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

New study finds no cervical cancer cases in HPV-vaccinated women

By Samantha Semmeling

Study proves efficacy of HPV vaccination at preventing cervical cancer, as UK Health Security Agency statistics show that uptake has still not returned to pre-pandemic levels.

Public Health Scotland announced this week that a new study has found no cases of cervical cancer in young women vaccinated as part of the HPV vaccination programme. The news comes as the UK marks Cervical Cancer Prevention Week 2024 and MPs commit to tackling inequality in the uptake of cervical screening and HPV vaccination.

The HPV vaccination programme was introduced in 2008 and aimed to vaccinate young women against HPV to prevent the development of cervical cancer, on the advice of the Joint Committee on Vaccination and Immunisation (JCVI).

The human papillomavirus (HPV) is a type of sexually transmitted virus, of which there are more than 100 strains. Many individuals will be infected with HPV over the course of their lifetime and in most cases the infection is harmless and clears on its own. However, persistent infection with high-risk strains of HPV can occur and lead to the development of cervical cancer.

Cervical cancer is the 4th most common cause of cancer in women worldwide, and HPV is responsible for almost all cases. Infection with the HPV virus is also linked to an increased risk of mouth, throat, and urogenital cancers in both men and women.

From 2019, the JCVI recommended that 12-13-year-old males, as well as females, should be offered the HPV vaccine to protect against these non-cervical cancers. Further, in 2023 the dosing schedule of the programme also changed to one dose only, as it was shown to be just as effective as two doses at protecting from HPV infection.

However, the most recent UK Health Security Agency statistics on HPV vaccination coverage published on 23 January this year demonstrate that although vaccination uptake has increased since the previous year, it has still not returned to pre-pandemic levels. Further effort is required to bolster vaccination programmes in schools to ensure young people across the UK are getting sufficient coverage.

“It is possible to make cervical cancer a rare disease”

NHS England announced in November last year that it aims to eliminate cervical cancer by 2040. To meet this ambition, it must ensure as many people as possible are vaccinated against HPV, as well as come forward for cervical screening. In addition to the vaccination programme in schools, NHS England plan to improve access to online vaccination appointments and offer vaccinations in more convenient settings such as libraries, community centres and local leisure facilities.

The Scottish study published in the Journal of the National Cancer Institute also concludes that “women from more deprived areas benefit more from vaccination than those from less deprived areas.” It found that cervical cancer incidence was significantly higher in women from the most deprived areas in Scotland, and that incidence substantially decreased for those who had three doses of the vaccine. This demonstrates the role that vaccination can play in the reduction of health inequality, emphasising the importance of ensuring vaccination efforts cover deprived areas.

Dr Kirsty Roy, a consultant in health protection at Public Health Scotland and co-author of the study, said: “It shows how effective the HPV vaccine is as there have been no cervical cancer cases to-date in fully vaccinated women who were given their first dose at age 12-13 years. Vaccination against HPV is shown to be effective in preventing cervical cancer, and along with regular screening for early detection and treatment, it is possible to make cervical cancer a rare disease.”

Dr Vanessa Saliba, UKHSA consultant epidemiologist, said: “The HPV vaccination programme is one of the most successful in the world with millions of doses given since it started in 2008. It has dramatically lowered the rates of cervical cancer and harmful infections in both women and men – preventing many cancers and saving lives.”

Jenni Minto, a Scottish Minister for Public Health, said: “The HPV vaccine programme is having a huge impact on preventing these cancers for those who have been vaccinated. Vaccination and screening remain the most effective ways of preventing and detecting cervical cancer and I would encourage those eligible to come forward to have the vaccine or attend screening appointments.”

Public Policy Projects’ (PPP) 2024 Cancer Care Programme will be investigating how to implement innovation in cancer care, as well as discussing how to overcome inequalities in access to care like screening and vaccination. Working with a range of cancer care stakeholders, including ICB and ICS leadership, cancer alliances, diagnostic and imaging networks, trusts, health innovation networks and charities, PPP will use examples, such as the work leading to Scotland’s exciting results, to produce policy recommendations aimed at improving cancer care for all across the UK.

