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Article 2 of a 3 part series on the NHS

Original illustration for Healthcare-Arena by Fran Orford

As anyone with any experience in repairing things will tell you “you can’t fix it until you know which bit is broken”.

But is the NHS broken? Maybe the more important question is whether we view the NHS a problem or an asset? Does it need fixing because it’s broken or does it need improving so that it can be better still?

The NHS is the most cost-effective health system in the world according to the Commonwealth Fund report “Mirror, mirror on the wall”(1). But we don’t have any way of measuring whether our hospitals are as efficient as our overseas counterparts in day-to-day delivery of healthcare (2).

However, three cost and efficiency issues for the NHS are critical right now:

  • Workforce: the cost of agency nursing
  • Junior doctors: new pay and conditions contract
  • Procurement: the new procurement processes being implemented and the relationships with suppliers

Workforce and agency staffing

The NHS employs 1.3 million staff, and had a pay bill of £45.3bn in 2013/14. Of that total, the bill for nurses was £19bn. A focus on safer staffing levels and an increase in the rate of nurses leaving the profession of 29% in the last two years has led to the doubling of agency nurses (3).

The unprecedented rise in the amount that the NHS spends on agency nursing staff is set to be at least £980 million. According to the Royal College of Nursing (RCN) there are an estimated 20,000 nursing vacancies in the UK but filling them is difficult as a result of workforce cuts, reductions in nurse training places, years of pay restraint and attacks on terms and conditions. This has caused many nurses to leave and also encouraged many others into agency work (4). The RCN is calling for serious workforce investment and sensible, long-term workforce planning. The money currently being paid to nursing agencies would, the RCN estimates, pay for 28,155 permanent nursing staff with the right balance of skills and experience.

Training qualified staff to fill those vacancies is currently the responsibility of Health Education England (HEE) who try to balance the requirements for future medical and non-medical workforce, training the existing staff and balancing local and national needs as well as prioritising workforce decisions in the context of wider systems and strategic goals. And all within an annual budget of £5bn of taxpayers’ money. The current HEE ‘Investing in people’ document (5) recognises the gaps but claims: “this does not automatically mean increased training is a necessary parallel response”, and adds “if we always respond … by increasing training, then we risk condemning ourselves to a system in which we use all our resources on the future workforce rather than the current”.

The HEE lays much of the blame for the need for new training places at management’s door. Apparently it is the result of a “leaky bucket effect” where “employers are failing to retain and develop their skilled staff”. Perhaps the authors of the report should have paid a little more attention to what the RCN says about how nurses feel they are being treated: the word ‘morale’ does not appear in the HEE report. The Royal College of Nursing’s 2014 pay consultation survey revealed that 96% of nursing staff felt undervalued and underappreciated (6); even the NHS’s own survey found 59% of staff feeling that the NHS does not value their work!

This challenging juggling act for the HEE is all set to change with the very new proposals to completely scrap nursing bursaries announced on 25th November. This proposal is allegedly to increase the number of student training places from 20,000 to 30,000 within the next four years in line with increased demand for nurses. According to George Osborne, nurses should fund their education through loans like the rest of the student population, except nurses – training on the job, working unpaid for almost 50% of the time ­– are not like other University students. The reason that it is even possible is because the HEE can be removed from the NHS budget ring fence, as yet another cut to non-frontline areas of NHS activity and funding.

Junior Doctors pay and conditions contract

As part of a plan to build an affordable seven-day-week NHS – where non-emergency health services are also available outside office hours and during the weekend – the Health Secretary proposed new pay and conditions for junior doctors. The new proposal, which many view as both a reduction overall earnings and unsafe working hours, has been a source of intense debate and resulted in overwhelming support for industrial action (76% of junior doctors). This was called off at the last minute but negotiations are still on-going. Safety concerns due to tiredness have been raised regarding the working conditions of frontline medical staff. The proposals set out pay and conditions including a 11% pay-rise, but simultaneously reveals longer working hours and unclear direction post-2019, highlighting both political incompetence and mismanagement of the NHS for many individuals. Politicians have the audacity to claim the doctors concern is that they will lose money.

Industrial action is not taken lightly; in fact this is the first time in NHS history that junior doctors were prepared to provide no care whatsoever as part of strike action. The cost-neutral offer of November 2015 is the basis for further negotiation. The BMA, NHS Employers (acting on behalf of the employers of junior doctors) and DH will work collaboratively to develop and oversee new contractual terms and conditions of service for junior doctors. Allowing negotiations to progress, NHS Employers have agreed to extend the timeframe for the BMA to commence any industrial action by four weeks (to 13 January 2016); the BMA agrees to temporarily suspend its proposed strike action; and the Department of Health agrees similarly to temporarily suspend implementation of a contract without agreement. The saga continues…

Procurement

The good news is that an e-procurement system is being put in place that will, for the first time, provide the NHS with a catalogue-type system for purchasing. The system will depend on the implementation of global GS1 coding and PEPPOL messaging standards throughout the NHS. Once in place, these systems will enable the NHS to control its non-pay spending much more accurately. There will also be spinoffs in patient safety as the GS1 barcodes will be accessible at any point in the supply chain (7). The role of the e-procurement strategy meshes well with the Carter recommendations which estimate that the introduction of the standards will allow every NHS hospital in England to save up to £3m each year while improving patient care (2).

