The UK must harness data and digital to revamp stroke aftercare – Mike Farrar

By Mike Farrar

Stroke is the single largest cause of complex disability and long-term thinking around stroke aftercare is critical in easing pressure on health and social care.

The NHS Long Term Plan places stroke aftercare as a key priority area for improvement. However, ongoing data shows that the promises to ensure the best performance in Europe for delivering clot-busting thrombolysis by 2025 and increasing the number of patients receiving reviews of their recovery needs (from 29 per cent to 90 per cent), is unlikely to be met.

The stroke pathway has seen significant improvements over the last decade. These include the introduction of hyperacute stroke units, improved brain-imaging, rapid thrombolysis and game-changing thrombectomy. However, it is likely that these interventions will be undermined by the failure to recognise the opportunities to help people return to productive lives after a stroke.

Stroke care is an area that has seen substantial improvement in the UK; while mortality rates have halved over the last 20 years, stroke remains the single largest cause of complex disability. Further to this, recent research from the Stroke Association five-year survival rates remains low.

The Stroke Association estimates that 100,000 people have a stroke in the UK every year, with two thirds of survivors leaving hospital with a disability. There are currently 1.2 million stroke survivors living in the UK, at an estimated cost to the health and care sector of £26 billion a year. This cost is expected to triple by 2035.

Missing parts of the stroke pathway

The provision of rehabilitation and aftercare is an essential element of the care pathway yet is often the least well supported and resourced, a situation not solely limited to stroke care.

This is not unique to the UK and clinicians in the USA are experiencing similar issues. Once a patient has left an acute situation, where the latest interventions, medications and technological advancements have been provided, the same level of attention just isn’t there post-discharge. There is often a marked deterioration in wellbeing with an undetermined longer-term impact.

Stroke aftercare: a faulty mindset

There is an underlying mindset within the system that the priority lies with acute care management and what happens after is less important. As a system, crisis response is generally exceptional, and innovation and resources tend to be focused on this stage of patient’s journey. But there is very little strategy – and the funding treadmill is perpetuated by continually focusing investment on acute interventions. But it is clear that the cost benefit is poor if a more strategic view of the whole care pathway is not taken.

The failure to provide effective rehabilitation immediately after an acute episode can lead to reduced functioning mobility and normal life for the individual. The consequence of this failure is an added cost for the health and care system, reduced economic productivity and can increase social care costs if it leads to patients losing their ability to live independently.

Masking the real data

The data currently collected typically identifies re-admitted patient episodes as a new case rather than allowing the system to recognise and then count it as a re-admission. This often masks the failure of the rehabilitation and ongoing support offered, which could have prevented further problems.

The link to co-morbidities is also missing, with more people dying in the first six months after a stroke from cardiac events, rather than consequences of a stroke – which means we are overlooking opportunities to influence outcomes in other ways.

The cost of high-quality rehabilitation may pay itself back over time but immediate cost pressures in the system can often mean that rehabilitation is not funded as a priority, in turn reducing patient outcomes.

Balancing the funding model

So, what should the path forward be from here? The key to achieving the right balance is to argue the need for a greater use of data and to provide the evidence to build up the business case. There are some professionals and clinicians leading the charge and looking for that evidence to balance the funding model.

The Mount Sinai health system in the USA recruited a randomly selected sample of people who were enrolled in a remote monitoring programme. Of the sample, 90 per cent of the sample had a crisis that the health system could have intervened on. Without the follow-up, these crises would never have been caught.

In Cardiff and Vale in Wales, they’re currently trialling a system that joins up the data to the patient – rather than the episode – to track the re-admissions and the patient’s entire journey through the health system. The data outcomes are providing interesting insights into chronic conditions and helping to modify care providers’ understanding of where they put their money.

The role of data and digital in stroke aftercare

There is also seeing a role for digital platforms to be used for virtual rehabilitation. There are many ways to do this and the growth of digital care technology in local authorities should be used to support and endorse these changes across the whole health and care system. As an example, Visionable’s platform allows any deterioration in health to be identified early to prevent serious problems occurring, including readmissions. As people wait longer for care, this early warning is crucial to avoid patient harm.

There’s a real opportunity to shift the way rehabilitation pathways are approached, and how outcomes are tracked. This dialogue should really appeal to the new integrated care systems and their integrated care boards as the NHS embark upon seismic structural shifts in 2022.

Through system-wide commissioning, there is the opportunity to balance the investment and provide transformation – and to deliver a genuine whole pathway, including more robust rehabilitation services. Enhancing data capture in real-time and making sure the money follows the patient could produce marked differences – not only for the public purse, but in the quality of people’s lives.

Royal College of Physicians issues stark warning over social care crisis

By Gabriel Blaazer

The Royal College of Physicians is warning that the combination of an ageing population and a lack of NHS workforce planning means the country is risking an unavoidable crisis in social care for older people.

The Royal College of Physicians (RCP) has issued a stark warning that NHS workforce shortages are driving the social care crisis in England and that the NHS is “woefully unprepared to cope with an ageing population.”

