News, Population Health March 26, 2024

Prioritise nutrition and hydration to boost broader health outcomes, says new report

By Integrated Care Journal

New report from PPP finds that efforts to implement a multidisciplinary approach to nutrition and hydration are needed to help address the dysphagia burden across the NHS.

A new report from Public Policy Projects (PPP) finds that with the UK becoming a ‘super-aged’ society, declining nutritional and hydrational status among elderly and frail populations will place increasing strain on health and care services.

The report, Prioritising nutrition, hydration and dysphagia in an integrated care context, states that while considerable work and investment has been allocated to reduce the incidence of obesity and the diet-related diabetes, malnutrition and hydration are not given the same focus, despite their significant impact on health outcomes and its role in the management of other conditions.

The report is the culmination of two roundtables held by PPP in 2023, which convened stakeholders to discuss how ICSs embed nutritional and hydrational health into integrated care strategies. The discussions focused on specific elements of the debate, including improving the management of dysphagia and care provided for frail populations in different care settings. Attendees included NHS England clinical leadership, allied health professionals (AHPs), including speech and language therapists (SLTs), social care providers, primary care representation nurses and other key health and care stakeholders.

*Graphic showing levels of elderly population at ICS level in 2021. Source: Census 2021*

According to the report, recent reforms to the health and care sector (most notably, the introduction of ICSs) present new opportunities to develop comprehensive approaches to nutrition and hydration, in a way that improves holistic patient care and saves valuable resource for the NHS.

However, among its recommendations, the report calls on the Department of Health and Social Care to launch a national review into food and drink provided across the care sector, to help improve the nutritional and hydrational status of frail citizens in social care. This review should follow the structure and ethos of the NHS Hospital Food programme, the report argues.

It adds that addressing dysphagia should be central to broader NHS goals of enhancing the quality of life for the elderly population, and that by prioritising the management and screening of dysphagia, the NHS could prevent avoidable hospital admissions and promote more efficient use of resources across the health and care sector.

Download the report here

To address the complex and multifaceted challenge of dysphagia, with various medical, neurological, and anatomical elements potentially contributing, will require systems to adopt a multidisciplinary approach, says the report. This will necessitate close collaboration between diverse teams of healthcare professionals, each with specialised expertise.

It finds that a multidisciplinary approach that includes speech and language therapists, dietitians, and physicians, is essential for managing dysphagia and addressing the complex healthcare needs of the elderly in a holistic fashion. To help enable this multidisciplinary approach, the report argues that the model of speech and language therapy sitting in community settings should be scaled nationwide, and adopted across ICSs within integrated care strategies. These strategies should also closely involve the voluntary sector.

The report also recommends an expansion of the speech and language therapy workforce, with ring-fenced funding for broader allied health professionals – in line with ambitions set out in the NHS Workforce Plan.

“The nutritional and hydrational needs of our elderly and frail citizens has been neglected for far too long. As the UK moves towards a ‘super-aged’ society, NHS organisations, care providers and integrated care systems must increasingly focus efforts on improving nutritional and hydrational health,” said report author and Group Editor at PPP, David Duffy. “It is vital that resources are orientated to support allied health professionals, particularly speech and language therapists, who play a vital role in maintaining nutritional health for elderly and frail citizens.

“Nobody in the UK should suffer from malnutrition or dehydration in this day and age, especially not our frailest and most vulnerable citizens. We hope that this report will help shine a light, not just on the scale of the problem, but also on achieveable solutions that we believe will help address the terrible burden of dysphagia.”

Recommendations:

NHS England must prioritise nutrition, hydration and dysphagia as part of its drive to improve system performance and broader health outcomes. Nutrition and hydration management are underdeveloped areas which can help enable success in key national strategies, such as the elective care backlog plan, workforce strategy, the urgent and emergency care plan and the delivery plan for recovering access to primary care.
Integrated care systems should consider dysphagia and wider nutritional and hydrational health as key parts of preventative health policies that can help future proof local health systems.
The Department of Health and Social Care (DHSC) should commission a national review into food and drink provided across the care sector. This review should follow the structure and ethos of the NHS Hospital Food programme. The review should be led by a range of stakeholders from within the NHS and social care, as well as representatives from industry and the private sector.
As the population becomes a ‘super-aged’ society, an integrated strategy is required to manage the health of the elderly and frail population. This should draw upon global and international frameworks provided by the WHO’s ICOPE framework.
ICSs should ensure that maximising the ‘intrinsic capacity’ of citizens is a key priority within integrated care strategies, to prevent deterioration of health and supplement preventative health policies.
ICSs should work to prioritise evidence-based nutritional and hydrational approaches within the social care sector, harnessing tools such as nutritional supplements where necessary, to assist those who have difficulty eating, drinking and swallowing.
The model of speech and language therapy sitting in community settings should be scaled nationwide, and adopted across ICSs within integrated care strategies. These strategies should also closely involve the voluntary sector.
NHS England should undertake a national dysphagia screening drive to identify individuals as early as possible. Social care staff and AHPs should be trained to conduct dysphagia screenings for all elderly and frail patients in their care, and much like falls, dysphagia should be considered among the primary risks in any risk assessment of elderly and frail patients.
The speech and language therapy workforce should be expanded with long-term ring-fenced funding for broader allied health professionals.

Download the report here.