Superficially, at least, this all seems very positive, but in advance of the full implementation of the new systems, significant savings are still to be delivered over the next four years and NHS purchasing departments are quite open about their desire to pass the problems of achieving these savings on to their suppliers. Healthcare Arena has seen letters from NHS Purchasing consortia explaining that although they recognise that “the private sector has its own pressures and the zero-inflation policy will potentially have an impact on your business” they are happy to rely on the suppliers’ “continued goodwill in helping us to move forward”! That degree of buck passing would probably lead to disciplinary action if it were directed at an internal department, but in this case it is directed towards external suppliers.

The most recent interim guidance from the Carter review is quite clear: the primary savings that can be made in the area of procurement will come from internal NHS organisational improvements (2). Carter reviewed procurement data from 22 hospitals and noted in the interim report that

“we collected all accounts payable and purchase order data … for the last two years and only 18% could be matched” (2).

The report also noted the variation in inventory management practices and concluded that:

“…there are greater savings to be had by managing the demand for products through better inventory management rather than price reductions.” (2).

Nevertheless, the purchasing consortium offers suppliers a number of ways they can help to reduce their prices, including: extending current contracts with improved prices, waiving carriage charges and retrospective rebates. Ironically, the consortium also suggests that suppliers might like to offer a discount for early payment … and therein lies a further issue: quite a few NHS Trusts have surreptitiously moved to 60-day, and in some cases, 90-day payment terms.

This is in direct conflict with the government’s position on large customers working with small business suppliers, which has been clearly stated: small businesses should be paid within 30 days of providing an invoice. However, some of the NHS Trusts have stated that their new 60-day terms apply for all suppliers, effective immediately. This is not a defensible position for taxpayer-funded organisation and is, in fact, in breach of NHS terms and conditions which state:

9.6       The Authority shall pay each undisputed invoice received in accordance with Clause 9.3 of this Schedule 2 within thirty (30) days of receipt of such invoice at the latest. However, the Authority shall use its reasonable endeavours to pay such undisputed invoices sooner in accordance with any applicable government prompt payment targets.

If the proposed Enterprise Bill is enacted then we can expect that the new Small Business Commissioner will be looking into the NHS’s procurement performance, especially in areas that have already been identified as causing dispute between small suppliers and large customers, which includes extended payment terms and discounts for prompt payment (8).

It is now time-critical that the Government and NHS pay urgent attention to:

  • “Joined up” workforce planning for both the long-term, and the interim period, while new medical staff with a scheduled reduction in the use of agency staff
  • Safe and fair treatment for NHS staff, delivering professional high-standard care should be rewarded with a reasonable wage and both safe and fair working hours
  • Proper rationalisation of procurement processes and implementation of e-procurement systems with enforcement of terms and conditions that meet the Government’s guidelines

So, if the NHS is already the most cost-effective healthcare system in the world in terms of value for money for the taxpayer, the only real way to have a significant additional impact is for the taxpayer to be prepared to pay more for healthcare. In its final section, Healthcare Arena looks at the challenges facing the NHS today. If the NHS is to continue delivering a first class service, increased funding, improved education and transparency are key to its future success.

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

 

References:

  1. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally [Internet]. [cited 2015 Sep 23]. Available from: http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror
  2. Carter. Productivity in NHS hospitals – Publications – GOV.UK [Internet]. [cited 2015 Sep 23]. Available from: https://www.gov.uk/government/publications/productivity-in-nhs-hospitals
  3. The cost of short-term planning – £1bn on agency nurses in 2014/15 – Frontline First [Internet]. [cited 2015 Sep 23]. Available from: http://frontlinefirst.rcn.org.uk/sites/frontlinefirst/index.php/blog/entry/nhs-runaway-agency-spending-report/
  4. RCN. The cost of short-term planning – £1bn on agency nurses in 2014/15 [Internet]. 2015 [cited 2015 Sep 18]. Available from: http://www.rcn.org.uk/newsevents/news/article/uk/the-cost-of-short-term-planning-1bn-on-agency-nurses
  5. Health Education England » Workforce plan for England 2015/16 [Internet]. [cited 2015 Sep 23]. Available from: https://hee.nhs.uk/2015/02/05/workforce-plan-for-england-201516/
  6. RCN responds to Health Minister’s comments on pay and morale [Internet]. 2015 [cited 2015 Sep 22]. Available from: http://www.rcn.org.uk/newsevents/news/article/uk/rcn-responds-to-health-ministers-comments-on-pay-and-morale
  7. NHS e-procurement strategy – Publications – GOV.UK [Internet]. [cited 2015 Sep 23]. Available from: https://www.gov.uk/government/publications/nhs-e-procurement-strategy

