New report highlights how pharmacy can redefine role within NHS

By Integrated Care Journal

The National Pharmacy Association (NPA) has published a new report outlining how independent pharmacies are ready to redefine their role within the NHS.

The NPA has published a medium-term prospectus for the development of pharmacy services, calling it a challenge to old ways of thinking and an opportunity to redefine the sector’s role in the NHS.

It follows months of dialogue with NPA members about what a clinical future could look like for the sector.

The document, Making Changes, Meeting Needs, will be shared with the King’s Fund and Nuffield Trust who are currently working on a new vision for the future on behalf of Community Pharmacy England.

Among the ambitions in the NPA’s prospectus are:

Improve the management of long-term conditions such as asthma, hypertension, heart failure and diabetes.
Expand preventative interventions to help make the NHS a wellness, health-inequality reversing service.
Shift focus from a downstream dispensing role to an end-to-end prescription management role, with a focus on good pharmaceutical outcomes.
Become the go-to professionals for optimising the use of medicines, including upgraded Structured Medication Reviews and post-discharge reconciliation.
Offer prompt and accurate diagnosis, risk stratification based upon genotype and the capacity for personalised treatments.
Increase medicines safety right across the care pathway.
Build on hospital touchpoints – preparing people going into hospital for elective care, give them a soft landing back into the community and reduce readmissions.
Dramatically improve access to primary care.

Making changes, meeting needs — Credit: National Pharmacy Association

With informed policy-making and sufficient public investment, NHS community pharmacy could during the remainder of the 2020s develop much further as a clinical care and safe medicines supply service, in ways that will cost effectively benefit patients, public and the NHS, the document states.

NPA Chair, Nick Kaye, said: “Building out from the existing portfolio of services, there are some major opportunities within this decade, encompassing prevention, medicines optimisation, long term medical conditions and urgent care.

“We are seeking to challenge orthodoxies that have limited the sector’s scope for too long. At the same time, these ideas are firmly planted in reality because our start-point is what our paymasters in the NHS want, not what we can dream up.

“Some of this is about redrawing the borders of pharmacy practice – for example applying pharmacogenomics to pharmacist prescribing.

“Other aspects are about re-imagining what is our domain as a sector; we are rightly based firmly in the community but our impact ought to be felt and formalised across the entire system, including hospitals. We need to be ‘in the community but out of the box’.

“We are confident that the large majority of NPA members – by their nature innovators – are open to the idea of ambitious, transformative change.”

While pushing the boundaries of clinical service development, the NPA says it is also clear that the safe supply of medicines should continue to be a foundation stone upon which other pharmacy-based support is built.

In a foreword to the document, Dr Claire Fuller, Chief Executive of the Surrey Heartlands Integrated Care System, praised the NPA for backing a “can-do agenda” for the sector. “This is the kind of thinking – based in an understanding of what commissioners need – that makes people like me sit up and take notice”, she said.

Making Changes, Meeting Needs lists the enablers that would need to be in place in order to turn these ambitions into reality. They include digital connectivity, a boost to workforce and a supportive national contractual framework (in May, the NPA published its ‘New Deal for Community Pharmacy in England’ which describes such a framework).

The NPA is inviting people to offer feedback on their report, please write to independentsvoice@npa.co.uk.

Damaging NHS disputes hindering progress on productivity, finds survey

By Integrated Care Journal

Trusts making progress on NHS targets and taking steps to boost productivity but concern mounting about staff morale and burnout as operational pressures take their toll.

Ongoing industrial action presents a major operational and financial challenge for NHS trusts, and is hindering all trusts’ ability to recover productivity, according to a new survey carried out NHS Providers. It highlights the scale of the task ahead for the NHS, as it simultaneously grapples with increasing numbers of patients with complex conditions staying in hospital for longer, emergency care pressures and limited bed capacity, exacerbated by the crisis-hit social care sector.

Trusts across hospital, community, mental health and ambulance services have made significant early progress towards meeting care backlogs for urgent and emergency care, cancer tests, long waits and diagnostic services as they strive to deliver better outcomes for patients, say NHS Providers.

They have introduced a range of measures to boost productivity in the NHS – delivering more care with existing resources – including targeted initiatives to improve staff health, wellbeing and retention alongside efforts to help discharge patients faster and adapting their buildings to treat more patients.

But trusts are now warning that eight consecutive months of industrial action across the NHS are taking their toll on efforts to cut waiting lists, with more than 651,000 routine procedures and appointments rescheduled so far and many tens of thousands more likely to be delayed as the health service faces back-to-back walkouts by junior doctors, consultants and radiographers in the coming days.

“Increasingly hard to improve productivity”

The new survey by NHS Providers, Stretched to the limit: tackling the NHS productivity challenge, outlines the scale and complexity of the challenge ahead, particularly as trust leaders count the cost of industrial action given the disruption to planned care, and increasing costs due to agency spend and the impact of consultant rate cards.

The Chief Executive of NHS Providers, Sir Julian Hartley, said: “Leaders and staff are working flat-out to cut waiting lists and to see patients as quickly as possible in the face of major obstacles.

“With waiting lists at a record high, trusts are keenly aware of the need to carry out more operations, treatments and scans. They are doing everything they can to see more patients more quickly and to deliver better quality care, including introducing virtual wards and new initiatives to speed up hospital discharge and offer more care at home.

“However, it is increasingly hard to improve productivity because of staff burnout, high turnover, vacancies, a rising number of patients with more complex conditions, stretched community and social care capacity, and fewer hospital beds per person than comparable countries.

