This briefing produced by The King’s Fund, the Nuffield Trust and The Health Foundation, provides an independent assessment of where the Spending Review leaves the NHS and social care.
Now that the dust has settled on the Chancellor’s announcements, our three organisations have come together to help ensure the debate is informed by a clear and objective analysis of the funding position and its implications for health and social care services.
- Total health spending in England will rise by £4.5 billion in real terms between 2015/16 and 2020/21.Looked at over the whole of this parliament, this will result in an increase of 0.9 percent a year, almost identical to the rate of increase over the last parliament. This is much less than expected following the announcement of the NHS settlement.
- This is because the Spending Review defined ‘NHS’ spending as NHS England’s budget, not the whole of the Department of Health’s budget – the definition used by previous governments.
- While NHS England’s budget will rise by £7.6 billion in real terms over the period, other health spending will fall by more than £3 billion, a 20 per cent cut.
- The additional investment will be front-loaded with a significant increase in 2016/17 which is very welcome. However, much of this money will be absorbed by dealing with deficits among NHS providers and by additional pension costs.
- With much smaller increases in later years, the NHS will struggle to maintain services, let alone invest in new models of care and implement seven-day services. This places even more emphasis on the huge challenge of finding £22 billion in productivity improvements by the end of the parliament.
- Public health spending will fall by at least £600 million in real terms by 2020/21, on top of £200 million already cut from this year’s budget. This will affect a wide range of services including health visiting, sexual health and vaccinations.
- Overall, the NHS is halfway through the most austere decade in its history. Public spending on health in the United Kingdom as a proportion of GDP is projected to fall to 6.7 per cent by 2020/21, leaving us behind many other advanced nations on this measure of spending.
- A number of uncertainties make the settlement for social care difficult to gauge but spending is likely to be broadly flat in real terms over the parliament.
- New powers to raise Council Tax by up to 2 per cent to spend on social care will provide flexibility for local authorities but are unlikely to raise as much as the government suggests and could disadvantage deprived areas with low tax bases.
- Additional money for social care provided through the Better Care Fund from 2017/18 is welcome but risks arriving too late with the sector already on the brink of a crisis and a further significant cut in funding to follow next year.
- The additional funding will not be enough to close the social care funding gap which we estimate will be somewhere between £2 billion and £2.7 billion in 2019/20, depending on how much is raised through the Council Tax precept.
- Social care also faces additional cost pressures from implementing the National Living Wage which will add another £800 million to these estimates, leaving an estimated total funding gap of between £2.8 billion and £3.5 billion by the end of the parliament.
- Public spending on social care as a proportion of GDP will fall back to around 0.9 per cent by 2019/20, despite the ageing population and rising demand for services. This will leave thousands more older and disabled people without access to services.
Key business challenge for 2016:
- The financial and emotional cost of the ageing population is one of the key issues facing society – considered by some to be a ‘time bomb’ that will take economies to a new crisis point
- The number of people aged 85 or over will reach 3.5 million by 2034 and account for five per cent of the total population, according to the Office for National Statistics
- Technology could have the answer – but only if businesses wake up to the challenge and get behind an innovation ‘space race’ in 2016
How to care for the oldest members of society is a pressing issue for the global economy but, despite their fast growing numbers and obvious need of support to remain independent, they are being neglected by technological innovators according to the Chief Executive Officer of new healthcare technology business.
According to projections by the Office for National Statistics, by 2034 the number of people aged 85 or over will be 2.5 times higher than in 2009. The cost of this ageing population is one of the key issues facing society with predictions of it crippling the country’s economy.
But healthcare technology company Protelhealth believes that the ageing population is a challenge that can be met and embraced with ingenuity and innovation. The firm already operates a successful e-business offering innovative healthcare products, however, Protelhealth’s Chief Executive Officer Norman Niven is concerned that not enough of the nation’s technological fire power is being put behind such products. He is urging entrepreneurs and technology innovators to grasp this challenge as a priority.
Mr Niven comments: “We have established an excellent platform through which new products for independent living can be taken to market, backed by guidance on the best product for each requirement. Yet our biggest challenge is a lack of products that both do the job and are acceptable to discerning consumers.
“Technology for younger consumers is delivered at an unprecedented rate, and they benefit from having innovative technology at the core of their day-to-day lives”, continues serial entrepreneur Niven. “From Fitbit activity trackers, through smart meters, to phone-linked home security systems – and yet we expect our parents and grandparents to rely on ugly and out-dated technologies such as emergency buttons and fall cords. This is something that cannot continue.”