For more information about PPP’s Cancer Care Programme in 2024 please contact:

Willy Morris, Senior Partnerships Manager, willy.morris@pppinsight.com.

Samantha Semmeling, Policy Analyst, samantha.semmeling@publicpolicyprojects.com.

New report models true economic impact of breast cancer to the UK

By Gabriel Blaazer

The report from Demos and Breast Cancer Now estimates the economic and wider societal costs of breast cancer and urges UK governments to enact measures to reduce the burden of the disease.

Breast cancer is predicted to cost the UK between £2.6bn and £2.8bn in 2024, potentially rising to £3.6 by 2034, according to new research from the cross-party think tank, Demos, and research and support charity, Breast Cancer Now.

The study, The Cost of Breast Cancer, warns that unless radical change is enacted to reduce the impacts of the disease on patients, the costs to the NHS (including screening and treatment), wider society and individual patients will rise by 40 per cent over the next decade. The report sets out the results of modelling to demonstrate some of the measures that could mitigate the worst of the human and financial impacts of breast cancer.

The report also highlights the human cost of breast cancer, and estimates the overall wellbeing costs associated with the disease at £17.5 billion in 2024. This is around six times higher than the estimated economic costs, and accounts for the wider impacts of breast cancer including costs incurred through reduced quality of life and early death, as well as the impact on carers, partners and children of breast cancer patients.

Around 55,000 women and 400 men are diagnosed with breast cancer each year in the UK (47,000 in England), with eight in 10 cases diagnosed in women 50 and over. This amounts to one woman being diagnosed with breast cancer every 10 minutes across the UK. Although breast cancer survival rates are improving, and 85 per cent of women with breast cancer now survive for five years or more, more than 11,500 women and men die from the disease each year in the UK, and the financial and emotional costs can be long-lasting.

Within the report, Breast Cancer Now urges UK governments “to urgently engage with the scale of the crisis” and to work with the charity on measures to improve the lives of people impacted by breast cancer and reduce the financial costs to the NHS and wider society. These include increasing screening uptake rates, which it estimates would produce economic savings of between £96m and £111m in 2034, and £1.2bn in wellbeing cost savings, also in 2034.

Also proposed is the introduction of cancer nurse specialists, who can provide support and information to cancer and their families and are specifically trained to offer psychological support. Research from Sweden indicates that having specialist psychology-trained nurses in place can lead to improvements in measured quality of life scores for patients and a reduction in total healthcare costs, including after the initial investment. Applying the same economic savings realised in Sweden to the NHS, the report estimates that providing cancer nurse specialists could produce more than £118m in savings to the NHS, as well as £312m in associated wellbeing costs.

Other proposals include measures to support patients to return to full-time work, which are estimated could potentially yield between £328m and £411m in savings in 2034. These savings would stem entirely from a reduction in productivity losses from illness and reductions in caring requirements.

News, Thought Leadership January 22, 2024

Integrated care systems: learnings through a Whānau Ora lens

By Cate Mentink

As integrated care systems mature, there is much the UK can learn from New Zealand’s holistic approach to understand the true impact of health and social care services.

The WHO defines health as “a state of complete physical, mental, and societal well-being, not just the absence of disease or infirmity.” Despite this comprehensive definition, a significant portion of healthcare prioritises physical health, overlooking other vital determinants that significantly influence individuals’ overall health and wellbeing.

The introduction of integrated care systems (ICSs) in the UK and the growing emphasis on a more holistic approach provide an opportune moment to better address needs and improve healthcare outcomes. Holistic healthcare delivery has been shown to lead to better patient outcomes, reduced barriers to access, and overall superior health.

Whānau Ora, a holistic health and social care model originating from New Zealand, serves as an exemplary, culturally grounded, integrated approach that is driving positive outcomes across the country. By embedding a holistic health and social care focus, it aims to provide wraparound services centred on supporting not only the individual but also the whānau (extended family) that surrounds them.

While the path to developing and implementing Whānau Ora has been iterative and not without its challenges, there is much that can be learnt and adopted in the UK and worldwide from Whānau Ora’s efforts in developing, defining, and implementing this model and its underlying philosophy.

