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Consulting professionals and managers about the NHS.

This site aims to bring out the truth about the state of the NHS. We reveal the views of current and retired NHS professionals, doctors, nurses and managers in particular. This has never happened in a public domain before. We also report stories of interest in order to provide a context. Find out more..


Some tips to avoid waiting to see your doctor……. but it is going to get worse, and more expensive whatever.

A relative had to call the doctor for a urine infection. It was painful, they had a fever, and yet no treatment was available without an appointment, and a sample of urine for culture. The urine was lost, and they went privately because there was “no other way” to get treatment! This cost time, energy and £65, but to the English Health Service it has cost another disillusioned taxpayer. Stories abound about poor access, delayed investigations, and subsequently poor outcomes. The shortage of doctors has been predicted for more than a decade, and the poor manpower planning that has led to those doctors we do have being “part time” is understandable for all of us close to the profession and the service. Disillusion is not confined to the public, but is endemic in the caring professions…. hence early retirement and emigration, and changes of career. Poorer parts of the UK will be more affected, as when there is undersupply doctors will choose to work in more affluent areas with better schooling and infrastructure. These areas will also have more people prepared to pay for the private option. Just as dentistry has “gone private”, so Primary Care (G.P.) is facing the exact opposite of the National, fair, mutual service(s) that Aneurin Bevan enabled in 1948. We are bringing back fear, rather than replacing it.

Some tips to avoid waiting to see your doctor…….

Write your symptoms down on headed paper and deliver it ( by relative if necessary ) as the doctor will have to read the letter, have it scanned into your notes, and act on it accordingly. The envelope should be addressed to your preferred or normal doctor, but make it clear that any doctor will be adequate. If you think it urgent mark the envelope as such, but be aware that GPs have been excused form being an emergency service. ( A true emergency, as defined by the state(s) and not by the patients, needs a 999 call, and attending A&E. ) Verbal messages over the phone are not recorded in a standardised manner, so recording is different in each practice. Emails either direct to a practice, or from receptionists receiving messages, are not necessarily copied into notes.  Access is going to get worse, and more expensive whatever: there are just not enough doctors for the next 15 years..

The “ideal” concept, as originally envisaged has died. We have to ration health care, so better that rationing is overt rather than covert. It must be universal for big expensive services such as cancer care, and heart surgery, but it may have to be local (post coded) for smaller items and services which are not expensive or life threatening. My personal preference is for means tested health care in the same way as we have means tested social care. This would allow combining budgets without internal argument. All that remains is for the press and the politicians to reach this conclusion. The bad news is that this will take decades, and many deaths.

The prospect of a “telephone app” doctor does not convince me at all. Advertisements in London have small print saying that, to access this service, you will need to re-register. The old adage of History, Examination and Investigation is being replaced by History, Investigation and then possible examination but by a different doctor. I predict: No continuity of care. No trust. Waste by over investigating, and then by litigation costs. What better incentives to go privately if you can afford it? What better way to destroy the health services by making them unofficially “two tier”?

Sarah Baxter reports that: “Doctors are quitting and surgeries are threatened. Services need radical reform” in the Times 11th December 2018.

Scary news. More than 350 GP practices may close next year and millions of patients face a three-week wait to see their doctor. To be frank I thought everybody in Britain, like me, was already obliged to book an appointment three weeks in advance. So whenever my children, say, need prompt attention for an ailment that might be serious but probably isn’t, I send them to one of those private walk-in clinics for £65 that you can find around the back of central London railway stations.

Not everybody has that opportunity, but I felt ashamed about running to the A&E after my son was prescribed a couple of Nurofen for a neck injury on the football pitch that turned out to be nothing. Equally, I’m not prepared to wait three weeks for an examination. I did try to change surgeries, but was told by a nearby GP practice that its situation was far worse……….

My NHS clinic is Theresa May‘s ideal – if only I could see a GP (The original Times article)


Sir, You report that, in the past year, 9.3 per cent of patients waited more than three weeks for an appointment (“Millions of patients face three-week wait for GP”, Dec 7). While it is undeniable that there are serious resource shortages at GP practices, there is much that patients can do to improve the performance of their GP service. In my local practice, patients fail to turn up to 5 per cent of booked appointments without giving prior notification. During the course of 12 months this wastes 50 per cent of the time of one whole doctor.