New analysis from the RCP shows that there is the equivalent of just one full time geriatrician per 8,031 people over the age of 65 in England. The findings use data from the RCP’s own census of physicians and the Office for National Statistics’ (ONS) population data and demonstrate the extent to which England’s care crisis is only set to grow.

The ONS estimates there will be more than 17 million people aged 65 and above in the UK by 2040, meaning 24 per cent of the population would require geriatric care. Additionally, many of the doctors currently providing geriatric care will, themselves, soon be requiring the same care, and 48 per cent of consultant geriatrics are set to retire within the next 10 years.

Considering these trends, the RCP, along with more than 100 medical organisations, is supporting an amendment to the Health and Social Care Bill requiring the government to publish “regular, independent assessments of the numbers of staff the NHS and social care system need now and in future.” No such data is currently publicly available. The amendment, currently being debated in the House of Lords, was tabled by Baroness Cumberlege and is supported by former NHS England Chief Executive Simon Stevens (now Lord Stevens of Birmingham), is set to be debated in the House of Lords

Responding to the RCP’s warning, Danny Mortimer, Chief Executive of NHS Employers and Deputy Chief Executive of the NHS Confederation, said: “As exhausted NHS staff strive to tackle the enormous treatment backlogs that have resulted from the pandemic, we must not forget about the pressures that our health and social care services face as they work to meet the growing needs of our ageing population.

“To be able to plan effectively for a future workforce, healthcare leaders need clarity in the shape of a clear long-term workforce plan. Sajid Javid’s recent commissioning of a workforce strategy is a very welcome step, but… we would urge the government to accept amendments requiring the health secretary to publish regular, independent assessments of the numbers of staff the NHS and social care system need now and in future.”

The President of the RCP, Andrew Goddard, said: ““I have dedicated my career to working in the NHS – a service that I am fiercely proud of – and yet it scares me to wonder what might happen should I need care as I get older. There simply aren’t enough doctors to go round, not least within geriatrics.

“The workforce crisis we’re facing is largely down to an astonishing lack of planning. All successful organisations rely on long-term workforce planning to meet demand and it’s absurd that we don’t do this for the NHS and social care system. The government needs to accept the amendment put forward by Baroness Cumberlege and make workforce planning a priority.”

Dr Jennifer Burns, President of the British Geriatrics Society, said: “These figures show very clearly the current nationwide shortage of geriatricians – a situation that will only get worse with the predictable rise in the numbers of older people across the UK needing healthcare.

“It is absolutely vital that these fundamental issues around the recruitment, retention, development and support of the workforce are addressed, and that there is a properly-resourced strategy for future needs. The British Geriatrics Society stands with the RCP in strongly supporting the amendment to the Health and Care Bill.”

New IPPR report argues health is ‘holding back UK economy’

By Niamh Macdonald

The UK will suffer an £8 billion hit to economic activity this year due to lack of government action to improve the nation’s health, according to a report launching the new cross-party IPPR Health and Prosperity Commission.

The IPPR report published today marks the launch of a new Commission on Health and Prosperity. The report warns that health inequalities and ineffective policies are shortening life expectancy in the UK, coupled with more years spent in poor health.

New analysis by IPPR and health analytics company Lane, Clark & Peacock, reveals that the workforce is also being affected as people face barriers to staying in work.

The IPPR is calling for a ‘new post-pandemic approach’ to the nation’s health to ensure that people can live long healthy lives as well as to strengthen the UK’s suffering economy.

There are now more than a million workers missing from the workforce compared to pre-pandemic levels. About 400,000 of these individuals are no longer working due to health factors, including long Covid, disruption to healthcare and declining mental health. The researchers warn that without intervention, this will drag down economic activity this year by approximately £8 billion.

The report states that the relationship between health and the economy is a decisive factor in the UK’s low productivity, low growth and significant regional inequalities.

According to the report, local level analysis reveals that someone living in North East Lincolnshire can expect to fall into bad health eight years than the UK average, while the output of their work is also valued at £8 less than the average. The report argues that this is a vicious cycle and that factors like lack of job opportunities can harm people’s health.

To explore how good health can be the foundation for a fair and prosperous economy, IPPR is launching a new cross-party Health and Prosperity Commission. The cross-party commission will be chaired by Lord Ara Darzi and former Chief Medical Officer Dame Sally Davies.

The report argues that the UK’s poor health outcomes and stagnant economy are a result of poor policy choices. According to IPPR, policy makers must now ‘set about putting the building blocks of good health in place’, including ‘good work, quality housing, local public health services’ and a ‘well-funded and staffed NHS. ‘

Dame Sally Davies, former Chief Medical Officer and co-chair of the Commission on Health and Prosperity, said: “A fairer country is a healthier one, and a healthier country is a more prosperous one. While the restrictions have eased, the scars of the pandemic still remain deep on the nation’s health and our economy.

“Not only are we facing a severe cost of living crisis, driven in part by pandemic induced inflation, we’re also experiencing a workforce shortage driven by poor health that’s holding back the economy. It has never been more important to put good health at the heart of our society and economy – and our commission will bring forward a plan to do just that.”