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Article 1 of a 3 part series on the NHS

Original illustration for Healthcare-Arena by Fran Orford

It all started so well. In 1946, the National Health Service Act was published, and on the 5th July 1948, the NHS created. Welcomed, fêted, needed. From the idea of universally available healthcare regardless of wealth, the NHS was initially based on three core principles: that it met the needs of everyone; that it be free at the point of delivery; and that it be based on clinical need, not ability to pay. Today, the NHS is a different beast, facing many new challenges. Stemming from extensive discussions with staff, patients and the public, these three guiding principles have expanded to seven principles that are still underpinned by core NHS values (1).

  • Principle 1. The NHS provides a comprehensive service available to all.
  • Principle 2. Access to NHS services is based on clinical need, not an individual’s ability to pay.
  • Principle 3. The NHS aspires to the highest standards of excellence and professionalism.
  • Principle 4. The NHS aspires to put patients at the heart of everything it does.
  • Principle 5. The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population.
  • Principle 6. The NHS is committed to providing the best value for taxpayers’ money and the most effective, fair and sustainable use of finite resources.
  • Principle 7. The NHS is accountable to the public, communities and patients that it serves.

Aspiring to excellence and attempting to meet such high expectations does not come cheap – there is a constant battle to maintain much-needed services in the face of financial cutbacks. But this is not new, almost from day one, the government was looking at ways to save money; the Guillebaud Report of 1955 found that in relative terms, NHS spending had fallen from 3.75% to 3.25% of Gross National Product (GNP) and that capital spending was running at only 33% of pre-war levels.

Governments continued to tinker with the NHS; cuts, changes, Acts, and reorganisations have happened almost on an annual basis since 1948. These can be viewed on an excellent Nuffield Trust info-graphic (2). Examples include:

  • 1973 – NHS Reorganisation Act.
  • 1983 – Griffiths report commissioned to explore staff and other resource efficiencies.
  • 1990s – split between purchasers and providers of care, GP fund-holders and a state-financed internal market to drive efficiency, the Patient’s Charter, NICE & NHS Direct established, GP fund-holding abolished, primary care groups (PCGs) established.
  • 2000s – 10-year plan implemented (modernisation, investment & reform), SHAs, PCTs created, and Wanless report recommends investment in NHS. In 2003 after reorganisation, foundation trusts established, then practice-based commissioning introduced, followed by the New NHS (2013, resulting from Health & Social Care bill), the Five Year Forward View (2014) and in 2015, the launch of devolvement in Manchester.

It seems that successive governments have almost been in a classic abusive relationship pattern with the NHS – “I only batter you because I love you…”. While waxing lyrical about the NHS to the rest of the world, in reality, they want savings to be realised and to contribute less to its running. The latter shouldn’t be too difficult, though. Figure 1 shows approximate GDP spend on the NHS since inception (Chantrill 2015).

Figure 1:  GDP spend on NHS since 1948 (3).

Figure 1: GDP spend on NHS since 1948 (3).
Figure 1

At Eight percent GDP, current NHS spending is at its highest, According to the Organisation for Economic Co-operation and Development (OECD) figures, UK spending is lower than other 15 other OECD countries, on a par with five, and above 11 others (4). However, the current Government has pledged to ‘invest’ £8bn pa into the NHS until 2020, the question is – can we stop money from leeching out of the NHS?

It would appear not. In 2015, NHS organisations in England ended the financial year with a total deficit of £822m, compared with £115m the previous year. As a result, the NHS regulator, Monitor and Secretary of State for Health, Jeremy Hunt, have thrown their toys out of the pram, with Mr Hunt, in particular blaming everything from agency staff costs to consultants playing golf (instead of working seven days per week). Foundation trusts were told by Monitor that their financial forecasts for the next year were untenable and further savings must be made on top of the £22bn they need to save over the next 12 months (5).

Does the government have a point? Carter’s interim report on NHS efficiency appears to support this (6).  For example, the review team has found:

  • A wide variation in spending on medicines, everyday healthcare items and on NHS facilities, including maintenance and heating, between the 22 NHS Trusts studied.
  • A potential saving of £5bn a year on NHS workforce and supplies.
  • An increases in hospital staff efficiency by just 1% could save the NHS around £400m per year.
  • A high level of inefficiency in NHS staff management; one hospital was found to be losing £10,000 a month in workers claiming too much leave.
  • Inconsistent costing for elective surgical procedures, such as hip operations (sometimes costing twice as much as they should).

A lack of research into cost-effective surgical implants. For example, more expensive hip joint prostheses did not last as long as less expensive ones, resulting in more hip replacements and hospital admissions. This single example costs the NHS an extra £17m each year.