Social determinants of health: prevention is promotion

The social determinants of health, the conditions in the environments we inhabit, play a crucial role in shaping our health and wellbeing. Understanding and addressing these environmental influences is essential to enhance health outcomes and reduce disparities. Studies indicate that social determinants may exert a more profound impact on health than individual lifestyle choices.

A hallmark of Whānau Ora is its emphasis on the individual’s broader context, recognising that their health is influenced by their surroundings. By promoting and improving health and social outcomes across a collective, rather than solely focusing on the individual, better health outcomes can be achieved. Whānau Ora has demonstrated positive and meaningful results across a spectrum of health and social determinants. By encompassing all dimensions of health and wellbeing, rather than a more medicalised, linear approach concentrated primarily on physical health, Whānau Ora has ensured that outcomes address the diverse needs of individuals across a range of key factors.

Within ICSs, a deeper understanding of an individual’s unique circumstances and environments is vital in reducing disparities and supporting positive health outcomes. Shifting towards long-term change and prevention, as opposed to treatment, is paramount. Developing a model of care that incorporates a more holistic approach is crucial for the NHS to advance and deliver better long-term outcomes for the UK.

Navigating the grey: connectors across services and support

Ensuring service users are connected with the right support at the right time can be a challenge across any health system. Those who are vulnerable or facing disadvantage often face greater difficulty in accessing services, translating to greater disparities in outcomes.

Kaiārahi (navigators) play an integral role in Whānau Ora service delivery, acting as a key connector, helping families to identify needs, prepare, plan, and use services effectively. Here, navigators act as a broker in accessing services; ones that meet the unique needs of the person accessing them. They also work as a go-between, understanding service demands and identifying opportunities for intervention to better meet ongoing needs.

The use of navigators has been shown to be an effective tool in improving identification of needs, access to care and navigation of care services across a range of different settings. This is particularly prevalent for indigenous groups and those facing barriers to accessing services and support.

A recent study showed that a third of people in England lacked confidence in accessing care through the NHS. With this in mind, it’s crucial to consider the ways in which the health system is being navigated, and whether further support could be beneficial – not only to help users connect with the right care and support, but also to help reduce the burden on the healthcare system of those accessing services that don’t meet their needs.

Measuring the true impact of health and social services

Worldwide, much of health care provision focuses on easily quantifiable outputs, with the focus primarily on physical health through measurable metrics, while ignoring other key determinants that can impact on wellbeing. The siloed treatment and measurement of physical health without consideration of the other factors means that often, outcomes of health and social care are not as effective as they could be.

Whānau Ora measures success through outcomes, focussing on the key changes that matter to families and using an outcomes framework to understand the impact of interventions. Over the last 10 years, there has been a shift towards assessing and understanding social value in health and social services.

Measuring based on outputs simply evaluates the activities undertaken by an organisation, but it fails to assess whether these activities are indeed effective or meet patient needs or intended outcomes. Measuring based on outcomes, on the other hand, enables systems to grasp the actual changes experienced and the impact they have created. Outcomes represent the positive differences brought about by the outputs.

However, measuring based on outcomes can present challenges in defining “success” and identifying suitable metrics. When encompassing a broad spectrum of health and social indicators, success will manifest differently for each individual and community.

Whānau Ora has established a comprehensive outcomes framework that tracks progress in alignment with both individual aspirations and broader societal indicators. This approach facilitates a more comprehensive evaluation of service effectiveness and support.

The NHS is also adopting a social value focus. This entails considering the impact of its services on individuals and communities, alongside traditional health outcomes measures. Developing and implementing an outcomes framework would be a significant step for the NHS in measuring and comprehending the genuine impact of its services. This data could then be utilised to guide decision-making and enhance services for the future.

Investing in relationships

The establishment and cultivation of strong relationships are paramount to the success of an integrated model and the forging of meaningful connections with the community. Whanaungatanga, a cornerstone of Māori culture and a core principle of the Whānau Ora approach, underscores the importance of building, nurturing, and maintaining connections within the community. Within an integrated system, robust relationships and trust serve as indispensable foundations for achieving shared objectives, strategies, and outcomes.

However, these enduring connections do not develop overnight. Investing, particularly in the form of time, is essential for nurturing these relationships and fostering ongoing trust and support across the system. ICSs within the NHS confront multiple challenges in collaborating across providers and organisations, with the workforce facing significant pressure and a lack of funding for long-term investment in outcomes.

