We rationed Public Health for too long. Now we realise how important it is to population health. Public health is in crisis, but it can be fixed (Published 27 March 2024) BMJ 2024;384:q760 by David J Hunter, emeritus professor of health policy and management1, Since 2010 a combination of austerity, Brexit, and the impact of covid-19 has considerably worsened the public’s health in England.123 Obesity levels have risen, fuelled by the consumption of unregulated ultra-processed foods, a chronic problem which successive governments have failed to tackle.4 Gains in life expectancy have stalled.5 Health inequalities, both between and within regions, are widening.6 Growing numbers of people are unable to work because of illness.7 The UK now has one of the worst health profiles of any high income country, especially among children,8 and its deteriorating health status is adding to pressures on the NHS. To secure social conditions that support healthy populations, we need the political commitment of governments to act for the common good and their investment in institutions that protect public health. We know that ill health is tied to social determinants, and while governments alone do not shape those determinants, it is their job to produce policies that improve social conditions and protect health. To do this they need well resourced public health agencies that are strong and politically effective in influencing policies in transport, housing, planning, consumer affairs, and finance. But public health is in crisis in England, with the country’s core agencies weakened by a broken government that has no interest in rebuilding the public services and infrastructure it has done so much to hollow out. After abolishing the principal public health agency, Public Health England (PHE),9 without warning midway through the pandemic in August 2020, the government replaced it with two new bodies. The UK Health Security Agency (UKHSA) is charged with health protection, and the Office for Health Improvement and Disparities (OHID) has responsibility for wider public health, including non-communicable diseases such as obesity. Set up in haste with no consultation, OHID lacks any of the (albeit limited) independence PHE had, being an opaque body scattered through the Department of Health and Social Care. Given its low profile and lack of a clear mission, it comes as no surprise that, despite denials from the government, it has recently been reportedly decimated under the guise of a “restructure.”10 OHID’s fate is in keeping with the government’s ongoing opposition to public health measures and fear of being accused of “nanny statism.” True to its neoliberal roots, the government is committed to the rhetoric of individual choice and to shrinking state support, which we refer to as “vulgar individualism.”11 Instead of this defunct philosophy, we urgently need a new social contract based on the principles of “social individualism,” a philosophy that recognises how the health and flourishing of populations depends on the right social conditions, and which is committed to using political authority for the common good A wake-up call Many of the measures that could be adopted to tackle our public health challenges have a sizeable and robust evidence base, so there is no need for further reviews or inquiries. The weakening of OHID should serve as a wake-up call. The next incoming government should reset public health policy and restore serious national public health leadership. A good place to start is the Hewitt Review on Integrated Care Systems. Ignored by the government, the review argues for a major shift upstream towards prevention and for investment that prioritises public health.12 England urgently needs a national agency for public health that is respected, free from government interference, and able to speak truth to power. NICE may serve as a model here given its impressive longevity and the global respect for its work,13 which is largely due to its organisational stability, governance, and arm’s length relationship with government. England could also learn from the devolved nations. Public Health Wales and, more recently, Public Health Scotland have made notable improvements to the health of their populations. In Wales, pioneering work has been conducted through health impact assessments covering topics such as the mental wellbeing of future generations and climate change,14 while in Scotland the introduction of minimum unit pricing for alcohol has reduced deaths directly caused by alcohol by 13.4% and related hospital admissions by 4.1%.15 Both bodies were established after consultation with key stakeholders and detailed attention was paid to their governance so that they have a degree of independence from government. Revitalising public health in the UK requires three key changes. Firstly, the government should consider establishing a body like the Office of Budget Responsibility or National Audit Office, with a remit that allows it to independently report on the effect of government policies on public health.16 Secondly, a cross-government approach is needed to make progress in realising the new social contract we advocate for aimed at tackling the social determinants of health. Lastly, priority should be given to restoring the funding cuts to local government17 and to public health whose funding has been reduced by 27% in real terms since 2015/16.18 Investing in the public’s health is not a cost but an investment in a more productive society. However, fixing public health also means reforming our broken political and public policy system.19 Missing above all from the UK government’s approach to the public’s health is the political will and competence to act. But for policy to stick these are essential prerequisites.
