The healthmatters blog; commentary, observation and review
British-based company set to save lives this winter as it reveals true cost of ignoring a flu vaccination
With UK death toll figures for flu higher than anywhere else in Europe, recent government findings suggest that flu vaccinations can reduce hospital attendance by 74% in children and 77% in the over 65s. With the ability to save 1 in 4000 lives, CFH Docmail has set its sights on encouraging more GPs to send flu vaccination reminders to vulnerable patients with its cost-effective mailing service.
Dave Broadway, MD at CFH Docmail Ltd, comments: “I believe that Docmail is a very simple solution to a potentially life-threatening issue. Saving funds within the medical sector is vitally important but, ultimately, the cost of not sending flu reminders to patients at the highest risk is far greater.”
Dealing with PFI payments needs coordinated government response, says expert
NHS trusts under the most serious financial pressures are the least likely to be able to terminate expensive private sector deals, warns an expert in The BMJ this week.
Mark Hellowell, a senior lecturer at the University of Edinburgh, says dealing with the problem of PFI payments “is likely to need a coordinated response from central government to ensure that trusts are reimbursed for their related costs.”
He describes how, in 2013, Northumbria Healthcare NHS Foundation Trust borrowed £114m from the local council to pay off private contractors who built and ran Hexham General Hospital, saving £14.3m over 25 years.
Other NHS bodies are likely to want to replicate such an approach to easing their financial pressures, but how feasible is this, asks the author?
He points to a number of potential obstacles for trusts that would like to follow this example.
Firstly, only a small number of foundation trusts have the finances to fund the large amounts required to terminate a PFI deal, he explains. Thus, trusts with the largest deficits, for whom the savings associated with termination are most important, are the least able to pursue this option.
Secondly, the Hexham termination was possible only because of a local county council’s willingness and ability to provide a loan. Given the tight financial constraints faced by local authorities in the coming years, few trusts are likely to have this option, he warns.
Thirdly, the termination fee may be so high that any savings would be negligible or even non-existent. For some trusts, he says, securing financing on such a scale may not be financially feasible.
If contract termination is not the answer to ending the financial pressures created by PFI schemes, then what is? He believes the simplest and most effective response is to adjust the payments made to trusts by commissioners to ensure that they are adequately compensated for their costs, including capital costs.
He points out that private finance has been the only option for new hospitals since 1994. And while he acknowledges that mistakes were made by individual trusts in the commissioning of large scale PFI projects, “most of them had no choice but to use PFI for what were widely recognised as non-discretionary investments.”
In this context, he concludes that “failing to reimburse trusts for their capital costs seems inequitable, and in an era of unprecedented spending controls this has the potential to compromise patient care.”
Higher trans fat intake associated with 20-30% increased risk, say researchers
Saturated fats are not associated with an increased risk of death, heart disease, stroke, or type 2 diabetes, finds a study published in The BMJ this week. However, the findings show that trans fats are associated with greater risk of death and coronary heart disease.
The study confirms previous suggestions that industrially produced trans fats might increase the risk of coronary heart disease and calls for a careful review of dietary guidelines for these nutrients.
Guidelines currently recommend that saturated fats are limited to less than 10%, and trans fats to less than 1% of energy to reduce risk of heart disease and stroke.
Saturated fats come mainly from animal products, such as butter, cows’ milk, meat, salmon and egg yolks, and some plant products such as chocolate and palm oils. Trans unsaturated fats (trans fats) are mainly produced industrially from plant oils (a process known as hydrogenation) for use in margarine, snack foods and packaged baked goods.
Contrary to prevailing dietary advice, a recent evidence review found no excess cardiovascular risk associated with intake of saturated fat. In contrast, research suggests that industrial trans fats may increase the risk of coronary heart disease.
To help clarify these controversies, researchers in Canada analysed the results of observational studies assessing the association between saturated and/or trans fats and health outcomes in adults.
Study design and quality were taken into account to minimise bias, and the certainty of associations were assessed using a recognised scoring method.
The team found no clear association between higher intake of saturated fats and all cause mortality, coronary heart disease (CHD), cardiovascular disease (CVD), ischemic stroke or type 2 diabetes, but could not, with confidence, rule out increased risk for CHD death. They did not find evidence that diets higher in saturated fat reduce cardiovascular risk.