Recommendations included in the interim report (5) include:

  • Better use of NHS staff through flexible working and better rostering.
  • Better use of prescribed medicines; for example, one NHS Trust saved £40,000 a year by using a non-soluble version of a medication.
  • More savings made on hospital items such as aprons, gloves and syringes. (For example, latex gloves costing £5.44 a box at one hospital are bought for £2.39 in another).
  • The use of a single electronic ‘catalogue’, facilitating more ‘competitive’ NHS purchasing.

Inefficiencies contribute to deficits, so can better management of NHS resources make substantive savings without affecting patient care? Probably, examples of wastage include the use of specialised equipment like imaging machines only on a Monday to Friday basis, and the overuse of agency staff (across all aspects, cleaners, nurses and drivers). Addressing these issues is critical; increasing running costs as well as and rising indirect costs such as clinical negligence are not sustainable. The leakage of money out of the NHS points to poor management and inefficiency and calls to question whether improvements in the running of NHS should be the government’s focus, rather than financial cutbacks. In part II (“Fixing the NHS”), Healthcare Arena explores NHS management, cutbacks and efficiency to ask if the organisation as a whole really needs fixing.

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

 

References

  1. The NHS Constitution. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/480482/NHS_Constitution_WEB.pdf Accessed December 2015
  2. Nuffield Trust. The History of NHS Reform. 2012. http://nhstimeline.nuffieldtrust.org.uk/?gclid=CKDAvbrttMcCFVdAGwodex8Bfg Accessed August 2015
  3. Chantrill C. UK Public Spending since 1990. http://www.ukpublicspending.co.uk/spending_brief.php Accessed August 2015
  4. The King’s Fund. Health care spending compared to other countries. 2015. http://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/health-care-spending-compared. Accessed August 2015
  5. Parnham D. The Carter Review. Procurement in the NHS. HealthCare-Arena. 20th July 2015. https://healthcare-arena.co.uk/the-carter-review-procurement-in-the-nhs/
  6. Department of Health: NHS Procurement. Review of Operational Productivity in NHS Providers. Interim Report. June, 2015. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/434202/carter-interim-report.pdf

 

 

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Image: ©vaeenma/iStock #50254576

In the UK, more than 3.2 million live with diabetes, up from 2.1 million in 2005. The majority (90%) have type-2 diabetes, which is linked to poor diet and obesity.

Diabetes arises when the body loses its ability to use or make insulin, a hormone that helps regulate the amount of sugar in the blood, causing uncontrolled blood sugar levels. Patients with diabetes are at risk for macrovascular complications such as myocardial infarction and stroke, and microvascular complications such as nephropathy, retinopathy, and neuropathy. It can lead to devastating complications such as blindness, and was the cause of 22,000 early deaths last year.

Many diabetics experience peripheral neuropathy (nerve damage), which can result in a loss of sensation or persistent, nagging pain. The loss of sensation can lead to sores or infection in the feet, which, if left undetected necessitate lower limb amputation (135 per week across the UK); diabetic peripheral neuropathy can also cause gnawing, tingling, shock-like, or shooting pain in the extremities, which causes great distress and has no cure.

The spiralling numbers of diabetes patients, following the trend of obesity, shows that the public may still be unaware of the severity of these conditions.

Human cost aside, what about the NHS?

The dramatic growth in the numbers of people with diabetes underlines the urgent need for prevention, before the disease burden overwhelms the NHS.

  • The NHS spends 10% of its entire budget managing diabetes
  • Diabetes already costs the NHS nearly £10bn a year, and 80% of this is spent on managing avoidable complications
  • In 2014-15, there were 47.2 million items prescribed in England for diabetes
  • Diabetes prescription accounted for 4.5% of the total number of items prescribed and 10% of the total cost of all prescribing
  • Since 2005-6, prescribing of antidiabetic drugs has risen by 107%, with the net ingredient cost increasing by 138.6%

Despite this exorbitant spending, the charity Diabetes UK has warned that only 60% of patients receive all the care processes they require for effective monitoring and treatment. There is huge potential to save money and reduce pressure on NHS hospitals and services, but without successful diabetes prevention, this figure will unquestionably rise to unsustainable levels.

If nothing changes then what will happen?

The shocking recent headline that ‘Diabetes cases soar by 60% in past decade’ (1) is likely to have worried many, because – as with obesity – it is not an easily reversible trend. Many believe that obesity causes prediabetes (non-diabetic hyperglycaemia), a metabolic condition that almost always develops into type-2 diabetes

According to data from Public Health England, five million adults in England are pre-diabetic; using much broader criteria, Diabetes UK actually estimates a UK-wide figure of around 18 million people as being risk of developing diabetes; and the British Medical Journal suggests a staggering third of all adults in England are already pre-diabetic (2). However, some doctors have questioned the value of the pre-diabetic diagnosis (3), arguing that only a small number – perhaps one in 10 – will go on to develop diabetes.

Despite these widely variable outcome predictors for diabetes, the fact that diabetes prevalence has soared, and obesity – the greatest risk factor for developing DM – continues to “spread”, it is highly likely that diabetes prevalence will continue to grow.