In the case of minor ailments, patients who agree to accept an appointment with a clinical nurse or agree to visit a pharmacy directly can improve the availability of doctors for more urgent appointments.
Richard Harvey
Oakham, Leics

Sir, Tony Blair made two big errors in his dealings with primary care: allowing GPs to opt out of 24-hour care and interfering with appointment systems that practices had fine-tuned to meet the needs of their patient population. As a result of being embarrassed on national television in a Q&A session with voters, he introduced a “one fits all” system incentivising practices to deal with all requests for an appointment within 48 hours. The only way this could be achieved was for practices not to allow booking in advance so the appointment book was empty at the start of each day. This created the rush hour at 8.15am and a lucky 30 got an appointment.

Any service where demand outweighs supply inevitably has a pinch point and in this scenario the bottleneck is at about two to three days. Urgent cases can still be seen on the same day and chronic conditions can wait a couple of weeks with no detriment to the patient. Illnesses such as sore throats, viral illnesses, diarrhoea and vomiting, etc get better without the need to be seen at all.
Dr Andrew Cairns
Petersfield, Hants

Sir, Maybe the delays in being able to see a doctor are not caused by, as you report, “the chronic shortage of GPs”. Out of the seven GPs in my doctor’s practice, six only work part time.
Douglas Stuart
Guildford, Surrey

Sir, It is not just general practice that is under enormous strain; patients across the country are also struggling to access NHS dentistry. More than half of NHS dental practices are closed to new patients and some people face a 90-mile round trip to get to their nearest surgery.

As chief executive of the largest provider of NHS dentistry in the UK, I see first-hand the acute shortage of NHS dentists, particularly in remote areas, and the impact this has on patients. The government urgently needs to train more dentists and, most importantly, allow high-quality clinicians from around the world access to work in the UK.
Tom Riall
Chief executive, mydentist

Sir I am lucky enough to be registered with a GP practice in west London which operates a system that ensures that medical advice can be easily accessed. Each weekday morning and four weekday afternoons a walk-in clinic is on offer where, as often as not, a patient is able to see the doctor of their choice without too long a wait. As well as this facility, an appointment — perhaps for a lengthier consultation — can be arranged using the phone, sometimes subject to a week’s delay. If this busy practice can achieve such a service, then why are not all practices aiming for such a system?
Sheila Keating
London W2

Image result for two tier service cartoonWorkload pressures and the GP shortage forcing practices … to close

GP surgery closures ‘will see 3 million patients lose out in the next year’ 



BREXIT will negatively impact the NHS and health services regardless of a deal, a new report has revealed, with devolved nations set to suffer the most.

Under the present funding rules, rationing of health services will need to be more severe, and more covert, in the devolved nations. NHSreality has warned about the problems of smaller mutual in health provision many times….. When readers listen to the debates next week, and think about their personal future, their chances in severe illness, and those of their nearest and dearest, they should think about this prediction… and this despite the figures on the infamous “red bus”…

Kate Whitfield reports in the Express 6th December 2018: Brexit news: How healthcare and the NHS will suffer, deal or no deal – BREXIT will negatively impact the NHS and health services regardless of a deal, a new report has revealed, with devolved nations set to suffer the most.

The report, titled “The NHS and Health Law Post Brexit: Views from Stakeholders and the Devolved Jurisdictions.” released on Tuesday, is made up of research and evidence from interviews around the UK. Concerns about the future of health care include staffing, shortage of medicines, public health, research and funding. Most worryingly, it appears devolved nations – Northern Ireland, Scotland and Wales – might be the worst hit.

Speaking at the launch of the report, researcher Professor Tamara K. Hervey said: “The risks of Brexit vary significantly depending on what kind of Brexit we have.”

However, she added: “No-deal is much worse for health and the NHS than the withdrawal agreement.”

So, whether Parliament votes the prime minister’s embattled deal through next week or not is likely to seriously impact the health sector.

Professor Hervey said: “There are major negatives no matter what kind of Brexit we look at.”

How will the NHS be affected?

The report revealed a number of key findings:


Concerns around staffing are compounded by the already existent shortage of healthcare professionals around the UK.

Northern Ireland is a particular concern, already in the grips of a chronic staff shortage.

