The healthmatters blog; commentary, observation and review
People in the UK are underestimating the cost of elderly care by £7bn[i] every year, according to research from Scottish Widows’ independent think tank, the Centre for the Modern Family. On average, UK adults estimate that residential care would cost £549 a week – when in reality it costs on average £866 for a place in a nursing home – leaving a shortfall of £317 every week[ii].
More worryingly, the deficit could be significantly higher in reality, since one in four (25%) people admit they have no idea how they would cover these costs for themselves or a relative. Only 15% of people are saving money on a monthly basis to pay for their own care when the time comes, and almost half (49%) say they avoid thinking about the issue because it makes them feel stressed. With an ageing population and growing care costs, the nation could be facing a care funding crisis.
Families footing the bill
Instead, half (49%) of UK adults say they will have to rely on a relative to help them cover the costs. This could leave families in a difficult financial situation, particularly as more than four in ten (42%) people have £2,000 or less in life savings to fall back on, meaning they could only cover the cost of care for a maximum of two-and-a-half weeks.
Half (50%) of UK adults believe the responsibility of helping parents to pay for care should be shared between siblings. However, almost half (48%) of those over the age of 55 still haven’t discussed who will take on this responsibility in their family. With more than nine out of ten (92%) people not saving anything to help their parents or other older relatives, this could lead to a significant shortfall in support, particularly as people estimate they could only afford to spend £69 a week on care for their parents.
A lack of understanding of the benefits system could also be problematic for many. Almost one in four people (24%) claim they would need, or expect, to rely entirely on state support, but two in five (42%) admit they don’t actually understand what benefits – both practical and financial – they would be entitled to.
An over-reliance on relatives to provide financial support already has a significant impact on families. Almost one quarter (23%) of those caring for a family member say it has put a strain on their finances. One in ten (12%) have been forced to make sacrifices to cover the cost of care for themselves or a relative, with a quarter (24%) of those people making major adjustments such as re-mortgaging their house. A similar proportion (22%) have been forced to make a moderate sacrifice such as taking on a second job to cover the costs.
Supporting relatives practically and financially also puts emotional strain on families. Of those providing care, four in five (80%) say it has had an effect on them, with more than a quarter (27%) admitting it has put a strain on their close relationships. Although women are more likely to say they have less time to themselves (48%) than men (34%) when caring for a relative, men (30%) are more likely to feel their family relationships have been impacted than women (23%).
Jane Curtis, Chair of the Centre for the Modern Family and non-exec director of Lloyds Banking Group Insurance, said: “The number of people in care in the UK will almost double by 2035. Our research shows that an over-reliance on relatives and the state could put families in serious financial difficulty. It can seem difficult to know how to prepare for the future, but to avoid a financial care crisis we all need to have an honest discussion on later life care as early as possible so no one is left footing a bill they can’t afford.
“As for state provision, it’s clear that many people simply don’t understand the social care benefits and support system. Providing clarity and raising awareness of what is and isn’t available is critical to helping people prepare for the longer-term future.”
i) We calculated based on underestimated price of residential nursing care per week (£317) (£866-£549) multiplied by current number of UK over-65s in care (421,100 according to the latest Laing & Buisson and detailed in Age UK’s ‘Later Life in the UK, August 2017’ report) including with nursing and multiplied by 52.
[ii] According to regional cost figures from Laing & Buisson Care of Older People, including England, Wales, Northern Ireland and Scotland:
|Adult population||Cost of care home with nursing per week||Amount spent in total||Percentage of national spend|
|All of UK||51,767,000||£866||£44,830,222,000||100%|
|Yorkshire and Humberside||4,270,777||£755||£3,224,437,013||8.25%|
A Newcastle University study claims that rapidly rising numbers of older people with substantial care needs will create a requirement for 71,000 extra care home places by 2025. The research – Is late-life dependency increasing or not?- was published in the Lancet on 15th August 2017
The study raises concerns about how the new places will be paid for and estimates that within four years £940 million will be required for social care in England. “If dependency prevalence remains constant, we estimate that by 2025 there will be an additional 353,000 older people with substantial care needs,” according to the project leader, Professor Carol Jagger. “While many of these people will live in the community, at current rates of provision this will mean a shortfall of more than 71,000 care home places by 2025. Our findings have considerable implications for relatives as older people will have complex needs, requiring sustained input from family carers or social care teams to support independent living.”
The number of years spent with substantial care needs for adults aged over 65 nearly doubled between 1991 and 2011, increasing from 1.1 to 2.4 years for men, and from 1.6 to 3 years for women. Sir Andrew Dilnot, a leading economist who led a government-commissioned review of social care funding, said spending on the care of older people would need to “increase substantially and quickly, although this increase does not mean that every individual will need large amounts of care.”
Commenting on the study, Nick Sanderson, CEO of Audley Retirement, said: “Britain’s ageing population brings with it significant societal challenges. High amongst the worries faced by this group is the question of later life living and the possibility of needing care. Both the NHS and local authorities are struggling to cope with the mounting pressure and traditional care packages are coming under increasing strain. Many people would ultimately prefer to remain at home as they age so it’s crucial we facilitate the development of housing that allows them to do this. High quality retirement properties with care available as and when required prepares people for changes to their health whilst enabling them to maintain their independence. There may be no simple answer to how we deal with the creaking care system, but we know the retirement village model is one that works, and we have a responsibility to drive that forward.”