The Protelhealth team believes that security, dignity and independence in old age are within the UK’s grasp, if – and only if – businesses develop the technological solutions needed to support the elderly and unwell to live at home successfully and for longer.
The firm has already launched telmenow.com – a website designed specifically to offer advice and innovative products to support those living at home. It showcases fresh and effective products such as the Pebbell GPS Tracking Device, trueCall call monitoring device and AliveCor® Smartphone Heart Monitor. And yet the pool from which to select effective and acceptable products is small.
Niven explains: “Our target consumers are proud and independent people who want to enjoy their later years in the same way they have lived, but to date product developers and technology innovators have not embraced them as a target audience. This is particularly shocking as they are one of the fastest growing consumer groups in the UK.”
Protelhealth’s appeal for 2016 is for UK technology to undertake a drive that resembles the ‘space race’ of the 1960s. President John F. Kennedy’s statement that the USA would land a man on the moon galvanised industry and science in the US to make major leaps to achieve his goal. In the same way, a period of focused attention on a clear goal could lead the UK to a period of accelerated and successful technological advancement. In driving for dignified home support for our oldest old, UK industry could achieve significant commercial success, and guard against spiralling healthcare and welfare costs.
Norman Niven concludes: “The generation that cared for its families and for the UK through times of turmoil, is now being poorly served by the generation that it raised. This is not due to lack of concern but the nature of modern society, whereby children can live many hundreds of miles from their parents and both men and women work full time. And yet the middle aged consumer relies heavily on technology to make many of their most basic actions possible.
“2016 is a critical year and one that could witness dramatic change. If consumers are more demanding, and businesses more innovative, the future welfare of the nation’s parents and grandparents can be improved dramatically. The UK could – and should – provide a benchmark for the world in using innovation to protect and support its most vulnerable residents, and we need to do so soon.”
- 47% are willing to be diagnosed digitally instead of face-to-face with their GP
- 67% would use wearable technology to monitor long-term medical conditions
- The majority already using healthcare technology report improved health
- 55% agree the NHS should provide free technology to help people play an active role in improving their health
Almost half (47%) of UK adults would be happy to be diagnosed remotely through digital health technology rather than face-to-face with a doctor, according to Aviva’s latest Health Check UK report. Men in particular are happy to replace a trip to the doctor with a digital diagnosis (53% versus 42% of women).
The growing appetite for digital health technology (including wearable health monitors, health advice mobile apps and video consultations with doctors) could remove the need for some doctor appointments and alleviate pressure on stretched healthcare services, helping the 58% of adults who struggle to get an appointment with a GP at a convenient time.
In a show of support for NHS plans to remotely monitor long-term illnesses, more than two thirds (67%) of UK adults agree they would be happy for a long-term medical condition (such as diabetes or heart disease) to be managed through remote digital monitoring. Those who are overweight (68%) or obese (71%) are particularly likely to be in favour of remote monitoring, perhaps as they are typically more likely to experience these types of illnesses.
Almost three in five adults (57%) agree digital health technology could improve their health or wellbeing, including 60% of overweight and 58% of obese people.
Although usage of wearable health technology – such as heart rate, symptom, or sleep pattern monitors worn as a bracelet or watch – is relatively low across the wider population, younger age groups are most active with this kind of technology. Almost one in six (15%) of those aged 25-34 use a physical activity monitor (compared to 8% overall) while 9% of 25-34s use a sleep pattern monitor (vs. 4% overall).
Among those adults who already use wearable technology, the majority report benefits to their health. For example, 63% of all age groups using a physical activity monitor say it has improved their health, rising to 66% of those with a heart rate monitor.
Many of those who are not currently using wearable health technology are open to doing so in the future. Three in five (60%) non-users would use a physical activity or heart rate monitor in the future, while 52% would consider using a sleep pattern monitor.
Table 1: Uptake of wearable health technology and the benefits to health
||Physical activity monitor
||Heart rate monitor
||Sleep pattern monitor
|% of UK adults currently using this
|% who say this has improved their health
|% who don’t use now but would be open to doing so in the future
Healthcare technology used for prevention as well as cure
As well as diagnosing and managing health conditions, health technology can also be used to prevent avoidable illnesses caused by poor lifestyle choices. Almost four in five adults (78%) agree that avoidable illnesses are putting too much pressure on the NHS as obesity rates continue to rise.2
Using the internet to access information about health and wellbeing is already commonplace, with 63% using the internet for this purpose. However, there is growing appetite for mobile apps which can also be used to actively monitor and improve physical wellbeing. These include nutrition tracker apps, medication reminder apps and physical activity trackers, such as running apps which allow the user to log runs, monitor overall progress and set future goals.