But cross-border care between Northern Ireland and the Republic is extra cause for concern: if the UK leaves without a deal and a hard border is re-instated, what will become of interacted healthcare services?


The possibility of shortages and the need for stockpiling has been discussed for some time now.

But here again, there are concerns about the devolved nations.

The findings state: “The key issue is the likelihood of multiple shortages taking place all at once, meaning that the normal responses are inadequate.

“The size of NHS England compared to devolved nations leads to worries about how professionals in Northern Ireland, Scotland and Wales


There are concerns about public health measures, such as combatting smoking, once the UK leaves the EU.

There are worries that, once the UK is no longer under EU regulation, commercial considerations may hold more influence.

The UK will also be leaving the European Centre for Disease Prevention and Control (ECDC) after Brexit, and the report urges the government to pursue a relationship.


The EU is involved in a range of vigilance systems that scrutinise health professionals, pharmaceuticals, medical devices, blood and tissue.

These measures facilitate the protection of patient safety, but may be at risk after Brexit.

Professor Hervey pointed out these dropped scrutiny measures could result in either “mistakes happening inadvertently” or “more powerful interests able to secure advantages” while the UK adjusts to the post-Brexit landscape.


The report finds that the loss of EU funding poses the biggest threat to Northern Ireland and Wales.

“The practical potential adverse impacts of this on health need to be addressed by policy makers in the immediate, intermediate and long-term period of Brexit,” the report said.

Download The NHS and Health Law Post Brexit


As standards fall – a rejection of volunteers…

It appears that amelioration of covert rationing by volunteering is not to be encouraged.

Image result for volunteer cartoon

Dennis Campbell in  the Guardian 4th December 2018 reports: Hospitals report warns against volunteers doing work of NHS staff – Study finds volunteers are vital but lack of clarity about limits of roles can lead to tensions

Volunteers play a vital role in hospitals such as by doing tea rounds and fetching medications but should never be required to do the work of trained staff, according to a report.

An estimated 78,000 volunteers perform a variety of roles in NHS hospitals across England. Richard Murray, the director of policy at the King’s Fund thinktank, which conducted the study, said that while it found frontline staff appreciated volunteers, that was “provided they were not being used as substitutes for paid staff”.

Patients appreciate the companionship, comfort and support volunteers can bring, according to the research. One of the almost 300 doctors, nurses and support staff interviewed said volunteers’ value lay in “bringing human kindness to a busy ward”.

Three out of four staff say volunteers help them care for patients, while almost a third believe they help free up their time to focus on clinical duties.

But the thinktank, which conducted the research for the Royal Voluntary Service (RVS) and the volunteering charity Helpforce, found that a lack of clarity about the limits of volunteers’ roles “could lead to tensions between staff and volunteers”.

Sir Tom Hughes-Hallett, the founder of Helpforce, said the ageing population meant hospitals would need greater numbers of volunteers in the near future, so the NHS should embrace their contribution.

Anna Chadwick, the lead dementia nurse at Mid Cheshire hospitals NHS trust, said RVS volunteers in its Leighton hospital in Crewe played a hugely valuable role. “The impact of volunteers giving their time to offer meaningful support to people who are unwell and often lonely and frightened is immeasurable,” she said. “The hospital environment can be overwhelming and a friendly face and chat can make the world of difference to a person’s experience.”

The NHS’s long-term plan is expected to map out how volunteers can help the health service and its staff cope with the challenges they face.

Matt Hancock, the health and social care secretary, said volunteers had been supporting patients in the NHS since its creation in 1948. “I want volunteering to be the norm across every NHS hospital, with volunteers given the tools they need to fit seamlessly into the organisations they are giving up their time to support, so that the public and clinicians can work side by side to deliver the best possible care to patients,” he said.

Image result for volunteer cartoon

Late cancer diagnosis… and poor cancer care. Let GPs have access to tests, and when there are enough, involve them in key treatment decisions.

Its not only the late diagnosis of cancer, influencing outcomes, which annoys NHSreality, but also the pretence that cancer and terminal care are under control in an ageing population. The opportunities to improve quality of life in the last few weeks and months is a great one. The subject of “advanced directives” or living wills is hardly discussed in society. This desperately needs to change… Teams of clinicians involving oncologists, GPs and Palliate Care consultants need to review far more cases together, and much earlier.