Cause of diabetes: unhealthy lifestyle, genes or gut microbiota?

Diagnoses are not always clear-cut: obesity and diabetes result from complex interactions between environmental and genetic factors. However, with 80% of people with type-2 diabetes being overweight or obese at the time of diagnosis (according to the International Diabetes Federation), the explanation for the recent exponential increases in numbers of type 2 is being placed on the expanding waistlines of the nation. Excess abdominal fat is an especially high-risk form of obesity: abdominal fat causes pro-inflammatory mediators to be released from fat cells, which effectively reduce insulin responsivity, a major trigger for type-2 diabetes.

Recently gut microbiota has shown to be involved too. Using mice genetically predisposed to obesity and metabolic disorders Ussar and co-workers showed that this phenotype is the result of interactions between gut microbiota, host genetics, and diet (4). This is somewhat encouraging: individuals may be amenable “reprogramming” of microbiota for ameliorating the development of metabolic disorders and may offer hope for faecal transplants in the future.

So what’s new? Is it as simple as healthy eating and more exercise?

Although diabetes medication is routine treatment, it basically helps to control the condition and is not preventative. These drugs fall into many categories, such as alpha glucosidase Inhibitors (slow carbohydrate digestion), incretin mimetics, and thiazolidinediones (reduce insulin resistance), to name but a few. With diabetes, the old adage – that prevention is better than cure – is a huge understatement.

Although to many, healthy lifestyle choices are common sense and almost intuitive, the NHS is preparing to roll out a diet, weight loss and exercise programme that has been shown to reduce the diabetes risk for a quarter of those who take it up. However implementing these recommendations into real world settings is a challenge for many.

Most people understand that in order to reduce risk of developing diabetes or reduce complications associated with diabetes they need to lose weight, exercise and eat healthily, but can find it difficult to maintain, so therefore patient support is critical. Mobile applications and web-based technology can be useful in self-management, and particularly for lifestyle changes in patients with diabetes.

A review of internet-based interventions highlighted that they were focused on management of glycaemic controls and drug titrations and rather than lifestyle changes, and that in this respect they lacked behaviour theory and educational components (5). This comes as a surprise as the lifestyle choices could be both cause and cure for the disorder. Promisingly, they found the tools available demonstrated improvements in behavioural, physiological outcomes as well as improved knowledge and self-efficacy. This suggests that utilisation of the almost ubiquitous smartphone as a motivational and educational tool may hold promise for managing type-2 diabetes for individual and peer-to-peer support using social media.

Another school of thought believes that a more drastic method is required: bariatric surgery. A recent study demonstrated that half of the type-2 diabetes patients who had weight loss surgery were cured for at least two years (6). Overall they were less likely to have heart problems (a common side-effect of uncontrolled diabetes), and reported improved quality of life and even those who weren’t cured were able to better manage their symptoms. In fact, so effective is this approach that NICE guidelines have reduced the threshold for consideration for surgery from a BMI of 35 with concurrent health to a BMI of 30-35 (7).

Clearly, in order to slow this wave of diabetes something must change, whether it is a more aggressive pre-symptomatic diagnostic phase with education and behavioural therapy, or decisive action regarding surgery at early stage or more effective symptomatic treatment. Technology must be embraced, so that patients can self-manage, self-motivate and prevent diabetes and its deleterious complications before NHS resources are overwhelmed with what is largely a preventable disease.

 

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. http://www.bbc.co.uk/news/health-33932930.
  2. Wise J. A third of adults in England have “prediabetes,” study says. BMJ. 2014;348:g3791. Epub 2014/06/12.
  3. Yudkin JS, Montori VM. The epidemic of pre-diabetes: the medicine and the politics. BMJ. 2014;349:g4485. Epub 2014/07/17.
  4. Ussar S, Griffin NW, Bezy O, Fujisaka S, Vienberg S, Softic S, et al. Interactions between Gut Microbiota, Host Genetics and Diet Modulate the Predisposition to Obesity and Metabolic Syndrome. Cell metabolism. 2015;22(3):516-30. Epub 2015/08/25.
  5. Cotter AP, Durant N, Agne AA, Cherrington AL. Internet interventions to support lifestyle modification for diabetes management: a systematic review of the evidence. Journal of diabetes and its complications. 2014;28(2):243-51. Epub 2013/12/18.
  6. Arora T, Velagapudi V, Pournaras DJ, Welbourn R, le Roux CW, Oresic M, et al. Roux-en-Y Gastric Bypass Surgery Induces Early Plasma Metabolomic and Lipidomic Alterations in Humans Associated with Diabetes Remission. PloS one. 2015;10(5):e0126401. Epub 2015/05/07.
  7. http://pathways.nice.org.uk/pathways/obesity – path=view%3A/pathways/obesity/surgery-for-obese-adults.xml&content=view-node%3Anodes-people-with-recent-onset-type-2-diabetes.