Almost one in six (15%) use a physical activity tracker app and 46% would do so in the future, while one in ten (9%) use a nutrition or diet tracker app and 38% are open to doing so.
As interest in digital health technology increases, 55% believe the NHS should provide free health technology to help people play an active role in improving their own health.
Dr Doug Wright, Medical Director for Aviva UK Health says,
“As mobile apps and healthcare technology integrate into everyday life, growing numbers are willing to put their trust in digital help or diagnosis. Using technology to identify common illnesses or help manage a long-term condition can remove the need for a face-to-face GP appointment, alleviating pressure on doctors and freeing up time for more urgent health matters.
“At Aviva we already offer some of our corporate customers a virtual health service app – babylon – which gives them quick and convenient access to family GPs, specialist consultants, and state of the art health monitoring and treatment.
“Technology can also aid proactive health management, allowing us to track and improve our health to avoid developing certain conditions in the first place. Many of us will already have this technology in the palm of our hands, or waiting under the Christmas tree this December. As well as using technology for entertainment and social media, people could be using it to get a greater understanding and control of their health and fitness. “
As winter bites care homes are coming under increased pressure to support the NHS by providing a layer of intermediate care that will help reduce the burden on acute hospital services.
Traditionally however care home residents experience 40-50%1 more emergency admissions and Accident & Emergency (A&E) attendances than the general population aged 75 and over, so any increased role has to be supported by improved patient management.
Under pressure staff, cost pressures and poor connectivity with primary care all contribute to a lack of proactive symptom management. Simply monitoring residents’ blood pressure, weight and hydration levels with information being fed directly into GP systems will help maintain health and prevent escalation to more specialist services. It will also be vital to the creation of additional intermediate care capacity. Digital health specialist, Inhealthcare, believe their new vital signs monitoring service can reduce emergency admissions of care home residents by acting as an early warning system.
Their care home service includes measuring the residents’ weight, hydration, blood pressure, heart rate and SPO2.
Inhealthcare’s Simon Jones, “Care homes can play a central role in filling the intermediate care vacuum – but only if the staff have the correct knowledge and skills, services are connected to local primary care providers and care is proactive. Whilst many homes already monitor vital signs, few integrate information into the NHS – a central requirement if escalation to secondary care is to be avoided.”
Inhealthcare’s CEO Bryn Sage, “The NHS have called for a clear strategy to free up hospital beds for those in need; firstly, by preventing avoidable hospital admissions and secondly, by supporting timely hospital discharge. Our vital signs monitoring service can do this by bridging the gap between secondary and community care.”
Inhealthcare’s technology integrates patients’ data into GP systems, improving the coordination between care homes and the local NHS because results can be viewed by all departments. If readings fall outside of a patient’s normal range, the appropriate NHS team is alerted. This means changes in health are highlighted early on, reducing the likelihood of hospital admission. The service supports earlier hospital discharge because it gives clinicians the confidence that if the patient is discharged, their full needs will be being met with regular and close monitoring.
Inhealthcare’s new service builds on their proven success of digitising existing care pathways*. NHS County Durham and Darlington Foundation Trust (CDDFT), one of the largest integrated acute and community services providers in England, adopted Inhealthcare technology to introduce an undernutrition monitoring service for elderly patients in 80 care homes. Ian Dove, the trust’s Business Development Manager says, “The NHS has known for a long time that care homes and the voluntary sector could expand out-of-hospital care delivery, if they could be more effectively integrated into local health and social care economies. The Inhealthcare platform provides the flexibility and interoperability we need to implement radically new models of care.”
1.Quality Watch. Focus on: Hospital admissions from Care Homes. January 2015. Accessed December 2015: http://www.health.org.uk/sites/default/files/QualityWatch_FocusOnHospitalAdmissionsFromCareHomes.pdf
- County Durham and Darlington Undernutrition Case Study October 2015
Actress Phyllida Law tells of challenges of caring for her mother: “You couldn’t leave the house”
Actress Phyllida Law – mother to actresses Emma and Sophie Thompson – has told of the impact of dementia on her mother and the challenges of caring for her, as Alzheimer’s Research UK launches a new report highlighting the heavy toll dementia takes on family carers. The report, Dementia in the Family: the impact on carers, comes as new polling reveals that nearly a third (31%) of non-retired people aged 55 and over are worried that their family members will have to care for them in later life, and shows the realities of daily life for carers who are looking after their loved ones. In-depth case studies in the report reveal how dementia changes family relationships, leaving people feeling socially isolated, and affects both the health and finances of family carers. The findings underline the importance of research to provide new treatments capable of reducing care needs for people with the condition.
