicly-funded social care. Individuals managing their own social care by using the benefits system will be challenged even as political rhetoric emphasises personalisation and personal budgets.
  • Instability in the hospital sector, particularly where there is PFI debt. This instability will also arise because of the inability of the NHS to respond to social and demographic changes (more very old, fewer carers), inherent inefficiencies in hospital organisation, plus declining staff engagement, motivation and confidence. The divide between DGHs and teaching hospitals will widen, and 50 or so Hospital Trusts will not achieve Foundation status.
  • Persistent variability in the quality of general practice, with a low skill base and poor organisation being widespread.
  • Growing official interest in the importance of individual responsibility for health, and family and friends being seen as essential support for those in hospital.

Immediate problems: The Health Matters seminars identified 10 problems that a Labour government elected in 2015 would need to address (but not necessarily solve) over a ten year period.

  1. Funding constraints, prompting not only smarter working but also reclassification of PFI and other historic debt as “toxic” so that it can be managed differently.
  1. Generic challenges (common to all health services in industrialised societies) including social and demographic changes, system obsolescence, unwarranted variability in service performance and outcomes, increasing expectations and intolerance of poor quality, and resistance to innovation. These trends suggest that general practice and DGHs are no longer workable, as currently organised. At the least, there is need to incentivise pro-active work, particularly in Primary Care, and to change incentives for hospitals admission and discharge.
  1. The separation of mental health services from other services and their fragmentation by out-sourcing. ‘Joined up care’ will remain an aspiration, and ‘integration’ will continue to be uncritically promoted as a solution ‘Integrated care’ is an unhelpful term and is better understood as ‘joined up care’ or ‘whole person care’, or ‘co-ordinated care’, though it is not always clear what distinctions are intended. National Voice has a working definition of joined-up or integrated care which is very patient centred. http://www.nationalvoices.org.uk/30-charities-call-david-nicholson-endorse-new-principles-integrated-care. Joined up care is needed in the NHS, and between the NHS and social care, because: 1) patient experiences of care are so often poor; 2) it may make financial trade-offs possible and 3) it may generate efficiency savings. The NHS is good at co-ordinated care for specific time-limited activities (maternity care, surgery, rehabilitation, palliative care) but less good when care coordination is needed for high volume, complex, long-term conditions – like serious mental illness.
  1. The variability of quality of care in general practice, its limited skill set and poor level of organisation, and the lack of NHS leverage over it. Although general practitioners are in theory well positioned to provide coordinated care, the discipline is unable to do so under its present contract. A new GP contract is needed which will, for example, restore responsibilities for 24 hour care to general practice.
  1. The fragile means tested/privatised economy of social care, and the commonly poor working relationships between the largely commercialised care home sector and the NHS. Free social care – one option being considered – could be funded by an Estates (Death) tax, or through hypothecated compulsory social care insurance. Free social care could be introduced in stages. One stage could involve drawing the care home sector further into the public domain. The different funding regimes are unhelpful, but providing social care for free will not in itself deliver more integrated services. Further institutional instability as a result of reorganisation would be very unhelpful. Transferring the NHS budget to local government would not only reduce the democratic deficit but also foster care coordination, but so radical a shift may not be necessary. Making a more explicit relationship between the Health and Well-Being Boards and the NHS Trusts might be sufficient.
  1. A historically weak political culture around the NHS, in which change is seen as a threat, and a deep democratic deficit, in which the public is excluded from NHS decision-making. There is a need for a mature political dialogue, but the mechanisms for it need to be established first.
  1. Public health has been marginalised just as the social determinants of health and illness have become clearer than ever. There will be need for more emphasis on health promotion directed at all non-communicable diseases and a radical, healthy food policy. Community development (to increase social capital) generates early benefits for health & wellbeing, so closer working between CCGs and Health & Wellbeing Boards should be promoted . Integration is not just something that happens at the level of the individual patient.
  1. NHS management has been re-organised too often, and has lost a great deal of experience and its collective memory. The decay of leadership means that the cadre of management needed not only to stabilise the NHS but also to promote organic growth within it, is weak.
  1. Quality of care in the NHS is undermined by rapid and repeated organisational changes, a narrow focus on targets and the decay of leadership (amongst clinicians as well as managers). Perceptions of the quality of care will be manipulated by those hostile to the NHS.
  1. Power in the NHS is dispersed across the health economy, without commensurate accountability across different centres of power, especially those in the commercial sector.

Future options: An incoming Labour government in 2015 could centre its policy towards the NHS on a response to the generic challenges, from two angles.

First, a balanced economy of health care should contain incentives that promote prevention, health promotion and more significant strategic role for public health, reinforce holistic care, and reduce reliance on hospitals. This will probably require some combination of hospital and community services with lead commissioners and shared or programme budgets as possible funding mechanisms, but in most situations combination will not be achieved by merger. This strategyis likely to require the abolition of the Quality & Outcomes Framework in general practice, and of Payment by Results.

Second, the key attributes of a service that meets needs can be defined in terms of:

  • The forward application of expertise (the most experienced in the frontline, in hospitals and community services – including out-of-hours services).
  • Emphasis on the management of uncertainty at all levels of the NHS to reduce patient referral/hand-on and ‘buck passing’.
  • Engagement of the public in NHS decision-making, and the NHS in community development, as a precondition for continued funding, with emphasis on increasing the power of ‘voice’ through use of social media.
  • The promotion of generalism (a holistic approach) in community and hospital services.
  • Making the maintenance of relational confidence between disciplines the primary task of NHS management.
  • Establishing single budgets and shared financial accountability as the norm across community and hospital services, along with a single outcomes framework, and funding mechanisms aligned to desired outcomes.

In 2015 a Labour government could promote the development of local services spanning community and hospital practices, similar to Kaiser Permanente-type health maintenance organisations, but without driving their growth using market mechanisms. The exact mechanisms for governing these local services should be the subject of natural experiments (because we do not yet know the optimal mechanism), changes can occur slowly and the new services can evolve over time. Such changes could occur within existing legislation, once section 3 of the Health & Social Care Act has been repealed.

Engagement of the NHS with community development, the wider public involvement in the NHS that seems likely to occur, and the evolution of local integrated services will push the NHS towards becoming part of local as much as national government. This shift in accountability and governance will also be slow and incremental, with no system wide re-organisation by decree.

 

Steve Iliffe

 

 

 

 

 

 

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