We seem to give plenty of money to research, cancer, but not enough to treat all our citizens, and the elderly in particular. The fact is that all lives are not equally valuable (vertical equity) and if care is rationed then it is appropriate to put a 24 year old before a 74 year old. It might be acceptable that those in work are operated on before those who are retired. After all it is workers taxes that are funding the system. Lack of foresight, planning and political denial have conspired together to create the anarchic, unfair, post coded, covert maelstrom of medical care that is the UK. Civil unreast is a risk, and it is essential to balance up life’s chances across the nation if we are to avoid it. If its going to get worse, at least make it fair! I suspect many elderly people have a better death by not having the most aggressive therapies, but this should be their choice rather than that of their consultant. Perhaps this explains the differences in survival and we have sensible rationing of oncological treatments. Informed consent only comes when there are alternatives, and oncologists are not consulting patients along with with GPs &/or Palliative Care consultants yet. We just don’t have the staff! Laura Donelly in the Telegraph reports 27th Feb: UK cancer survival rates lag 15 years behind other major countries – Patients in Britain more likely to be denied chemotherapy or radiotherapy than those in Australia, Canada or Norway UK cancer survival rates are lagging 15 years behind other major countries because of a lack of chemotherapy and radiotherapy, research shows. For the first time, experts at University College London examined the differences in treatment for eight cancer types across three continents. They found cancer patients in the UK were much less likely than people in other countries to receive chemotherapy or radiotherapy. Those who did receive it were forced to endure longer waits, while the disease was spreading. The differences were most stark among older patients, with those in Canada seven times as likely to receive chemotherapy, compared with those in Britain. Researchers said the lower rates of treatment in the UK helped explain why Britain’s cancer survival rates were 15 years behind those of comparable nations. Across the countries examined, the UK was worst for cancer of the stomach, lung, colon and ovaries. The UK five-year-survival rate for stomach cancer was just 20.8 per cent in 2010-14. This is lower than figures other countries achieved 15 years earlier. In 1995 to 1999, Australia had survival rates of 25.7 per cent, while Canada had 21.5 per cent, with 21.3 per cent in Norway. Experts said NHS shortages of both staff and equipment meant patients were too often being denied treatment or waiting so long that it could no longer benefit them. The studies, funded by Cancer Research UK and the International Cancer Benchmarking Partnership, published in the Lancet Oncology examined data from more than 780,000 patients in Australia, Canada, Norway and the UK diagnosed between 2012 and 2017. In total, just 31.5 per cent of cancer patients in the UK received chemotherapy, compared with 42.1 per cent in Australia, 38.5 per cent in Canada, and 39.1 per cent in Norway. For radiotherapy, the UK figure was just 19.8 per cent, compared with 25.7 per cent in Canada, 23.9 per cent in Australia and 22.5 per cent in Norway.
Older patients fared particularly badly in the UK. Just 2.4 per cent of UK patients aged 85 and over received chemotherapy, compared with 8.1 per cent in Australia and 14 per cent in parts of Canada. Experts have also warned of “fatalistic” attitudes – especially towards older patients, and those with other health problems – with rushed consultations meaning that there was not enough time to explore treatment options. Dr John Butler, clinical lead for the International Cancer Benchmarking Partnership and an ovarian cancer surgeon, said: “For many aggressive cancers – such as ovarian, lung and pancreatic cancer, it’s vital that people are diagnosed and start treatment as soon as possible. “Lower use of chemotherapy and radiotherapy in the UK could impact people’s chances of survival, especially for older patients. “Although we have made progress, the last benchmark showed that cancer survival in the UK is still around 10 to 15 years behind leading countries. “This study captures missed opportunities for patients in the UK to receive life-prolonging treatment.” Dr Butler said there were a number of likely factors behind the trend. “In some cases, it’s about patients being so unwell by the time they are diagnosed that they are not well enough to receive chemotherapy. And furthermore, if there are long delays in the diagnostic pathway then that is more likely.” He said the low rates could also reflect “nihilism” from some doctors, in assuming that the side effects of treatment were not worth the potential benefits, particularly in elderly patients. The figures, which used international benchmarking data, tracking survival between 1995 and 2014, found that the UK figures were often on a par with other countries 15 years earlier. For colon cancer, the UK’s rate of 58.9 per cent in 2010-14 was similar to those in Australia and Canada 15 years earlier. Australia now achieves survival rates of 70.8 per cent for colon cancer, while Canada is at 66.8 per cent. UK lung cancer survival, at 14.7 per cent, is similar to the rates in Australia and Canada 15 years ago. Latest benchmarking data has Australia at 21.4 per cent and Canada at 21.7 per cent.
Michelle Mitchell, chief executive of Cancer Research UK, said: “All cancer patients, no matter where they live, deserve to receive the highest quality care. “But this research shows that UK patients are treated with chemotherapy and radiotherapy less often than comparable countries. “When it comes to treating cancer, timing really matters. Behind these statistics are people waiting anxiously to begin treatment that is key to boosting their chances of survival.” Prof Pat Price, a leading oncologist and chairman of the charity Radiotherapy UK, said the study showed “devastatingly” poor levels of access to treatment. The co-founder of the Catch Up With Cancer campaign said: “A shortage of oncologists and front-line staff to deliver treatment, insufficient equipment, lengthy travel times, a negative approach to cancer care, particularly in the elderly, and an acceptance of variable and poor care in some parts of the country have all resulted in patients not receiving the treatment they need. This is simply not good enough for cancer patients and is costing lives.” The study also compared trends within the UK. Take up of chemotherapy and radiotherapy was lowest in Northern Ireland and Scotland. The studies also found the average time to start chemotherapy was 48 days in England, 65 in Scotland, 57 in Northern Ireland and 58 in Wales. In New South Wales, Australia, the wait was lower at 43 days and 39 in Norway. For radiotherapy, the UK fared even worse, with it taking 63 days to start treatment in England, 53 in Northern Ireland, 79 in Scotland and 81 in Wales. In Alberta, Canada, the figure was 48 days and 53 days in British Columbia, while in New South Wales, Australia, it was 43 days. An NHS spokesman said: “More people than ever are being diagnosed at an early stage of cancer and more treatment options are available – and over the last 12 months, nearly three million people received potentially life-saving cancer checks compared to 1.6 million in 2013. “Whilst cancer survival is at an all-time high, it remains crucial for people to come forward and get checked if they have unusual symptoms – finding cancer earlier saves lives.” A Department of Health and Social Care spokesman said: “These figures cover only the period from 2012-2017. “Since then, we have made significant investment in cancer diagnosis and treatment, including £162 million towards radiotherapy equipment and £2.3 billion to launch 160 Community Diagnostic Centres across England, which will help us achieve our aim of catching 75% of all cancers at stage one or two by 2028. “Cutting waiting lists is one of the Government’s top five priorities, and we have treated record numbers of patients over the last year. “Survival rates are also improving across almost all types of cancer, and we will shortly legislate to create the first smoke-free generation – the biggest single public health intervention in decades.”