In a new YouGov survey commissioned by Alzheimer’s Research UK, the UK’s leading dementia research charity, three in 10 non retired people aged 55 and over in the UK said they were concerned that in later life, their family would need to care for them.Dementia in the Family shines a spotlight on experiences shared by many of the 700,000 people in the UK who are caring for a loved one with dementia. Through in-depth interviews with four families who are living with the condition, the report shows that carers find their role both challenging and rewarding.
The carers spoke of the way dementia has affected relationships within their families, at times creating unwanted tensions as well as changing how carers interact with the person with dementia. Interviewees told how their caring role, which sees them prioritise their responsibilities to their loved ones over their social lives, has left them isolated from friends and other family members. Although many felt their role was rewarding and had strengthened the bonds between them and their loved one, all the carers experienced high levels of stress and had faced financial costs associated with the condition.
Phyllida Law has first-hand experience of the toll a caring role can take, having looked after her mother, Meg, for several years after dementia took hold. She said:
“The night time was particularly difficult: at dusk my mother would often think she was in the wrong house, or she would call for breakfast in the middle of the night, not knowing what time it was. When you’re worn out because you haven’t slept, you can be in danger of losing your temper, and that’s very hard. I wasn’t as isolated as some people, and I was lucky because I had help from the people in my mother’s village and from my two daughters [Emma Thompson and Sophie Thompson], who also helped me financially. But caring for Ma, you couldn’t leave the house without taking her with you, so you did feel very stuck a lot of the time.
“A treatment that could help people like my mother would be unimaginable. It’s extraordinary to think of the advances that have been made for diseases like cancer, and it would be wonderful to see that for dementia.”
Hilary Evans, Chief Executive of Alzheimer’s Research UK, said:
“For many people the festive season is a time to think about family, but for countless families across the UK dementia is taking a heavy toll, leaving people socially isolated and struggling financially. The experiences highlighted in this report will be recognised by people up and down the country who are dealing with the challenges of caring for a loved one with dementia.
“A diagnosis of dementia ripples far beyond the person affected, it touches whole families, and we owe it to them to do all we can to tackle it. Across the UK over 700,000 people are caring for someone with dementia, but it’s estimated that if we could delay the onset of dementia by five years, by 2050 we could reduce the number of carers by a third. Research has the power to bring about new treatments and preventions that could transform lives, but to reach that goal we must invest in research now.”
Just 38% of women start rehabilitation following heart attack, angioplasty or surgery
More than 24,000 female heart patients are missing out on crucial rehabilitation, putting them at risk of further heart attacks, according to a new report1 from the British Heart Foundation (BHF).
Just 38 per cent of female patients who have a heart attack, angioplasty or bypass surgery receive any cardiac rehabilitation.
Analysis shows that cardiac rehabilitation services are neglecting female heart patients, with just over 14,000 taking part in cardiac rehabilitation out of 38,500 eligible female patients in England in 2013/14. A further 5,500 women could take part if services fixed the current gender imbalance and matched male uptake levels (52%).
In England, around 122,000 patients are eligible for cardiac rehabilitation but just 47 per cent receive it, despite a government target2 of 65 per cent.
In some parts of the country patients had to wait as long as seven weeks to start rehabilitation following a heart attack3, nearly double the recommendation of starting within 28 days.
When someone suffers a major heart event, such as a heart attack, and need life-saving surgery or medicine-based treatment, they should then be referred for rehabilitation to help their recovery and reduce the risk of another heart attack.
But at some rehabilitation centres, as few as ten per cent of patients are women, partly because services are failing to refer and encourage female patients to take part. There are also concerns that older women and men are not attending cardiac rehabilitation following a medically managed heart attack.
The National Audit of Cardiac Rehabilitation (NACR), which is funded by the BHF and hosted at the University of York, combines data from 164 centres in England, as well as centres in Wales and Northern Ireland.
Cardiac rehabilitation offers physical activity support and lifestyle advice, such as exercise classes and dietary guidance, to help people living with heart disease manage their condition and reduce their risk of associated heart events.