BBC News 26th November 2018: Cancer care: England still lagging behind the best

GPs need better test access to improve cancer diagnosis
OnMedica27 Nov 2018

Cancer patients wait more than a year for diagnosis
The Times22 hours ago

Early cancer diagnosis rates drop in several areas
Health Service Journal26 Nov 2018

Cancer care still falling behind in England

Letter in the Times 28th November 2018:

Sir, As senior academic GPs working in cancer research, we agree that the UK’s performance in timely diagnosis of cancer is distressingly poor but contend that the solutions proposed in your leading article (“Catch Up on Cancer”, Nov 26, and letters, Nov 27) are flawed. Patients with possible cancer are often older, most have at least one pre-existing long-term health problem and many have complex medical histories. These are the very patients that the providers of online diagnostic services prefer to avoid. A straight-to-specialist service will shunt the workload of sorting out patients with non-specific symptoms on to NHS specialists, whose capacity is under at least as great a pressure as general practice and who generally lack a broad expertise outside their own discipline.

GPs are highly skilled at making diagnoses, despite the pressures they work under, and their referrals for suspected cancer have doubled in number since 2009. However, they need the same access to sophisticated diagnostic tests as their counterparts enjoy in other high income countries and they don’t need the downward pressure on referrals being increasingly exerted by our NHS. At the same time research is urgently needed to develop new diagnostic tests that work well for ruling out cancer, and to translate them into clinical practice, so that GPs can more efficiently select those patients who do need specialist assessment.
Professor Greg Rubin, FRCGP
; Professor Willie Hamilton, FRCGP; Professor Richard Neal, FRCGP; Dr Fiona Walter, FRCGP

Seeking informed consent on Brexit

Many discussions around informed consent relate to the GMC, the duties of a doctor, and centre around whether the patient has been offered all choices, and the different risks involved in each choice. In politics, no less and no more. Citizens need to be aware of the reality of their decision, short term and long term if that can be assessed. Several of my Brexit friends are claiming that another vote will mean civil unrest. I ask them whether that depends on the result or not, and they of course answer yes. Why are they so afraid of another vote. It will either cement their position and unite the country in Brexit, or it will have changed. The same friend says that more people have died who voted Brexit, and more people have gained the vote who will probably vote remain. My argument still stands… We could well “die anaesthetised” if the politicians don’t vote the deal out, and ask for another referendum.

Image result for informed consent cartoon

Tom Moberley opines in the BMJ: Seeking informed consent on Brexit

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4816 (Published 15 November 2018) Cite this as: BMJ 2018;363:k4816

Despite all the diverging views on Brexit, few people would accuse the government of demonstrating skill, or even competence, in its handling of either negotiations on an exit settlement or preparations for the departure itself. These failings raise the risk that the UK will leave the EU without any deal and that whatever arrangement is reached will be unlikely to satisfy either leavers or remainers.

This week in The BMJ we take a close look at what Brexit will mean for the NHS, examine the arrangements needed ahead of 29 March 2019, and ask what doctors can do to mitigate the effects on health.

Niall Dickson, chief executive of the NHS Confederation and co-chair of the Brexit Health Alliance, warns that disruption to healthcare from a bad Brexit will risk lives (doi:10.1136/bmj.k4770). A series of features show how poor preparation for Brexit threatens the supply of blood products, insulin, and radioactive isotopes and the treatment of patients with rare diseases (doi:10.1136/bmj.k4724).

Amid all this concern and uncertainty, The BMJ, the BMA, and the Royal College of Nursing argue that doctors should support calls for a new referendum on the final deal agreed for the UK’s withdrawal from the EU. Fiona Godlee, The BMJ’s editor in chief, Chaand Nagpaul, the BMA’s chairman, and Donna Kinnair, acting chief executive and general secretary of the RCN, make the case in a joint editorial (doi:10.1136/bmj.k4804). They argue that the public must be allowed to make an informed choice on issues that will affect the UK for generations to come.