However, consumption of industrial trans fats was associated with a 34% increase in all cause mortality, a 28% increased risk of CHD mortality, and a 21% increase in the risk of CHD.
Inconsistencies in the included studies meant that the researchers could not confirm an association between trans fats and type 2 diabetes. And they found no clear association between trans fats and ischemic stroke.
The researchers point out that the certainty of associations between saturated fat and all outcomes was “very low,” which means that further research is very likely to have an important impact on our understanding of the association of saturated fats with disease. The certainty of associations of trans fat with CHD outcomes was “moderate” and “very low” to “low” for other associations.
They also stress that their results are based on observational studies, so no definitive conclusions can be drawn about cause and effect. However, they say their analysis “confirms the findings of five previous systematic reviews of saturated and trans fats and CHD.”
And they conclude that dietary guidelines for saturated and trans fatty acids “must carefully consider the effect of replacement nutrients.”
It is probably no longer plausible to claim we have 48 hours, one week or one election to save the NHS, but it does feel that in some sense we are at a significant juncture in thinking about the care system; a time for a fundamental rethink.
There are some things we don’t need to think about too much. There are some obvious fixtures that all but those on the fringes would agree on.
- Our healthcare service should be free at the point of need and funded predominantly through (progressive) taxation. (A big genuine question is why we think of social care differently.)
- We have a well-developed and mostly effective system of public provision of health care and there is limited scope and no economic rationality for its replacement by private organisations or for market competition being artificially introduced.
- Where decisions are made about health care resource allocation and priority setting then this must be through arrangements that are open and transparent and those making the decisions should be accountable through our established democratic structures.
- Care providing bodies which are publicly funded must be open and transparent in their decision making and must engage and consult with those who may be affected before making significant decisions.
- Patients have the right to involvement in their care and communities have the right to be involved in decisions about care services that affect them.
But even given a pretty wide area of general agreement in principle there is limited progress on making real all but the first bullet point.
But within the broad tent of agreement we are still faced with the need for a coherent answer to a few basic questions.
Should we have an NHS at all?
Why don’t we have a National Care Service alongside a National Education Service, and a National Housing Service? Why is remedial health care different? What glues health care into the rest of public services?
Is it really National, there are lots of local variations so what does the N mean?
What bits of our health does the H cover? Not public health.
Is it really a service or should the S now be for system?
What is the NHS for?
Mostly the NHS is thought to be for fixing illness. But maybe we want a wellbeing service which deals better with prevention and with broader care needs, with learning disabilities, with mental as well as physical health.
If the NHS as a major public body should it be an exemplar around good practice and should its contribution to public value be developed?
What is the NHS?
Most of the NHS is understood to be publicly delivered (through NHS Trusts and GP Practices), but much of it is not and never has been. Is the NHS made up of all bodies and organisations that deliver health services paid for by the state? Why are GP Practices which are bound to the NHS through contracts different from private organisations linked by the same (or very similar) contractual arrangements?
Is the planning/commissioning function part of the NHS? If it moved from CCGs to Health and Wellbeing Boards or was shared, is it in or out?
What are the boundaries of the NHS?
For historical but illogical reasons we have an entirely separate system for social care which is means tested and organised through local authorities and which is almost entirely privatised in terms of provision. But over time the boundary between the NHS and the rest of care is constantly moving – services that were free become means tested. Public Health is no longer within the NHS.
Does it matter? These are questions that don’t get discussed as even asking them tends to make some people cross. However it really is the time to think much more fundamentally about the NHS for two different sets of reasons.
First we are about to enter a new era. The NHS has always been separate in some sense – the fight to bring it firmly into the family of public services organised through local authorities was lost. In very general terms we had 4 decades of the initial Bevanite model for the NHS. This had some overall coherence as regards dealing with acute illness but was weak in terms of dealing with long term illness, had limited management, no real accountability, no public and patient involvement and poor and unequal access. It was probably inefficient in the way it allocated resources but we have no way of knowing as it was weak in terms of data and information.