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Will the disposable vape ban save the NHS from another health epidemic?

By Sienne Amer

As the government confirms its plans to ban the sale of disposable vapes, Sienne Amer examines the impact of vaping on the NHS so far, and to what extent the ban will help avert another health epidemic.

The UK government recently announced its plan to ban disposable vapes to protect children’s health and tackle the significant rise of vaping among young people. While we have not yet seen the full health impact of the younger generation using vapes, this ban may be a welcome first step in limiting the impact of what could have become the next health crisis.

The devices have appeared on the market recently and rapidly risen in popularity, which is why there is still little research available on the extent to which vaping harms our health. Introducing this ban has the potential to limit the impact vaping has on the NHS, which is already stretched responding to other health crises caused by tobacco smoking, alcohol abuse, obesity, and an ageing population.

There are 4.7 million people in Great Britain who use e-cigarettes, 31 per cent of whom are disposable vape users. Disposable vape brands are targeting children, using bright colours for packaging and a variety of interesting flavours, with the fruit flavours making them far more likely to appeal to children. A shocking 21 per cent of secondary school children have tried vaping and 57 per cent of disposable vape users are aged between 18 and 24. The most popular brand of disposable vapes, Elf Bars, were removed from supermarket shelves last year after the nicotine levels were found to be at least 50 per cent higher than the legal limit. The lack of regulation of these products is an issue, regardless of the effects of use.

Disposable vapes contain nicotine, and inflict similar impacts to any other nicotine product, including heart disease and other cardiovascular disorders, along with respiratory and gastrointestinal disorders. Children are especially susceptible to the toxicity of nicotine, which can impact brain development, leading to shorter attention spans, anxiety, depression and reduced cognitive function.

It has also been shown that when the coils in the e-cigarette are heated, toxic metals, including aluminium, chromium, iron, lead, manganese, nickel and tin leak into the e-liquid, which are then aerosolised, inhaled and absorbed by the lungs. E-liquids have been shown to contain ingredients that generate pulmonary irritants and carcinogenic carbonyl compounds, all of which can lead to respiratory, gastrointestinal, and constitutional symptoms, in addition to an increased risk of early onset strokes.

Although vaping is still recognised as a safer alternative to smoking by the NHS, there has not been sufficient investigation into the long-term impacts on health. Other countries, such as the United States, have recognised the impacts of vaping; in 2019, the US Center for Disease Control and Prevention announced an outbreak of e-cigarette/vaping product use-associated lung injury (EVALI) after it caused the deaths of several young people.

While there have not been any recorded e-cigarette related deaths reported in the UK, in 2023, the NHS recorded 420 vaping related hospital admissions, 15 of which were for children aged under 9, demonstrating the severe risk to health young children are exposed to.

When compared to just under half a million hospital admissions caused by cigarette smoking-related illnesses, the health impacts of disposable vapes appear to be minor. However, conventional cigarettes were only recognised as a significant health hazard in 1964, more than 40 years after the introduction of cigarette manufacture, showing the time it can take to fully understand the long-term effects a product can have on human health.

The NHS is already dealing with several other health epidemics, with smoking costing the NHS in England £2.6 billion per year, approximately 2 per cent of the NHS budget. Obesity costs around £6.5 billion a year and is the second biggest cause of preventable cancer. Alcohol abuse costs £3.2 billion a year in England. This is a total of £12.3 billion of the yearly NHS budget going towards preventable illnesses, and the cost of vaping would be an additional burden on NHS.

To what extent is vaping impacting the NHS?

At present, there is no record of the health-related costs associated with vaping. But modelling the cost to the NHS using smoking data could provide an estimation of the impacts vaping will have. The UK smoking population is equal to 6.4 million people, causing 474,000 hospital admissions a year at a cost of £2.6 billion. The model assumes that 7 per cent of the population requires hospital admissions, with each admission costing approximately £400.

The 420 admissions related to vape use last year would have cost the NHS approximately £168,000. However, vape-related hospital admissions only started to be recorded in 2019 and since then, there has been a 237 per cent increase in admissions. An annual growth of 10 per cent in the vaping population is also expected to cause an increase in admissions. This means that, if only 7 per cent of the vaping population is admitted, the cost to the NHS would be £132 million per year, excluding any impact of an uptake in the number of young people seeking mental health services as a result of the toxic effects of vaping.

The ban on disposable vapes is estimated to affect 2.6 million people in Great Britain – including 316,000 18-to-24-year-olds, who other than vaping, have never regularly used tobacco products – saving a large proportion of young people from the risks caused by nicotine dependence and vaping. As disposable vapes were initially introduced to the market as an alternative to cigarettes, there is a high risk that 75 per cent of people will revert to traditional tobacco products.

Since the focus of the ban is solely on disposable vapes, alternative e-cigarette products will continue to be available for people trying to quit smoking. It is crucial that information should continue to be collected and published, through platforms such as NHS Digital, to monitor and understand the health impacts of the current vaping generation, even post-ban. Hospitals should be advised to continue to use the ICD-10 code to improve data on vaping-related admissions, along with adjusting advisory information to support the disposable vape ban.

Sienne Amer is a Net Zero Graduate at Lexica.

Study developing AI to spot lung cancer risk from patient data

By Integrated Care Journal

Researchers are developing artificial intelligence which they hope will help to identify patients most at risk of lung cancer before symptoms have even appeared.