Matthew Taylor, NHS Confederation chief executive and commission member said: “The pandemic has shown how deep health inequalities shape and cut across the lives and livelihoods of people across the country.

“Yet this is not new, disparities in health have not suddenly appeared, they have been part of the make-up of our society for decades. As millions of people now face the reality of a cost-of-living crisis there is an urgent need for a much bolder and more strident approach to tackling inequalities to create improved population health and stronger economic wellbeing.

“We are delighted to be part of the Commission on Health and Prosperity and look forward to reflecting member insight. ”

Time to fix the gender diagnosis gap for autism

By Charlotte Perry

As well as increasing global acceptance and understanding of the condition, this year’s Autism Awareness Month should be used to highlight growing and concerning gender diagnosis gaps.

Four times more boys than girls are diagnosed with autism, according to Spectrum News, yet more women are referred for a diagnosis in adulthood than men. This suggests they are missed in childhood and raises questions as to whether the prevalence of autism in girls is higher than those diagnosed.

Autism effects a range of behavioural traits, from difficulties with communication skills to repetitive behaviours and overreactive sensory experiences. However, medically and socially, society has grown accustomed to recognising autism through a male presentation. Well known hallmarks of the disorder, such as hyperactivity and fixated interests, tend to be heavily externalised by boys. Meanwhile, females internalise these symptoms, and may instead present with anxiety, emotional ‘breakdowns’, and more passive bouts of misbehaviour.

Whether due to genetic differences or social expectations, there remains a concerning gender gap in both research and diagnosis. The Autistic Girls Network (AGN) campaigns for better recognition and diagnosis for autistic girls. Their 2022 white paper, Autism, Girls, & Keeping It All Inside, outlines the key differences in presentation of autism in girls compared to boys. It addresses the stereotypes leading to late referral, such as girls simply ‘being shy’, and discusses the complications when autism is left undiagnosed.

As AGN boss Cathy Wassel recently said, “we need everyone to be able to see those young people who never raise their hand or speak up in class, who are situationally mute, who are on the edge of friendship groups, who have strong sensory sensitivities. ”

AGN’s paper also suggested that 20-35 per cent of females with anorexia nervosa may also be autistic. This evidence for an increased co-occurrence of autism and eating disorders in girls is lacking representation in autism diagnostic tools, therefore widening the gender diagnosis gap.

Within their white paper, The AGN lists key recommendations that would benefit both acceptance and diagnostic tools used in relation to autism. They suggest that the presence of co-occurring health conditions should act as a flag to referral for autism investigation, with diagnostic tools adapted to include typical female presentations as well as male. Improving research not only on autism in girls, but also the intersectionality of ethnicity, aging, menstruation, and menopause is needed.

“We need to get rid of the stigma as we have a whole generation of women who weren’t recognised and are only now realising why they have felt different, and often ‘not enough’ all their lives,” continued Cathy, “we need this to happen especially in schools, which can be very difficult places for our autistic young people. ”

As Autism Awareness Month draws to a close, the push for overall acceptance and understanding across society must continue. But so should the medical and research community be urged to take practical steps to shrink diagnosis gaps based on gender and ethnicity lines. It is essential for healthcare workers to understand gender-specific presentations of autism for diagnosis, consideration and education should be systemic.

Life expectancy significantly below average for women in England’s poorest areas

By Integrated Care Journal

Life expectancy for women living in the poorest 10 per cent of areas in England is lower than overall life expectancy in any OECD country except Mexico, reveals analysis by the Health Foundation.

The analysis shows that women living in the poorest 10 per cent of areas in England have an average life expectancy of 78.7 years. This is considerably below the average of 83.2 years for the whole of England and less than the overall life expectancy for women in countries including Colombia (79.8 years), Latvia (79.7 years) and Hungary (79.6 years). In Mexico, which has the lowest life expectancy at birth of any Organisation for Economic Co-operation and Development (OECD) country, women live on average 77.9 years.

Women living in the richest 10 per cent of areas in England have an average life expectancy of 86.4 years. This is higher than overall life expectancy for women in any OECD country, aside from Japan which has the highest female life expectancy for all OECD countries at 87.3 years.

These figures demonstrate the harsh reality of health inequalities in England, where those in the poorest areas can expect to live significantly shorter and less healthy lives in contrast with the richest areas.

The government white paper on ‘health disparities’ is currently expected in early summer, following a pledge in February to increase ‘healthy life expectancy’ by five years and reduce the gap between the healthiest and least healthy local authorities.

The Health Foundation warns that the government’s strategy for improving health has so far failed to ‘grasp the scale of the challenge’ and that based on pre-pandemic levels, it will take almost two centuries to achieve that increase.

The rising cost of living is a compounding factor which may further widen health inequalities. The Health Foundation notes that the pandemic has taken a toll on the finances of many poorer families. Rising prices will mean that increasing numbers will be forced to choose between going without essentials which are important for living a healthy life.

Jo Bibby, Director of Health at the Health Foundation, said: “The stark reality in the UK is that the poorest can expect to live shorter and less healthy lives than their richer counterparts.