Trusts are also warning that it will be very difficult to deliver the government’s overall demands in terms of performance while delivering unprecedented efficiencies, seeking to protect quality of care for patients.

The survey finds that:

Almost nine in ten (89 per cent) trust leaders said the scale of the efficiency task is more challenging than it was last year.
Almost three in four (73 per cent) did not think they had access to sufficient capital funding over 2023/24 to cover the costs of vital repairs to buildings and equipment.
Nearly two thirds (61 per cent) were not confident that they and their system partners would hit targets to reduce long waits for mental health care.
Fewer than half (43 per cent) expect to meet an interim recovery target of 76 per cent of A&E attendances to be seen within four hours during 2023/24.

The findings reveal widespread worry among trusts about having to deliver more for less as budgets, staff and resources are stretched to the limit, leaving trust leaders facing increasingly difficult dilemmas about how to sustain services in the future.

Despite an overall increase in workforce numbers and the welcome promise of more staff in the future through the new long-term workforce plan, rising concerns about staff morale and burnout also continue to play heavily on trust leaders’ minds. They are contending with 112,000 vacancies across the health service in England with staffing numbers and skill mix failing to keep pace with growing and changing demand.

This is piling on the pressure, with trust leaders identifying discharge delays, relentless demand on emergency care, a lack of investment in social care and a dependency on agency staff as the biggest barriers to returning to pre-pandemic levels of productivity.

They are clear that capital investment in the NHS estate is also key to boosting productivity. This would allow trusts to expand bed capacity and community provision, deliver digital transformation, bear down on care backlogs and eliminate the persistent inefficiencies created by creaking buildings and equipment.

But with the NHS capital maintenance backlog now exceeding £10bn, and only a handful of trusts benefitting from much-needed investment through the New Hospital Programme, a great many more need urgent major capital investment to overhaul their ageing estates to achieve better – and safer – outcomes for patients.

Sir Julian Harley added: “Industrial action also poses a significant financial risk to trusts, given the disruption to planned care, and increasing costs due to agency spend and the impact of consultant rate cards.

“The new long-term workforce plan with its focus on recruitment, training and retention could finally put the NHS workforce on a sustainable footing if commitments are made to keep it updated and funded. But the benefits of that plan can only be reaped with a wider focus on productivity and its enablers, many of which we explore in this report, such as investment in management capacity and capital.

“If we are to ramp up productivity across the NHS, we need a step change in capital investment to provide more beds, more community care, a digital revolution, a safe and comfortable therapeutic environment, and appropriate support for social care.”

Digital appointments could save the NHS £167 million per year: report

By Integrated Care Journal

Opening new digital pathways could free up capacity and help reduce NHS elective care backlog

Giving patients greater digital control over their hospital appointments could avoid 1.6 million unnecessary appointments and create a national annual system saving of £167 million, according to a new report commissioned by, patient engagement platform supplier, DrDoctor.

The report, commissioned by DrDoctor, a patient engagement platform supplier, and conducted by health economics consultancy Edge Health, analysed NHS outpatient appointment data. It suggests that allowing patients to request appointments using Patient Initiated New Appointments (PINAs) and Patient Initiated Follow-Ups (PIFUs) could significantly help to reduce the backlog in NHS elective care.

Reducing outpatient follow-up appointments

The data reveals that putting patients on digitised PIFU pathways for both high-volume, low complexity conditions and smaller volume, higher-complexity conditions could lead to at least 1.18 fewer outpatient follow-up appointments per patient. If implemented nationally, this could free up the waiting list for 1.4 million hospital appointments, creating capacity for more patients to be seen, and saving the NHS £167.2 million per year.

The report finds that the average time between the first appointment and follow-up appointments is also longer when patients are on a digital PIFU pathway. This indicates that when patients can initiate follow-up appointments themselves, they are likely to wait longer, which in turn creates more capacity for new patients to be seen, reducing waiting times further.

Supporting the elective backlog recovery

Edge Health examined the use of DrDoctor’s solutions at two of its customer sites, including PIFU and PINA tools at Guy’s and St Thomas’ NHS Foundation Trust (GSTT) in their physiotherapy services. The time and cost savings from more than 50 million outpatient appointments were applied to a national rollout to calculate the overall impact in the NHS.

The report finds that patients with mild symptoms for low complexity conditions may not need a first appointment at all. Using a digital PINA pathway to address this could reduce the number of people waiting for hospital appointments by more than 210,000, freeing up appointments for patients who need clinical care.

Tom Whicher, CEO at DrDoctor, welcomed the research findings and said: “This report demonstrates much-needed real-world evidence on the benefits of PINA and PIFU at scale. Given that the national target for 5 per cent of outpatient attendances using digital PIFU was recently dropped, the report should give confidence to providers on how these processes, enabled by digital tools, play a vital role in tackling the backlog and creating efficiency savings.”

GSTT has been using DrDoctor’s PIFU tool for musculoskeletal and hand therapy services since January 2022. The report found that more than 70 per cent of physiotherapy patients on a PIFU pathway chose not to return for a second appointment, compared to 44 per cent of non-PIFU patients. A greater number of PIFU patients also chose to request follow-up appointments later than those not on the PIFU pathway (84 per cent had it in 120 days or under vs 88 per cent in 90 days or under).