A team from Nottingham Trent University and Nottingham University Hospitals NHS Trust aims to create an AI-driven model which can autonomously piece together subtle clues and signs in patients’ data to identify those at risk so that they can be investigated further.

There are about 48,500 new cases of lung cancer in the UK alone each year with almost 35,000 people dying from the disease.

The team wants to address the current challenge of European health systems manually identifying people at risk of certain diseases and also help to reduce the financial burden by ensuring services are used by those who need them the most.

It will involve developing a system to recognise factors which might make an individual high risk and then creating ‘synthetic’ data in order to train it to pick up even the weakest signals that there could be an issue.

The aim is to help save lives by identifying people before the disease becomes symptomatic because that can be too late for patients with lung cancer.

The Nottingham team are the UK partners in PHASE-IV-AI, a much larger €7.6m project funded by the European Union’s Horizon Europe research and innovation program.

The project involves 20 partners from ten European countries and aims to unlock the full potential of AI and data analytics in health care in a secure and privacy-compliant way.

As well as lung cancer, the developments of PHASE-IV-AI project will also be validated by other partners in prostate cancer and ischemic stroke. Lung cancer and prostate cancer are among the top three priorities in tackling cancer in Europe, while neurodegenerative diseases are one of the most relevant issues with the EU’s ageing population.

If successful, it is hoped that the Nottingham team’s model could be trained to identify risk for other serious diseases and rolled out to hospitals and organisations across Europe willing to utilise AI-driven diagnostics.

It is thought that AI can enable real innovations in health care, and that AI systems which can process vast amounts of data quickly and in detail can be harnessed as a tool for preventative health care and clinical decision-making.

Despite this, the way in which information is currently stored across European countries and the limited access to health data can form a barrier to innovation, as developing trustworthy and responsible AI systems often requires large datasets for training and validation.

“The hope is that we could develop an AI-driven model for hospitals which they can then utilise and run to help find those most at risk,” said Dr Mufti Mahmud, an Associate Professor of Cognitive Computing in Nottingham Trent University’s School of Science and Technology.

He said: “Countries have huge amounts of clinical practice data, and we want to understand how we might harness this to identify the right people, so they can be invited for more focused diagnostics. We need the system to be able to find people before they start showing symptoms, and ultimately to help save lives.”

“Health care data storing is very sensitive, very private, so by developing synthetic data we can train the model to function responsibly and to provide the reasons why it selected an individual.”

Nottingham University Hospitals NHS Trust lung cancer consultant Professor David Baldwin said: “Identifying the right people for cancer screening is vital to ensure that the most people benefit whilst not harming people who have a low risk of developing lung cancer.

“AI offers the opportunity to improve the way we target screening programmes to make them more clinically and cost effective. AI is also changing practice in many other areas of lung cancer care. AI tools can help reduce the workload of specialists like radiographers and radiologists, as well as treatment costs, and improve outcomes for patients.”

Women spending 1.5 times more than men on personal health, report finds

By Gabriel Blaazer

Survey commissioned by Deloitte reveals that women in the UK are spending £1.5bn more each year across all categories of out-of-pocket spending, and recommends more specific action to support women’s health in the workplace.

Women in the UK are spending over £1.5bn more than men on medical-related expenses each year, according to a survey of working adults commissioned by the Deloitte Health Equity Institute Europe. YouGov conducted the survey of 3156 men and women aged over 18 for Deloitte, to gain a clearer picture of “out-of-pocket” health spend – how much money they spend on personal health and care each year.

The Women’s Health Cost Gap in the UK survey finds that 52 per cent of employed women spend out-of-pocket on health each year, versus only 39 per cent of men, suggesting that women experience more pressure to spend their own money on personal healthcare. In total, the women surveyed spent 1.5 times more than men, averaging £305 a year, compared to £210 for men. The figure of £1.5bn was reached by multiplying this £95 surplus by the number of working women in the UK – 16.06 million.

Women also spend more on all categories of out-of-pocket spending, according to the survey. These include fertility, menopause and menstrual health, but also medical diagnostics and wearables, private counselling or other mental health support and general healthcare (e.g. dentistry or physiotherapy). At least some of this differential may be explained by the ‘pink tax’, whereby products aimed at women are priced more expensively than those aimed at men. Women may also be more likely to seek specialist (and therefore more expensive) treatment for female-specific concerns.

In general, the survey finds that women are more aware of the women’s healthcare benefits being offered by employers than men. 40 per cent of men responding to the survey did not know if any women’s health benefits were being offered, versus just 17 per cent of women.

However, many employees lack awareness of measures that could be implemented to support women’s health; 42 per cent of men said they didn’t know how workplaces could support women’s health, versus 17 per cent of women.

The survey finds that 60 per cent women are more attracted to companies which invest in women’s health benefits, rising to 67 per cent among younger women. Only 31 per cent of men felt this way. Despite these figures, only 28 per cent of women consider the provision of women’s health benefits a key factor when choosing a job (compared with 14 per cent of men), suggesting that it is not a deal-breaker.

The report makes several recommendations to address gender-based health disparities in the workplace. Among these, it recommends employers work actively to create women-friendly working environments which understand and account for the specific health needs of women, and to promote a culture where women can take leave for conditions without it negatively impacting their career prospects. This recommendation supports recent guidance issued by the Equality and Human Right Commission guidance, which says that employers could be sued for disability discrimination if they fail to make “reasonable adjustments” for employees going through menopause.