It’s been a tough few weeks for the NHS, criticised over its legacy IT systems, alleged weakness to cyber-attacks and constantly under scrutiny for its spending and investment decisions. Yet, even with these high profile challenges in mind, no-one can deny it’s one of the UK’s most treasured and relied-on organisations. Our National Health Service plays a vital role in the nation’s health by providing free critical care to all regardless of background or income, even though its doctors and nurses face major budget and resourcing constraints each and every day.
The organisation is under major pressure to improve the quality of its services and financial management, even against a backdrop of financial constraints. Even with stretched budgets and challenging economic conditions, the NHS must make further investments in digital transformation programmes in order to deliver a fully rounded quality patient service and cut growing costs.
A House of Lords committee recently backed the Government to make technology uptake an ‘urgent priority’. As an organisation delivering vital services on a national scale, the NHS has already seen pockets of benefits from investments in bold initiatives to improve diagnoses and treatments, such as big data analytics, artificial intelligence (AI) and the Internet of Things (IoT). However, the pace of IT adoption across the health service has varied from trust to trust, and even across departments within trusts, which means achieving consistency across the country has long been a challenge.
With that in mind, this feature will investigate how the NHS can improve patient care through technology without compromising its values as an organisation that’s free and open to all. Additionally, I’ll take a look at what a truly digital NHS could look like and how this would improve patient services in terms of accessibility, availability and engagement with treatment plans and wider services.
Building a multi-channel health service
There are already ambitious plans in place for improving the NHS through the use of smarter IT and increased access to technology. The government has also initiated its policy to make the service ‘paperless’ by 2020, ensuring all documents are digital to improve the flow and consistency of patient information.
It was also recently announced that the NHS was investing in a new AI-powered ‘chat-bot’ service to provide support and information for mothers. This interactive resource will provide 24/7 access to approved guidance around breastfeeding, reducing the time spent on phone lines and relieving pressure on the health service, whilst ensuring mothers are given the information they need.
As some of you may already know, the first few months of parenting are typically awash with anxiety, late night trips to the hospital or frantic phone calls asking for advice and guidance. This rush for information – from breastfeeding advice to treating colic – is never ending and can require 24-hour support.
Of course, nobody wants to be making regular trips to the local hospital, so this chat-bot service provides a digital-first solution with advice, guidance and reassurance at a user’s fingertips. This new service provides cost-effective around the clock support, while also preventing unnecessary hospital visits and reducing waiting times on inbound calls into the NHS helplines.
Driving NHS IT forward
Recent research from Nuance also revealed that nearly half of NHS Trusts (43%) are investing in artificial intelligence (AI) technology, to enable patients to ‘self-help’ when accessing services. This new data, obtained under the Freedom of Information (FoI) Act, revealed that many NHS Trusts are considering harnessing technology – such as virtual assistants, speech recognition technology and chat-bots – to ease the pressure on healthcare workers across their organisations.
The research also revealed a developing approach to mobility. Nearly half (47%) of trusts now permit staff to work ‘on the go’ using mobile devices to more efficiently complete tasks such as developing patient records, saving those working in the community valuable travel time and expense.
An intelligent future
AI and chat-bots are clearly the latest buzzwords in the technology industry, but for the NHS, the power of these technologies could mean much more than just implementing ‘gimmicky’ new tools at a reduced cost. This technology has the potential to transform the wider NHS, supporting patients to self-help, as well as helping doctors with suggested diagnoses or long-term care proposals.
We are in an age in which citizens, customers and patients are all seeking the ability to self-help, to self-diagnose and to self-determine. Our NHS can meet these objectives by investing in intelligent technology that not only saves doctors, nurses and healthcare professionals vital time, but that also truly puts patients in the driving seat when considering their health and overall wellbeing.
Frederik Brabant, MD, Chief Medical Information Officer at Nuance
Due to people beginning to live longer in Britain, their health needs become more specific, meaning they need a certain type of care that will guarantee they live the best life possible. What this means, is that care homes need to use greater amounts of, and more intelligent, assistive technologies.
Greater living environments will need to be created for patients who need long-term care. This will ensure that patients are cared for appropriately when those in care require increasing amounts of supervision and attention.
Focusing on quality
Quality of care homes will be the new focus of those that are funded privately and through social care within the next 20 years. This is because it has been suggested that this strategy has the potential for people to ‘live healthier and longer lives’, as Jane Ashcroft suggested in the Silver Chic report in the future of care homes.
Design of care homes will remain important. For example, to help residents to be exposed to sunlight for the longest periods of time possible. As well as this, connectivity will also be a priority to help combat loneliness. To do this, care villages will use small bridges intersecting various gardens so that residents will closer to both their natural environment and other residents within the community.
Evolution of technology in our care homes
Royal Blind – specialists in care homes for the blind and care homes in Paisley – has assessed how care homes will be run in the future, and the technologies that will revolutionise the way people are cared for.