We then had the era from the 1990’s which introduced both managerialism and marketisation, pretty well mixed up. It still left a separate NHS remote from other public service. It shifted the paradigm away from professionals and towards managers and (maybe) patients. Access and efficiency improved, regulation and public and patient involvement were introduced, planning (commissioning) was split from provision. This culminated in the Lansley proposals which were the first bold step towards an NHS that was a regulated market, with improvement driven through competition amongst providers and which opened the way to alternatives for funding and for a switch to an insurance system.
It is pretty clear the H&SC Act which emerged as a watered down and less coherent version of the Lansley ideas is not being implemented as conceived. All the evidence shows competition and commissioning does not really work and so the era of markets has ended. The Five Year Forward View which appears to be the current strategy for the NHS does not remove the market infrastructure it just ignores it.
The second set of reasons flows from the impartial analysis of what needs to be done? (Something must be done, this is something.) What is it that needs fixing? The recognised big issues are:-
- The NHS contributes very little directly to improving health (other than in the obvious sense of fixing illness) or to reducing health inequalities.
- The NHS has major unjustified variations in terms of quality, efficiency and outcomes generally. Variations in quality occur even within the same organisation.
- The professions and NHS managers are poorly adapted to the need for shared decisions making and for public and patient involvement.
- The cost of care rises faster than GDP growth and the tensions this creates are unresolved.
- We have an unstable system with no real strategic direction either nationally or locally. We have no idea around levels of funding even in the short term. We have poor management as many good managers have gone and there are too many organisations to supply good managers to them all.
- There is a growing realisation that organisational changes as such and especially major top down reorganisations of the whole system don’t work. There is also an understanding that stability is important. So how is change brought about?
Anyway that is a long way of saying that before we launch another reorganisation or another 10 year plan or a five year view or even a new party policy position there needs to be some new thinking and some new answers to the most basic questions.
44% of doctors wouldn’t recommend their profession to others, says new research. Increasing cost of education and lack of financial incentives will put off future generations
As a new intake of doctors prepares to start work this week, new research from Wesleyan, the specialist financial services provider for doctors, reveals that an increasing number of those already working in the profession would not recommend their career to family members and friends.
In sharp contrast to findings a year ago, 44% of doctors said they would not recommend their profession, compared with 30% in 2014.
However doctors are still more likely to recommend their career than other professionals. Wesleyan’s research highlights that over half (55%) of teachers would not recommend a career in the classroom while 50% of dentists and 48% of lawyers take the same view of their own profession.
The number of doctors who would not choose the same career if they could start again has also risen to a third (33%) compared with 25% in 2014. Increased workload and stress were cited as the main factors for this.
More than nine out of ten (95%) doctors said increased pressure caused by ongoing changes in the profession was a major cause of concern, with more than half (56%) of those saying they felt permanently under pressure.
When asked what they were most concerned about over the next five years, NHS funding emerged as the biggest worry for more than half (51%). Changes to the NHS Pension Scheme and the possible privatisation of the NHS were also highlighted as major issues by just under two fifths (39%) while 13% raised concerns over consolidation of services in the NHS.
Three quarters of doctors felt that the increasing cost of education and training, along with changes to pay and conditions, will mean future generations will be put off entering the profession.
Mr Martin Bircher, a Consultant Orthopaedic surgeon and Member of Wesleyan’s Advisory Board, said: “The planned changes to the NHS, such as the new NHS 7-day service contracts for both Hospital Doctors and GPs, do have some merits in terms of the potential to improve patient care. However, there will inevitably be significant resource issues and they appear unlikely to ease the already heavy demands placed on medical professionals.
“Despite these challenges, being a doctor remains a hugely rewarding profession. A desire to care for others is what makes people want to become a doctor and being able to put this into practice every day is a privilege. That is why the majority of doctors in this survey say they would choose the same career again if they were at the beginning of their professional life.”
Alan Whiting, Wesleyan Group Head of Marketing, said: “Our medical customers tell us that they are facing huge change in their professional lives, which is causing them uncertainty and stress, and this is supported by this new research.
“Doctors are also being hit financially; they have seen a drop in income in real terms as pay rises fail to keep pace with inflation. In addition, changes to the NHS Pension Scheme mean they are paying more to retire later and on less income. Then there are the pension tax changes which are hitting doctors at the latter stages of their career.
“While the majority say they would become doctors again and would recommend it to others, the fact more have become disaffected shows the profession could become less attractive to new entrants.