We have a large proportion of the younger generation feeling disenfranchised in the FPTP (First Past the Post) system we have now, and so being unwilling to waste their time voting. The drivers towards this are lack of housing, lack of reliable altruistic long term politics, fast media distribution of often false news, (Girls Mental Health especiallyis threatened) and a threat that they might be conned by the media… And of course the betting industry will complain! There is the added risk of “spiked drinks” which has happened to Kate McCann (Times Radio) and other celebrities and a brigade of people. The mental health of dying patients is better with continuity of care, but we all know thats a dream now. Choosing how we die is important… The Fench are removing state provision of drugs for new cases of non psychotic depression.and anxiety. The bill for “Big Pharma” should reduce, and the savings made fund the alternative treatments for depression: exercise, gardening, singing, art, hobbies etc. We in the profession know how hard it is to stop these drugs, but also how many side effects and unintended consequences there are. Overuse of Benzodiazepines, intensively marketed over decades, has led to a dependency culture. We fell into the same trap with Opiates and in the USA particularly, fentanyl is the coming plague which is possibly coming here. Gambleing, encouraged by on-line living, is an oncoming tsunami as well.. We need to treat and care for those with psychosis, and with the oncoming drugs epidemic there will be many more of them. The NHS has one of the worst sickness and absentee rates in the world. This is partly because it acts as a working safety net for many low paid workers. It also employs many part timers, and it needs to provide creche and schooling facilities for these workers if they are to work maximally and efficiently with less time away. The “friday afternoon” culture means that hospitals, and recently, schools are now much less efficient than they used to be. In my neglected town centre children appear at friday lunchtimes with noone at home. They are free to do as they wish, and often the health and social care services are at low staff levels concurrently. Junior doctors in GP training should all do a session in Psychiatry as this may become the bulk of their work… As a doctor said to me the other day, many patients each day come to see them and say “Its m’e mental Dr”….
in the Spectator 22nd Feb 2024: Why Britain stopped working – there is a 50 minute podcast to explain the differences both before and aftter covid between the UK and the rest of the world. “According to The Spectator’s calculations, had workforce participation stayed at the same rate as in 2019, the economy would be 1.7 per cent larger now and an end-of-year recession could have been avoided. As things stand, joblessness is coexisting with job vacancies in a way that should be economically impossible, writes Kate Andrews in the cover story. She joins the podcast alongside Paul Nowak, general secretary of the Trades Union Congress (TUC), to debate the problems plaguing Britain’s workforce. (03:11)” ….. “One factor seems to be the inability of medical and welfare services to help with mental health problems” “Over 22% of the working age population in Middlesborough is unemployed. In Hartlepool its 24%; in Blackpool 25%. Were watching these people waste away..”…. “Britain is one of only a handful of countries …whose workforce has not bounced back”. “Even in 2019, a year before lockdowns, the number of working age people who were off with long term sickness had already risen to 2 million. Now its almost 3 million”. “The department of work and pensions predicts it to increase by another 1 million in the next 3 years. According to the ONS 53% of those off work with depression.. ” “Workers are disincentivised from increasing theit hours, as their efforts yield diminishing rewards,” “working age disability benefits are expected to rise from £19bn to £29bn in the next partliament, while the bill for working age incpacity will jump from £26bn to £34bn. ” “In april the income tax to be paid by a cleaner working 35 hrs on minimum wage will be almost 50% higher (than in march) due to “fiscal drag”, the stealth tax whereby thresholds are frozen rather than raised in line with inflation. Some of the lowest paid workers will be hit hardest in proportion to their pay, with those on £16000 losing £780 – equivalent to about 5% of their earnings” Meanwhile council tax will also rise… A single parent working 30 hours a week could stand to lose 76p of every £1 they earned in extra work, due to the withdrawal of universal credit and the loss of other benefits.”
Sir, Regarding your report “Anti-psychotic drug reviewed after 400 deaths” (Feb 19), I have met Kate Northcott Spall and it is clear she has an important story to tell. We identified areas where the standard of care for people with schizophrenia and other forms of psychosis could be improved and I am confident that her brother’s experiences will help to drive change. Clozapine is the most effective treatment for schizophrenia and other psychoses. However, it is also associated with side effects that can be life-threatening when not monitored effectively, and there have been cases where it has contributed to deaths that could have been prevented. There also exists longstanding discrimination against people with severe mental illness. Services for them are under-resourced; there is little research around their needs; and they are made to feel ashamed about their condition, so hide it or do not engage in treatment. This can no longer continue. We must create an environment where everyone can thrive and participate in society. Dr Lade Smith President, Royal College of Psychiatrists
27th Feb – What’s going on with girls’ mental health? BBC Claudia Hammond and guests consider the worrying statistics around mental health issues in children and young people – in particular, the long-term trends among teenage girls.
Force field analysis (Lewin 1951) is widely used in change management and can be used to help understand most change processes in organisations. Unfortunately management in the 4 health services fails to change rapidly enough: the risk reward ratio for the politicians in charge is too great.( NHSreality opines on NHS management )
In force field analysis change, is characterised as a state of imbalance between driving forces (e.g. new personnel, changing markets, new technology) and restraining forces (e.g. individuals’ fear of failure, organisational inertia). To achieve change towards a goal or vision three steps are required……..