Meanwhile on BMJ Opinion two doctors who are currently MPs also argue that the public must be allowed to have its say. The Conservative Sarah Wollaston, who chairs the health and social care select committee, and Labour’s Paul Williams, a fellow committee member, liken the situation to a patient consenting to an operation (https://blogs.bmj.com/bmj/2018/11/13/there-is-no-version-of-brexit-which-will-benefit-the-nhs-only-varying-degrees-of-harm/). “To proceed without informed consent would not only be grossly unethical, it would also place the blame for the unintended consequences squarely at the feet of all those politicians who allowed it to happen,” they say.

Godlee, Nagpaul, and Kinnair ask doctors to consider adding their voice to this call for a people’s vote by telling their MPs that they want an informed choice on the final Brexit deal.

“You could also share this information with your colleagues and patients,” they say. “We believe the evidence of a detrimental effect on the nation’s health is clear. Please join our call for a people’s vote on the final Brexit deal.”

Image result for informed consent cartoon

Bullying and harassment cost NHS over £2bn a year, – It’s got that bad, and that expensive!

NHSreality has covered bullying, harassment and whistleblowing many times. We are of the opinion that only a form of “zero” management, by which I mean removing all performance targets, and allowing management to do its own thing as it wishes for a few years, will work. Once morale has improved and a new culture of trust has been established, mutually agreed performance indicators can be addressed again. It’s got that bad, and that expensive!

Ingrid Torjesen in the BMJ reports; Bullying and harassment cost NHS over £2bn a year, study suggests  BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4463 (Published 24 October 2018) Cite this as: BMJ 2018;363:k4463

The consequences of bullying and harassment in the NHS cost the service in England at least £2.28bn (€2.58bn; $2.96bn) a year, an analysis suggests.1

Researchers used data from NHS Digital to gauge the impact of bullying and harassment on sickness absence, employee turnover, productivity, sickness presenteeism, and employment relations. The authors described the final £2.28bn figure as an “extremely cautious” estimate, as several costs lack reliable evidence.

The analysis, published in the journal Public Money and Management,1 estimated that the cost to the NHS from sickness absence due to bullying is £483.6m a year. This assumes that the 24% of NHS staff who are bullied will “conservatively” have 71% more time off (seven extra days a year) on top of the average 9.36 sickness days. The average daily pay rate of the 1.046 million NHS staff is £140.12.

Staff absences are estimated to cost the employer an additional 62.5% on top of the salary costs of absent staff members, equal to an extra £302.2m. This cost largely reflects the agency staff and overtime required to cover for absent staff.

The cost of “presenteeism”—the productivity lost when staff continue to come to work while being bullied and are more prone to making mistakes—was estimated at £604.4m, twice as high as the costs of absenteeism due to bullying harassment.

Of the 24% of NHS staff who reported being bullied, an estimated 15% (3.6% of staff overall) consequently left their employment. The cost of replacing each of these 42 681 staff is £5614.00—a total of £231.9m. The reduced productivity of the new staff replacing them is estimated to cost £13 489 each while new employees get up to speed, equal to £575.7m overall.

Annual industrial relations, compensation, and litigation costs from bullying and harassment are estimated at £83.5m. This is based on a predicted 8.5 cases of bullying and harassment at each of the 234 NHS organisations a year, each costing an average of £41 963.

The authors suggest improving existing staff surveys to better capture the types of behaviours attributable to bullying and to understand how staff feel about current procedures to tackle workplace bullying. With a better idea of the effectiveness of current strategies, improved methods could be developed, they say.

Duncan Lewis, professor of management at Plymouth University and one of the authors, said, “Research has increasingly demonstrated the risks to patient care and safety but not addressed the cost to the organisational effectiveness of the NHS. We hope this study kickstarts serious attention to the substantial diversion of funding away from patient care that current levels of bullying cause.”

Image result for work bully cartoon

BMJ Leader: End the culture of fear in healthcare

Stalling life expectancy in the UK

Stalling life expectancy in the UK

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k4050 (Published 27 September 2018) Cite this as: BMJ 2018;362:k4050 by Veena S Raleigh, senior fellow at the Kings Fund

We must look at austerity and beyond for underlying causes

The stalling of improvements in life expectancy in the UK since 2011, highlighted again in the most recent data,1 has prompted much comment and speculation about the causes. Longevity is the ultimate measure of health, and the flatlining of life expectancy after decades of steady improvement has unsurprisingly led to calls for action.2 The Department of Health and Social Care has belatedly commissioned a review by Public Health England (PHE).