The report also finds that PIFU led to many patients requiring fewer outpatient appointments, creating capacity to reallocate these appointments to patients with more complex care needs who need to be seen more frequently. The ability to reallocate these appointments has created capacity for an additional 9,268 patients, at the value of £719,476 per year.

Rashida Pickford, Consultant Physiotherapist, GSTT, was involved in the research and said: “The analysis shows the benefits of using technology to give patients more control over their appointments. Avoiding clinically unnecessary appointments means we can provide a better patient experience and free up much-needed time for clinical and administrative staff.”

The report also concluded that from the patient’s perspective, demographic factors such as age, do not limit engagement with digital PIFU pathways. Tom Whicher added: “Often there are concerns about digitisation because it isn’t accessible for everyone. And whilst that can be true, this report confirms that it’s often an exception rather than the rule.”

DrDoctor helps manage around 25 per cent of NHS outpatient booking activity and provides digital PIFU, PINA and patient engagement services in over 45 healthcare organisations.

PPP’s Population Health Management Collaboration Framework

By Mary Brown

A new framework from PPP enables ICSs and business to assess and measure the progress of their collaboration on population health management.

Over the first half of 2023, PPP ran a series of roundtables for our Population Health in Business series, to analyse and explore the impact of business on the health of local populations, and explore how this impact can be leveraged to deliver benefits to businesses, workforces and communities. As the report highlights, ensuring that local business activity is sensitive and responsive to local health challenges requires close collaboration between business and local authority leaders. This collaboration, ideally, should occur within the framework of the integrated care partnership (ICP).

ICPs are intended to allow ICS leaders to “bring together a broad alliance of partners concerned with improving the care, health and wellbeing of the population”, as well as spearheading the integrated care strategy for a given system. Each ICS can decide which partners are included in the ICP, however suggested partners include local Health and Wellbeing Boards (HWBs), social care providers and members of the VCSE sector.

As conveners of local health-relevant organisations beyond the NHS, ICPs have the potential to rebalance the focus of health and care away from acute hospital settings and towards the broader health needs and goals of communities. This will empower organisations not traditionally involved in health-related decisions to make more active contributions to public health outcomes. Businesses have the potential to serve as partners in the delivery of a health inequalities strategy given their impact on their workforce and surrounding communities, and grow the impact of assessments such as the JSNAs already produced by HWBs.

The PPP PHM Collaboration Framework – part 1 of 2 (click to enlarge)

Joining up business and public health

By bridging the gap between public services and local industry, ICPs can support and monitor actions taken by businesses to create healthy workplaces and support employee health, assisting in setting priorities and objectives and advising on health and wellbeing issues. ICPs can also serve as forums of communication and alignment between ICSs, businesses and local health-relevant organisations, enabling businesses to contribute more effectively to community health.

ICPs could also play a central role in enabling better public-private data exchange, which will be crucial in determining the quality and impact of PHM insights. As a broad alliance of partners, ICPs can provide a forum through which businesses and local authorities can improve the accessibility and availability of data. While the needs and capabilities of businesses with regards to data usage vary significantly within an ICS region, the development of PHM strategies is ultimately a process that caters to the needs of a specific population reflected in health-relevant data collected and held by businesses.

The full Population Health in Business report can be accessed here.

Where businesses are able to share insights and collaborate to improve health outcomes within the same population (both with one another and with local authorities), there is a significantly greater opportunity for mutual needs to avail themselves – thereby laying the groundwork for more effective collaboration. The blueprints for such a collaboration can then be shared between ICSs and with central authorities such as DHSC, and local government including the Local Government Association and the Department for Levelling Up, Housing and Communities, to facilitate their development of data standards as recommended by the Hewitt Review.

However, though the report suggests that businesses should collaborate with one another and local authorities, using the ICP as a connecting forum, it must be recognised that many of these partnerships remain underdeveloped and that their progress is likely to be asymmetric. It is therefore necessary that businesses take an active role in assessing the strength of their own actions on health inequalities and their collaborations with local authorities.

PPP’s PHM Collaboration Framework – part 2 of 2 (click to enlarge)

A framework for collaboration

There are ongoing concerns within ICSs around the challenges of balancing the unique local needs and priorities of regions with national standards. In order for all ICPs to partner with local businesses in achieving improved regional health, collaboration and data sharing frameworks should be utilised to ensure consistent goals and progress across regions with different priorities, while avoiding duplication and so as not to discourage inter-ICS collaboration.

In order to support businesses and ICPs to implement the findings and recommendations from the series, PPP has crafted a suggested framework for ICS and businesses to collaborate and measure progress.

The framework is intended to compliment other matrices, such as the Leeds City Council Business Progression Framework, the JRF Business Progression Framework (both assembled by Les Newby and Nicky Denison), and the ICS Maturity Matrix (created by Cathy Elliott). These matrices provide examples of best practice and rough guides for organisations to evaluate their own progress as health-enhancing institutions. As such, the PPP PHM Collaboration Framework is intended to guide businesses to evaluate their own progress towards partnering with local authorities and interacting against local health systems to develop robust preventative healthcare and target causes of ill health.

The full Population Health in Business report can be accessed here.

News, Oracle Health July 12, 2023

Creating a data-driven health organisation across Milton Keynes

By Oracle Health

Between 2018 and 2023, Milton Keynes University Hospital NHS Trust gained a large set of clinical data. On its journey with Oracle Health, the trust has transformed into a data-driven organisation, improving patient experience, lowering the cost of care, enhancing the staff experience, improving population health, and addressing health equity.

