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NHS England

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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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Microbiome data now being gathered may form the basis for a ‘personalised’ approach to improving individual microbial populations

Image: ©Pixelbliss/Shutterstock #280702511

In May 2015, a molecular microbiology study was published in the Proceedings of the National Academy of Sciences (1). This study showed that gut bacteria could be DNA ‘fingerprinted,’ as their DNA sequences were shown to represent a unique form of identification in more than 80% of individuals examined (1). This study has little to do with ‘CSI’-style forensic identification but does have implications for our health, diet, development and genetics and our ability to defend ourselves from true microbial pathogens (1).

That the human body is believed to contain ten times more microbial cells than human cells (trillions of them) can be an uncomfortable thought. Even more remarkable is that, in terms of numbers, the population of these microbes accounts for up to 90% of the total number of cells associated with our bodies. Our human microbial population weighs between 1% and 3% of our total body mass (1.5 kg); this is equivalent to the weight of the largest human internal organ, the liver (2).

The terminology of the body’s flora and fauna can be confusing. This could be why someone, probably working in advertising, came up with the phrase ‘friendly bacteria.’ The term ‘microbiota’ is the collective noun that refers to the viruses, fungi and bacteria that inhabit our bodies, mainly in our gut and on the surface of our skin. The microbiota has a commensal and a symbiotic relationship with us. The term, ‘microbiome’ is used to refer to the collection of the genomes of these microbes. These two names, ‘microbiota’ and ‘microbiome,’ are often used interchangeably.

Our view of our personal microbial health has changed during the past 20 years. Until the 1990’s there was the ‘germicidal view’ that all bacteria were harmful and that we should be doing all we could to sterilise our home environment, ourselves and our food. There are now increasing numbers of scientific and healthcare news stories, as well as television commercials, which advise us to encourage and nurture our own, resident, and very personal ‘friendly bacteria.’

As with the dietary anti-oxidant ‘industry’ that arose from cardiovascular research in the 1980’s, the food industry has been swift to promote the sales of dietary probiotic supplements. Global sales of probiotics have been reported as £13.6 billion ($21.6 billion USD) in 2010 and are expected to exceed £19.6 billion ($31.1 billion USD) during 2015 (3).

In February 2015, an editorial collaboration between the journals, Nature and Scientific American, resulted in the publication of a series of special reports entitled, Innovations in the Microbiome(4) These and other recent publications have helped to place the importance of the normal human microbial population further into the medical spotlight.

For almost a century, epidemiological studies have shown that diet has a profound effect on human health. Recently, the link has been made between diet and the gut microbiota, with emphasis on the effects that a ‘western’ diet of refined foods and high protein have on these organisms. In 2011, a study linked long-term dietary patterns to changing gut bacterial enterotypes in humans (5). In 2014, a study in wild mice clearly demonstrated that dietary change can induce gut bacterial ‘enterotype switches’ within hosts (6). ‘Biome reconstitution’ has been proposed as a treatment approach to immune disorders, including allergy and autoimmune disease and to preventing colonic cancer, obesity, diabetes, and metabolic disease (7, 8).

In the past ten years, sequencing technologies have allowed the development of a detailed reference database of the diverse microbes that inhabit our bodies. In 2007, in the US, the National Institutes of Health (NIH) Human Microbiome Project (HMP) Consortium was launched, consisting of more than 200 members, from nearly 80 universities and scientific institutions (9). In its 2012 report, the HMP listed the major ways in which knowledge of the human microbiome may change the future of science and medicine (10). The HMP has considered the potential privacy issues surrounding knowledge of the individual microbiome, the flow between human microbes and those found in nature (in water and soil) (10).

The microbiome data now being gathered may form the basis for a ‘personalised’ approach to improving individual microbial populations. Most importantly, solutions to microbial antibiotic resistance may be found through increasing knowledge of microbial interactions. At this same time comes the realisation that overuse of antibiotics, as part of our ‘war on germs’ mentality, has allowed true microbial pathogens to develop antibiotic resistance. The lack of a functioning and complete personal microbial population leaves us vulnerable to bacterial pathogens that we may be increasingly less able to fight.

In 2013, the Chief Medical Officer for England highlighted the increasing problem of antibiotic resistance. These concerns led to the Department of Health launching a five-year Antimicrobial Resistance (AMR) Strategy, which is supported by NHS England’s Antibiotic Awareness Campaign (11,12). In October 2014, Public Health England produced the first report on the English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) (13). These latest initiatives by the medical profession and healthcare regulators to reduce antibiotic prescribing is just one approach that has to be made.

The European Molecular Biology Laboratory (EMBL) annual conference, held in Heidelberg in June 2015, was devoted to the topic of the Human Microbiome (14). This meeting included discussions on the design of possible therapeutic or dietary interventions to prevent and treat disease. An announcement was made at the meeting of the first results from the Personalised Nutrition Project, run by research groups in Israel (15). The u-Biome Project is a crowdfunded ‘citizen science’ initiative that is set to analyse the microbiome in the context of individual health and is currently recruiting participants (16).