To policy makers, it recommends action to ensure that women can access treatment and care regardless of their age, sexuality, ethnicity, disability or postcode, as well as provision of adequate funding for women’s healthcare services and the financial incentivisation of research into women’s health.

Liz Hampson, partner and head of Deloitte’s European Health Equity Institute, commented: “Women spend significantly more treating ongoing poor health, or seeking out specialist treatment at their own cost, contributing to a higher overall out-of-pocket spend. This ‘health cost gap’ which exists can be attributed to a variety of reasons, including being misdiagnosed more and incidents of pain ‘taken less seriously’ in the healthcare system, underinvestment in women’s health services and underrepresentation of women in medical research.

“Addressing gender-based disparities in health requires a collaborative approach – something that requires investors, healthcare providers, policy makers, life sciences companies and employers to take action on.

“Supporting women’s health is not only important for society, but a sound investment in the future of the workforce and overall economy.”

The full report, including the questions, responses and recommendations, can be accessed here.

West Midlands rolls out pharmacy-based bowel cancer screening

By Integrated Care Journal

Region becomes country’s first to speed up bowel cancer screening using technology as part of Levelling Up Smart City Region programme.

The West Midlands has become the first English region to screen people for bowel cancer in their local pharmacy, at home or at other local settings, using new colon capsule endoscopy services (CCE) – also known as ‘pill cam’.

Screening people in their own community rather than in hospital will help to significantly cut waiting times and speed up lifesaving diagnosis. It is expected that 2,000 people will use the new technology across the West Midlands in its first year, with waiting times cut from 30 weeks to just two.

The rollout of ‘pill cam’ is the first time this innovative, clinically proven screening technology will be available to residents in Birmingham and Solihull. It will also significantly increase bowel cancer screening capacity in Coventry and Warwickshire and follows successful trials led by University Hospital Coventry and Warwickshire NHS Trust and WM5G.

This is the first part of the pioneering £10 million Levelling Up Smart City Region programme led by the West Midlands Combined Authority (WMCA). It is a key part of the £1.5 billion deeper devolution deal agreed between the government and the WMCA last year.

The programme sets out to use cutting-edge wireless technology to help revolutionise the way healthcare is delivered within local communities and aligns closely with plans to increase NHS productivity set out in last week’s Budget.

The NHS Productivity Plan focuses on three key areas: transforming access and services for patients, using data to reduce time spent on unproductive administrative tasks, and updating fragmented and outdated IT systems.

Through the Smart City Region programme, the West Midlands is already leading the way in all three areas, rolling out CCE, developing an exemplar hospital that addresses issues around capacity and flow, and trialling the use of AI and data to improve primary care tasks and measure intervention outcomes for conditions such as diabetes.

WM5G, which is part of the WMCA, leading health-tech innovation, has partnered with Corporate Health International (CHI) to provide the ‘pill cam’ service and will work in close partnership with the NHS Birmingham & Solihull and Coventry & Warwickshire Integrated Care Boards to deliver the screening.

In addition to colon capsule endoscopy, the WMCA will also be expanding prevention, remote monitoring, and smart hospital services. This will help more people stay healthy and in-work, avoid being admitted to hospital or get discharged faster and be supported to live at home for longer.

Andy Street, Mayor of the West Midlands and WMCA chair, said: “The roll out of this life saving technology is a direct result of the West Midlands winning the competition in 2018 to become the UK’s 5G testbed.

“That has left a lasting legacy for the West Midlands which is now the UK’s best connected 5G region and a national leader in the real-world use of innovative 5G products and services like the ‘pill cam’.

“Bowel cancer is the second biggest cancer killer in the UK but the disease is treatable and curable if diagnosed early. The ‘pill cam’, as part of the Smart City Region programme, has the potential to provide thousands of local people with an earlier and easier diagnosis and the treatment they need to survive this disease.”

Dr Adil Butt, Consultant Gastroenterologist and Clinical Service Lead for Endoscopy at Queen Elizabeth Hospital Birmingham, said: “Adopting clinically proven and remotely available technologies, such as CCE, enables both quicker diagnosis by streamlining existing referral pathways and releases valuable extra capacity within existing systems.

“This makes the diagnostic process more convenient for all, bringing previously hospital-based specialist care closer to patients by delivering screening services in their local community. This vital extra capacity comes at a critical time when the UK is facing a significant diagnostic backlog.”

Dr Mark Andrew, Consultant Gastroenterologist and Clinical Service Lead for Endoscopy at Good Hope Hospital said: “CCE is an established diagnostic examination that helps provide access to patients whilst protecting their dignity. I am pleased to see with the support of WM5G and CHI we can hope to offer this bowel test on a larger scale, whilst also reducing our carbon footprint.”

Dr Cornelius Glismann, Managing Director at Corporate Health International, said: “This contract is clearly a game-changer for the region and we are looking forward to working in partnership with WM5G and the health care providers to rapidly roll out Colon Capsule Endoscopy across the region.

“Our Colon Capsule Endoscopy technology was developed in direct response to a team-member’s personal experience of bowel cancer screening and was therefore designed with a firm focus on reducing waiting times while improving patient experience.”