What’s the background and context?

Over the past few years, Milton Keynes University Hospital NHS Foundation Trust (MKUH) has been on a clinical digital systems journey. Due to the recent advances in the organisation’s Oracle Health (formerly Cerner) electronic patient record (EPR) system between 2018 and 2023, they have gained a large set of clinical data. This has enabled MKUH to make strides in visualising and using information to support the Quintuple Aim, which includes improving patient experience, lowering the cost of care, enhancing the staff experience, improving population health, and addressing health equity. MKUH continues to advance in this field, with its goal being to evolve from a data-driven organisation today to analytic excellence in the future.

Using data to drive EPR adoption and help improve patient outcomes

MKUH had historically hoarded data and used information for outputs including statutory and ad hoc reports. However, with limited resources, the Trust struggled to find the right information for the right end users. Their data workforce and skill set were designed based on needs of traditional NHS statutory reporting, so using data more directly as an enabler for improving staff experience and patient health outcomes was an alien concept.

There was a gap between teams that needed to manage the data and format it in a way that made it meaningful and useful to those making clinical or operational decisions. The way MKUH accessed the data was down to the end users using the system and understanding the workflows. In the initial stages, once data had been clinically validated, the team could create dashboards for a small subset of users.

A dawn happened when Cerner Millennium was connected directly to the Trust’s PowerBI instance, a Microsoft product that allows users to pull in data and information to produce dashboards and visualise data in a way that’s meaningful and insightful to the end users. As PowerBI is used across the Trust for a multitude of purposes, including this data within the same platform enabled a more seamless user experience. Creating dashboards of rich data is academic if they are unusable.

Ways data is being used to drive the organisation

The very first project to use data differently analysed the way MKUH was receiving pathology and imaging results in Cerner Millennium, and the process of endorsing those results. This was a real technological response to an organisational need. Electronic endorsing of results was, at the time, a new concept that MKUH clinicians had variably adopted. There was often discussion about how electronic endorsing could be improved. How do we improve adoption, and how can we measure it? How do we know who is and isn’t endorsing results? How do we know we’re improving it? This became a sticking point, and the hospital didn’t know how to move forward.

Presenting the data through PowerBI enabled the team to split the data by department or lead clinicians responsible for results, allowing them to share the report with clinicians. Through PowerBI, it’s also possible to give access to the full report – with snapshots once a month – so each lead clinician or department could see how they’re doing, with a league table. After examining the data, the team decided to set a target: 80 per cent of results would be endorsed within two weeks. They then discovered the data included encounters for consultants who had previously left the organisation, which prompted MKUH to look at their leavers processes. For example, what steps must be taken when a clinician leaves?

Many results were attributed to senior nurses and midwives, which prompted the team to bring them into the fold in conversations and, if appropriate, have them endorse their own results. Occasionally, clinicians were ordering in the wrong encounter, which would then associate the wrong lead clinician with it. Having the data has shed fresh light on the process, and MKUH has discovered much more than it anticipated. It took time to organise this dataset, with completion only coming about in 2020 following the 2018 go-live. The team did several things wrong and made mistakes before they were able to share the correct data on endorsing results.

The next big phase was development work in response to the challenges presented by the COVID-19 pandemic. At its onset, MKUH was still an organisation driving the need for data, as opposed to being a data-driven organisation. The Trust was eager to see the data, which enabled it to prioritise the work. By compiling the data, the team had a new technical skill set across the department, but the real challenge was understanding the dataset – bridging the gap between understanding workflows and managing data.

The team experimented with the COVID-19 data, which provided several different visualisations. Two years into the pandemic, they were using the fifth version of the dashboard, which allowed them to view patient cohorts by postcode, interrogate cases of nosocomial infection (hospital-acquired COVID-19 infections) in patients, and look at those patients’ location histories – including their previous wards and beds, and which other patients they may have been in contact with.

Specific views of this report were also provided to Milton Keynes and Buckingham local health teams, with shared data sorted by relevant postcodes. These reports were updated daily, and team feedback showed that the information shared was very helpful. In December 2020, MKUH was part of the first wave of COVID-19 vaccination centres and utilised the Cerner mass vaccination workflow, Microsoft booking application, and PowerBI to create twice-daily site reports. These reports flagged data quality issues, monitored progress through the vaccination centre, and provided metrics – regarding the number of patients vaccinated, how many patients were waiting, and so on.

COVID-19 was the first time the team focused on building a system that was conducive for reporting and sharing data, and the first time data drove the way the system was built.

Designing the system with data in mind

An example of designing the system with data in mind is the revaluation of free-text fields where users can add unstructured text. MKUH knew it would require time investment to make changes. For example, MKUH reviewed a midwife form used to record patient birthing preferences. Assuming the form was completed, no action was taken, nor did the data go anywhere. MKUH redesigned the form entirely, with data in mind. Answers to questions now populate the antenatal document, meaning anyone who treats patients can view, and take into consideration, their birthing preferences. The nature of the form was then changed so it was rendered into textual narrative document and easier to consume.

Currently, reporting is available to the midwives – refreshed daily to show the number of forms completed and by which midwife. The Trust then uses this data to target extra training. For instance, it’s important for the rendered note to be completed, as this document is shared with the patient through the MyCare patient portal. When reviewing the reporting, if the Trust sees more forms than completed notes it follows up with the midwives, reiterates the process, and ensures they complete the two-step process so they can create the note again.