Despite these hurdles, concerted efforts must be made to foster collaboration, strengthen partnerships, and cultivate trust within integrated care systems. A fundamental aspect of building any meaningful partnership lies in dedicating time, energy, and commitment to fostering trust and a shared understanding of common goals and objectives. For integrated care services to truly embody the essence of integration, this must be a cornerstone of the NHS’s approach.

Working towards a more integrated future

Integrated care models worldwide offer a wealth of insights and practises that can be leveraged to support the NHS ICSs’ ongoing objectives and vision.

While no system is perfect, the Whānau Ora model exemplifies key attributes that can be learnt from and adapted to meet the NHS’s evolving requirements. Embracing a more holistic approach, considering the social determinants of health, optimising service navigation, evaluating the impact of interventions by measuring outcomes, and investing in strengthening relationships all contribute to ongoing advancement and improvement in the delivery of integrated care, ultimately driving the crucial goal of improved health and care outcomes.

Cate Mentink is a Healthcare Strategy and Planning Consultant at Lexica

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Internal staff banks help trusts meet 40% rise in demand

By Integrated Care Journal

New analysis has revealed that the number of shifts being successfully filled by internal staff banks has increased over the last year, helping to meet a simultaneous sharp rise in demand for temporary staffing in 2023.

Healthcare staffing specialists Patchwork Health analysed temporary staffing data from 17 NHS trusts that use digital staff banks. The analysis compared shift fill rates from the staff banks between January-September 2022 and January-September 2023.

The data revealed a 40 per cent year-on-year increase in demand for additional staff to fill vacant shifts, as the NHS has grappled with rising patient waiting lists alongside staff sickness and absences.

Despite this significant increase in the number of vacancies being advertised, data from trusts using a digital staff bank showed that shift fill rates were not only maintained in comparison to 2022 levels, but increased. Fill rates rose to 77 per cent in 2023, up from 75 per cent the year before, meaning that more than 3 in 4 vacant shifts advertised were successfully filled by staff registered to internal banks. This demonstrates the ability of a temporary staff bank to help trusts meet a significant rise in demand.

The data from Patchwork Health also showed that during the period for 2023, the top 20 busiest days in terms of demand for additional staff were all strike days, when increased staff absence left the trusts with a higher number of workforce gaps to fill. The strike days accounted for 13 per cent of all temporary staffing demand in the nine-month period.

Trusts that can rely on internal digital staff banks to fill short and long-term vacancies can reduce their over-reliance on (and the costs associated with) sourcing clinical staff through third-party locum agencies. The NHS pays more than £3bn a year to locum agencies to provide doctors and nurses at short notice.

Dr Anas Nader, CEO and Co-Founder of Patchwork Health, commented: “The NHS has faced a significant rise in both patient demand and staff shortages over the past year. A marked increase in the number of temporary staffing vacancies is reflective of just how far this demand has intensified.

“It’s so encouraging to see the shift fill rate from digital staff banks simultaneously rising, helping trusts to effectively tackle and meet this growing challenge, and keep services safely staffed. It’s a promising indication that the consistent use of an effective, dynamic staff bank can help us to remain resilient and weather fluctuating demand, while reducing over-reliance on costly locum agencies to plug staffing gaps.”

Social care system in sustained crisis despite ‘record’ investment, report finds

By Integrated Care Journal

2023 Sector Pulse Check report describes the current situation in social care as “arguably more perilous than ever”.

Unsustainable financial and workforce pressures are forcing adult social care providers to turn down new admissions and close services, as government grants are not reaching the people who need them most, according to a new report commissioned by Care England and the learning disability charity, Hft.

Based on a large-scale survey of adult social care providers, the 2023 Sector Pulse Check report finds that despite the sector receiving a £7.5bn funding boost in Chancellor Jeremy Hunt’s 2022 Autumn Statement, there has been little progress in the key challenges facing social care.

In a statement, Care England described the current social care environment as “arguably more perilous than ever.”