Technology is becoming more advanced as quality within our care homes becomes a priority. It is helping to ensure that patients remain safe within care homes while allowing them to live longer, healthier lives.
To help those living with dementia, clusters within buildings can be coloured variously with different lighting so that they are able to recognise their own living quarters. These types of technologies then, are specifically designed to ensure patient comfort, and help to guarantee their safety while living in care. Also care homes are now beginning to utilise sensors in rooms and systems within the building that alert staff when a patient has fallen, or when they have stopped moving.
Independence within the care home
To ensure that people within the care system feel independent, technology that is continuously improving will help residents live in a more self-sufficient way and will help with their specific needs.
Current technology can help monitor steps taken and the distanced travelled, as well as the heart rate of a patient. In the future, they will help to monitor fluid retention and respiratory rates, helping to lower hospital admissions, allowing patients to understand their own symptoms more effectively before they require medical assistance.
Robotics in care
Robotics will help calm down dementia sufferers who have to deal with extreme stress, used through robotic pets that can respond to human touch and respond in intelligent way.
Robots will be used to carry out general tasks that need to be carried our daily, whereas wearable robotic suits will help patients who suffer from arthritis to stand and walk. Giving them a better quality of life within the care system.
To make life easier, tasks that might be difficult will all be robotically controlled. Controlled curtains alongside voice commands that also control lights and other devices will be used to help those who are blind and have visual impairments. Care homes will be improving for both patients, their family and the staff that work within the home. The technologies that are already being utilised, and the systems that are being proposed, will help patients lead more independent and comfortable lives so that they can live a happier and healthier life for longer.
For many midwives working on the front line, the latest figures revealing that maternity wards in England were forced to close 382 times in 2016 will come as no surprise. During the 33 years that I was a midwife, sadly, I also saw many maternity units close and it’s extremely worrying to see that it’s still happening. A closed unit is a very busy unit and for both the pregnant women in the ward and the nurses, it can be an extremely stressful time. Once a ward is closed, many pregnant women can be pulled from pillar to post and forced to go to alternative hospitals, which can cause added stress at a time that is already quite daunting for them. This uncertainty around where mothers will be able to give birth is leaving some in fear that they could be caught out, and won’t have the time to reach the nearest ward that is open.
Women need to know they are in safe hands when they are giving birth. But to arrive at their maternity unit to find it is too busy and they have to be turned away disrupts the whole ethos of antenatal care. The point of antenatal care is to provide woman with the knowledge and ability to be calm and in control when their labour starts – yet for some, the calm birth they have been promised is not mirrored in the services provided when a unit is closed or is short of staff. In the serious cases we’ve seen at Fletchers Solicitors, women have been left in labour for lengthy periods of time without a midwife with them, or the midwife has been expected to care for two women at the same time. There have also been instances where women have had to wait to be induced as staff were not available to start the procedure.
But perhaps the most concerning consequence of the staff shortages has been delays in operations taking place. We recently handled a case where a client was left waiting for a tear to be repaired for three and a half hours following a traumatic birth. As a result, she suffered excessive blood loss and needed an urgent blood transfusion. From these figures, it’s clear that our maternity services are suffering a severe staffing crisis. We are now at a crucial point where staffing and capacity issues must be addressed as a matter of urgency to improve the safety of maternity services. We must work to prevent more women from being turned away from the hospital where they had planned to give birth. It’s up to the Government to start investing in the future of our NHS to alleviate the pressures on already overworked staff, otherwise resources are only going to become more stretched and unsustainable.
Carline Ashton, in-house midwife at Fletchers Solicitor
The state health service (NHS) in Britain has been a huge success fulfilling the vision of its founders; it has freed the poor from the fear of illness, provided assured careers for its staff, coped with demographic change, an information revolution, the rise of new and professional management and technological innovation. It remains free at the point of use, funded from general taxation, free from market imperatives and part of the fabric of the welfare state.
In 2018 it will have been in existence 70 years, most people in Britain have no pre-NHS experience. It is taken for granted, “We contribute according to our means and receive according to our needs” regardless of age, race, gender or social class.
In 1959 I entered Medical School and retired in 2015. I have worked in the NHS as a hospital doctor, a principal in general practice, a Director of Public Health, an Academic in Social Medicine & Public Health and for some nine years in Africa and Papua New Guinea as a clinician and academic; I have worked for locum agencies and done private practice. I have been a Manager and taught management skills. There has been involvement with NICE, the BMA, the RCGP, the IBS and the Faculty of Public Health. I believe that the NHS, with some reforms and a new model has an even more important role in the future.
The present model of the NHS is outdated, inefficient and often inappropriate- what follows is a personal vision for the future of the service over the next 25 years. This model is sustainable, evidence based, effective, caring and would deliver real health gain for the people of Britain within a reasonable envelope of time and money
50-70% of doctors’ workload should be performed by clinical practitioners/ medical assistants/ nurse practitioners. We need 50% fewer doctors, differently trained.
Clinicians e.g. Nurse practitioners can be trained in three years or less; they are less costly to train and employ, they are more likely to remain attached to a particular work site over time; their clinical care is more conservative and less costly than doctors (use of investigations, prescriptions).Their career aspirations are different, they are often content to remain at this professional grade for a working lifetime, competent and experienced..