 

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NHS England’s CEO outlines the implementation of the ‘Five Year Forward View’ at this year’s NHS Confederation conference

Image: ©Rick Partington/Shutterstock #274143101

On 23rd October 2014, NHS England published its Five Year Forward View, which began with the statement (1,2):

‘the NHS is at a crossroads and needs to change and improve as it moves forward.’

The NHS Five Year Forward View was developed by several organisations that oversee and deliver health care (2). These organisations include NHS England, Public Health England, Health Education England, Monitor, the NHS Trust Development Authority, and the Care Quality Commission, with input from patient groups, clinicians and independent experts (1,3,4,5,6,7). This collective document, the Five Year Forward View, was developed as a five-year plan of how the NHS should change if it is to close the widening gaps in the funding and quality of care of the NHS (2). It includes a description of various local and national models of care required to support healthcare delivery, disease prevention, new models of service delivery, and integration of services (2).

The NHS Five Year Forward View had three main recommendations (2):

  • Firstly, that we all take our health more seriously, to reduce the health burden due to alcohol, smoking and obesity.
  • Second, that changes should be made in the way that health services are provided, including by combining health and social care.
  • Third, that the government provides financial support to allow the delivery of high-quality NHS services. In the latter case, staged funding increases were proposed to close the £30-billion gap by 2020/21.

The NHS Five Year Forward View detailed the following new models for future health care provision (2):

  • GP practices to be allowed to combine into single organisations providing a wider range of services.
  • New organisations to be created that provide both GP and hospital services together with mental health, community and social care.
  • Creation of seven-day-a-week networks to patients needing urgent care.
  • Sustaining local hospitals, if clinically justified and supported by local commissioners.
  • Concentrating some services into specialist centres.
  • Allowing groups of midwives to set up NHS-funded midwifery services to give women the choice of having home births.
  • Provision of more health and rehabilitation health services in care homes and thus improving the quality of life and reduce hospital bed use.
  • Provision of more support for carers and encouraging volunteering.

On 3rd June 2015, the NHS Confederation held its annual conference in Liverpool (8,9). The conference was attended by more than 3,000 health-sector leaders. NHS England’s CEO, Simon Stevens delivered the keynote speech on the opening day and set out his plans for how the NHS could deliver the Five Year Forward View(2). The priorities include redesigning NHS emergency care, tackling poor performance and harnessing the health service’s purchasing power. Simon Stevens told the NHS Confederation conference audience (9):

“We, the National Health Service, have set out our stall before the British people and come together to charter our own destiny.”

Simon Stevens did acknowledge that previous strategies for improving NHS performance have not only failed but have been ‘tested to destruction.’ He added that he saw no likelihood of the NHS receiving additional cash this year but announced several specific improvement measures during his keynote speech (9).

Recommended Improvement Measures for the NHS, June 2015:

1) Poorly Performing NHS Regions

New measures are recommended to tackle poor performance in three regions: Essex, North Cumbria, and North-West Devon. These measures will include a ‘success regime’ for regulators working with NHS England in these regions (9).

2) Re-design of Emergency Care

The urgent redesign of emergency care in the NHS will be an attempt to address a current system that is confusing for patients who have conditions that could be treated by their GP or even pharmacist (9).

3) NHS Purchasing

The importance of harnessing the ‘purchasing power’ of the NHS is highlighted by recommendations that the NHS should review some of its biggest areas of spending. The high-cost areas that are targeted include the use of employment agencies, for medical and nursing staffing. Temporary staffing costs are the single largest cause of hospital deficits (9).

4) Learning Disability Care

New models for learning disability care are recommended, including a closure programme for some long-stay institutions, following a programme of transition (9).

5) Public Health

At the NHS Confederation conference, Simon Stevens reiterated some of the points about public health previously made by the Health Secretary, Jeremy Hunt (9). The public health issues that will take priority include smoking, lack of exercise, obesity and alcohol, all of which create health consequences that place an increasing burden on NHS resources (9).

It can sometimes be difficult to appreciate how much healthcare in the UK is improving and just how resilient the NHS has been during the financial storms of recent years. Protected NHS funding and dedicated NHS staff have been the key reasons for these improvements and resilience. Seventy years after its creation, despite its problems, it is important to find hope in the fact that millions of people are working for the same thing, to maintain and improve the National Health Service.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

(1) NHS England website: http://www.england.nhs.uk Accessed June 24, 2015

(2) NHS England. Five Year Forward View. Published October 23, 2014. http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf Accessed June 24, 2015

(3) Public Health England website: https://www.gov.uk/government/organisations/public-health-england Accessed June 24, 2015

(4) Health Education England website: https://hee.nhs.uk Accessed June 24, 2015

(5) Monitor website. https://www.gov.uk/government/organisations/monitor Accessed June 24, 2015

(6) NHS Trust Development Authority website: http://www.ntda.nhs.uk Accessed June 24, 2015