“As a specialist provider of financial advice for doctors, Wesleyan can help them plan their finances and make the most of their money. We also understand the wider professional issues that can impact their career path and their future earning income.”
Wesleyan is a mutual financial services provider for medical professionals.
Christie + Co review commentary from industry leaders following its evaluation of the state of the nursing workforce
In June Christie + Co, specialist property advisers, released a report ‘The UK Nursing Workforce: Crisis or Opportunity’ looking at the main issue affecting the care sector; staffing. Now, Christie + Co review the responses to the report from key players in the sector.
Key themes raised by industry leaders include:
Workforce planning: One of the key issues raised in the Christie + Co nursing report and consistently by The Royal College of Nursing (RCN) is workforce planning. At their yearly conference the RCN passed a resolution calling on the government to change their lackadaisical approach to nursing workforce planning. They also noted that particularly within England, workforce planning was devolved to local clinical commissioning groups and local education and training boards, however, Health Education England also worked on regional target setting for nursing commissions based on projections for future demand. The concern raised by the RCN was that workforce planning was increasingly driven by affordability and not demand. The Christie + Co report stated that the shortfall of nurses was 24,000 and towards the end of June Health Education England announced that 23,121 extra nurses will be trained over the next four years to meet growing demand.
Staff turnover: The nursing report highlighted that as pressure on the aging workforce, from an aging population, continues, we will see a significant number of nurses leaving the profession. It also highlighted that the drop-out rate from nursing courses was 20%. A recent report by the National Care Forum highlighted the correlation of staff turnover to salary level, with the greater turnover amongst those paid lower salaries; the issue of funding and what operators are able to pay remains a key issue.
Shortage occupation list: In the nursing report care home operators discussed the shortage occupation list and it was also highlighted in House of Lords debate. There are continuing questions as to why nursing was not added to the list. It is clear that without foreign nurses the shortfall would be even more extreme and the announcement that foreign workers earning under £35,000 will be deported has been widely condemned.
Career pathway: Andrea Sutcliffe, Chief Inspector of Adult Social Care at the Care Quality Commission, at the Westminster Health Forum on Elderly Care recognised the need for upskilling care assistants and creating a clear career pathway for care assistants, so they can become skilled in some of the roles that are traditionally being delivered by fully qualified nurses, with the appropriate support and supervision from nursing staff. A key factor raised in the House of Lords debate was how to entice young people into the care profession, particularly taking into account that demand in the area will increase dramatically in the coming years. Care home operators, including HC One and Barchester who were both interviewed for the nursing report, are looking at solutions to bridge the gap between care assistant and nurse, through upskilling care assistants.
2015 Budget: The budget announcement of a new living wage will bring new challenges for the industry and put a number of operators in an unsustainable financial position in the absence of compensatory fee rate increases. The new living wage is likely to have a significant negative impact with this further demonstrating why local authority fee rates need to be set at a level which covers the true cost of providing care. It remains to be seen if additional funding will be provided and we urge all stakeholders to consider carefully the ramifications of implementing the new living wage without this compensatory realignment of fee rate levels.
Michael Hodges, Director of Healthcare Consultancy at Christie + Co comments: “We have seen positive inroads on a variety of the key themes raised in our report and there does seem to be a genuine push from many industry parties to work together to find solutions. However, this week’s budget also clearly shows why a fully joined up approach is needed around the issues of care home funding, staffing and workforce planning.”
Download ‘The UK Nursing Workforce: Crisis or Opportunity’ report here:
FRANCIS CRICK INSTITUTE and UCL Cancer Institute scientists, funded by Cancer Research UK, the Academy of Medical Sciences and the National Institute for Health Research, have shown how the level of genetic chaos in tumours could help predict patients’ response to chemotherapy according to research published in Cancer Discovery today (Tuesday).
The scientists analysed several tumour samples taken from eight different oesophageal cancer patients before and after chemotherapy. For each tumour, they assessed whether particular genetic faults were present in all the samples from each patient, or in only a proportion of them.
They found that most tumours were made up of a patchwork of faults. The more complicated this patchwork and the greater the genetic differences within each tumour, the more aggressive the tumour and the less likely it was to respond well to cisplatin – a drug commonly used to treat oesophageal cancer.