Many medical procedures can be performed by non-doctors without impairing the outcome achieved. A clinical practitioner can be taught a complex procedure which is perfected over time e.g. Caesarean section, hernia repair, cataract removal, administration of a general anaesthetic. A good deal of health care is routine and repetitive working on well-designed algorithms. The medical skill is in determining the most appropriate management and care e.g.an operation, an investigation, and in determining a treatment plan on the basis of a presumed if tentative diagnosis.
The doctor-in primary or secondary care does not need to do the procedure him/her self-provided there is the expertise available. The doctor is managing, teaching and supervising a team of10+ others in the ward, the theatre or in primary care, most importantly the doctor is looking critically at workload, effectiveness and outcome, the doctor is auditing the work of the unit. (A platoon in the British Army is 25-30 soldiers; they bond together and work effectively and loyally)
A Salaried Service;
Primary Care in the 21st.century needs to be streamlined into the main health service.
The private contractor status of the GP should end and be replaced by a salaried service with training, refreshers, promotions and a definite career structure. Four or five primary care doctors (equivalent in status and paygrade to Consultants in secondary care) would co-ordinate the work of some 100 people in the care of a patient population of 25-50,000
The polyclinic model ( energy efficient, purpose built and ease of access to its population means demolition, compulsory purchase and capital investment) is best, with on-site physiotherapy, psychology, minor surgery, social work, laboratory, radiology and day beds There must be a single linked medical record, accessible, used by and updated by all the caring agencies and the patient/person. There should be visiting/linked consultation with secondary care e.g. OPD, teleconsultation, domiciliary visits.
A clinic serving 25-50,000 people would be fully staffed from 7.00 to 23.00 with consultations-booked and urgent access through the day, telephone/skype consultations, e-mail and provision of house visits as necessary, mainly performed by clinical practitioners working with a doctor lead.
Staff would work 8 hour shifts which might be staggered two hourly i.e. 7am-9am-11am-1pm-3 pm and the numbers/mix of staff determined by patient flow and workload. The service would operate daily (Sunday to Sunday) and staff would work five, eight hour shifts (40 hours) with 4 of those hours reserved for catch up ,paperwork, audit)
Out of Hours (OOH) from 11pm to 7am the clinic would be open with a small team including a doctor. OOH emergencies would be directed there with ability to perform telephone triage, advice, short term admission for observation and domiciliary visits.
Overtime and additional money for unsocial hours should be abolished. All “on-call” work should be acknowledged and paid at 50%.
All clinical staff would be contracted to be available for all shifts shared equally and a maximum 40 hour week. The overall employment package should take account of the demanding hours (salary, subsidised food, rest facilities-showers, beds, car parking working environment, crèche, and holidays) and the need to nurture the workforce, develop its skills and reward long service financially (study leave, retraining ,seniority awards at 10/15/25 years of service)
.Part-time contracts would take account of shifts offered e.g. a P/Timer available for all shifts but working a 40 hour week would have 50%of the Full/T salary. A P/T unavailable for unsocial hours working 20 hours per week would receive 10-20% less.
These agencies should be taken over and run by the state as part of the health care service;
Presently these companies are competing with one another in the market place, their main concern is to produce profits and reward shareholders. It is proposed that with a single, state agency there would be an agreed tariff of payments appropriate to the skill- type and grade of the employee, the timing and duration of employment and the administrative costs of the agency.
As it would not be a service run for profit, the fees charged would be less and the formal registration/assessment of applicants ensures standardisation and quality of locum work. Arguably with better terms and conditions for health care employees, gaps needing urgent cover and long term vacancies would be less.
An improved contract and conditions would mean that fewer staff would feel impelled to take on extra shifts for financial reasons or disillusion with working in the service.
No fault compensation is the best way of controlling and reducing the increasing sums paid out and the cost of defence premiums for workers while eliminating expensive and prolonged litigation
. The costs to the state health system are a significant part of the whole budget and yet this money is, in one sense, largely wasted.
The accusation, investigation, “trial” can take many months; it can damage the litigator and have grave consequences for the professionals involved-stress, burnout, suicide and inevitable decline in the quality of their clinical work.
A rapid investigation to determine the problem and its remedy should run in parallel with agreed financial payments available once the harm done has been assessed and its impact upon the litigator determined by a neutral arbiter.
If clinical/system error is found this can then be examined, reported and corrected without jeopardy to the clinician.
Professional bodies-GMC, GNC would still be involved and take further action if appropriate.
The Private Sector:
The role and purpose of the Private sector needs re-examination
The private sector and its use is part of the freedom of individuals-as patients or as clinicians. The private sector can set standards for quality and patient care. In this sense it can show the state service what may be accomplished, albeit, with often more resources-staff, buildings, facilities.
However there can be conflicts of interest when health workers work across both sectors. The private sector tends to “cream off” cold, standard, surgical procedures; it provides little data on its work and profit; it does not contribute to the training of staff. Its first priority is for profit and to the shareholder and it can withdraw its service at any time with no consequence to itself
These areas need to be clarified and an agreed code of conduct determined with necessary sanction if failure to comply. A strong, thriving private sector should be limited to 10%of the whole health care of the UK in any year.