Personally, I am more afraid of a stroke than of cancer. I and my profession are aware that with good palliative and terminal care, preferably of a personal and continuous nature, that there are plenty of ways to relieve pain and ditress. But the distress and disability from a stroke can be mentally debilitating. Long term. And can fail to improve even with physiotherapy, speech and occupational therapy, and most important, psychological therapy. We will be only able to pay for limited amounts of expensive gene therapies. If everyone cannot have these therapies than young people will rightly have preference. It is older people who get strokes, and “in place of fear” is an anachronism to me as a doctor who might have a stoke himself at some point. It is then, if the stroke effects fail to improve, that I would like the option of Dignitas. Many colleagues feel the same. I will be delighted if cancer survival improves in the UK, Wales in particular, but the late diagnosis and treatment are the major reasons: not the absence of expensive new drugs.Can we afford the new drugs – in all 4 systems? (Patents expire at 12y usually, so perhaps in the long term?) St Marys Hospital 11th Jan 2024: Landmark national study supports use of whole genome sequencing in standard cancer care
Sequencing the genome of tumours as standard will help doctors personalise cancer care and provide a more accurate prognosis for patients, scientists have said after conducting the largest study of its kind. By looking at the entire tumour DNA of more than 13,000 patients, scientists identified specific signals that helped predict the survival rates of patients, as well as sometimes indicating the best treatment. They say the research supports the further rollout of genomic medicine on the NHS. Dr Nirupa Murugaesu, principal clinician in cancer genomics and clinical studies at the research company Genomics England, called the study a “milestone in genomic medicine” that was helping the NHS to “realise the promise of precision oncology”. “We are showing how cancer genomics can be incorporated into mainstream cancer care across a national health system and the benefits that can bring patients,” she said. The findings are part of the NHS’s 100,000 Genomes Project, which was started in 2012 to investigate the role of genetics in disease. It was created in anticipation of a future in which an understanding of DNA increasingly informs healthcare. Since its inception, the cost of sequencing a genome has fallen by 90 per cent, and the NHS has started the Genomic Medicine Service. The new findings, which are already informing clinical care, were possible because scientists were able to sequence the genome of patients with 33 different kinds of solid tumour, alongside their entire cancer genome. They were then able to follow the patients through their treatment over the subsequent years.
Researchers estimated that over 90 per cent of brain tumours and 50 per cent of colon and lung tumours had genetic information that suggested a course of treatment Some mutations seemed to have a significant impact on outcomes. For instance, in the subset of patients with a mutation present in a gene called CDKN2A, which is known to make proteins that suppress tumours, the five-year survival rate in the cancers studied was about 50 per cent, compared with 75 per cent in those without mutations. Other genetic changes helped predict what healthcare approaches might work. The researchers estimated that over 90 per cent of brain tumours and 50 per cent of colon and lung tumours contained genetic information that suggested a course of treatment.
Professor Sir Mark Caulfield, vice-principal of health at Queen Mary University of London, said that NHS trusts involved in the study had already applied the findings. “We know in the East Midlands, the largest centre in the study, they took action on about 25 per cent of those results,” he said. “And that changed cancer care for some of the patients. Some got into clinical trials. Some of them got medicines they wouldn’t have got. Others avoided medicines because their genetic make-up suggested that if exposed they would have been at risk of harm.”
Many of the mutations they identified are already known to be important, and can be spotted in less comprehensive tests, called panel tests, tailored to the relevant genes for each cancer. Andrew Sharrocks, professor of molecular biology at the University of Manchester, believes these would still be a better use of resources than exploring the whole genome as was done in this study.
“One of the most important aspects is whether treatments are available for whatever genomic change is identified. If there are none available, then having all this information becomes a bit pointless. It might be more beneficial to just assay [analyse] the things that are known to influence treatment options which would be cheaper,” he said.
However, even if this were true, costs have been falling to th e extent that there would soon be no price difference — and then, the research showed, there would be an advantage to getting the full picture, he said.
We dont know how much UK competition there was for the UK health service (England only) IT contract. NHSreality sisprects that Palantir was one of a select naieve group of bidding firms that have not yet realised that they will invest millions, only for the specification to change. They will be arguing about cash flow and delayed payment until the next century, and in the end its likely to be “not good enough” for purpose. GPs hold the holistic information needed by all specialities. They should lead the design, and it is equally rediculous that the 3 dispensations apart from England are not included. Citizens do move from one dispensation to another, but lack of integration is failing us all. The whole is also self evidently not an NHS any longer. ” The real problem is that the platform does not include GP or social care data and so the delivery of services will continue to be hampered by fragmentation. “…. No more needs to be said. The New technology can revolutionise the NHS, if only staff will let it – From personalised medicines to precision gene therapies, AI diagnostics to drone deliveries, futuristic innovations mean our health service is on the brink of much-needed, sweeping changes — but old mindsets die hard . An essay from Rachel Sylvester in the Times 2nd December 2023: Rainbow-painted drones will soon be flying over London, delivering medical supplies for the NHS. The Civil Aviation Authority has approved a pilot scheme in which high-priority blood samples will be whizzed between Guy’s and St Thomas’ hospitals, avoiding traffic and speeding up test results. If the trial is successful, drone delivery will be extended for the health service across the capital, ensuring rapid transport of time-sensitive drugs and expensive surgical equipment at a tenth of the price of a motorbike courier. This is not a futuristic fantasy. Northumbria Healthcare NHS Foundation Trust has already successfully introduced drones for transporting chemotherapy, which has a limited shelf life, to remote, rural hospitals. On the south coast, medication that would normally take four hours to get from the pharmacy manufacturing unit in Portsmouth to the Isle of Wight, via taxi and hovercraft, arrives in 30 minutes by drone. “We are bringing on-demand delivery to healthcare,” says Alexander Trewby, chief executive of the drone company Apian, which was founded by two NHS doctors. “We think it’s wrong that a patient can get a pizza delivered to their bedside but it takes a couple of days to get their lab test turned around.” Slowly but surely, technology is transforming healthcare in the way it has revolutionised banking, shopping, dating and entertainment. Personalised medicines, precision gene therapies, robotic surgery, AI diagnostics and predictive data analytics are no longer the stuff of science fiction, and if rolled out across the health service will dramatically boost productivity and improve outcomes for patients. At the Huddersfield Royal Infirmary, artificial intelligence has slashed the time it takes to read chest X-rays from seven days to seven seconds, reducing the workload of radiologists by a third and allowing the hospital to identify patients with suspected lung cancer more quickly. The clinicians initially double-checked all the scans the machine said were “normal” before giving patients the all-clear but Adrian Hood, a consultant radiologist, says: “We never caught it out. It was always right.” Now the doctors concentrate on the “abnormal” scans to accelerate treatment for those who need it and improve survival rates.