Importantly, the cells within these more aggressive tumours were also prone to picking up additional faults following cisplatin exposure, suggesting that the chemotherapy itself was driving new mutations and genetic chaos in drug resistant tumours.
This knowledge could one day be used to identify groups of patients with more aggressive tumours that would benefit from different approaches, such as earlier surgery or combinations of ‘smart drugs’ that target specific faulty molecules within tumours.
Study leader Professor Charles Swanton from the UCL Cancer Institute and Francis Crick Institute, said: “Studies like this are edging us closer to being able to predict cancer’s ‘next move’, hopefully leading to sophisticated new treatment combinations that will outsmart the disease before it can really take hold. This will be particularly crucial for hard-to-treat cancers like oesophageal cancer, which has seen disappointingly little improvement in survival in recent decades.”
Dr Kat Arney, Cancer Research UK’s science information manager, said: “Oesophageal cancer claims nearly 8,000 lives every year and more than half of all patients die within twelve months of diagnosis, so we’re urgently investing in more research to understand the disease, detect it earlier and treat it more effectively. By understanding the genetic chaos that lies at the heart of these tumours, we hope to make a real difference to this stark statistic and keep many more families together for longer.”
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Latest figures show 23,000 deaths from cardiovascular disease (CVD) could be prevented if people with mental health problems had the same outcomes as the general population.
The British Heart Foundation (BHF) is calling for integrated care to be made a priority for NHS services, to reduce this shocking number of deaths resulting from current, disparate services. It is also committing to offer more support in helping those living with mental health conditions to improve their physical health through new resources, its Heart Helpline and alliance of healthcare professionals.
People with serious mental illness die, on average, 20 years earlier than the general population – a life expectancy similar to the 1950s. This is often because behaviours which increase the risk of cardiovascular disease, including an unhealthy diet, smoking, excess alcohol and lack of exercise are more prevalent amongst people with mental illness. Weight gain is also a common side effect of several drugs used to treat various mental illnesses.
The charity say scope to improve the physical health of people living with mental illness is vast, as 11 million people in the UK experience mental health problems and 5.5 million live with a common mental disorder2. With these patients twice as likely to develop diabetes and three times more likely to die from heart disease3, the BHF wants to see a transformation to ‘person centered’ care which will improve treatment and save lives.
Dr Mike Knapton, Associate Medical Director for the BHF, said: “Too many lives are needlessly lost because of historic attitudes towards treating mental health problems. There are huge links between mental and physical health and we need to put an end to the view that the body and mind are two entirely separate entities.
It is essential that we adopt a holistic approach to treatment and offer patients the support and resources to make them more aware of their health risks. The BHF’s new booklet, ‘Everyday Triumphs’, helps people living with mental health conditions make small lifestyle changes to ensure a healthier heart.”
To improve these shocking mortality rates the BHF is urging key decision makers to address the disconnect between physical care and mental health services.
The Everyday Triumphs booklet can be given to patients by GPs and mental health professionals as part of the care they are giving patients.
For more information on this visit: bhf.org.uk/triumphs
Indian advocacy group urges Woody Allen to accept display of anti-smoking messages across latest film
A New Delhi advocacy group that provides health information to young people has written to the Hollywood director, Woody Allen, urging him to release his latest film, Blue Jasmine, in India. Allen recently pulled the film from the country’s cinemas because India’s anti-tobacco laws require a static anti-smoking warning to appear on screen whenever a character lights up.
India’s Cigarettes and Other Tobacco Products Amendment Rules 2012, which came into effect in September last year, state that cinemas must run a health warning at the bottom of the screen every time a character uses a tobacco product. The rules also require cinemas to run anti-tobacco advertisements at the beginning of the film and halfway through.
A 2011 study published in Tobacco Control found that adolescents who had high levels of exposure to smoking in films were twice as likely to try a tobacco product in their lifetime as teenagers who had little exposure.
Several Hollywood films released in the past year were shown in compliance with the new law and fared well at the box office.
KK Aggarwal, a doctor and anti-smoking campaigner, said that warning messages were important and acted as a deterrent.
BMJ 2013; 347:f364
Editorial comment: An interesting development in India. Perhaps one that we should follow in this country. Paul Walker