Rehabilitation can help reduce the number of deaths by 18 per cent over the first six to twelve months2 and can cut readmissions by a third (31%).
Dr Mike Knapton, Associate Medical Director at the British Heart Foundation, said: “It is appalling that less than half of eligible female heart patients receive cardiac rehabilitation. Thousands of women are missing out on a vital step in their recovery, increasing their risk of another heart attack.
“That’s why health services urgently need to make rehabilitation more accessible to women, who are either not referred or are put off attending, to help save more lives.”
Professor Patrick Doherty, Director of the NACR, said: “This report shows that while some programmes promote an attractive rehabilitation service and have really high uptake of female patients, the majority of programmes struggle to ensure enough women take part.
“Service providers and commissioners should take action to improve the appeal of the programmes and promote them in a way that motivates female patients to attend. A range of options should be offered including community and self-management approaches, all of which have been shown to benefit patients.”
Nichola Brown, 52, from London, had a stent fitted after a heart attack in 2012. She took part in cardiac rehabilitation once a week, for six weeks, and still continues to go to the gym.
Nichola said: “When you’re recovering from a heart attack it can be quite scary, but my cardiac rehabilitation programme was brilliant. You get access to experts such as specialist cardiac nurses, nutritionists, and exercise instructors to educate and help you. At the end of rehabilitation I was feeling much better and still continue to go to the gym. More women should be encouraged to take part, it’s just so important.”
Lisa Dalgleish, health and care solicitor at leading law firm BLM, looks into some of the challenges and liability risks resulting from the proliferation of digitalised healthcare and new technologies.
The BBA, the trade association representing the UK banking sector, has reported that there are 9.6 million log-ins to internet banking every day and £2.9 million is moved by customers using banking apps every single week. Meanwhile, online retail purchases were made by 81% of Brits last year. When it comes to booking holidays, finding your dream destination, paying for it and then printing out the plane tickets from the comfort of your own sofa, purchasing is now more convenient than ever.
Against the continued rise in popularity for the convenience of digital solutions across all aspects of our daily lives, is the healthcare sector on track to keep pace with the ever-evolving digital world?
Last year only 2 per cent of the population engaged with a digitally enabled transaction with the NHS, according to the Department of Health’s National Information Board (NIB).
Efforts to increase digitalised healthcare provision in the UK are now essential for the NHS and beyond. In fact, NIB’s ‘Personalised health and care 2020: a framework for action’ states that: ‘Better use of technology and data is a prerequisite for supporting and enabling the key developments needed to reshape the health and care system.’
mHealth, wearable and implantable technologies, medical equipment and devises connected to ‘the Internet of Things’, remote consultations, diagnoses and treatments and a variety of other healthcare innovations, once only the predictions of science fiction and now real, are set to hit unprecedented heights in 2016 and beyond.
But with new technologies come new risks – so what implications should we be aware of? How can we manage all of the data – personal and extremely valuable data – that is produced by these new technologies? What are the key vulnerabilities? Is ‘medjacking’ the biggest emerging threat?
‘Medjacking’ is a term coined to describe the use of malicious software (‘malware’) as a means to launch cyber attacks on healthcare systems. This is usually done by hackers placing malware on networked medical devices – giving them the ability to remotely control medical equipment.
Medical devices may be vulnerable to attacks on their security systems that are installed by the manufacturers. Some manufacturers, especially those with low budgets for cybersecurity, turn to open source code and libraries for security solutions. They may be using older, more exploitable code, with known vulnerabilities in their products.
Where security systems are managed solely by the manufacturer’s external technicians, healthcare providers are totally dependent on manufacturers to maintain security.
Cyber attacks on healthcare providers
Medical devices have emerged as a new target for cyber attacks. In a report published in June 2015, one cyber defence company reported a case at an unnamed hospital where hackers were able to plant malware in surgical blood gas analysers.
The hackers then used the equipment as a back door to find passwords throughout the hospital’s IT systems and leak sensitive information. Another case involved hackers creating a backdoor access point through a hospital’s X-ray system.
The information that healthcare providers hold is more valuable than payment card information held by retailers. Health organisations often have complete profiles of people including national insurance numbers and medical health information that is impossible to change in light of a data breach. Health data attacks give hackers the information they need to commit identity fraud and organisations are vulnerable if their security systems are not sufficiently robust.
The healthcare industry is now using ‘apps’ in the same way as the fitness industry, to track patient health and assist with treatment compliance.