A long term and flexible strategy,
The future direction of Information Technology (IT) in health is particularly difficult to predict as its applications multiply, as computing power expands and as human beings learn to use and become safe and comfortable with the digital revolution. Here change will come quickly altering the way people use the service, the response of clinicians, clinical investigation and robotic devices in human care. At the same time the system must have the ability to provide access, confidentiality and safety.
The clinical record needs to available to all clinicians involved with a person. It need to be updated in real time and patient friendly so that the patient can participate in the record and ensure its accuracy
It is suggested that to ensure continued and adequate investment, maintenance and cyber security that 0.25% of the health budget be ring fenced for this purpose.
Need, demand, fairness and transparency
A new model needs to be considered
The most difficult elements of health care to determine are need and outcome, presently the system is often managed on a mixture of demand, new technology, demographics, expediency, pragmatism and politics. There are recurrent funding crises, staff feeling ignored, ill-prepared and with little say while the media often concentrate on failures with a blame culture fuelled by high expectation and expensive, time consuming litigation.
Management decisions and the decision pathways are not transparent. They are difficult to challenge and are rarely revisited.
It is proposed that for every main specialty- i.e.
(Surgery) General Surgery, Cardiac Surgery, Orthopaedics, Obstetrics, ENT, Ophthalmology etc.
(Medicine) Sexually transmitted disease, Nephrology, Neurology, Dermatology etc.
(Mental Health) Psychiatric illness, Learning Disability etc.
(Support services) Radiology, Pathology, Microbiology, Haematology etc.
(Public health) Communicable disease control, Health Promotion etc.
That a group of key individuals (maximum 20 people) be proposed-
Consultants in specialty, Nurses, GP’s, Patient representatives, Managers of the service, Epidemiologists and Health Economists (the epidemiological and health economic methods and models would be standardised across all the groups).
The group would be chaired by an independent manager and would try to determine the real population normative needs in the next 3-5 years taking account of new technologies, evidence from clinical trials, incidence, prevalence, prevention and outcome. The aim is to recommend a “bread and butter” service to meet the needs of a UK population in the first part of the 21st.century.The key factors are ethical awareness, environmental impact and clinical/cost efficiency, effectiveness and measurable benefit e.g. DALY’s, QALY’s, morbidity and mortality
Their recommendations, once agreed could be translated into the requirements for skilled staff, equipment and buildings with the essential logistics and infrastructure to provide. The consensus which emerged would be the best estimate of population need for a population of 500,000 with concessions for age, gender, race and deprivation and the anticipated health gain. The process of discussion and reasoning would be transparent and could be challenged
All the specialties would report and a global sum established. Government would then decide how much of the GDP was available for health care and thus the percentage which could be realistically funded-possibly 60-70% at best. It would mean that every specialty was funded at 70%-cardiac surgery or learning disability. If more or less funding was available then the 70% might be raised to 75% or lowered to 65%.
Funding then in place the group would monitor the effects of this pattern of delivery by auditing agreed outcomes or proxies and to see how their estimates were appropriate.
The group would review their service every three years to reflect changing patterns of disease, socio-demographic change, and new technologies. Over several cycles the whole process would become better informed and better understanding of need and outcome emerge.
The local management responsible for the health care of 500,000people would commission on the basis of these recommendation and the provider networks would have a clear indication of longer term service development. Arguably there should be some flexibility, a leeway of 1-2% in “commissioning/providing” to take account of local factors.
Health Care in the UK needs to be rethought; it needs to be evidence based and affordable. The decisions around health need to be transparent and the reasoning open to scrutiny and challenge. The tools to achieve this are now available.
At present there is uncertainty about the real funding needs and optimal skill mix to best meet the health needs of the UK population.
Up to date information, the changing nature of clinical interaction and accurate, timely health records require a funded, safe system provided through a national, agreed and funded Information strategy.
Every member of staff needs to be developed, nurtured, and reskilled over his/her career; they must be routinely involved in contributing ideas and in planning the service
Shift work (8-12 hours) and a standard 40 hour week for all staff is recommended
The number of doctors should be reduced and new or existing Clinical grades expanded to replicate much of the work doctors do. E.g. Nurse practitioner, Physician’s Assistant.
Primary Care should become a salaried service, the independent contractor status is no longer appropriate. The service would be led by doctors and serve population hubs of 25,000 people based upon a polyclinic model
Locum agencies should be an integral part of the health service
No fault compensation would be less costly, less distressing and more effective in providing early compensation, avoiding a blame culture and learning from errors
The patient voice, interaction and perspective is essential in planning and auditing health care
A different methodology based on the epidemiology of common conditions and their management is suggested which tries to link need with outcome and uses health economics to determine costs The present tools, while not perfect are adequate and over several cycles would be improved.
. This model should be debated, refined and then trialled.
Peter Sims Saturday, 05 August 2017
Recent analysis by ACA of data held by the World Health Organization (WHO), the Organisation for Economic Co-Operation and Development and the Commonwealth Fund about the healthcare systems of G20 members reveals which countries are driving healthcare innovation and which are underperforming in certain areas. The study examines factors such as the percentage of publicly funded healthcare, the percentage of GDP spent on healthcare and the number of beds and nurses available in each country.Japan has the highest percentage of publicly funded healthcare (84%), which is significantly higher than the OECD average of 72 percent. The role of the state in providing healthcare services outstrips many other developed countries. Japan is closely followed by the UK (83%), Italy (78%), Germany (77%), and Turkey (77%).