(7) Care Quality Commission website: http://www.cqc.org.uk Accessed June 24, 2015

(8) The NHS Confederation website: http://www.nhsconfed.org Accessed June 24, 2015

(9) NHS Confederation Conference, 2015. Stevens issues clarion call to NHS leaders to redesign care for patients. June 3, 2015. https://www.england.nhs.uk/2015/06/03/redesign-care/ Accessed June 24, 2015

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Antimicrobial Research Collaborative (ARC) recommends CRE screening as a priority for admissions to high-risk specialities

Image: ©nata-lunata/Shutterstock #220986358

The Gram-negative bacterial family of Enterobacteriaceae, includes the species Klebsiella, Enterobacter, and Escherichia. These bacteria can cause opportunistic wound infections, gastroenteritis, pneumonia and septicaemia, particularly in hospital patients, including post-operative patients. Carbapenem-resistant Enterobacteriaceae (CRE) is now a serious concern for the NHS (1).

In 2009, reports first emerged from the USA that these new hospital-acquired, antibiotic-resistant bacteria, had caused death in hospital patients. A prediction was made at this time that CRE could be even harder to eradicate than methicillin-resistant Staphylococcus aureus (MRSA) or antibiotic-resistant Clostridium difficile.

Following reports of cases of CRE in more than a dozen hospitals in England and Scotland in 2009, the then Health Protection Agency (HPA) (now Public Health England) issued a warning about what it called, ‘a notable public health risk’(1). Initially, CRE was thought to be imported from patients having had surgery in India and CRE was considered to be a consequence of the increasing number of UK patients travelling abroad for surgery each year (> 100,000 in 2013) (2).

In 2015, a joint collaboration between Imperial College Healthcare NHS Trust, Imperial College Academic Health Sciences Centre (AHSC) and Imperial College London has created a new multidisciplinary research group, the Antimicrobial Research Collaborative (ARC) (3,4). The aim of the ARC is to translate research findings into new infection prevention strategies. This initiative will have an important role in addressing the problem of antimicrobial resistance (AMR).

As part of the ARC collaboration, in April 2015 researchers lead by Professor Alison Holmes, Director of the National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU), Imperial College London, published their review of current CRE screening strategies in the Journal of Infection(5,6). Among the findings of this study, they noted that admissions to high-risk specialties were likely to have higher CRE prevalence rates and that the higher prevalence of CRE resulted in higher detection rates and lower false-positivity rates (6). These researchers have recommended that CRE screening should be prioritised for hospital admissions to high-risk specialties (6).

The CRE strains are resistant to all the standard antibiotics now used in the NHS. Furthermore, some of these resistant bacteria have been shown to survive in hospital environments, such as table surfaces and door handles.

In May 2015, a publication by Weber and colleagues in the US, in the journal Infection Control & Hospital Epidemiology (ICHE) (published online in Feb 2015), reported that CRE-infected patients contaminated the environmental surfaces of hospital rooms in 8.4% of cases, but at low levels (7). Three species of CRE, Enterobacter, Klebsiella, and Escherichia, survived poorly, with 15% survival after 24 hours and 0% survival after 72 hours (7).

The survival of enteric organisms, such as CRE, is likely to be less than the survival of MRSA on hospital surfaces, due to differences in the structure of the bacterial cell capsule. The ICHE study shows that the levels of contamination and survival are high enough to be important in terms of CRE transmission (7).

In conclusion, carbapenem-resistant Enterobacteriaceae (CRE) are an important group of infections for the new multidisciplinary antimicrobial resistance (AMR) teams to target. Despite their reported limited growth and survival on hospital surfaces, the increasing number of reported cases supports the view that now is not the time to be complacent about hospital infection control.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

(1) Public Health England. https://www.gov.uk/government/organisations/public-health-england Accessed June 16, 2015

(2) Office for National Statistics, Travel Tends 2013. http://www.ons.gov.uk/ons/dcp171776_361237.pdf Accessed June 16, 2015

(3) Imperial College Healthcare NHS Trust. http://www.imperial.nhs.uk Accessed June 16, 2015

(4) The Antimicrobial Research Collaborative (ARC), Imperial College, London. http://www.imperial.ac.uk/arc Accessed June 16, 2015

(5) The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London. http://www1.imperial.ac.uk/hpruantimicrobialresistance/ Accessed June 16, 2015

(6) Venanzio V, Gharbi M, Moore LS, Robotham J, Davies F, Brannigan E, Galletly T, Holmes AH. Screening suspected cases for carbapenemase-producing Enterobacteriaceae, inclusion criteria and demand. J Inf 2015;pii:S0163-4453(15)00197-8. http://www.ncbi.nlm.nih.gov/pubmed/26070742 Accessed June 16, 2015

(7) Weber DJ, Rutala WA, Kanamori H, Gergen MF, Sickbert-Bennett EE. Carbapenem-resistant Enterobacteriaceae: frequency of hospital room contamination and survival on various inoculated surfaces. Infect Control Hosp Epidemiol. 2015;36(5):590-3. http://www.ncbi.nlm.nih.gov/pubmed/25661968 Accessed June 16, 2015

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Standardisation is predicted to save the NHS £5bn a year by 2020

Image: ©daizuoxin/Shutterstock #257787856

The NHS is the fifth largest employer in the world (1). In the UK, the public healthcare industry spends nearly £40 billion per year on commissioning its health services for local people. This year, the procurement of NHS goods and services have been reviewed and concerns have been raised.