Professor Martin Green OBE, Chief Executive of Care England, commented: “The narrative that social care is under pressure is not a new one. What’s disappointing is that we find ourselves in a worsening crisis amid the Government’s narrative of ‘record investment’ into the sector.

“While the Government did make substantial commitments in the 2022 Autumn Budget, the outcomes have not matched the ambition. The new money into the sector has not led to tangible change or any significant progress towards ‘fixing adult social care’.

The report highlights how headwinds facing the social care sector include rapid and dramatic energy cost increases and unfunded rises in the National Living Wage, which contributed to 40 per cent of adult social care providers ending 2023 in deficit, the report says.

Recent funding initiatives from the government, such as the Market Sustainability and Improvement Fund and the International Recruitment Fund, have failed to mitigate funding concerns for the majority of providers, the report states; 84 per cent of care providers surveyed said that these measures made no difference to their organisation’s overall financial sustainability over the past year.

This has resulted in a reduced capacity for the sector to deliver care across providers, and the report finds that:

43 per cent of providers closed services or handed back contracts;
18 per cent offered care to fewer people;
39 per cent considered exiting the market altogether.

Workforce challenges remain widespread

The findings are concerning for a sector already facing deep-rooted and systemic challenges, particularly around workforce retention and recruitment. Despite a recent rise in international recruitment, staffing shortages remain widespread across the sector, with approximately one in 10 posts vacant in 2023/23. Nearly half (44 per cent) of organisations had to turn down admissions due to a lack of staff in 2023, the report finds.

Care England’s statement argues that the government’s approach to mitigate workforce are not working, and cites the recent tightening of overseas care staff and growing concern over the state of local government finances. Hft and Care England are calling on the government to implement immediate measures to support the care sector, including improving commissioning practice, revising VAT arrangements and removing barriers to ethical international recruitment.

Professor Martin Green OBE added: “It’s clear that the way our system is funded needs a rethink. For years, adult social care providers have absorbed increased costs and inflationary pressures without corresponding funding. When money is made available it simply isn’t cutting through. Recent changes to immigration rules and an insufficient Local Government Finance Settlement this year further suggest a government that is heading in the wrong direction. The sector’s needs are now on red alert.

“Our long-term vision remains one of a sustainable sector that is financially viable and an attractive destination for staff. While this may seem a distant reality, there are a range of policies at the Government’s disposal that would help turn the tide and put us on the path towards a sustainable future. As we count down to a general election, the Government must now make good on their promise to fix our sector.”

Steve Veevers, Chief Executive of Hft, said: “It is difficult to offer words of hope and motivation when the past 12 months have seen the adult social care sector engulfed in a sustained state of crisis.

“Despite moving away from the immediate challenges posed by the COVID-19 pandemic, there has been little respite from the fundamental financial and workforce pressures that have faced our sector for many years. The fact that 43% of providers told us they closed a part of their organisation or handed back contracts last year is testament to this.

“Our report provides several realistic, practical and impactful suggestions – including reforming VAT, revisiting the new visa laws for international workers and establishment of national commissioning standards – which we shouldn’t delay in implementing if we want to see real change from the next Government.”

Speaking to ICJ at the launch event, Veevers argued that ICSs, with their remit for joining local services, present an ideal avenue through which to improve access to social care. However, in line with recommendation area four in this year’s Sector Pulse report, he stressed that social care representation on integrated care boards and integrated care partnerships needs to increase in order to adequately reform the sector.

The full 2023 Sector Pulse Check report can be accessed here.

The need for innovation in ocular care

By Andy Hill

Andy Hill, CEO at NuVision Biotherapies, explains why innovating ophthalmology could contribute to recovering NHS waiting lists and help to establish the UK as a global player in the development of cutting-edge solutions in ocular care.

There are currently 630,000 people awaiting ophthalmology treatment on the NHS in England alone, which is the second-highest waitlist. This becomes an increasing concern when considering that ophthalmology is noted as the busiest outpatient service in the NHS and is struggling to cope with demand.

It was recently reported that NHS patients are being forced to pay for urgent eye care or risk going blind because of long waitlists. There is a huge need to support the NHS in the management of eye conditions to reduce the burden on patients, healthcare professionals and taxpayers. But is there anything that can be done to support the recovery of the ophthalmology waiting list?