This year has seen the launch of Apple’s ‘iWatch’, which is able to monitor heart rate, blood glucose, sweat and sleep patterns. Various other fitness bands offer a variety of options for capturing an individual’s key health data, and consultants are predicting that up to 75% of the global population will be expected to use devices like this in the future.
We are also moving into an era of ‘implantables’. Google’s smart contact lens has the potential to monitor a person’s glucose levels or other vital signs. Drug companies are working on implantable smart pills that work with Bluetooth to inform doctors and family members if a patient has taken his or her medicine.
The progression from remote health monitoring to health apps will see patients monitoring and assessing their own health issues and managing their own prescriptions, relying on applications to inform patients to take clinical action and make diagnoses.
A new generation of bionics that can connect wirelessly with the nervous system and enabling ‘feeling’ sensations is now available to patients in the UK. These devices are implanted directly into the nerve to process and transmit signals wirelessly to an external device.
A £1.4m UK research project lead by Newcastle University aims to develop novel electronic devices that connect to the forearm neural networks to allow two-way communications with the brain. This could allow the hand to communicate directly with the brain, sending back real-time information about temperature, pressure and shear force. A £5.3 million award from the Engineering and Physical Sciences Research Council will also be used to develop smart trousers, to help disabled and older people walk and biosensors to monitor how patients use equipment or exercise during rehabilitation.
Where the data sent through such devices is not encrypted, there is greater potential for a hacker to intercept or even modify that data. The former poses a security risk, the latter a threat to human health.
Technology can provide many answers to the challenges faced by healthcare providers. It can provide new and effective treatments, where patients can be treated away from hospitals and surgeries, reduce the scope for human error and result in costs savings.
However, the increasing use of technology means that more and more data is being held by healthcare providers and the high value of that data means that they have become increasingly attractive targets for hackers.
The focus of technological development therefore needs to be as much on the security of the data obtained as on the effectiveness of the devices themselves. Whilst there have not been any reported UK data breaches involving cyber attacks against healthcare providers so far, healthcare providers should be prepared.
To answer this question, we have examined previously unpublished results from the British Social Attitudes (BSA) survey. In the 2014 surveyand in 2002, respondents were asked to rate how much they trusted NHS doctors, nurses and hospital managers to put the interests of their patients above the convenience of the hospital.
The results (see Figure 1) showed that overall, nurses were the most trusted group closely followed by doctors, with hospital managers trailing behind.
However, a closer look reveals a reduction in some levels of trust: the proportion of respondents reporting that they trusted nurses ‘just about always’ dropped from 30 per cent in 2002 to 21 per cent in 2014. Statistical testing suggests this is a true reduction, and not due to chance variation in the survey.
It is important to note that the available data does not give a picture of any fluctuation in levels of trust between 2002 and 2014 and that there are many factors that may have affected trust in nurses. That said, if this is a sustained drop in trust, it may be the case that public scandals involving nurses could be a potential contributing factor, for example, the public outcry and extensive media coverage surrounding the quality of care at Mid Staffordshire NHS Foundation Trust and the subsequent findings of the Francis Inquiry, which began in 2010 and published its final report in February 2013.
By contrast, public trust in doctors remained broadly unchanged and encouragingly, trust in NHS hospital managers improved. The proportion of respondents reporting that they trusted managers ‘just about always’ or ‘most of the time’ increased from 21 per cent in 2002 to 29 per cent in 2014.
Who trusts doctors and nurses?
People who have had recent contact with NHS services (defined as personal contact with inpatient or outpatient services in the past 12 months) were more likely to trust NHS doctors and nurses ‘just about always’ than those who had not (20 per cent compared to 11 per cent for doctors, and 25 per cent compared to 13 per cent for nurses). Recent personal contact did not appear to affect trust in NHS hospital managers.
This difference may reflect genuine relationships of trust built between individuals and the doctors and nurses who care for them, but also perhaps a degree of gratitude for the care that individuals have received. The difference may also be partially driven by negative media reporting having a greater influence over the views of those with no recent personal contact.
Trust also appears to be related to age: older respondents were more likely to trust doctors and nurses ‘just about always’ than younger respondents (see Figure 2). This is perhaps partly because older groups were more likely to have had recent contact with health services, or it may reflect generational differences in attitudes and expectations regarding ‘professional’ status.