In Birmingham, the NHS has introduced a dermatology tool that works a bit like a plant identifier app, using AI to analyse a photo of a mole and assess whether it could be cancerous. Meanwhile, the Brainomax AI-enabled CT scanners that are operating in 24 hospitals across England have tripled the number of stroke patients who recover with no or only slight disability by almost halving the time it takes to get them from the emergency department to a specialist stroke unit. Other hospitals are using the power of data to drive efficiency with remarkable results. Chelsea and Westminster reduced its waiting list for elective surgery by 28 per cent before the strikes threw a spanner in the works. By replacing multiple Excel spreadsheets with a unified data platform, the hospital tripled the productivity of administrative staff and increased use of operating theatres by more than eight per cent. Bruno Botelho, director of digital operations and innovation at the hospital, says staff sickness levels have fallen “significantly” in some areas while public satisfaction has also risen. “Of course it’s about reducing the waiting, making the best use of the resources we have and providing better outcomes for patients but it’s also about engaging staff and bringing the organisation together to deliver transformation,” he says. In Wales, Hywel Dda hospital has seen a 35 per cent reduction in the number of beds filled with patients who are medically fit to go home after introducing Faculty’s Frontier AI tool that predicts discharge dates. If replicated across England it could free up 4,500 beds. With ambulances queueing outside hospitals and waiting lists at a record high, the political debate goes round in circles about funding and pay, staff shortages and bed numbers. In some parts of the NHS, though, radical solutions are emerging. Homerton Hospital in east London has introduced an e-triage system in A&E that uses a digital questionnaire accessed through a wall of iPads to prioritise the sickest patients and manage demand. It is going to add technology that will use the iPad camera to measure blood pressure, heart rate, respiratory and oxygen levels in seconds by analysing subtle changes to blood flow under the skin. The doctors who have seen it in action say it works in a similar way to facial recognition technology. They hope it will further reduce waiting times and also flag up potential sepsis cases, which are notoriously hard to spot for stressed medics in a busy accident and emergency department. As the health service reels from crisis to crisis, there are many reasons to be pessimistic, but science and technology offer a genuine cause for optimism. Robotic surgery has simultaneously improved clinical outcomes for patients and reduced hospital stays. Algorithms will soon transform the ability to predict and prevent illness, with personal risk scores for each patient based on their genetics and lifestyle. The NHS is trialling a blood test designed to detect more than 50 types of cancer before symptoms appear. Artificial intelligence is accelerating drug discovery at an incredible rate. Scientists recently used AI to discover a new antibiotic that can kill a deadly superbug that is resistant to all other treatment. Sir Patrick Vallance, the former government chief scientific adviser, told The Times Health Commission that medicine is entering a “new era of cures” which will revolutionise healthcare if embraced by the NHS. Last month Britain became the first country to authorise a medical treatment that uses a gene-editing tool to reverse the symptoms of sickle cell disease, possibly permanently. Another study is sequencing the genomes of 100,000 babies to assess the feasibility of screening newborns for rare genetic conditions. In time, the heel prick given to all children at birth could be used to find those at risk so that a defective gene can be altered or removed to ensure they never get the disease. Sir John Bell, Regius professor of medicine at the University of Oxford, says scientific discovery is moving faster than at any time in his 40-year career. “It’s an incredibly exciting time,” he says. “The pace of innovation in medicine is greater now than I’ve ever seen it.” But he warns that, despite some courageous trailblazers, the health service as a whole is failing to capitalise on the enormous opportunities offered by science and technology. “The challenges that the NHS has got can only be resolved if we get better at adopting and implementing innovation. That includes digital tools and AI, novel therapies and devices. All the evidence suggests that we are really bad at all those things and it’s hard not to associate that failure to innovate with the fact that we’re lagging behind the rest of the world.”