MKUH can then report on the number of booked patients who are more than 34 weeks pregnant and have no birthing preferences noted. This highlights gaps in the process and enables the Trust to follow up with patients to ensure their information is complete at the time of delivery. Capturing this level of data also enables the Trust to gain a better understanding of the birthing preferences of the Milton Keynes population. All of this is possible because workflows were designed with these data aims in mind, rather than being an afterthought. In simple terms, the report was designed before the data-capture forms.

MKUH has started a journey with the Oracle Health Command Centre, including real-time, predictive analytics using AI. This takes a dataset from historical EPR statistics and allows the organisation to review real-time statistics with added predictions on the hospital bed state in four-, eight-, or 12-hour intervals. This was only recently implemented, so as MKUH continues to progress, the Trust will assess the predictions accuracy and then work to update the algorithms to better align with actual events.

There are also other pilots exploring how to better use data within buildings and the hospital environment. MKUH didn’t know how its wards and spaces were being used, and with upcoming building projects, there were opportunities to take a data-driven approach to hospital design and ergonomics. As there was no existing way to accurately manage this, MKUH worked with partners Haltian and their Empathic Building solution to track staff movements – with permission – and equipment around a particular ward. By starting with the question, the organisation wanted to answer, MKUH could then build a solution that captures required data and presents it in a manner that allows management to make more informed decisions about the future hospital design with patients and staff in mind.

How does the NHS culture need to change?

National datasets feed into decision-making at a regional and national scale more generally, and into commissioning more specifically. There will always be a place for this mechanism, even if it could benefit from a little pragmatic consolidation.

When a hospital is reactive to local, regional, or national targets, the effort invested in reporting against those targets is increased and improvements are generally seen in that area. There’s a clear cost versus benefit case for the invested time and effort that brings in roles from all parts of the management structure; financial incentives are a big driver for this activity.

Finding alternative ways to commission hospitals so incentives are different but just as attractive has been a more recent approach and represents a move away from pay-as-you-go. If this were done in parallel with reducing how prescriptive that commissioning activity is, providers are afforded the space and incentive to be more innovative in the ways they deliver services. Were there support on how to introduce those innovative models into hospitals – whether exemplar sites, services, or cases that used information to respond to this challenge successfully, access to models or approaches that can be applied locally, or short-term training offered by NHS centres of excellence to develop the skills to lead on such work – then there could be a culture shift. This would be contingent on local efforts bearing fruit, so end-to-end support would be needed.

The world of information governance has come so far since COVID-19 and the introduction of the EU General Data Protection Regulation (GDPR). It is important that an information governance program considers events that can impact the organisation and legal requirements, while also considering operational efficiency. The work done across OneLondon, the Wirral, the Great North Care Record, and many more demonstrates information governance is possible and doesn’t need to be restrictive.

It’s not just NHS culture that must change. Hosting data and information management functions no longer needs to be an extortionately expensive offering. However, the commercial, well-known products available to the NHS for this purpose remain at inflated costs – leaving many to keep what they have, make difficult decisions to spend money on these platforms instead of direct care, or try to use local in-house solutions or open-source options that require significant in-house expertise.

MKUH is developing a growth culture as it responds to having data available to drive organisational change. This culture change is in progress and this case study highlights some of the benefits being realised and the ideas being explored.

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Major agreement to deliver new cancer vaccine trials

By Integrated Care Journal

Government signs agreement with BioNTech SE to provide up to 10,000 patients with precision cancer immunotherapies by 2030.

The Government has announced the signing of a major agreement with pharmaceutical company BioNTech, to deliver precision cancer medicine to 10,000 patients by 2030, supported by NHSE’s Cancer Vaccine Launch Pad and new laboratories to be set up by BioNTech around England. The agreement brings the NHS a step closer to transforming cancer treatment for patients, using the technology first used during the pandemic against COVID to create personalised cancer immunotherapy options.

Groundbreaking progress towards trials has been far quicker than expected, as although the initial partnership saw the first trials rolled out in Autumn of 2023, trials for MRNA cancer vaccines for colorectal cancer already underway at University Hospitals Birmingham NHS Foundation Trust (UHB). Further trials are to be set up around England, with the majority of trials involving patients expected to commence from 2026.

Dr Lennard Lee, Associate Professor at the University of Oxford, said:

“The United Kingdom has delivered a stunner. We are off the starting block for another vaccine advance, but this time against cancer. What is most surprising is that our country’s outlook has changed. There is global acknowledgement of the UK opportunity, and capacity for vaccine research. There is also high level of confidence in our hospitals, clinical researchers and the cancer research infrastructure. If the aforementioned issues were addressed using the path forged by our coronavirus vaccine response, this is the perfect recipe to deliver transformative benefits to those affected by cancer and realise the potential of vaccines for cancer”.

In March of this year, after a partnership between Government and BioNTech was first announced in January, PPP ran a roundtable entitled Implementing precision medicine in the UK: The case of cancer vaccines, chaired by Dr Lennard Lee, Associate Professor at University of Oxford and National Clinical Advisor at DSIT and Joanne Hackett, Head of Genomic and Precision Medicine at IQVIA. The roundtable was attended by clinical oncologists, oncology researchers, pharmaceutical companies and policy experts, and discussed the opportunities and challenges posed by the undertaking of cancer vaccine trials in the UK.