“The government has committed to addressing stalling life expectancy and this has been described as a core part of the levelling up agenda. However, the government has so far failed to acknowledge the mountain it needs to climb to bring life chances in the UK in line with other comparable countries. Investing in people’s health is an investment in the economy.

“For many people, poor health is a significant barrier to work and training. The economic impact of lost output and health costs associated with poor health adds up – these are estimated to cost the UK economy around £100bn a year.

“If we are to see progress, there needs to be a fundamental shift in the government’s approach, from a focus on people’s individual responsibility and choices towards actively creating the social and economic conditions that enable them to live healthier lives. This means providing secure jobs, adequate incomes, decent housing and high-quality education.

“To achieve this, improving health should be made an explicit objective of every major policy decision. Otherwise, the gap between rich and poor will further widen and ‘levelling up’ will remain little more than a slogan.”

Community Diagnostic Centres: A critical response to regional inequalities

By Niamh Macdonald

The latest report from Vanguard, Assessing the current state of play of CDC delivery across England, 2021, provides much needed clarity on the current status of CDC rollout and identifies where more support is required to achieve regional equality in healthcare provision.

The backlog in patient care is affecting every region across England, with waiting lists at an all-time high and services struggling to keep up with demand. Community diagnostic centres (CDCs) were earmarked by Sir Mike Richards as a necessity across communities to support quicker and safer access to both elective and diagnostic procedures in 2019.

A few years and a global pandemic later and the need for streamlined diagnostic service provision is now greater than ever.

An additional layer to the elective care crisis is the disproportionate impacts being felt across England; while no region of the country has been left untouched by the crisis, some are clearly being affected more severely than others. The approach to delivering CDCs is also disjointed across regions and their respective integrated care systems (ICS).

To deliver high-quality diagnostic care in the face of the backlog, a joint up and co-ordinated approach is vital. The latest report from Vanguard, Assessing the current state of play of CDC delivery across England, 2021, outlines the findings of a Freedom of Information (FOI) research project, undertaken in 2021. The findings of the report not only provide a bigger picture on the current status of CDC rollout but also identifies where more support is needed in order to achieve regional equality in healthcare provision.

Compounding inequalities

Health inequalities have been widening across England in recent years and these societal fault lines were underscored by the impact of Covid-19. There is currently a gap of almost 19 years in healthy life expectancy between the most and least deprived areas of the country. Further still, during the pandemic average life expectancy fell for the first time since 2000.

Higher rates of Covid-19 were concentrated in the most deprived areas of England, intensifying pressure on the hospitals and care services within these regions. This has caused patients living in these areas to suffer the greatest disruptions to elective care services.

According to evidence submitted by the Health Foundation to the House of Commons Health and Social Care Committee, patient treatment completion in the most deprived areas of England has fallen by 31 per cent, while completion fell to 26 per cent in the least deprived areas. Regional inequalities are only set to widen as the effects of the pandemic continue to impact patient waiting times.

“A joint up and co-ordinated approach across England is vital to minimise the disruption to services and reduce the patient care backlog.”

Targeting inequalities with CDCs

The Vanguard report, Assessing the current state of play of CDC delivery across England, 2021, provides an overview of current CDC delivery across England. The region with ICS, STP and Clinical Commissioning Groups (CCGs) that are farthest along in their delivery strategy is the Southeast. A high proportion of respondents reported to have a strategy in place and expect their CDC to be fully operational in the next three years. The Southeast also had the highest proportion of respondents that identified CDCs as a high spend priority.

Contrastingly, just one-third of respondents in the West Midlands identified CDCs as a high spend priority. Furthermore, the West Midlands region has the highest waiting lists for all procedures in England, accounting for 20.5 per cent of all national waiting lists as of July 2021. It is evident from the current picture of CDC roll out that more regionally tailored support is needed to level out delivery across the country, ensuring that the impact of CDCs is maximised.

Central to the CDC ‘mission’ is to minimise regional inequalities by supporting the delivery of integrated care, helping to join up disconnected patient pathways and bring services closer to the communities that use them. It is hoped this will expand capacity and improve access to care. By increasing the capacity to tackle waiting lists, the successful implementation of CDCs could help to reduce healthcare inequalities and disparities in patient outcomes.

Lindsay Dransfield, Chief Commercial Officer at flexible Healthcare Spaces provider, Vanguard said: “CDCs are an essential component to reducing patient care backlogs, creating more accessible healthcare for individuals in more deprived areas.

“Following the recent government announcement that £2.3 billion is to be spent on increasing diagnostic activity across the UK, it is now more important than ever to reduce regional health inequalities through the introduction of more CDCs.”

Fair access to funding

While the Health and Care Levy, introduced in September 2021, provides significant funding for tackling waiting lists and elective care backlogs, there remains significant challenges in ensuring equitable distribution of funding. For CDCs to be rolled out with more consistency across England, the government must ensure that regions are able to fairly access funding and support. There is currently a lack of clarity across ICS/STP/CCGs around how decisions are made to allocate funding, this lack of guidance is detrimental to regions already being impacted by higher waiting lists and capacity issues.