The BSA survey also asked about trust in well-known institutions, including parliament, government and the media; when asked whether they tended to trust these institutions, just 1 per cent responded that they trusted the media a great deal, 2 per cent trusted government a great deal and 3 per cent trusted parliament a great deal. Although the questions were phrased differently, they provide an insight into the different levels of trust that the public places in doctors and nurses compared to those working in other sectors. By comparison to other groups, doctors and nurses appear to enjoy a high and enduring level of public trust.
These findings are supported by the results of surveys by other organisations: Ipsos MORI’s latest polling found that doctors were the most trusted profession, with 90 per cent of respondents trusting them to tell the truth. In contrast, just 16 per cent of respondents trusted politicians and 22 per cent trusted journalists to do likewise. This poll showed that trust in doctors has been consistently high while trust in politicians has been consistently low for the past 30 years.
These insights into public opinion may be relevant to the current high-profile dispute between government and the medical profession over doctors’ contracts and seven-day working. Who will the public support? Will this make a difference to the outcomes of the debates? Both sides are now negotiating a new agreement following talks supported by the Advisory, Conciliation and Arbitration Service. But while the industrial action planned for earlier this month has been postponed, there remains a possibility of future strikes if a prompt resolution is not reached. Might this cause erosion of public trust in doctors, which has, until now, been so steadfast? Or will public favour stretch to supporting doctors over strike action?
The British Social Attitudes survey is conducted annually by NatCen. The King’s Fund funds questions relating to health, and reports on these each year.
The BMA has marched its junior doctors up to the top of the hill, and marched them down again. The manoeuvre appears to have scared the Secretary of State for Health enough to make him back down on imposing a new contract for doctors in training. It has emboldened the BMA enough for it to resume the negotiations that it had broken off in October 2014. Jeremy Hunt looked tired and worn, which probably serves him right for intervening in an industrial dispute and making it worse.
On Saturday 28th November the BMA announced that, after two days of talks with the Advisory, Conciliation and Arbitration Service (ACAS), it seemed “increasingly unlikely that we will be able to avert Tuesday’s (1 December) industrial action”. Before the planned strike Dr Yannis Gourtsoyannis, of the BMA Junior Doctors Committee, described in a message to “our fellow NHS workers, trade unionists and campaigners” how the junior doctors were resisting the “imposition of a contract that we feel would jeopardize the profession, patient care and the NHS for a generation”. He signed off with the very doctorish phrase “Kind Regards”, but added the unusual (for medicine) flourish “and Solidarity”.
By Monday November 30th the BMA was able to announce that it had agreed to temporarily suspend its proposed strike action and the Department of Health had similarly agreed to temporarily suspend implementation of a contract without agreement. Time runs out for negotiations on January 13th 2016, but the negotiating period may be extended.
Calling off the strike at short notice did not necessarily avoid disruption of NHS services; thousands of outpatient appointments and planned operations had been rescheduled, but at least military doctors were not deployed.
So what was at stake in all this conflict? Three things stand out from the joint memorandum of understanding published on November 30th.
The first is that there is no more money on the table. The cost-neutral offer made by the employers in November 2015 remains the basis for further negotiation. Pay protection – a strong demand amongst Junior Doctors – will need to come from within the current budget for medical staffing, so there must be losers as well as winners amongst doctors in training. This probably means that overtime payments will decline.
The second is that part of the government’s aim was to secure safe and effective medical staffing in hospitals every day of the week. All parties in the arbitration supported the idea that the quality of care and patient outcomes (including death rates) would be the same every day of the week. Admission of ill people to hospital peaks around 4pm, and these people take four to five hours to diagnose, stabilise and transfer to wards (or operating theatres). The current contract treats work after 7pm as unsocial hours, qualifying for overtime payments. The proposed new contract aims to move the boundary for unsocial hours (on weekdays) to 10pm, so reducing the salary bill during periods of peak activity. Redesignation of Saturday between 7am and 7pm as normal working time will also reduce salary costs for those working at weekends, without reducing their working time.
The third is that the dispute is presented in very different ways to different audiences. Junior Doctor organisers, reporting on the opening rounds of negotiation to colleagues, have focussed on establishing pay protection, pay for all work done and some form of protection for academics.
These details are important to Junior Doctors but not necessarily to the rest of us. We are given the message that the Junior Doctors are saving the NHS – a clear message on demonstrators’ placards – and that the government’s desire for a new contract puts the whole NHS in jeopardy.
Here is how one BMA Divisional secretary informed his members about the reopening of negotiations.