A key insights report has been produced from this roundtable. In order for cancer vaccine trials to be a success and for benefits to be felt equitably, the report makes a number of policy recommendations, including:

NHS England and DHSC should review the progress of their funded plan to tackle backlogs due to the pandemic and talking waiting lists for elective care, given that targets for oncology services, and other elective care services, are continually unmet. The success of cancer vaccine trials will be dependent on investment that factors in the costs incurred in the clinical settings in which they are taking place.
Multidisciplinary teams should be formed during cancer vaccine trials so that pressures on frontline medical staff and overloaded clinical settings are reduced, lightening the burden of clinical trials overall.
As part of the overhaul of regulatory processes, the MHRA should consider ethical fast-tracking as part of their review.
New incentives should be developed to encourage trial participation from underserved groups with lower socioeconomic status, this would serve to overcome historical barriers to trial participation that often limit the diversity of trial participants. Hospital trusts should mobilise trusted community leaders to encourage those who may be vaccine hesitant to engage with clinical trials, if appropriate.
The UK government should engage in positive communication and advertising campaigns, including informative documentaries, to inform the public about the potential personal and social benefits of cancer vaccines.

Rethinking cancer care: a system strategy for improved outcomes

By Lucia De Santis and George Batchelor

Boosting early detection and reducing backlogs through data-backed, collaborative initiatives will be crucial to addressing the deteriorating state of cancer care in the UK, write Edge Health’s Lucia De Santis and George Batchelor.

In the battle against cancer, the UK is grappling with alarming statistics, with outcomes for colon, lung and pancreatic cancers being particularly sobering. According to the Comparator report on cancer in Europe 2019, the UK was last out of all Western European nations for 5-year survival of colon cancer, as well as among International Cancer Benchmarking Partnership (ICBP) jurisdiction countries (Figure 1).

Figure 1: Age-standardised incidence, mortality rates and 5-year net survival for Colon cancer. Arnold M, Rutherford M, Lam F, Bray F, Ervik M, Soerjomataram I (2019). ICBP SURVMARK-2 online tool: International Cancer Survival Benchmarking. Lyon, France: International Agency for Research on Cancer. Available from: http://gco.iarc.fr/survival/survmark, accessed [08/06/2023]. (Click to enlarge)

The complex factors behind the UK’s cancer outcomes

Understanding the root of this crisis is not straightforward, as many intertwined factors play roles, from cultural attitudes affecting help-seeking behaviours to underinvestment in critical medical resources. As a doctor in a busy acute trust, I could not grasp why one of my patients only presented to hospital long after his skin tone had turned an unmistakable dark shade of yellow, a tale-telling sign of his late-stage lymphoma. On the other hand, as of 2021, the NHS operated with around 63 decade-old LINACs (essential cancer treatment machines), and the UK has the lowest number of PET-CT scanners per 100,000 people among International Cancer Benchmarking Partnership countries.

The UK’s uphill struggle is deep-seated, with it having the worst cancer survival rates in the EU as far back as 1995. NHS’s low spending on cancer treatments and restricted access to cancer medicines for patients have been contributing factors.

Turning the tide: a dual-pronged strategy

Despite the complexity, there are attainable starting points for improvements: boosting early detection through the two-week-wait (2WW) referral pathway and ensuring prompt diagnosis and treatment through collaborative approaches that have proven successful in other countries.

Front one: boosting early detection

Data shows that cancers identified via a 2WW referral are often diagnosed earlier, and result in fewer diagnoses during emergency admissions, with implications for survival.

Analysis on stage at diagnosis performed by Cancer Research UK (Figure 2) demonstrates this clearly, with 30 per cent of cancers detected via 2WW referral being at Stage 1, versus just 8 per cent of cancers detected through an emergency presentation to hospital.

Figure 2: Proportion of cancers by stage at diagnosis by route of detection. Source: Cancer Research UK Early Diagnosis data, accessed June 2023. (Click to enlarge)

However, across England, there is a glaring disparity in cancer detection rates – that is, the number of confirmed cancers that are detected via an urgent suspected cancer referral (2WW). This is intimately related to the overall volume of 2WW referrals (Figure 3), where higher figures are associated with a higher detection rate.

Patients whose practices have a lower threshold to refer under the 2WW programme fare much higher chances to have cancer detected via this route and as shown above, at an earlier stage. This, again, has implications for treatment and survival.

The national disparity between these practices not only means that average figures for cancer outcomes are affected by differing primary care strategies, but also that there are wide inequalities of care across the nation.

Cancer alliances and primary care networks can play an essential role in encouraging practices to revisit their referral behaviours. This effort can help reduce healthcare inequalities and potentially save lives by identifying and treating cancer earlier. Understanding what drives referral rates and promoting effective referral practices can make the difference between a life saved and one lost, and in the end spare the much higher healthcare and societal costs associated with late-stage cancer.

Front two: tackling backlogs through collaboration

Our second strategy is to reduce backlogs through collaboration. The NHS’s diagnostic capacity is currently strained, as the steady decline in patients diagnosed within the 28-Day target since its 2021 introduction suggests.

Figure 4: Proportion of patients referred for suspected cancer who meet the 28-Day faster diagnosis standard that was introduced in 2021. (Click to enlarge)

Taking cues from countries like Denmark, which successfully improved cancer survival rates by centralising specialised care and launching data-focused initiatives, the NHS can rethink its approach. By making comprehensive cancer patient data centrally available, we can make more informed decisions, improve workflow, and direct finances more effectively.