The Vanguard report recommends that the government and NHS “remove bureaucracy in the national procurement process to ensure CDC delivery is accessible for all bodies involved with the ICS”. Unnecessary bureaucracy in the procurement process has cost and time implications for healthcare providers, in some cases making it impossible for them to undertake the application process.

On top of reducing bureaucracy around funding, the report recommends putting in place regionally ringfenced budgets for CDCs that are calculated based on a number of indicators, such as waiting lists, current budgets, staffing requirements and available land. This will ultimately help to provide a more consistent approach in the roll out of CDCs and subsequently generate fairer patient outcomes.

A co-ordinated approach

Central to the NHS Long Term Plan is the goal of delivering fully integrated community-based healthcare. To achieve this, the Vanguard report demonstrates the need for a clear framework for CDC delivery to provide clarity across ICSs. A joint up and co-ordinated approach across England is vital to minimise the disruption to services and reduce the patient care backlog, but the benefits must be felt equally. With the most deprived areas of England facing some of the harshest consequences of the pandemic, the roll out of CDCs is an important step in ensuring accessible and equal healthcare.

The Vanguard report recommendations include:

Put in place clear, accessible national funding streams in order to secure confidence in CDC delivery and enable the development of long-term, futureproofed plans.
Ringfence central Government funding for CDC delivery per region, assessed on a range of factors (such as number of patients, average time for delivery of care, number of ICSs in region) to ensure the roll out of CDCs is fair and serves to actively reduce regional inequalities.
Develop localised awareness and education programmes for ICSs to ensure all bodies involved with CDC delivery are aware of the opportunities available to them in terms of funding, partnership opportunities and have access to necessary additional support to ensure the success of CDC delivery.
Broaden the national awareness of regional health inequalities and provide additional support and resources, beyond funding alone, to regions suffering from covid-related backlogs to better prepare them for future incidences of heightened pressure and to prioritise patient outcomes.
Remove bureaucracy in the national procurement process to ensure CDC roll out is accessible for all bodies involved in the ICS.
The Government and NHS should actively identify appropriate infrastructure partners who can rapidly design, build and commission appropriate high quality, safe clinical infrastructure and develop a register of verified infrastructure delivery partners to ensure CDC delivery is consistent on a national scale.
Develop a sustainability guide for CDC delivery to help the NHS reach its goal of Net Zero carbon by 2045.
Promote Modern Methods of Construction (MMC) for CDC delivery to transform existing facilities and create purpose-built new estates that have the flexibility to be re-purposed and expanded upon, enabling a rapid response to changing demands and enabling ICSs to build out there CDC in a modular fashion to tackle patient waiting lists.

Making the creative leap: a healthcare case study

By Simon Dodds; Alan Macdonald; Fay Wilson; Terry Young

Amid greater demand for NHS services, increased use of computer modeling in the planning stages can improve efficiency of delivery.

Plan-Do-Study-Act (PDSA) is deeply embedded in the NHS – and why not? It is simple to grasp and easy to explain. It puts improvement in the hands of those who deliver the care, empowering staff with knock-on benefits for patients. However, it is focused on incremental improvements, and may miss what works well already.

Increasingly the NHS must introduce new systems and services quickly, which is where PDSA runs out of steam as a way to manage innovation. In early 2021, Birmingham and District General Practitioner Emergency Room (Badger) Group set out on its final phase of rapid access delivery. Badger group, which delivers out-of-hours primary healthcare to local patients, was preparing to open a drive-through facility in Bourne Road in Aston. When planning for the opening of this facility, the team used an adapted form of PDSA and added something new.

The adapted feature was to stick to a cycle – study, plan, do (SPD) – which emphasises iterative solutions. Cycles are key to systems design, because it is impossible to specify anything completely from scratch. Also, as a solution is developed, the problem often changes. With rapid access, for instance, making it easier for people to reach the care they need can risk creating bottlenecks and queues as people converge on the new facility.

The innovation was to use computer simulation alongside measurement based on physical facilities. Models may be built and assessed faster than a real service, which speeds the design process up enormously. Models are also safe, since nobody suffers during a simulation. Figure 2 shows an example of two cycles of a design process using SPD at its core.

Study

GK Chesterton said, “The Reformer is always right about what’s wrong. However, he’s often wrong about what is right.” It is critical, therefore, to analyse what works well at each stage of an emerging design, as well as to understand what remains problematic.

With each cycle of the design complete, there is usually more evidence and data to feed into the next plan and computer models can address two questions:

Is the plan likely to work as intended? This is the ‘what works’ question.
Under what circumstances is it likely to fail? This is the ‘what risks’ question

In this case, as several rapid access, drive through facilities were built over a short period, the data available for study became very detailed – as shown in Figure 3.

**Figure 3: Example of the depth of data available for later deployments of rapid access clinics based on earlier clinics.**

Plan

Given increasingly sophisticated data, it is possible to plan in ever greater detail and with greater confidence. Planning is an interactive process, ideally drawing in as many stakeholders as possible. White boards, as shown in Figure 4, are an effective thinking tool at all stages of the process.