“”….the future of the NHS is not a minor subject, and that’s what is really at stake. Doctors’ and nurses’ working conditions are central to the provision of a high standard of health care. The agenda is to further down grade us all: our Junior colleagues were only the first. We hear that changes in the Consultant’s contract are imminent. Nurses will surely follow. GPs are slightly different but are also under great pressure. All in the name of making the NHS more attractive to private bidders”.
He went on to remind readers of Edmund Burke’s saying: “The only way for Evil to flourish is for good people to do nothing”
So the conflict is not only about the potential exploitation of medical labour, but also about resisting privatisation of the health service – an evil that could flourish if this conflict over unsocial working hours is resolved in favour of the government.
This might strike some as odd. How will an argument about overtime payments (amongst other job-related concerns) lead to privatisation of an industry? Even if the connection was obvious, why does the public display of concern about privatisation appear now, deployed in support of a conflict over a contract? Why did it not appear before, say around the Health & Social Care Act, which openly proposed marketization of NHS services?
It might be tempting to see the use of a political slogan in a contract dispute as cynical opportunism. Although understandable, this would obscure what is happening even further. There is a sense that protecting doctors is protecting the NHS. The BMA has always conflated the interests of the profession with the interests of the public; what is good for the doctor is good for the patient. It has been able to do this because the logic is partially correct – try operating without a surgeon, or an anaesthetist. All other disciplines and roles – nursing, management, physiotherapy, portering, cleaning, radiography, catering and so on – are necessary to run a hospital but not sufficient to run a health service. Given what hospitals do (save lives), doctors are their lynchpins. And when we say “NHS” what we usually mean is hospitals.
The problem is that doctors want hospitals run on their terms, which are not necessarily shared by others, including NHS management. Hospital managers need to roster medical staff to meet patients’ needs, but junior doctors would like to work as few unsocial hours as possible, preferably at advantageous pay rates. It is difficult to see how this conflict of desires can be resolved within the budget currently available for medical staffing. More funding may be needed to give each side what it wants, and that will require a political fight within government.
So another round of Saving the NHS seems likely, when the quiet but difficult debates around the negotiating table give way to catastrophizing rhetoric before the TV cameras. This will be a relief to political campaigners who have been struggling to get much attention for their efforts to prevent privatisation. Labour’s attempt to play the saviour of the NHS in May 2015 was an electoral flop, and independent campaigns desperately need a shot of energy. By an irony of history this may come from the BMA, which once opposed the idea of a national health service.
Steve Iliffe 6/12/15
A free online course led by world-renowned experts at the University of Exeter will offer participants the opportunity to explore how developments in the field of genomics are transforming knowledge and treatment of conditions such as diabetes.
Genomic Medicine: Transforming Patient Care in Diabetes is the latest in the University’s series of Massive Open Online Courses (MOOCs). Registration is now open for the four week course, which introduces the topic of genomics using the University of Exeter Medical School research expertise into diabetes to illustrate the impact of current genomics knowledge and genomic testing.
The course uses the huge advances in the field of genetics that have been made in the last 10 years to illustrate how genomics can inform our understanding of disease risks for individuals, families and populations, looking at patterns of inheritance as well as genetic mutations, gene discovery and genomic sequencing.
Participants on the four week course are guided through their study by Professor Maggie Shepherd , and Dr Anna Murray and Professor Sian Ellard, lead educators and experts from the University’s genomics research group.
Lead educator on the course, Professor Sian Ellard, said: “The University of Exeter has recently celebrated 20 years of ground-breaking molecular genetics research and has been at the forefront of incredible advances in the genomics of diabetes. We are now able to use test DNA to pinpoint the precise mutation which has triggered the form of diabetes, meaning we can deliver more targeted and effective treatment. This is an incredibly fast growing area of research, as we strive to find ever more effective treatments and hopefully, a cure. The development of this course means we are able to open up the fascinating subject of genomic medicine for everyone, making the subject accessible for all.
“The course is open to anyone with an interest in how this genomic era is changing medical science, as well as individuals who just want to learn more about the future of genomic medicine. Throughout the course there will be lots of opportunity for people to debate the impact and value of genomic testing and how this can lead to improvements in clinical care”.
Elements of the course will reflect the current understanding of the strategies for genomic testing and will use patient experiences to explore the mechanisms of diabetes and the genetic diagnosis for the disease.
The online course will also introduce bioinformatics resources and techniques used to interpret the wealth of genomic data generated by the latest laboratory techniques.
The Genomic Medicine: Transforming Patient Care in Diabetes online course begins on 22 February 2016 and takes place over four weeks. Participants can register now via the Future Learn website.