The NHS collects extensive data on cancer patients, encompassing their entire journey from referral to treatment. The key to better cancer care is ensuring the data is available centrally to key organisations and decision-makers, such as integrated care systems and Cancer Alliance leaders, to make evidence-backed financial, workflow and population health decisions and foster collaboration.

Sharing cancer data can help speed up diagnosis and treatment for patients. For instance, by sharing a cancer patient tracking list (PTL) across multiple trusts, patients who are at risk of breaching targets can be identified early and receive timely care. This strategy can also address the shortage of diagnostic appliances or services and specialised treatment.

Figure 5: Example of how cancer alliance PTL data could be pooled to estimate breach risk scores and inform waiting lists to either allow local prioritisation or highlight mutual aid opportunities. (Click to enlarge)

The road ahead: data-driven initiatives and collaboration

The current state of cancer care in the UK calls for an urgent, systemic response. By prioritising early detection and fostering data-driven collaboration, we can significantly enhance the prognosis for the UK’s cancer patients.

Expediting early detection efforts, particularly through increased 2WW referrals, is crucial to change the narrative. These efforts, when paired with the power of collaborative and data-driven care models, can revolutionise the cancer care landscape. It’s a potent combination that can help us ensure that no matter where patients live, they can access timely and high-quality cancer care. This system-wide approach presents an opportunity not just to catch up with our European neighbours, but to potentially lead the world in effective cancer care.

Sector responds to long-awaited workforce plan

By Gabriel Blaazer

Long-awaited workforce plan aims to deliver thousands more doctors, nurses and midwives through expansions in training places and degree apprenticeships.

The NHS has today published its much-anticipated Long Term Workforce Plan, promising a “once in a generation opportunity” to address the staffing shortages that have beset all parts of the health service in recent years. The government has pledged £2.4 billion over the next five years to fund the additional training and education measures included in the plan.

The number of medical school training places will increase from 7,500 to 10,000 by 2028 and to 15,000 by 2031, with areas with the greatest shortages being prioritised. The number of GP training places will increase by 50 per cent to 6,000 by 2031, and the number of adult nurse training places will almost double, with 24,000 extra nurse and midwife training places being promised, also by 2031.

The plan will also give greater prominence to apprenticeships, offering “earn while they learn” degree apprenticeships to trainee doctors for the first time. One in six (16 per cent) of all training places for clinical staff will be offered through apprenticeship by 2028, while the increase in nursing degrees will be accompanied by a 40 per cent rise in nursing associate training places over five years, with increases in other associate roles also promised.

A “huge step forward”

The plan has been broadly welcomed by medical organisations and those representing NHS staff, with NHS Confederation Chief Executive, Matthew Taylor, saying: “The government should be commended for backing NHS England to produce a thorough, bold and ambitious plan – one that has taken on board much of what the wider NHS has been asking for. There is much to welcome, not least the planned doubling of medical school places, the ambitions around apprenticeships and degree apprenticeships and the commitment to recruit more staff into mental health, community care and primary care roles.”

Andrea Sutcliffe, Chief Executive and Registrar at the Nursing and Midwifery Council, said: “Nursing and midwifery are rightly at the heart of this plan. Investing the time, money and effort needed to ensure we have a growing, capable and confident nursing and midwifery workforce is the right thing to do.”

While welcoming the “huge step forward” in terms of the commitment to train more clinical staff, the Chief Executive of The Health Foundation, Dr Jennifer Dixon has called for the measures to be backed by legislation, citing previous “good intentions [for reform] that have fallen by the wayside”. Dr Dixon also warned that “the plan relies on optimistic assumptions about improving NHS productivity”.

The Long Term Workforce plan alludes to “a renewed focus on retention”, which “could mean the health service has at least an extra 60,000 doctors, 170,000 more nurses and 71,000 more allied health professionals in place by 2036/37”. Measures to address retention include more opportunities for career development within the NHS, “improved flexible working options”, and reforms to NHS pensions.

Will the plan be enough?

However, a number of organisations have noted that the plan makes no mention of pay and conditions, which are widely held as key barriers to the health service’s ability to attract and retain sufficient numbers of staff. Dr Jennifer Dixon added that “leaver rates among NHS staff are close to record levels, and years of below inflation pay settlements mean the wages of many NHS staff have fallen behind comparable occupations. Training more staff is essential, but this will be little good if the NHS is unable to retain the staff it’s already got.”

Dr Billy Palmer, Senior Fellow at the Nuffield Trust, added that the plan “will fail unless it is followed up by efficient, effective ways we can fix the holes in the workforce by making the NHS a place where people really want to work. This must include taking a look at our broken pay review system, which has aggravated dissatisfaction.”

The plan also makes no mention of social care, described by Matthew Taylor as a crucial next step for the NHS to “revive and thrive… alongside extra investment in capital and technology.” The sector currently has an estimated 165,000 posts vacant – close to 10 per cent of all roles. Nadra Ahmed CBE, Chair of the Care Provider Alliance, added: “Social care providers share the same staffing shortages, funding challenges and cost of living pressures as our NHS colleagues” and called for “an equally necessary plan for social care”.

Other measures included in the plan aim to increase the speed at which new staff can reach the front lines. These include a consultation with the GMC and medical schools to shorten the length of medical degrees to four years, and allow student nurses to join the workforce as soon as they qualify in May, rather than waiting until September.

An additional 150 paramedics will also be trained annually, and training places for clinical psychology and child and adolescent psychotherapy will be increased, “on a path to increasing by more than a quarter to over 1,300 by 2031”.