Genevieve Edwards, Chief Executive at Bowel Cancer UK, said: “Around 43,000 people are diagnosed with bowel cancer in the UK each year, but a lack of capacity to meet demand in endoscopy services means there are often long waits between referral and testing, leaving thousands of people awaiting tests that could either confirm a diagnosis or put their minds at rest.

“The use of new technologies such as Colon Capsule Endoscopy helps identify those who require urgent colonoscopies so they can be tested and begin treatment more quickly.”

Rehab for all: fixing the NHS rehab access gap

By Kate Tantam

ICU nurse and creator of the Right to Rehab Campaign, Kate Tantam, shares her perspective on the importance of universal access to rehabilitation in the NHS.

I am an ICU nurse who has been collecting stories of recovery and rehabilitation since 2018.  The reason is simple – the wider public and even many health care teams absolutely do not see the impact of rehabilitation services. For many years rehabilitation services have been seen as the “nice to have, the icing on top of the cake”. I fiercely believe that rehabilitation is the icing in the middle of the cake, it cements everything together.

Rehabilitation is transformative. It is vital. It ensures that our patients make a full recovery and gets them back to the people and things that they love.  And while myself and my multi-disciplinary colleagues are aware of this fact every single day, the NHS system is not prioritising rehab. This fails dedicated and skilled healthcare workers and our patients across the UK.

My patients’ goals may not seem big – to hold their grandson, to make a cup of tea, to go to the loo on their own, to say ‘I love you’ – but for those who can’t move their arms or legs or have lost the power of speech, this is a mountain to climb.

Universal access to quality, person-centred rehab doesn’t exist across the NHS. It means that millions of people don’t have access to NHS rehab services in their area. Many of these people can’t afford to pay for private rehab services, creating huge economic inequality when it comes to recovery. Tragically, this means people’s lives must be put on hold, their conditions deteriorate, and they don’t stand a chance to reach those important personal goals or make a full recovery. This clearly impacts long term return to work, caring responsibilities for loved ones, ability to keep hold of housing and income with reliance on external financial support.

Christian is one of these stories – a young man working full time in his own business. He came into ICU over Christmas in 2022, was in multi-organ failure, and was an alcoholic. He spent months in ICU, and nearly a year in hospital. He was so unwell he had to have multiple abdominal operations, is now diabetic and has a colostomy. He had a rocky time, but I am incredibly proud to say that he is back at work. He is fitter than he has ever been and is debating becoming a model for Colostomy UK, sharing his recovery to support others and clinical teams.

Rehabilitation is work that needs all of us to partner with patients, loved ones and each other.  When healthcare professionals get it right, it makes every single person involved remember why they joined Team NHS. It doesn’t matter where they are in this team – the paramedic who brought the patient in, the GP who supported them after admission, the manager who sorted the funding for the service or the domestic assistant who cleans the ward – everyone impacts that story and shares its success.

I started this campaign for all the patients who aren’t as lucky as Christian. I see it every day across the UK and hear from clinical teams who feel lost fighting against the tide.

So, I joined forces with independent creative agency, Pablo, to create a campaign that celebrates patients’ ‘firsts’ since hospitalisation – the first tentative footsteps or first halting words – those monumental milestones for patients lucky enough to receive specialist rehabilitation care. The aim of the campaign is to raise awareness of the impact of rehabilitation and to ask for a rehabilitation strategy in every trust and a named lead.

This is a campaign that has had no budget – everything has been donated and we have all been working clinically full-time. For me, this demonstrates perfectly that the people who value rehabilitation will do anything they can to support and improve it. I work with a team of nurses, physiotherapists, speech therapists, doctors, occupational therapists, psychologists, dietitians and when we have the resources to support our patients to reach their goals and return home to their lives following traumatic accidents or life-threatening conditions, there is nothing more rewarding.

Some of my own patients’ first steps are now on billboards across the UK, including one patient who suffered a bilateral stroke on either side of her brain stem. She couldn’t sit, use her right arm or legs, she could no longer talk or even swallow and had to be fed via a tube. Her re-learned voice is now on a national radio advert promoting the campaign. The overarching message is for NHS leaders to provide much needed rehab services in all areas of the UK.

The campaign directs people to PetitionForRehab.com, where they can sign a petition calling for rehab to be made available everywhere and for a named rehab lead to be appointed on every hospital trust and board in the UK.  And much like it takes a multi-disciplinary team to support a person’s recovery through rehab, the call for universal access to quality rehab comes from a multitude of individuals, teams and organisations.

The campaign is supported by more than 30 healthcare charities, royal colleges and professional bodies such as the Chartered Society of Physiotherapy (CSP), the British Geriatric Society, Asthma+Lung UK, the Royal College of Occupational Therapists, and the Stroke Association who are all members of the Community Rehabilitation Alliance.

My ask of you is that you talk about rehabilitation, share your local stories of rehabilitation success, listen to your patients, their loved ones and each other.  The NHS is the sixth largest employer in the world – together we surely can achieve anything.

To sign the petition and call for universal access to access rehab services, please visit PetitionForRehab.com.

Unpacking cancer disparities in England

By Rachel Millar

Despite major gains in diagnosis and treatment, England continues to experience high disparities in cancer outcomes, with social and financial deprivation major drivers.