The negative effect of post-2008 “austerity” on health, social care, and other public spending is cited as a potential cause in studies examining temporal associations between mortality trends and markers of NHS performance and public spending.34567 Other features of this complex mortality story also warrant consideration, including the parallels with what’s happening elsewhere.

International parallels

Several high income countries have seen a slowdown in longevity improvements since 2010.89 As in the UK, the slowdown is greater at older ages, especially among women, and is driven by some similar causes of death (although the contribution of opioids to falling life expectancy in 2015 and 2016 is so far unique to the US).8 Two parallel but distinct developments warrant further consideration: an underlying deceleration in the rate of improvement affecting most ages, and periodic mortality peaks—mainly affecting older people—that compound the general slowdown.

The decelerating rate of improvement in mortality from cardiovascular disease is a substantial contributor to the steady slowdown in longevity improvements.89101112 The underlying causes are unclear and could include changes in risk factors such as obesity and diabetes and the diminishing effects of primary and secondary prevention strategies. In the UK, improvements have also slowed for several other causes of death—for example, chronic respiratory disease. Adding to the complexities of interpreting changes in cause of death is the rising proportion of deaths attributed to dementia and Alzheimer’s disease (resulting partly from diagnostic and coding changes), many of which are associated with other conditions.

Alongside this general slowdown are annual fluctuations in mortality, notably the sharp fall in life expectancy in many European countries in 2015 (which was greater in France, Germany, and Italy than in the UK), with a recovery in 2016.8 Such large, abrupt, and widespread increases in mortality followed by a recovery are unprecedented in recent years and suggest a common cause. Deaths from respiratory disease had an important role.8 The mortality monitoring agency EuroMOMO (www.euromomo.eu) reported excess winter deaths in 2015 across much of Europe, including the UK. Most of these were in older people and were attributed largely to flu, based on corroborative information on morbidity, the flu strain in circulation, and low efficacy of the vaccine.1314 The pattern of excess winter deaths reported for other years is also similar across much of Europe and points to the role of flu, pneumonia, and respiratory disease more generally in some years.

Understanding the underlying causes

In summary, the general deceleration in mortality improvements in many high income countries since 2010 has been compounded by periodic bad winters. The slowdown has different components, affecting different age groups and sexes differentially,10 but with some similarities across countries. Austerity probably hastened and caused some deaths in the UK, especially among elderly people. It doesn’t explain why similar mortality trends are seen elsewhere, and why the slowdown in, for example, Germany, Sweden, and the Netherlands—which experienced little austerity—has been greater than in Greece, Spain, Portugal, and Ireland, where austerity was most severe. The causes are likely to be multifactorial and need further deconstruction.

Unpacking the causes of the multiple concurrent changes is complex but essential for tackling the underlying drivers. Learning from international experience should be part of this. Furthermore, analyses that aggregate multiple years mask annual fluctuations in mortality that are key to understanding what’s happening in both “good” and “bad” years. For example, just as 2015 was a “bad” year in many countries, life expectancy in several countries including the UK increased sharply in 2014. This was possibly aided by 2014 being a benign year for flu, as reported by EuroMOMO.

Looking ahead, PHE and EuroMOMO report substantial excess winter deaths for 2017-18, largely attributable to flu, and deaths from flu and pneumonia were at or above epidemic threshold for 16 weeks in the US last winter, one of its longest flu seasons.15 Like 2015, 2018 could be a poor year for some countries, including the UK.

Annual mortality changes therefore need closer scrutiny, as do secondary causes of death—for example, comorbidities associated with dementia deaths and cardiovascular and other deaths precipitated by acute respiratory infections. The dataset for England linking hospital patient records with mortality records16 could provide additional, valuable insights into comorbidities and causes of death, including by deprivation level. The effect of widening inequalities on the mortality slowdown also needs closer examination. Timely analysis of such factors should become routine for PHE and the Office for National Statistics (ONS).17

The UK’s life expectancy is below that of many comparator countries, especially for women, for whom there has been no improvement since the slowdown started in 2011. Inequalities are widening, and the UK’s healthcare expenditure and resources are below those of comparator countries. Beyond learning from international patterns, PHE and ONS need to examine urgently why the UK’s life expectancy is falling further behind—including through collaboration with international agencies where appropriate.