The USA (48%) and Brazil (46%) were the two countries with the lowest figures for public finance. Brazil’s low funding could in part be down to its public health system run by Rio’s state government reaching breaking point at the end of last year after authorities admitted to a budget shortfall, which was blamed on the drop in oil revenue.
The USA is the number one country when it comes to healthcare as a percentage of GDP (17.1%) and health care spending far exceeds that of other high-income countries. Available cross-national pricing data suggests prices for healthcare are notably higher in the U.S., potentially explaining a large part of the higher health spending.
France has the second highest healthcare spend as a percentage of GDP (11.5%) and Germany the third (11.3%). Turkey and Mexico were the G20 countries with the lowest percentages (5.4%) and (6.3%). The UK was in eighth position (9.1%).
Whilst the UK has ranked well for public funding and its GDP percentage, it was less successful when it came to other areas. The UK was in the bottom five for the number of available hospital beds (261 beds per 100,000 people). The countries that ranked lower were Canada (258), South Africa (231), Brazil (229) and Mexico (152).
The UK was also in the bottom five for the number of nurses having only 300 nurses per 100,000 people. The only two countries with lower results were Turkey (248) and Mexico (244). The shortfall could be attributed to the cuts in the numbers of training places in each year under the coalition government. A recent report revealed the NHS is facing such a chronic shortage of British nurses that one in four had to be recruited from abroad in 2015.
In contrast, Japan fared particularly well in these sectors coming first place for the most hospital beds (1317 per 100,000) and third place for the number of nurses (1081 per 100,000). Other countries that performed well included Germany (fourth position for hospital beds and first position for number of nurses) and France (fifth and fourth positions).
ACA’s Director of Operations James Ware commented on its latest findings by saying:
“Our analysis reveals the UK stands out as a top performer in most categories except for healthcare outcomes, where it ranks near the bottom of results. We hope the latest G20 summit will help to accelerate addressing some of the UK’s key healthcare issues. It’s also interesting to see how well countries such as Japan and Germany fare in several categories.”
The above healthcare data was taken from the following data sets; theOrganisation for Economic Co-Operation and Development, the World Health Organisation and the Commonwealth Fund and all GDP and population figures are taken from the World Bank. The data sets are relative of 2015 which at the time of publishing is the most recent data consistently available for all countries.
The country’s chosen were representative of those selected to participate in theG20 summit, as these represent the largest global economies. However, not allcountries have been included, due to data sets not being publicly available or from a credible source.
To fairly compare certain statistics such as the number of nurses and number of hospital beds, these figures were standardised relative to the population of the given country, to show figures comparative to every 100,000 members of the given economy.
The first memoir by Henry Marsh , neurosurgeon, ( Do no Harm 2014) was received to high acclaim. His second book is a mixture of personal memoir, detailed description of the craft of neurosurgery with wider reflections on the practice of his speciality and thoughts on the NHS , to which he is passionately committed. He is also facing retirement, and his own ageing and mortality.
“I am starting all over again, but am running out of time “he writes.
He describes the internal cemetery surgeons have in their imagination, where they can revisit the patients who died, either because of surgical error or the wrong decision to proceed to operate at all.
The descriptions of micro brain surgery are fascinating –a tiny spatial misjudgement can result in catastrophe for the patient –but his reflections on the difficulty of making the decision to operate or not are just as powerful. The patient will die without an operation –but may be left with profound disability if operated on. He has difficult conversations with patients and their families and feels the burden of those decisions.
After retirement from the NHS he spends time operating in Nepal-language barriers means those conversations cannot be had, and because the patients are paying for the surgery, they insist on operations even when the outcomes will be disastrous. He describes the way a fee for service private system distorts clinical decision making. He is obviously devoted to his work, hardworking and sees his patients as people with their own lives.
However he is also arrogant, nostalgic for the days when junior doctors in training worked 80 hour weeks, resents moving from a smaller hospital( where he was left to get on as he liked,) into the large teaching hospital ,albeit with state of the art facilities. He is anti-management and scathing about systems of clinical governance. This has made him a heroic figure to some –to others, they can see that working relationships must have been very difficult. He describes a serious altercation with a nurse who refuses to go against protocol despite his instructions (luckily for him this happens just before his retirement -otherwise he almost certainly would have been disciplined.) It’s interesting that he is able to be honest about this, as the incident certainly does not show him in a good light.
He retires from the NHS angry that he is no longer completely” in charge “as the consultant. Retirement means continuing to operate in Nepal and the Ukraine, where he eventually (inevitably ?) falls out with his long standing colleague .He takes on a” retirement project”, renovating an old cottage –still being practical with his hands.
This is a mixture of a man –with a capacity for great arrogance and great humility. He has a refreshing ability for reflection –on his work, on his own impending mortality and the wider issues of euthanasia. As he describes himself with all his flaws, he does not come over as likeable. However, this is a fascinating account, well written and well worth reading.