The problems of NHS procurement are ingrained and result from the inflexible bureaucratic behaviours of a large organisation where NHS Trusts operate their market powers autonomously. These problems in the public sector, which have developed over a long period of time, must be rather difficult for the business community to understand.

In May 2014, the British Medical Association (BMA) published a guide booklet for GPs and commissioners, which aimed to protect workers’ rights in medical supply chains (2). This guidance was last published in 2008; views have been expressed on how little had changed since then (2, 3).

In June 2014, Lord Carter of Coles was appointed by Health Secretary, Jeremy Hunt, to chair the NHS Procurement and Efficiency Board. On 11th June 2015, NHS Procurement at the Department of Health’s published its interim report, Review of Operational Productivity in NHS Providers (4). This report outlines the findings of a year-long review carried out by Lord Carter, who worked with a group of 22 NHS providers (4). A full report is expected to be published later in 2015.

The ‘Carter Review’ is the third major review conducted on NHS procurement and spending, within the past decade (4).

The findings of the Carter Review can be summarised as follows:

  • There was found to be a wide variation in spending between the 22 NHS Trusts studied, involving purchasing of medicines, everyday healthcare items and on NHS facilities, including maintenance and heating.
  • The NHS could save £5bn a year on workforce and supplies.
  • Increasing hospital staff efficiency by just 1% could save the NHS around £400m per year.
  • Inefficiencies were identified in the way NHS staff were managed; one hospital was found to be losing £10,000 a month in workers claiming too much leave.
  • Some elective surgical procedures, such as hip operations, were costing double the amount they should in some parts of the NHS. Some more expensive hip joint prostheses used did not last as long as less expensive one, resulting in more hip replacements and hospital admissions. This one surgical example costs the NHS an extra £17m each year.

Some of the recommendations of the Carter Review include:

  • Better use of NHS staff could be made through flexible working and better rostering.
  • Better use of prescribed medicines could have a substantial impact; for example, one NHS Trust saved £40,000 a year by using a non-soluble version of a medication.
  • Major savings could be made on routine hospital items such as aprons, gloves and syringes. For example, latex gloves costing £5.44 a box at one hospital are bought for £2.39 in another.
  • The use of a single electronic ‘catalogue’ should be implemented to facilitate more ‘competitive’ NHS purchasing.

The implementation of these recommendations is predicted to save the NHS £5bn a year by 2020, across medicines, routine hospital items, estates and staffing (4). Cutting the number of NHS product lines from more than 500,000 to fewer than 10,000 and being more efficient at procurement could save the NHS up to £1bn by 2020 (4).

On 11th June 2015, the Nuffield Trust issued a press release containing the following statement from Chief Executive, Nigel Edwards (5):
‘Lord Carter is right that there is waste within the health service and that enormous savings could be made through standardisation. But this has been a long-standing issue in the NHS. Spending public money better has been the holy grail of public sector spending reductions over the past 20 years. Diagnosing the problem is the easy bit. Getting solutions to stick is much, much harder.’

Following publication of the review, Lord Carter is now working on publishing an efficiency template for a ‘model hospital.’ The measure of efficiency in every hospital will be called the Adjusted Treatment Index. In September 2015, a Department of Health report will set out what each NHS hospital is expected to save by putting in place the recommendations of the Carter Review(4).

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

(1) NHS Health Education England. Infographic. http://www.nhscareers.nhs.uk/media/1779231/hee_nhs65.pdf Accessed June 18, 2015

(2) BMA News. Ethical Procurement for General Practitioners and Clinical Commissioning Groups – Ensuring the protection of labour rights in medical supply chains. June, 2014. http://bma.org.uk/working-for-change/international-affairs/fair-medical-trade/tools-and-resources/ethical-procurement Accessed June 18, 2015

(3) BMA News. BMA helps GPs back fair NHS purchases. May 15, 2014. http://bma.org.uk/news-views-analysis/news/2014/may/bma-helps-gps-back-fair-nhs-purchases Accessed June 18, 2015

(4) Department of Health: NHS Procurement. Review of Operational Productivity in NHS Providers. Interim Report. June, 2015. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/434202/carter-interim-report.pdf Accessed June 18, 2015

(5) Nuffield Trust Press Release. The Nuffield Trust responds to the Carter Review. June 11, 2015. http://www.nuffieldtrust.org.uk/media-centre/press-releases/nuffield-trust-responds-carter-review Accessed June 18, 2015

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