The rationale for learning more about the ‘normal’ or ‘optimal’ microbiome, and how to reconstitute or nurture it, is an important component of individual healthcare (17, 18). For the future development of interventions for resistant microbial pathogens, the human microbiota may play more than just a ‘friendly’ role, it may be life-saving.

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) Franzosa EA, Huang K, Meadow JF, Gevers D, Lemon KP, Bohannan BJ, Huttenhower C. Identifying personal microbiomes using metagenomic codes. Proc Natl Acad Sci U S A. 2015;pii 201423854. http://www.pnas.org/content/early/2015/05/08/1423854112 Accessed June 10, 2015

(2) The Human Microbiome Project. Structure, function and diversity of the healthy human microbiome. Nature 2011;486:207-14. http://www.nature.com/nature/journal/v486/n7402/full/nature11234.html Accessed June 10, 2015

(3) Business Communications Company (BCC) market research data for sales of probiotic foods and supplements, 2010 and 2015. http://www.bccresearch.com/pressroom/fod/global-market-for-probiotics-reach-$36.7-billion-2018 Accessed June 10, 2015

(4) Special Report. Innovations in the Microbioma. Scientific American Vol 312, Feb 2015. http://www.scientificamerican.com/editorial/innovations-in-the-microbiome/ Accessed June 10, 2015

(5) Wu GD, Chen J, Hoffmann C, et al. Linking Long-Term Dietary Patterns with Gut Microbial Enterotypes. Science 2011;334(6052):105-108. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3368382/ Accessed June 10, 2015

(6) Wang J, Linnenbrink M, Kunzel S, et al. Dietary history contributes to enterotype-like clustering and functional metagenomic content in the intestinal microbiome of wild mice. Proc Natl Acad Sci USA 2014; 111:E2703-E2710. http://www.pnas.org/content/111/26/E2703.full Accessed June 10, 2015

(7) Parker W, Ollerton J. Evolutionary biology and anthropology suggest biome reconstitution as a necessary approach toward dealing with immune disorders. Evolution, Medicine, and Public Health 2013;2013(1):89-103. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3868394/ Accessed June 10, 2015

(8) Grice EA, Segre JA. The Human Microbiome: Our Second Genome. Annual Review of Genomics and Human Genetics 2012;13:151-170. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3518434/ Accessed June 10, 2015

(9) The National Instututes of Health (NIH) Human Microbiome Project website http://commonfund.nih.gov/hmp/index Accessed June 10, 2015

(10) National Institutes for Health (NIH). Human Microbiome Project defines normal bacterial makeup of the body. Genome sequencing creates first reference data for microbes living with healthy adults. June 13th 2012. http://www.nih.gov/news/health/jun2012/nhgri-13.htm Accessed June 10, 2015

(11) The Department of Health Antimicrobial Resistance (AMR) Strategy 2013 to 2018. First published September 10, 2013. https://www.gov.uk/government/publications/uk-5-year-antimicrobial-resistance-strategy-2013-to-2018 Accessed June 10, 2015

(12) NHS Antibiotic Awareness Campaign. Last revised 24th Sept 2014. http://www.nhs.uk/NHSEngland/ARC/Pages/AboutARC.aspx Accessed June 10, 2015

(13) Public Health England. English Surveillance Programme Antimicrobial Utilisation and Resistance (ESPAUR) Report. Published Oct 10, 2014. https://www.gov.uk/government/publications/english-surveillance-programme-antimicrobial-utilisation-and-resistance-espaur-report Accessed June 10, 2015

(14) European Molecular Biology Laboratory (EMBL) website. http://www.embl.de/aboutus/general_information/index.html Accessed June 10, 2015

(15) The Personalised Nutrition Project website. http://newsite.personalnutrition.org/WebSite/Home.aspx Accessed June 10, 2015

(16) u-Biome – Sequencing Your Microbiome website. https://www.indiegogo.com/projects/ubiome-sequencing-your-microbiome#/story Accessed June 10, 2015

(17) Grogan D. Microbes in the Gut Are Essential to Our Well-Being. Scientific American. Feb 17, 2015. http://www.scientificamerican.com/article/microbes-in-the-gut-are-essential-to-our-well-being/ Accessed June 10, 2015

(18) Parums D. ‘Indigenous’ Human Microbes – the Microbiota and the Microbiome. Thomson Reuters Life Sciences Connect. May 26, 2015. http://lsconnect.thomsonreuters.com/indigenous-human-microbes-the-microbiota-and-the-microbiome/ Accessed July 6, 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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In May 2015, a molecular microbiology study was published in the Proceedings of the National Academy of Sciences (1). This study showed that gut...
Original illustration for Healthcare-Arena by Fran Orford