The life sciences industry is worth over £94 billion a year to the UK. Yet the number of patients enrolled into commercial clinical trials by the NHS has dropped by 44 per cent in the past five years at a cost of almost £1 billion to the health service and far more to the wider economy. Last week the NHS announced that the contract for a new federated data platform had gone to a consortium headed by the American analytics firm Palantir. Privacy campaigners raised concerns about a company that has worked with intelligence agencies and military organisations being involved in healthcare — but Palantir will not be able to access, use or share data for its own purposes. It is a software provider that will help to connect different systems within the NHS. The real problem is that the platform does not include GP or social care data and so the delivery of services will continue to be hampered by fragmentation. There needs to be a grown-up debate about data privacy. A YouGov poll for the Times Health Commission found that 68 per cent of the public would be happy for the NHS to allow their medical records to be shared between clinicians; and 56 per cent said it was more important to them to be able to easily book appointments, order prescriptions and view their medical records than to protect the security of their records. The potential efficiency gains were laid bare by the finding that 7 per cent of patients said that they or a member of their family had missed an NHS appointment because a letter had not arrived in time, or at all. That represents hundreds of thousands of appointments, a shocking waste of resources. If the tax office and banks can keep sensitive financial information safe, there is no reason why the NHS cannot protect health data.
The UK Biobank, which this week released the DNA sequences of 500,000 people along with the volunteers’ de-identified medical records, also shows the huge value of NHS data for scientific research. It is already being used by 30,000 scientists from 90 countries looking for clues about how to prevent and treat disease — and who are paying for access to the genetic treasure trove. Since the pandemic there is a public appetite for technology to play a greater role in healthcare. Virtual wards, which allow people to be treated at home, freeing up space in physical hospitals, have been widely welcomed. More than 32 million patients have signed up for the NHS app but the health service is lagging behind. Ten per cent of hospitals are still paper-based and the computers that do exist can take half an hour or more to switch on. Senior consultants report being unable to cut and paste documents, meaning they have to retype their notes multiple times. One study found that doctors are wasting 13.5 million hours a year on inefficient IT. It should not take expensive management consultants to work out why NHS productivity has slumped. The health service has spent more than £1 billion on storing paper medical records over the past five years but it has spectacularly under-invested in technology, repeatedly raiding the capital budgets that fund IT projects to chuck money at the latest winter crisis. It is doing it again now and it is a false economy. Joe Harrison, the chief executive of Milton Keynes University Hospital who is also NHS England’s digital lead, calculates that every £1 spent on technology generates between £3.50 and £4 in savings. At his trust, there are no document storage costs because all the paper records have been thrown out and the dusty basement archive converted into a suite of modern consulting rooms. Doctors use voice recognition technology to transcribe their notes automatically during ward rounds and there is a Harry Potter-style “marauder’s map” to track staff and equipment. The hospital is also handing out 2,000 Apple watches to diabetes patients, which they will be able to keep if they exercise a certain amount every day. The programme will pay for itself if a single amputation is avoided.
Technology has the power to rebalance the relationship between doctor and patient, allowing people to take more control of their own health. In Estonia, Denmark and Israel, patients can book appointments, see test or scan results and access their medical records using an app. It is convenient but it also encourages a sense of responsibility. This is the only way in which the NHS is going to cope with an ageing population and a growing number of patients with complex long-term conditions. Of course there are reasons to be cautious. This week, a study published in the British Medical Journal warned that telephone or online appointments could put certain patients at risk, although the researchers found that the vast majority were safe. The story of the failed blood-testing firm Theranos, whose founder Elizabeth Holmes was convicted of fraud, is a warning that the new frontier of medicine is still a Wild West and that regulation has not caught up with the reality of genetics and AI. Earlier this year Babylon Health, a tech start-up championed by Matt Hancock as health secretary, went bust having received millions of pounds from the NHS. The role of AI raises ethical questions. It is crucial that databases used to train the machines are properly representative of the population so that, for example, the technology is equally effective with all skin colours. Clear limits must be set. An AI embryo selection tool used by some fertility clinics improves the chances of a healthy pregnancy by as much as 30 per cent. It is programmed to choose the most viable embryo for implantation — but if the technology advances and it is in future possible for the machine to choose the gender, intelligence or eye colour of the child, should it be allowed to do so? I would say not. The way in which the NHS buys drugs will need to be rethought. The new gene therapies are (for now at least) incredibly expensive. A single treatment can cost £1 million or more. This may be money well spent if the patient is cured (and goes on to live a long life, paying taxes while not requiring other types of healthcare) but the NHS cannot afford to pay for many such therapies in a single year. The National Institute for Health and Care Excellence is looking at ways for such novel treatments to be funded over a longer period, rather like a mortgage, with a claw-back written into the contract if they do not work as effectively as hoped. There will also be challenges for the NHS workforce — in future the health service may need more data analysts and fewer dermatologists — but it cannot stay stuck in the analogue age. Seventy-five years after its creation the National Health Service has a tendency to mythologise its past, but it must look to the future. Tony Young is a surgeon from Essex who founded four health-tech start-ups as a junior doctor and says he “had to fight the health service the whole way”. Now he is in charge of innovation at NHS England and has recruited 1,100 NHS staff to his clinical entrepreneurs programme, which encourages doctors to think outside the box. Between them they have founded nearly 500 companies — including the one flying rainbow-coloured drones across London — and raised £870 million. “At the moment we have 15,000 centenarians in the UK. When the NHS turns 150 in 2098, it is predicted that there will be 1.5 million centenarians. How do we deal with that? Technology has to have a key role to play,” says Young. “People say, ‘there’s a risk of doing something new’. Let’s measure that risk. Let’s mitigate that risk. But let’s look at the risk of the status quo because you could come to harm while waiting to be seen.”