Dr Linda Patterson Retired NHS consultant physician
Henry Marsh Admissions A life in Brain Surgery is published by Weidenfeld and Nicolson: 2017
Alzheimer’s Research UK, the UK’s leading dementia research charity, has backed a call from the Brexit Health Alliance for the government to protect patients’ interests in Brexit negotiations.
In dementia research, the UK is currently leading the way with recent statistics showing the country’s research productivity has almost doubled over six years, compared to much smaller increases in other countries. At the same time, the number of UK dementia publications that are internationally collaborative have increased. But Alzheimer’s Research UK has already outlined concerns that if this collaborative effort is threatened, momentum could be lost, leading to unnecessary delays in the search for much-needed treatments.
Dr Alison Evans, Head of Policy at Alzheimer’s Research UK, the UK’s leading dementia research charity, said:
“It’s vital that people with dementia do not lose out as we negotiate our exit from the European Union. Research offers our best hope for transforming the treatments we can offer to people with dementia, and if medical research is to continue to thrive we must protect cross-border collaborations that are helping to speed up our efforts. New breakthroughs in research must reach the people who need them quickly, and co-operation on issues such as regulation of new treatments is crucial to ensure people with dementia in the UK can benefit from advances in medicine. Alzheimer’s Research UK backs today’s call and would urge the government to ensure that these issues are firmly on the table during Brexit negotiations.”
Bulk buying has a slow start
A programme of rationalised procurement of commonplace products needed by the NHS is running behind schedule (Nick Carding HSJ 28 July 2017). The aim of the Nationally Contracted Products (NCP) programme is to reduce product and price variation by agreeing deals for a shopping list of products on behalf of all NHS Trusts with a minimal number of suppliers. Products for the NCP are identified by NHS Business Services Authority and NHS Supply Chain based on advice from a Department of Health-funded clinical evaluation team. Contracts are then awarded to suppliers after NHS-led E-auctions.
NHS Improvement forecast that 12 centrally-purchased product lines – including examination gloves, patient dry wipes, syringes, and needles – would be available by this summer. NHS Improvement (NHSI) claimed that these products account for around £100m of NHS annual expenditure, and that the NCP team anticipated savings of up to 25 per cent, subject to market circumstances. So far only two of the 12 categories have been made available – couch rolls and blunt needle products – saving the NHS about £2 million so far.
The whole process is turning out to be slower than expected, with “supplier engagement”, currency fluctuations and contract complexity getting in the way of more rapid procurement. Reading between the lines, it looks as if commercial suppliers are being cautious about NHS attempts to shape and control the market. NHSI says it will introduce another 120 products to be made available by the end of December this year, with an estimated gain of £4million.These products include toilet rolls, bedpans, double adjustable crutches, scissor clamps, surgical face masks, and trays. The NHSI spokesman said more categories of products will be rolled out as the programme continues next year, unlocking more of the targeted savings. Ominously NHSI will “contact” NHS Trusts that carry on shopping individually rather than use the NCP product catalogue.
Enter the strong
There is leadership and then there is leadership. Northern Lincolnshire and Goole Foundation Trust, which was placed in both quality and financial special measures earlier this year, is about to get a new leader( Allison Coggan, HSJ, 28 July 2017). Dr Peter Reading, who has a history of turning around struggling Trusts, is moving from Price Waterhouse Cooper to be its new chief executive. His long career as a senior manager in teaching hospitals led to a turnaround role in Doncaster and Bassetlaw Hospitals FT from 2010 to 2011 and then Peterborough and Stamford Hospitals FT from 2012 to 2014. He is said not to shirk from difficult conversations.
Meanwhile a team of leading consultants has been assembled to lead 14 national reviews aimed at improving efficiency and reducing unwarranted variation in the outcomes of NHS services (Allison Coggan, HSJ, 20 July 2017). The team will visit every Trust running services in their specialty as part of the Getting It Right First Time (GIRFYT) programme and use Trusts’ data to highlight variation and outcomes. The team will produce national reviews of each specialty with work beginning before the end of the year, at a cost of £60m. The reviews will cover: Breast surgery, Acute and general medicine, Cardiology, Respiratory medicine, Geriatric medicine, Dermatology, Neurology, Gastroenterology, Diabetes and endocrinology, Renal medicine, Anaesthetic and perioperative medicine, Hospital dentistry, Intensive and critical care, and Imaging and radiology.
Flexibility for Whom?
A report from the Institute for Public Policy Research argues that younger workers face a future employment landscape that could damage their mental health and wellbeing unless action is taken now.
As a result of the evolution of the UK labour market over the past 25 years, today’s generation of younger workers – millennials and centennials (those born during or after 1982) – risk losing out on access to permanent, secure and fulfilling work. Compared to previous generations, they are more likely to be in work characterised by contractual flexibility (including part-time work, temporary work and self-employment).
Relatedly, they are also more likely to be underemployed (and so be working fewer hours than they would like) and/or overqualified (being a graduate in a non-professional or managerial job). For some young people in part-time or temporary work (particularly where this involves being underemployed and/or overqualified), their experiences of work may be putting their mental health and wellbeing at greater risk.