In December 2023, The Lancet Oncology published a landmark paper highlighting the “astounding inequality” in the risk of dying from cancer in England. Researchers from Imperial College London looked at the 10 most deadly cancer types in England and analysed the risk of dying from these across England’s 314 districts from 2002 to 2019.

Although the overall risk of dying from cancer before the age of 80 had declined over that time period, their analysis shows huge inequalities in risk depending on where in the country someone lives. For women, the risk of dying from cancer was one in 10 in Westminster, while for women in Manchester the risk was one in six. Meanwhile, the picture for men ranged from one in eight in London’s Harrow to one in five in Manchester. The study found that lung cancer had one of the highest inequalities in risk across areas with those at greatest risk areas having triple the risk of dying from lung cancer compared with those in lowest risk regions.

The concept of health inequalities is now well established in the UK and beyond. The publication of the DHSC Black Report in 1980 demonstrated that, although there had been a general improvement in public health since the introduction of the welfare state, there were widespread health inequalities across the country. It found that the primary cause for these inequalities was deprivation. Over four decades later, there is now a vast body of evidence examining health inequalities and the evidence suggests that despite new treatments and technologies, overall health is deteriorating, and the inequalities are widening.

Social determinants still a major influence

Research has shown that for cancer, the social determinants of health impact both prevalence and prognosis. The Health Foundation describes the social determinants of health as the “social, cultural, political, economic, commercial and environmental factors that shape the conditions in which people are born, grow, live, work and age”.

A 2020 report demonstrated that more than 30,000 extra cases of cancer in the UK each year can be attributed to social and financial deprivation, while survival was found to be worse among the most deprived groups. Many of the risk factors for cancer are influenced by the social determinants of health. For example, individuals residing in areas with higher levels of deprivation are 2.5 times as likely to smoke compared to those in the least deprived areas, and they find it harder to quit.

Diet inequality is also an issue that affects the most deprived in society. Research has shown that people in deprivation have poorer diets, and consumer higher levels of poor quality, ultra processed, high calorie food than those in the least deprived areas. This population also suffers from much higher rates of obesity. As a result of such social determinants of health, those that grow up and live in deprivation are more likely to get cancer, but the story doesn’t stop there.

Variations in diagnosis

There is huge variation across the UK in cancer diagnosis. There are currently three UK screening programmes: for bowel, breast and cervical cancers. In theory these screenings are open to everyone eligible, however, in reality there are various barriers to screening that disproportionately affect certain populations, and this leads to inequalities in diagnosis.

Barriers to screening are an active area of research but there are several factors that have been identified to contribute. Stigma is one factor, with research showing that cancer stigma is linked to lower screening uptake, and this tends to be more prevalent among people from ethnic minority backgrounds.

Another barrier recognised is the practicality of attending a screening. For example, other responsibilities such as work or caring may make it difficult to get to an appointment. There are ways to overcome these barriers and increasingly NHS services are implementing changes to make screening more accessible to everyone. For instance, research suggests language barriers hamper screening uptake and therefore translation services can help overcome this. Also, offering greater flexibility on appointment times and re-invitations for those that haven’t responded have been found to positively impact uptake in underserved populations.

Overall, there are clearly gross inequalities across both the risk of developing cancer and the prognosis once it has developed. However, as researchers gain deeper insights into these inequalities and the mechanisms that contribute to them, NHS and public health services can implement best practices in order to try and level the playing field for cancer care. In April, Public Policy Projects will be hosting a round table event looking at regional inequalities in prostate cancer, so look out for the report later this year.

Heart disease single largest factor behind out of work ill health

By Integrated Care Journal

New report finds that people are more likely to leave work due to a heart condition than any other health issue, and warns that faltering efforts at prevention have cost thousands of lives.

Heart disease is the single largest driver of people leaving the workforce due to ill health, according to new research from the Institute for Public Policy Research (IPPR).

The new paper, Broken hearted: A spotlight paper on cardio-vascular disease, finds that a heart disease diagnosis brings with it the largest risk of a person leaving the labour market, and that someone diagnosed with cardiovascular disease (CVD) has a 22 per cent chance of leaving their job. This compares to a 14 per cent risk for someone with a mental health condition and 16 per cent for a person with cancer.

Almost one in three of all working-age people who are economically inactive have a heart, blood pressure or circulatory condition, the report says. This figure rises among over 50s, a group the government is currently targeting in its efforts to get people back to work.

The report also reveals significant variation in CVD mortality across England and Wales, with the North West the worst affected region. It estimates that if the entire UK saw the same outcomes as the best tenth of local authorities, there would have been 32,000 fewer deaths in 2021 along – equivalent to 5 per cent of total CVD mortality.

Around 80 per cent of deaths from heart disease are preventable, with diet and nutrition, metabolic risks (e.g. high BMI) and tobacco use constituting the three greatest risk factors.

The report cites analysis from the British Heart Foundation that since February 2020, there have been nearly 100,000 more deaths involving CVD than would otherwise have been expected. It attributes this decline in outcomes to a slowdown in progress on prevention over the last decade. If the last decade had seen even half of the progress on preventable CVD mortality observed between 2005-2020, the report estimates that there would have been nearly 33,000 fewer deaths in 2019- equivalent to one in 20 deaths that year.