The new rearrangement of the ministers sitting in their deckchairs on “NHS Titanic” is likely to achieve little for health care. The government does not know who to give health to – so we have another short lived minister for an organisation with a short prognosis. No waiting list reductions are likely in my lifetime…. With the highest sickness and absenteeism record in the western world, along with losing staff, increasing efficiency will be a right challenge. Like managers in the 4 health services, ministers are learning to move on before theiy can be accountable.. Managers and commissioners are stuck in the provider procurer split, where the money moves with the patient. So Wales is bust and cannot afford good care, and its citizens wait longer with the outcomes you might expect.Mr Barclay is replaced by Ms Atkins…. so?With strikes, social care void, and no meaningful manpower plan, on top of the waits….I remember putting “ergophobia” and “plumboscillosis” on sickness certificates way back….
The Times leader 14th November opines: Careless Inefficiency – Fixing low productivity should drive radical improvements Attempts to examine the NHS’s ills often alight on simple and superficially plausible diagnoses: that the health service is chronically short of funding, understaffed, or both. But it is worth seeking a second opinion. What these rote explanations cannot account for is the puzzling productivity crisis at the heart of the service. Despite a larger budget and higher staff numbers, the NHS is treating fewer patients than it did before the pandemic. To its credit, NHS England has woken up to this productivity problem; as reported in the Times, the service has contracted the consultancy firm McKinsey to carry out a ten-week review into the causes of its poor performance. Once recommendations are ready, they must be ambitiously implemented: doing so is the only way to put taxpayers’ money to its most effective use and turn around a sclerotic service. Though disputes over staffing levels and funding are often the most noticeable symptoms of disorder in the NHS, evidence suggests that neither is at the root of the service’s productivity slump. The NHS employs 16 per cent more doctors than it did four years ago, and 37 per cent more than it did in 2010. Even adjusting for increased staff absence due to sickness, manpower has increased. Real-terms funding is up by £20 billion. The mystery is why greater resources are being put to worse use. Elective surgery has slumped, as have the number of incidents recorded by ambulance services. Against the backdrop of a growing workforce, it is not obvious that throwing more staff or money at the service would do much good. Given such dismal figures, it is hardly surprising that the prime minister’s ambition to slash waiting lists looks doomed to fail. The list stands at a record 7.78 million; but this figure may well play down the scale of the crisis. More than 11 million patients are in need of follow-up care — including those waiting for referrals and cancer check-ups, or needing treatment for post-operative complications. Taking these cases into account brings the total waiting list to more than 18 million. None of this induces confidence in the NHS’s ability to weather what could be a tougher winter than last year’s, which left patients stalled in queues of ambulances outside A&E departments. Surveys of hospital leaders show that eight in ten fear this winter will be worse; only 27 per cent expect the quality of health care to be “high” next year. Just what underlies the chronic lack of productivity in the NHS is uncertain. One explanation is that though staff numbers are up, they have not risen in the right places. While there are more hospital doctors than ever, there are 2 per cent fewer family doctors than in 2019. Only one in four GPs now work full time. The knock-on effect is to increase pressure on hospital services. A higher standard of community care would also help to shift the NHS’s emphasis away from acute treatment and towards much-needed preventative initiatives. Another likely source of inefficiency is the long-term underinvestment in capital assets — buildings and equipment — within the health service. Over the same period that its workforce increased by 26 per cent, the value of its capital assets rose by 4 per cent. This looks like a particularly inefficient use of funds at a time when technological breakthroughs in the management of data and diagnostics could dramatically improve patient outcomes. Taking such innovation seriously could put a fragile health service on the mend.
Times letters 15th November: NHS productivity Sir, reports that management consultants have been brought in to boost productivity in the NHS, despite higher budgets and more staff, highlight deep-rooted management challenges (news, Nov 13; leading article & letters, Nov 14). While managers are often portrayed as a burden, the truth is that good managers run organisations effectively. Research from the Chartered Management Institute and the Social Market Foundation found that, on average, 43 per cent of NHS hospitals scoring above average in management practices achieved “high quality” outcomes — better patient care — compared with 14 per cent of those below average. Embedding a pipeline of skilled managers into the NHS, through proven routes such as degree level and senior leader management apprenticeships to upskill existing, knowledgeable and hardworking staff, is crucial if we are serious about finding a longer-term fix to the productivity problem. Anthony Painter Policy director, Chartered Management Institute Sir, A management consultancy can surely only address management. This approach may have relevance to business, but only where healthcare itself is a business can measures of productivity be easily defined and become an arbiter of good function. The NHS is not a business. It is a public service, and while the number of services it produces is one measure, the quality, accessibility, and reach of those services is at least as important and may not be captured in a business-focused review. Professor Tony Redmond Stockport
Letter follow up on NHS productivity Letters 16th November: Curing NHS ills and Letters 17th November on Productivity: Sir, A good start to improving NHS productivity would be to recognise that the NHS is over-administered and undermanaged (news, Nov 13 & 15; letters, Nov 14 & 15). Clinical teams need the support of experienced managers to reduce unwarranted variations in performance in all areas of care and freedom from overbearing bureaucratic oversight. The NHS relies on the discretionary effort of its staff and this has been eroded by the pandemic, staff sickness and chronic staff shortages. Political leaders must show they value staff and find a way of resolving industrial disputes. Investment in new buildings and technologies must be prioritised to support the adoption of innovations in care. This means not raiding capital budgets to cover gaps in running costs, as is happening yet again. The effects of endemic short termism by successive governments are now in plain sight. Professor Sir Chris Ham Solihull, West Mids
Sir, The root of poor NHS productivity is widespread unexplained variability in performance. Every NHS activity is done to world-class standards in some places but appallingly badly in others. Bringing the poor performers up to and beyond the average, as McKinsey will recommend, would improve overall productivity by 20 per cent or more. However, since there are few mechanisms for transferring best practice and extraordinarily poor understanding of what resources each activity consumes at the local level, this will be rather difficult to achieve. David Hulbert Ex-NHS trust non-executive director and McKinsey consultant, London N1
Sir, As a consultant paediatric radiologist I am all too aware of the limitations of human visual perception and remain hopeful that artificial intelligence algorithms will deliver genuine benefits to patient care (“AI tool could help prevent one in five heart attacks”, news, Nov 14). However, the direction of this research is, in my view, misguided. As technology becomes more advanced, we will doubtless be able to identify ever more individuals at risk of cardiovascular disease, but epidemiology already tells us most of the adult population is at risk. Promotion of a healthy lifestyle across the board would be a better use of resources as 80 per cent of heart attacks and strokes are preventable. I appreciate the headline “Common sense could help prevent four in five heart attacks” is unlikely to make your front page, but now we have a minister for common sense, who knows what is possible. Dr Michael Jackson Edinburgh
Sir, The management consultancy McKinsey has been brought in by NHS England to examine why it is not performing more operations than before the pandemic (“NHS failing to improve despite rise in budget and staff”, Nov 13). Perhaps they could save money by instead asking their own consultant surgeons.