**Figure 4: Hand drawing used as part of the design process**

Do

The strength of the Badger approach is that it could use a variety of protoypes throughout the process, starting with a computer model of the local spread of the Covid pandemic. Computer models were also built to test out each clinic that was commissioned, and those clinics in turn were used to prototype aspects of the next stage of delivery.

This process sustained rapid cycles of development and successful deployment of a new type of care delivery through a series of easy access units in less than two years from initial concept to the latest drive through clinic.

Did it work?

On October 21 2021, the first patients drove through Badger Group’s purpose-built clinic. There is capacity for up to 500 a day, and they are still coming.

The mass vaccination campaign has alerted many in healthcare to the potential of pop-up provision, and many examples exist, run out of anything from tents to cathedrals. What is unique about this example is the advanced methods used to deliver a sequence of easy-access clinics during a time when the NHS was under extreme pressure.

Each opened as planned and worked as predicted. And that is exceptional.

About the authors

Mr Simon Dodds, MA, MS, FRCS

Simon Dodds is a general surgeon at University Hospitals Birmingham NHS Foundation Trust. He studied medicine and digital systems engineering before following a career in general and then vascular surgery. In 1999, he was appointed as a consultant surgeon at Good Hope Hospital in North Birmingham and applied his skills as an engineer and a clinician in the redesign of the vascular surgery clinic and the leg ulcer service.

In 2004, the project was awarded a national innovation award for service improvement. This experience led to the design, development, and delivery of the Health Care Systems Engineering (HCSE) programme.

Alan MacDonald, BSc

Alan studied at Nottingham Trent University and has a BSc (Hons) in Biomedical Science.

He worked for the Badger Group as an Out-Of-Hours primary care team leader and later became a data analyst. Since the start of the COVID-19 pandemic in March 2020, he became directly involved with the development of a multi-lane drive through Covid Referral Centre at the NEC.

He has been instrumental in the deployment of other temporary drive through clinics across Birmingham. He has also been actively part of the original team who were successful in applying this concept to the first purpose-built drive through clinic in the UK

He is frequently involved in new & novel projects within the out of hours primary care sector and is currently studying Health Care Systems Engineering.

Dr Fay Wilson, MBChB, FRCGP

Fay trained in Birmingham and has practiced there as a GP there since 1985. Her extensive national and local portfolio includes: NHS HA Non Exec, GMC fitness to practise chair, and associate postgraduate dean at Health Education West Midlands. She has served on the council of the BMA and other bodies. Fay brings people together to develop new models of care, a notable success being the Birmingham Multifund co-operative, a pioneering nurse-led walk-in centre and a prototype GP provider-at-scale ahead of its time in the mid-1990s.

Dr Wilson is medical director and co-founder of Badger, a GP social enterprise since 1996 providing out of hours and urgent primary care. COVID-19 introduced her to systems engineering, new people and new ways of thinking. Her ambition for the last decade has been to slow down.

Prof Terry Young, BSc, PhD, FBCS

After 16½ years as a research Engineer, Divisional Manager and Business Development Director, Terry became a professor at Brunel University London for 17 years.

He has a BSc in Electronic Engineering and Physics, a PhD in laser spectroscopy both from the University of Birmingham, UK.

His research has been in health technology, health services, and information systems. He has taught information system management, project management and e-Business.

His awards include the Operational Research Society’s Griffiths Medal, 2021, for analysing the return simulation methods offer when used to improve healthcare services.

Prof Young set up Datchet Consulting in 2018 to support innovation on the borders of academia, health and industry, of which the project reported here is an excellent example.

Care employers come together for Ukraine

By Integrated Care Journal

With the conflict in Ukraine raging, care employers are working together to provide opportunities for those displaced to work and find a home in the UK.

Care employers have been working together to understand how they can provide a meaningful employment opportunity for those displaced from Ukraine and other parts of the world and finding a home within the UK.

The National Care Forum (NCF), the leading association of not-for-profit care and support providers, in association with the Care Provider Alliance, have brought together a wide range of partners committed to offering support. This includes expertise from across national and local government, housing, recruitment specialists, legal and immigration experts and regulators.

Employers and partners are working closely with recruitment experts to enable displaced people from Ukraine and other parts of the globe to identify roles within the care sector, direct individuals to localised support and ensure that employers work together to provide the best opportunity for those who wish to work.

While this work progresses, the broader support for people displaced from Ukraine through the Homes for Ukrainians scheme is being clarified. Alongside this, local government has an important role in regards to how local support will work, and specific roles and responsibilities are still emerging. It is imperative that the desire to work is aligned with the need for displaced people to be connected into wider community and pastoral support.

Vic Rayner OBE, CEO of the NCF said: “Like many people affected by the plight of the people of Ukraine, care employers are pulling together to take action to help. The ideas are progressing at pace, and there is a strong desire to do something meaningful to help the people of Ukraine, and others from around the globe who arrive into the UK.

“We are pulling together opportunities for care and support employers to share details of available job vacancies, which we hope will be tied into the broader communications for displaced people. There are many other ways for people to offer support, including support to Ukrainians needing care and support, assistance with vetting and matching, and those who have a housing solution.