New analysis reveals younger workers in part-time and temporary work are more likely to experience poorer mental health and wellbeing, while there is more of a mixed picture among those who are self-employed. Similarly, younger workers who are underemployed or overqualified also experience worse mental health. This is likely to be explained – in part, but not entirely – by part-time and temporary work being linked to low pay and insecurity.
The full report – “Flexibility for who? Millennials and mental health in the modern labour market” – can be downloaded from https://www.ippr.org/
Austere times for private medicine?
It is not just the NHS that is worried about its budget; the private medical sector is too. Increases in insurance premium tax (IPT) are causing distress in the private health insurance market. IPT is a tax levied on general insurance premiums. In the 2015 Budget IPT was increased from 6% to 9.5%. Then, in October 2016 there was a further increase, taking the rate to 10%. In June 2017 IPT was increased again, to 12%. Elliott Silk, speaking for Wealth and Investment managing company Sanlam UK said: “The escalating cost of the tax is reaching a tipping point, and will likely affect employers’ ability to offer private healthcare as a benefit in the workplace. The Government should consider ring-fencing private healthcare from the increase to IPT”.
Over the last decade the cost of private medical insurance doubled, mainly because of the costs of new treatments (especially cancer therapies) in an ageing population. Part of the reason for the jump is that more people were buying private insurance and using it. Around 5 million people in the UK have private medical insurance, of which four-fifths are covered by corporate (employer purchased) policies. The average cost is just over £700 a year, but there are wide variations between policies, and prices for older customers can be much higher. (Source: Oliver Ralph, Insurance Correspondent, Financial Times, May 6th, 2016)
Bits of the NHS quarrel with each other over lots of things, size being one. For example the North Staffordshire GP Federation does not support the Staffordshire and Stoke-on-Trent STP or capped expenditure proposals aimed at the creation of a single community and mental health provider covering Staffordshire and Shropshire (Shaun Lintern HSJ 27 July 2017). The GPs want a multispecialty community provider based on the local North Staffordshire and Stoke-on-Trent footprint, arguing that the needs of these local communities are different from needs elsewhere in Staffordshire. The economies of scale that the STP desperately needs to save money point to the need for a big organisation, whilst the GPs doubt that proposed mergers will yield savings. Little wonder that progress with STPs is slow.
Stuffing their mouths with gold (or bronze, silver or platinum)?
Data obtained by the Health Services Journal shows the amount paid to senior doctors on top of their NHS salaries was £157m in 2015-16 and £147m in 2016-17 – tidy sums given the public sector pay freeze. The awards were paid to 2,948 consultants in England and Wales during 2015-16. The number receiving the awards dropped to 2,779 consultants receiving an award up to March 2017. The 2016 annual report from the Advisory Committee on Clinical Excellence Awards said more than 25,300 consultants in England and Wales (54 per cent of the consultant workforce) received an award (Shaun Lintern HSJ 28 July 2017). Clinical excellence awards are added to consultant pay and are pensionable.
The Clinical Excellence Awards (CEA) scheme is intended to recognise and reward those consultants and senior academic GPs who contribute most towards the delivery of safe and high quality care to patients and to the continuous improvement of NHS services. In particular, awards are made to doctors who:
Demonstrate sustained commitment to patient care and wellbeing or improving public health
Sustain high standards of both technical and clinical aspects of service while providing patient-focused care
In their day-to-day practice demonstrate a sustained commitment to the values and goals of the NHS by participating actively in annual job planning, observing the private practice code of conduct and showing a commitment to achieving agreed service objectives
Through active participation in clinical governance contribute to continuous improvement in service organisation and delivery
Embrace the principles of evidence-based practice
Contribute to knowledge base through research and participate actively in research governance
Are recognised as excellent teachers and or trainers and or managers
Contribute to policy-making and planning in health and healthcare
Make an outstanding contribution to professional leadership.
The function of CEAs varies across the nations of the UK. In England they are awarded to consultants and academic GPs who perform ‘over and above’ the standard expected of their role. In Scotland the CEAs are intended to reward consultants who show commitment to the NHS by not doing private practice.
The administration of the scheme is in the hands of the Advisory Committee on Clinical Excellence Awards. There are 12 levels of award. Levels 1-8 are awarded locally by employing NHS Trusts, with 8 being the highest, and levels 10-12 (silver, gold and platinum hereafter) are awarded nationally. Level 9 awards can be awarded locally or nationally, and are usually referred to as ‘bronze’.
The value of individual national awards in England and Wales for 2016-17 was £35,832 for “bronze”, £47,110 for “silver”, £58,888 for “gold” and £76,554 for “platinum”. Local awards, run by individual NHS employers, varied from £2,986 to £35,832.
CEAs, once called ‘distinction awards’ or ‘merit awards’, were introduced at the foundation of the NHS in 1948 to win support for it – Aneurin Bevan is said to have described these awards as “stuffing their mouths with gold”. By 1979 about half of all consultants received an award during their careers and at any one time just over a third were award holders. Negotiations about a new consultant contract were rumoured to include removal of clinical excellence awards, including those currently held (Shaun Lintern HSJ16 February 2017). If that happens it will be interesting.