The impact of poor eye care

It’s well known that good eye health and access to effective care have a direct impact on multiple stakeholders. Patients are of course the first to feel the repercussions of long waitlists and deteriorating eye health, but healthcare professionals, organisations and the taxpayer are also at high risk of being negatively affected.

According to a recent study, around 1.93 million people in the UK are affected by sight loss and blindness caused by a range of conditions, including age-related macular degeneration, cataracts, diabetic retinopathy, glaucoma and under-corrected refractive error. The economic consequence in the UK adult population has been valued at anywhere between £7.2 and £19.5 billion, with costs directly affecting the healthcare system reaching £3 billion at the time of the study.

One important factor to consider which, if fully understood and investigated could lead to a notable reduction in that burden, is that a significant proportion of sight loss and blindness is preventable. If we can secure greater investment from public and private organisations, new innovative therapies will be developed which can directly improve eye health through better access to early intervention and prevention.

Let’s take a look at the National Eye Health Strategy Bill that calls on the Secretary of State to publish a national eye health strategy for England. The objectives of the Bill are clear; to improve eye health outcomes, reduce waiting times for eye health care, ensure providers of eye health care work together in an efficient way, increase the capacity and skills of the eye health care workforce, and make more effective use of research and innovation in eye health care. Despite the many barriers that are in place, there is hope that the objectives set out in this Bill are achievable.

Accessing innovations in ocular care

Across the globe, great strides in innovating ocular care continue to be made. According to Dr Peter McDonnell, Director of The Wilmer Eye Institute and Professor of Ophthalmology at Johns Hopkins University, who co-chaired the December 2023 EyeCon conference; “There’s so much innovation going on in ophthalmology that it’s really impossible…for anybody to read all the journals and see all the articles that are coming out.”

Recently in the UK, the Association of Optometrists (AOP) updated clinical guidelines to include the application of amniotic membranes for dry eye disease patients, which opened up treatment access through optometrists in an outpatient setting. But what does this mean for the industry in practice and the NHS waiting list?

Optometrists have a new therapeutic option to support patient care with a treatment that integrates easily into existing clinical practice and effectively supports healing, limits inflammation formation, and reduces pain. Our OmniLenzⓇ, a specialised bandage contact lens enables our amniotic membrane, Omnigen®, to be loaded onto the ocular surface in a four-to-six-minute procedure without the need for surgery. In the longer-term, the availability of an amniotic membrane-based treatment in primary care will take the pressure off scarce NHS resources, allowing secondary-based care to reduce the current ophthalmology waiting list by focusing on patients who can only be treated in a hospital setting.

Clearly innovations can have a positive impact on every stakeholder involved in the provision, delivery and receipt of quality eye care. And to continue driving the UK’s world-leading innovations in this industry, we must remain open to knowledge sharing and collaborative practices. This will be supported by keeping up-to-date on the latest clinical studies and available resources on the range of eye conditions that global populations are facing, and the potential solutions.

What next?

It appears that we’re currently balancing on a precipice. On one side, we have an ever-worsening waiting list, while on the other we have an ongoing commitment to innovation that could transform ocular care for the better. In the UK and across the globe we’re seeing professionals in the public and private sectors scoping out new solutions to ocular conditions and treatments. For example, the use of AI to train surgeons remotely and monitor eye health with smartphone apps. And in May 2023, the NHS published new clinical guidance with the aim of reducing waiting times for eye care services for patients in England.

If you know where to look, organisations across the UK are advancing world-leading innovations in ocular care. But it’s important that we stay open to learning from other countries. For example, in the US significant ophthalmology-related FDA approvals have occurred or are due to occur imminently. Intraocular injections will be deployed to treat geographic atrophy, an advanced form of age-related macular degeneration, which previously had no treatment. Meanwhile, new data suggests that low-dose atropine can be very effective in reducing the magnitude of myopic progression in young children.

I’m very hopeful for the future of eye care in the UK and globally, and that as an industry we remain committed to supporting patients, professionals and our healthcare systems in overcoming the barriers and pressures that they are currently facing in the delivery of effective ocular care.

For more information on the innovative therapies that are being developed in ocular care, please visit: https://www.nu-vision.co.uk/patients/.