“However, there remain significant unanswered questions around regulatory requirements, right to work entitlement, safeguarding, etc. We need the government to work at pace alongside adult social care employers to resolve this. Furthermore, we are working with other partners, to understand how most effectively the sector can be engaged to provide a solution at this moment of crisis.”

WHO reveals almost entire global population breathing unhealthy air

By Niamh Macdonald

Almost the entire global population (99 per cent) breathes air that exceeds World Health Organization (WHO) air quality limits, and threatens their health, according to the 2022 update of WHO air quality database.

The new air quality database, released on 4 April, is the most extensive yet in its coverage of air pollution exposure on the ground. The database now includes measurements of annual mean concentrations of nitrogen dioxide (NO2), a common urban pollutant and measurements of particulate matter with diameters equal or smaller than 10 μm (PM₁₀) or 2.5 μm (PM_2.5).

A record number of over 6,000 cities in 117 countries are now monitoring air quality, revealing how their populations are breathing unhealthy levels of fine particle matter and nitrogen dioxide. The data also shows that people in low and middle-income countries are suffering the highest exposures.

A worsening health emergency

The database demonstrates the threat of air pollution to human health. Particulate matter is capable of penetrating deep into the lungs and entering the bloodstream which can cause cardiovascular, stroke and respiratory impacts. There is also emerging evidence that particulate matter impacts other organs and causes other diseases.

Nitrogen dioxide is associated with respiratory diseases, particularly asthma, which lead to respiratory symptoms, such as coughing or difficulty breathing. This further leads to increased hospital admissions and visits to emergency rooms.

Dr Maria Neira, WHO Director, Department of Environment, Climate Change and Health, said: “After surviving a pandemic, it is unacceptable to still have 7 million preventable deaths and countless preventable lost years of good health due to air pollution. That’s what we’re saying when we look at the mountain of air pollution data, evidence, and solutions available. Yet too many investments are still being sunk into a polluted environment rather than in clean, healthy air.”

Last year, WHO responded to the growing evidence base for the significant harm caused by even low levels of many air pollutants by revising its Air Quality Guidelines. The guidelines were made more stringent, especially for Nitrogen dioxide and particulate matter, an action that was supported by the health community, medical associations and patient organisations.

Now, through the 2022 database WHO aims to monitor the state of the world’s air and feed into progress tracking of the Sustainable Development Goals.

Commenting on the report, Francesco Tamilia, Policy Analyst at Public Policy Projects and author of The climate crisis and its impacts report said: “The science and data are increasingly clear on the extreme threat air pollution poses on human health, damaging every organ in the human body. World Health Organization has done an incredible job revising its Air Quality Guidelines last year, making them more rigorous. The latest air quality database is another important step in measuring the damaging affects air pollution has on the population’s health.

“National governments have no excuses, either they implement those guidelines and avert millions of premature deaths, or they will knowingly neglect the health of their populations.”

News, Partners, Population Health, Social Care, Thought Leadership, Workforce April 4, 2022

More support needed for “fatigued” social care workforce

By Mary Brown

On the 16th March 2022, Public Policy Projects (PPP) hosted an evidence session entitled The Social Care Workforce: Averting a Crisis as part of its report series The Future of Social Care. PPP’s Social Care Network examines the most urgent issues facing social care and presents tangible solutions to address workforce challenges in the sector.

The crisis facing the social care sector is fundamentally a workforce one. The sector itself is a large employer in the UK, employing about 1.54 million people, equivalent to five per cent of the workforce. As one participant noted, “the sector itself is a huge contributor to the economy and to society”. Given that staff pay is the single biggest expenditure faced by care homes, workforce management should be front and centre whenever system finances are being considered.

Even before the pandemic, there were about 112,000 social care vacancies in England, with jobs paying only £8.50 an hour. Following the pandemic, the vacancy figures are assumed to be worse. Key issues driving individuals away from working in the social care sector include low pay, stressful working conditions and a low sense of worth.

A participant of the evidence session emphasised that the working conditions of the social care sector have led to 74 per cent of care professionals reporting that they regularly experience stress at work, an average number of sick days 25 per cent above the national average, and a staff turnover rate significantly higher than the national average.

As phrased by one participant, social care is suffering from a “fatigued workforce” not only due to the pressures of the pandemic, but issues which have existed within the sector for much longer. The problems within the social care workforce are chronic , and are considered by many to constitute a crisis. As one participant said, “clearly a workforce strategy is one of the absolute essentials that we need to have to make a success of the sector over the next decade or so”.

“The social care sector should work alongside recruitment organisations to recruit young, bright people into social care, and help them consider where a career may lead.”

One problem identified was narrow recruitment to the sector. It was stressed that within social care, “we should cast our nets wider in a recruitment approach… and recruit not only people with previous experience”. The social care sector should work alongside recruitment organisations to recruit young, bright people into social care, and help them consider where a career may lead.

It was also suggested that more effort must be made to recruit hard-to-reach and underemployed groups, including people living with disabilities, and immigrant workers. “What frustrates me is that there are individuals in these groups who can be wonderful, caring staff [but]are missed, because hiring managers are too narrow in their focus”, said one participant.