The NHS has employed more surgeons, but many senior ones have gone part-time as they have become disillusioned, so the actual number of full-time equivalents has gone down. The number of operating theatres and lists is the same, so new surgeons have taken lists from older and more experienced ones, reducing the number of operations. The punitive tax regulations, which are finally being addressed, led to premature retirements and a huge loss of morale. The CPI-adjusted pay of consultants has fallen by 30 per cent in 12 years.
Did Covid influence this? Yes. Surgeons had no option but to continue to operate, unacknowledged and often without effective PPE, knowing many in China and Italy had died in similar circumstances. Why is the government deaf to all of this? Twenty-five years ago, most senior doctors were faithful Conservative voters. The systematic devaluation we have experienced has reversed that, so the government no longer sees us as worth investing in. Almost without exception, doctors used to shore up the NHS by working far beyond their contracted hours, but no work force that feels undervalued will work to its full potential. Alistair Jenkins, Hugh Gallagher, Bruce Jaffray, Joe O’Donohue, consultant surgeons; James Graham, consultant radiologist, Royal Victoria Infirmary, Newcastle
The leading articl in the Sunday Times 29th October is honest, and holds out little hope. The article may be correct that “only Labour has the political space to enact genuine change”, but would we voters not respond to ANY party that was honest now? I have been unable to persuade pacifist Liberals to be brave, honest and upstanding, although I have been speaking out for 20 years. NHSreality is afraid it will have to get worse, with an increase in excess deaths, waiting lists, and private health care for those who can afford it.It seems politicians, managers and the media are all in this conspiracy of denial togther, and as far as making suggestions that other systems might be better – silence.
The idea that someone trained in 2 years can do the job of a diagnostician, whose “surgical sieve” excludes the less obvious options for a diagnosis . In the UK a GP is prepared to live with some uncertainty and use time as a diagnostic tool, but this method of rationing care will die as citizens expect certainty, instant investigation and diagnosis. NHSreality predicts that the ratio of normals to abnormals will rise exponentially, and the waiting lists for everything will lengthen. Physician Assistants without long term planning and the cooperation of the profession, are likely to be a political sop and a systematic failure. 16th October 2023 in LBC views and news: Plan to pump 10,000 fake doctors into the NHS is insane and dangerous, writes James Perkins You might not have heard of a ‘physician associate’ – and that’s not your fault. They probably won’t tell you. A physician associate walks and talks like a doctor, but they are no replacement for one. To become a physician associate you need to complete a two-year postgraduate course or three-year apprenticeship. But despite much less learning than the five years a junior doctor must undergo to be qualified, they are often paid more than them. Which is why the government’s plan to flood the NHS with 10,000 more of them over the next 15 years doesn’t make any sense. There’s certainly no money-saving aspect. This is simply another corner-cutting exercise to quickly plug gaps in a struggling NHS that will put patients at risk. Importing the idea from America and asking under-qualified and ill-equipped graduates to make life-saving decisions is, obviously, a bad idea. Getting 10,000 of them to replace actual doctors is a terrible one. Far from saving doctors work (their original purpose), they often create more. Physician associates are unregulated so cannot be held accountable for their mistakes, meaning doctors must recheck any critical decisions they make. Critical decisions are made quite frequently in hospitals. But they’re not just overstretching doctors and creating more work; they’re harming patients. A recent Daily Mail investigation has found brain bleeds misdiagnosed as inconsequential headaches and lung disease mistaken for a chest infection. Doctors say they are “increasingly concerned” by this. Over the summer, hundreds signed an open letter to the Royal College demanding that physician associates (that they insist should be called physician ‘assistants’) stop introducing themselves to patients as doctors. They claim that they are ‘passively permitting themselves to be referred to as doctors’ by patients who see some scrubs or a smart shirt and – understandably – make that assumption. So until this dangerous plan is scrapped, the next time someone in a hospital tells you “I’m part of the medical team,” it could be a clever lie by omission. The person who’s just diagnosed you might not be a doctor at all. The government must stop cutting corners with the NHS and fill the gaps with the only people properly qualified to: doctors.
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