While virtually all NHS waiting lists have grown steadily in recent years, exacerbated by the pandemic, cardiology is something of an outlier, and waiting lists have tripled since 2012, higher than the overall growth in NHS waiting lists.

IPPR is calling on the government to implement a recovery plan for treating cardiovascular disease, helping both the NHS and the economy, by:

Delivering new preventative policies, such as extending the current ‘sugar levy’ on soft drinks to all high-fat and high-salt products, and using the revenue to subsidise healthy food options.
Getting waiting lists for cardiology down, through increasing access to preventative medications, retaining staff and expanding access to personalised care.
Investing in research, with an immediate injection of £220 million for R&D in cardiovascular disease prevention – with an explicit goal of crowding in private investment.

Chris Thomas, author of the report and Head of IPPR’s Commission on Health and Prosperity, said: “After great strides in tackling cardiovascular disease in the 20th century, the UK is now stalling if not reversing. This is not just costing lives, but also livelihoods. The good news is that heart disease is one of the most preventable health conditions, but the government has to get on to the front foot and deliver proactive policies. Both human lives and economic prosperity depend on it.”

The full report can be accessed here.

BMA survey finds widespread concern among doctors over role of physician associates

By Gabriel Blaazer

The BMA calls for immediate pause to recruitment into Medical Associate Professional (MAP) roles and to limit the scope of MAP roles to administrative and low-risk clinical tasks.

A majority of doctors have expressed concern that physician associates (PAs) and anaesthesia associates (AAs) are undertaking tasks beyond their competence, according to a new survey from the BMA.

In the survey of more than 19,000 doctors, nearly 80 per cent reported concerns that MAPs were “occasionally or frequently” working on tasks for which they are underqualified, with 87 per cent believing that the current rules pose a risk to patient safety, some or all of the time.

A majority of doctors also believe that working with PAs and AAs has increased their workloads, according to the survey. Only 21 per cent of respondents reported a decrease in their workloads since the employment of MAPs, while more 55 per cent reported that their workload had instead increased.

Professor Phil Banfield, BMA Chair of Council, said: “NHS England tells us that ‘Physician Associates support doctors in the diagnosis and management of patients,’ supposedly giving doctors more time to deliver the high-quality care only they can give.

“But the reality appears to be the exact opposite – too many doctors are telling us that working with PAs is instead draining their time and energy. The responsibility for signing off prescriptions and ensuring the PAs are working within their proper scope of practice quite rightly falls on the supervising doctor, but also those doctors working alongside them; as scope has inappropriately crept ever further it has made far more work for doctors than it has saved.

86 per cent of doctors also reported concern that the role of MAPs, and the difference between MAPs and fully qualified doctors, is not well understood by the public, and that many patients may wrongly assume they are being seen by a fully trained doctor. 80 per cent said they would support the change of terminology from Associates to ‘Assistants’, as they were known until 2013.

The House of Lords is expected to consider this week the Anaesthesia Associates and Physician Associates Order 2024 statutory instrument, which if passed, will see the GMC appointed as regulator of MAPs. 72 per cent of respondents to the BMA survey expressed their opposition to the move. The BMA itself has called for all legislators to oppose the Order, arguing instead that regulation of MAPs should fall to the Health Care and Professions Council.

Liberal Democrat Peer, Baroness Sal Brinton, has tabled a motion of regret outlining concerns about the regulation of MAPs falling under the remit of the GMC, as well as about the nomenclature applied to MAPs, which the motion states “risks confusion for patients”.

Professor Phil Banfield added: “The House of Lords will soon have a chance to oppose damaging legislation that aids that blurring of lines by regulating PAs under the GMC, the doctors’ regulator rather than the more appropriate Health and Care Professions Council.

“The Government and NHSE should be instead ensuring that PAs return to their original purpose of supporting, not replacing doctors, so that doctors can get on with utilising the diagnostic and treatment skills they have spent so long at medical school gaining their expertise in.  Their scope should be strictly defined and, to ensure patients are not confused, the title returned to the more accurate “physician assistant” – then they can play their valuable role in supporting the delivery of NHS care safely.”

The BMA has made the following recommendations:

There should be an immediate halt to the recruitment of Medical Associate Professionals (MAPs) in the UK, including PAs and AAs on the grounds of patient safety (as called for by the BMA in November 2023). Long term expansion plans for the roles must be paused.
All legislators must oppose the Anaesthesia Associates and Physicians Associate Order 2024. The House of the Lords must vote against it in the days ahead. MAPs should be regulated by the Health Care and Professions Council, as called for by the BMA in response to the original DHSC consultation on regulation in 2017.
The titles should revert to physician assistant and physician assistant (anaesthesia) / anaesthesia assistant to avoid public confusion.
The scope of the roles should be strictly limited to the original intention of supporting doctors with administration tasks and a defined range of low-risk clinical tasks.
The UK has a severe shortage of doctors. This should be urgently addressed by fully funding increased specialty training places and opening Additional Roles Reimbursement Scheme (ARRS) funding to GP recruitment.
Training opportunities for doctors must be protected. Doctors and medical students should be prioritised for all clinical and training opportunities. This means that within a department/practice any procedure, clinic opportunity, or other structured learning event must be offered to doctors first before being offered to non-doctor staff.  The training of physician associates and anaesthesia associates must not compromise the training of current or future doctors
MAPs should not be utilised on any level of doctor rota or perform, train in, or consent to invasive or life-threatening procedures. They should not be receiving any specialty referrals or be in roles requiring them to give specialty advice. They should not make unsupervised treatment decisions or management plans. They must work under direct on-site supervision at a level commensurate with their qualification and not be using on-the-job experience to work beyond their formal level of qualification.