Cost of living driving worsening health, finds Nuffield Health

By Gabriel Blaazer

Efforts to improve health outcomes being stifled by cost-of-living crisis, with many unable to afford simple measures to improve their physical and mental health

A new report from Nuffield Health has reaffirmed the damaging link between the high cost of living and worsening health outcomes in England. Nuffield Health’s The State of the Nation’s Health and Wellbeing in 2023 summarises the findings of Nuffield Health’s third annual Healthier Nation Index, a survey of 8,000 UK adults that asks detailed questions of all aspects of respondents’ physical and mental wellbeing.

It found that slightly more than one-third of people have experienced declining physical and mental health over the last twelve months (35.1 per cent and 33.7 per cent, respectively), and that nearly 50 per cent of people have experienced declining financial health over the same period. 63.2 per cent of respondents believed that the cost of living crisis is having a ‘negative impact’ on the nation’s health – a fact supported by an ever-growing body of research.

A central role for ICSs

On 13 June, Nuffield Health convened a roundtable discussion at the House of Commons, supported by MPs Kim Leadbeater and Dr Lisa Cameron, to explore the findings of the report. The roundtable highlighted the vital role that integrated care systems (ICSs) will have in ensuring that local population health strategies are responsive to the many factors influencing health, not least cost-of-living challenges.

The attendees of the Nuffield Health roundtable at the House of Commons (click to enlarge)

It was also noted that collaboration is crucial to effectively addressing the health impacts of the cost-of-living crisis “across multiple sectors – not just the NHS”, according to Nuffield Health’s post-event briefing. Contributors agreed that ICSs should seek to use “their convening ability… to collaborate with local anchor institutions, voluntary and community sector partners and local residents” to produce holistic solutions that address the multitude of factors driving poor physical and mental health.

An example of local solutions that can promote good health is the local prioritisation of building healthy environments. The need for these spaces can be best understood at neighbourhood and place level, and this insight can be turned into action through integrated care partnership strategies and collaboration with local partners, including local authorities. Participants in the roundtable identified that individual behavioural changes will only go so far, and that policies that ignore the contextual environment in which people live and work are bound to be limited in their effectiveness.

Leadership on prevention

While the key role of ICSs was discussed, it was also acknowledged that leadership around the prevention of ill health must come at the national level, with accountability shared across all government departments. It was emphasised that the most impactful preventative measures are best driven at the local level, so the role of national government should be that of an enabler for localised action, “empowering and supporting residents to be engaged in solutions, from inception to delivery”.

At the same time, greater clarity around terminology and the ultimate objectives of prevention are required, which can be instigated at a national level. Helping the population to understand how vital prevention is, and will be, for the sustainability of the healthcare system, will help to increase buy-in for measures that require the active participation of citizens.

There is also a role for employers to play in supporting the health and wellbeing of their workforce. As working practices have shifted so much in recent years, so too should employers’ strategies for supporting workers, particularly those working in remote or hybrid working environments. This is especially important for women, who tend to be disproportionately affected by poor mental health in the workplace.

Many of the themes to come out of the roundtable discussion understandably align with Nuffield Health’s recommendations made in the report, which argues that the health and wellbeing of the population is our most important national asset, and should be a national priority.

More than 1 in 10 NHS mental health jobs currently vacant despite sharp rise in demand

By Integrated Care Journal

An additional 450,000 people a month are contacting mental health services in 2023 compared to 2020, while antidepressant prescriptions rise by millions in just a few years.

New analysis of the latest NHS statistics by Clerkenwell Health show that more than 1 in 10 mental health professional jobs in the NHS are currently unfilled. The analysis also reveals significant regional disparity with the North West and Midlands faring worse than average, with 17.5 per cent and 14.9 per cent respectively of mental health jobs vacant. This compares to an overall NHS medical vacancy rate of 5.8 per cent.

The figures come alongside a sharp increase in the number of people seeking contact with NHS mental health services every month – rising consistently from 1.3 million people a month in June 2020 to 1.75 million people a month by March 2023. Meanwhile an extra 3,000 people every month are also occupying a bed in a mental health hospital, when compared to January 2021.

The latest NHS data also shows a sharp rise in the number of antidepressants prescribed. Between October to December 2022 (the latest figures available), 22 million antidepressants were prescribed to an estimated 6.6 million identified patients. This compares to 15 million prescriptions in Q1 of 2015 and 19.6 million in October to December 2020.

The new analysis comes from Clerkenwell Health, the first commercial organisation in Europe to design and deliver clinical trials for a range of drug developers to find novel treatments for complex mental health conditions. They are working with drug manufacturers to explore innovative treatments for conditions with which the NHS is struggling to cope including treatment-resistant depression, anxiety, PTSD and alcohol use disorder, as well as conditions affecting the central nervous system.

Clerkenwell Health is developing trials to test the use of psychedelics such as psilocybin to treat a range of mental health conditions and are actively recruiting participants.

Tom McDonald, Chief Executive Officer at Clerkenwell Health, said: “With a sharp rise in people contacting mental health services and antidepressant prescriptions rocketing in just a few short years – all amidst a major mental staff shortage – it’s clear the need for innovative mental health treatments has never been more acute.

“There is no silver bullet, but a growing body of research suggests that psychedelic drugs could be ground-breaking for the treatment of complex mental health conditions. The Government must help accelerate the number of clinical trials being delivered in the UK to help new treatments reach patients more quickly and stem this growing problem.”