Staff retention rates in social care are low. Network members noted that social care workers often leave the sector for other, similarly paid jobs, such as retail roles, while few choose to leave and work for the NHS. One network member identified that “between care assistants in the NHS and the social care sector, there is around a 23 per cent deficit in social care. The terms and conditions are vastly better in the NHS. Pensions, sick pay, overtime and unsocial hours all contribute to that deficit.”

Essentially, social care workers are underpaid and undervalued. For both better recruitment and retention, social care workers must be appropriately paid and treated as though they are valued. Some network members identified low pay as the key driver for individuals choosing to leave the social care workforce, and yet, it was emphasised that social care is a both a skilled and psychologically demanding profession, and should be commensurately well-paid.

However, funding in the system is limited, and paying the workforce is the sector’s single biggest expense. One participant said “there is not a settlement from government or local government that actually meets the cost of care to enable us to pay a proper wage for the level of skill, ability, responsibility, dedication that [care workers] have”. Furthermore, a high proportion of social care workers are on zero-hours contracts; in London, this figure stands at 41 per cent of social care workers. Therefore, many social care workers have to deal with pay inconsistency and insecurity, on top of being low-paid.

“Network members were in agreement that social care is, and should be publicly regarded as, a skilled profession.”

While pay is regularly described as the most pressing issue in the workforce, one participant argued that in their experience of conducting exit interviews with workers, it is not low pay, but rather a low sense of worth which leads people to leave the profession. While higher pay is one way in which care workers can be practically appreciated, it was agreed that more must be done to value care work both by improving the public image of care workers and ensuring that internal structures provide support and give value to workers.

Network members were in agreement that social care is, and should be publicly regarded as, a skilled profession. “It is not the kind of job that everyone can do,” said one participant. “It is a skilled job, which requires the creation of quality human relationships and working with people who have complex care needs… it is a real skill and should be regarded as the same as working in health.”

Social work is challenging and worthy of respect, all participants agreed. One commented that “no two days in social care will be the same; you have to be agile and move with that, so it does take very special people to take those roles”. The public status of social care work must be elevated to reflect this, and the workforce to feel appropriately valued if these retention issues are to be effectively addressed.

Securing an integrated future

For a supported workforce, good leadership is essential. One participant noted that in the social care system “there is a varied approach to leadership”, and good leadership is not always evident in the system. Given the demanding nature of social care work, it is essential that carers feel well supported in their roles. One participant added that “workers do not stay because of a good job, they stay because of a good manager”, and therefore, proper leadership training must be a central goal of the workforce plan.

A practical solution suggested by one of the network members to combat low recruitment, retention and the poor image of the profession was a ‘social-care-first’ scheme, mirroring the successful teach-first scheme. Many other sectors have emulated the ‘teach-first’ template with great success. The aim of the scheme is to engage with young people to consider social care work as a career by espousing the value of a career in care. Such a scheme would emphasise how care work has the potential to transform the lives of dependent individuals, and the importance and value in building personal relationships with system users, improving the image of the profession. As part of the scheme, there should also be structured leadership, coaching and mentoring training, for the purpose of also transforming the quality of social care. This may serve to solve some of the leadership issues in the sector, as young and bright individuals will be well trained to manage and lead social care in the future.

Now that the NHS and social care are moving towards integration, participants noted that for a true and fair integration of the systems, employees should be paid and treated equally. One participant called for a joint recruitment scheme for the NHS and social care, with equal pay offered. It was also emphasised that NHS workers receive many ‘perks’, particularly since the start of the pandemic, which social care workers do not (including food and drinks discounts from certain companies).

Other suggestions to aid the integration of the NHS and social care workforce included social care placements and secondments for NHS staff, in which they are exposed to social care, and the richness and value of social care work. The status of care work must be elevated for proper integration of the two systems can occur, in order that social work and NHS work can be equally respected.

A large part of the discussion focused on the role of volunteers within the social care sector, and the value they bring to both paid carers and system users. Volunteers are an invaluable part of the social care workforce given that they reduce pressure on care workers, improve patient experiences, facilitate higher quality of care to drive better health outcomes, and strengthen community connections. One participant said that in the context of social care, “volunteering is a public health tool. There is a body of medical research which talks about the huge benefits for mental health and physical wellbeing for patients”. Volunteers also serve to raise the visibility of the social care sector.

Since the start of the Covid-19 pandemic, the UK has seen an unprecedented rise in the numbers of people volunteering in their local communities. During the pandemic, the UK had 12.4 million people volunteering in their local communities. 4.6 million of these were first-time volunteers. Currently, the UK has a window of opportunity to make the most of the interest in volunteering to reduce the immense pressure on care workers.

As part of the workforce strategy, there needs to be investment to drive the volunteer sector, for the wellbeing of the social care system and its users. However, time is undoubtedly of the essence; as one participant emphasised, “there is an urgency to the conversation we are having. As Covid dissipates, what we don’t want is for people to go back into the corners of their community and not come out again to contribute.”

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