Developing Joint Forward Plans: how ICBs can strengthen integrated planning

By Alison Tonge

Integrated care boards (ICBs) have been tasked with reviewing and updating their Joint Forward Plans, setting out their priorities and how they will deliver care over the next five years. The challenge is not so much in writing or reviewing their plans, but in making them workable and achievable in the face of mounting pressures.

National priorities and objectives for the NHS continue to focus on recovering core service delivery and maximising productivity. Meanwhile, we are all aware of the significant challenges facing the service, including access to primary care, ambulance response times and elective care waiting lists, exacerbated by a limited workforce, financial pressures and strike action.

Although system-based working is designed to address some of these challenges, it brings its own pressures as partners need to establish new ways of working together and shift towards more outcomes-focused activity. System partners must manage day-to-day organisational priorities alongside system-led direction, making best use of the skills and resources available to deliver more joined up care.

Truly integrated planning requires organisations to combine a coordinated strategic approach with integrated operational delivery so that plans are grounded in reality, and sufficient flexibility is built into the planning process to enable teams to adapt to changing demands. This means drawing together three layers of planning; the strategic-level Integrated Care Strategy which sets out what will be done, the Joint Forward Plan which describes how the strategy will be achieved, both supported by more detailed operational business plans setting the specifics of what will be done when, where and by whom.

Drawing on our experience of delivering complex national programme such as the COVID-19 vaccination programme, as well as system-level change projects such as demand and capacity planning, there are five key elements ICBs should consider in developing strategic and operational plans.

1. Establishing a clear starting point. When assessing priorities and opportunities for change, start by building a clear picture across the system of what is already in place and what resources and skills are available. Notwithstanding some of the obstacles that may yet need to be addressed to enable fully integrated working, systems have an opportunity to bring together truly multidisciplined teams, involving specialists across primary and secondary care as well as local authorities and the voluntary and community sector.

How can these skills be combined to achieve more for patients? Although access to employee information is not universal across systems, NHS data is readily available through the Electronic Staff Record (ESR) and the national workforce Minimum Data Set (wMDS), and workforce data sharing with local authorities can and is being done to aid planning in some areas. This information, combined with details of related services, estates and other assets, can provide a much richer starting point for planning, building in existing learning and reducing the risk of duplication.

2. Intelligence-led decision-making. Access to data and analytics has advanced significantly and continues to grow at pace across the NHS. From identifying priorities using population health management and risk stratification, through to modelling new pathways and monitoring impact via dashboards and other interactive tools, effective use of data provides the evidence to underpin a case for change, target resources efficiently and evaluate the impact of new initiatives. Integrated planning requires a single source of truth that gives system partners a transparent view of priorities, opportunities and impact to support decision-making at both a strategic and operational level. This intelligence has to be coupled with an understanding of the benefits and impact that need to be delivered as a result of the interventions, creating an integrated measurement approach describing triple value and social value impact.

3. Connected outcomes and drivers of change. The most effective dynamic plans are those that connect the drivers of change to the outcomes being sought and consider this from a whole system perspective. In implementing a new pathway, for example, considerations should include the impact on wider services, such as A&E, diagnostics, outpatients and primary care and the equity of access and outcome for the population concerned. What skills and resources will be needed – both in effecting the change and in altering how this may impact wider teams? Will this impact how a system’s workforce or estate is used, or the budget required? Are the right supply chains in place? This level of detailed impact assessment enables system leaders to fully understand, plan and implement the necessary activities to achieve the intended outcomes.

4. Effective engagement. Clinical engagement is essential in gaining a realistic understanding of the impact of activities – existing and new – and the opportunities for improvement. In delivering more integrated working, we need to build in joined-up, multidisciplinary engagement to fully understand some of the potential opportunities and barriers that need to be addressed. Alongside patient engagement, this input can inform the drivers for change, leading to more resilient plans. Moreover, ensuring staff and patients feel heard and appropriately engaged and supported through change can improve both staff retention and patient experience.

5. Clear, integrated governance. Underpinning strategic and operational plans should be clearly defined, multidisciplinary, connected governance to enable effective decision-making at every level across the system. ICSs need to work at scale and at pace, able to make confident decisions without unnecessary bureaucracy. There is a balance to strike, of course, and appropriate safeguards must be in place, but if we are to deliver change by drawing together multi-disciplinary teams to work on joint projects across system partners, the governance and risk management needs to be equally integrated and clear.

Systems are facing similar challenges across the country. Although each place and system will have its own characteristics, there is much we can learn from each other. Drawing on best practice, building networks, such as the Integrated Resource Planning Network, and sharing both successes and failures will help the NHS fast-track improvements and eliminate unnecessary duplication.

By developing integrated plans that connect the strategic with the operational, incorporating clear governance and evaluation, systems can not only achieve more using their collective resources, but also encourage more effective information sharing across England to support the NHS’s national priorities.

Alison Tonge is Executive Director of Strategy and Innovation at NHS Arden & GEM