rupert-dunbar-reesGuest interview – ‘Outcomes’: the most misused term in the NHS?

The NHS has seen a real shift in focus towards outcomes. But do we really know what the term means? Dr Rupert Dunbar-Rees, founder and CEO of Outcomes Based Healthcare, talks to Highland Marketing’s Matthew D’Arcy about disentangling outputs to define outcomes.

News in brief

Hunt says IT spend protected in financial crisis: Health secretary Jeremy Hunt has given IT as an example of the kind of long-term investment in the health service that he wants to see as the NHS battles with a financial crisis and funding gap, reported Hunt appeared at the Commons’ Health Select Committee, alongside NHS England chief executive Simon Stevens and NHS Improvement chief executive Jim Mackey, as part of its inquiry into the Department of Health and NHS finances. The three were asked about national support for the Five Year Forward View to close a £30bn gap between NHS funding and demand by 2020-21, progress on the 44 sustainability and transformation plans, and what would happen if they failed to deliver. Chris Hopson, the chief executive of the NHS Confederation, told the same group of MPs that the NHS was no longer able to balance demand, NHS constitution commitments and the money available, and that sustainability and transformation plan areas were drawing up plans they knew they could not deliver. However three witnesses rejected those claims, with Hunt arguing that the NHS could produce the required efficiency savings while also improving quality. With a growing and aging population, he said more money would need to go into the system, but “the key is that as more money goes in, it should not be used as a sticking plaster for short term pressures but to deliver long term sustainability”.

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Ambulance patients face long A&E delays: Thousands of patients taken to hospital by ambulance face long delays before being seen by accident and emergency staff, figures for England have shown, reported the BBC. NHS bosses blamed “increasing demand” for the problem – ambulances should be able to hand over patients to A&E staff within 15 minutes of arrival. There were 76,000 waits over an hour in 2015-16, up from 28,000 in 2013-14. The number of waits of more than 30 minutes rose by 60% over the same period, from 258,000 to nearly 413,000. Shadow health secretary Jon Ashworth said: “It is clear that this government has failed to grasp what is happening in our overstretched hospitals.” Christina McAnea, of Unison, which represents ambulance staff, said: “There’s a national crisis in the ambulance service because of an extreme lack of funding across every part of the NHS.” In Scotland the NHS is also struggling to meet demand with new figures showing a fall in patients seen on time at A&E. The Scotsman reported that statistics for the week ending 9th October showed that 92.6% of all patients were seen and either admitted, transferred or discharged within four hours – below the Scottish government’s interim target of 95%. Liberal Democrat health spokesman Alex Cole-Hamilton said: “These are the worst weekly A&E performance statistics that we have seen since March 27. Winter is coming and pressure on doctors and nurses working on the frontline of our NHS is only going to get worse. Scottish National Party ministers cannot afford to simply cross their fingers and hope for the best. Doctors, nurses and patients need extra support now.”

NHS cash cut giving us a ‘bigger hill to climb’ in face of rising demand: The financial challenges facing the NHS over the next five years will be made worse because the Department of Health (DH) didn’t meet its funding demands, the chief executive of NHS England told the Health Select Committee. “For the next three years we didn’t get the funding that was requested… so as a result we’ve got a bigger hill to climb,” said Stevens. “Given we’ve got an ageing and growing population, if you just look at the population growth – even before you take account of ageing – 2018-19 will be the most pressurised year for us – where we actually will have negative per person NHS funding growth.” Health secretary Jeremy Hunt who also appeared before the committee, defended the DH against charges that it had given misleading information about NHS funding, reported National Health Executive. The government has said it has given the NHS an additional £8bn funding over the next five years, and in an interview with the Manchester Evening News, Theresa May said: “The government has not just given [Stevens] £8bn extra, we’ve given him £10bn extra.” However, the committee’s own report found that the true figure was closer to £4.5bn, because the department changed the definition of health spending to apply only to the NHS and did not allow for cuts in areas such as public health. Hunt insisted: “Whether you call it £4.5bn or £10bn, it doesn’t matter. It’s what the NHS said they needed and it’s extra money going to the frontline.”

Welsh budget: Labour promises extra £240m for NHS: An extra £240m for the NHS has been announced in the Welsh budget, reported the BBC. Spending plans had been shaped by the “unprecedented challenges” posed by Brexit and the resulting loss of European funding, finance secretary Mark Drakeford said. “In these uncertain times, we have published a one-year revenue budget, which will provide stability and assurances for our valued public services in the immediate future while we work collectively to plan for the future,” he said. Funding commitments in the budget include £4.5m towards a pledge to raise the savings limit for people in residential care to £50,000. Responding for the Welsh Conservatives, finance spokesman Paul Davies said he hoped the draft budget would “deliver for Welsh communities where so many others before it have failed”.

NHS England sets out funding for GP infrastructure, indemnity and mental health: Nearly 300 GP practices will receive premises or technology investment this year as part of a plan to invest £900m in general practice infrastructure by 2020/21, NHS England has announced. NHS England, chief executive Simon Stevens told the National Association of Primary Care in Birmingham that 300 schemes would receive support this year “subject to passing a set of due diligence checks”, reported GPOnline. Stevens also set out plans to invest £11m this year in expanding psychological therapies to support patients with long-term conditions, and a £5m winter indemnity scheme to subsidise costs for GPs working in out-of-hours and 111 services. The £11m funding will pay for the development of 22 psychological therapy schemes across 30 clinical commissioning group areas, some of which are expected to begin seeing patients within the next three months, as part of plans to deliver an extra 3,000 mental health therapists in GP practices. Stevens said: “The NHS needs strong primary care services and today we’re taking further practical action to provide GPs with modern surgeries to work from, expanded staff to offer their patients a wider range of mental health care, and better support for GPs who look after patients at evenings and weekends. We meant it when we said GP services are the bedrock of the NHS, and we’re backing that commitment with concrete action to deliver the GP Forward View.” GP funding in England will rise to the 11% share of the NHS budget GP leaders have campaigned for once local investments are factored in, according to analysis by the Royal Collage of General Practitioners, GPOnline also reported. 

Health secretary announces ‘one-stop’ plan to expand role of GPs: Health secretary Jeremy Hunt has announced a new programme aimed at moving more patient services to GP practices from hospital, reported Pulse. Hunt said that under his “GP one-stop programme”, the NHS will be going through “condition by condition” to see which can be handled in general practice rather than secondary care going forward. He said that the NHS has to “get back to basics and think how many issues and problems could actually be solved with a visit to a general practice” rather than “sending someone to the back of another queue”. Speaking at the Best Practice conference in Birmingham, the health secretary said: “I think it is quite sobering to note that the entire outpatient budget for hospitals is around the same as the entire general practice budget. [But] I think as far as patients are concerned they would much prefer it if a lot of those problems were sorted out inside general practice.” Hunt said his plan would include a range of conditions, such as, for example, diabetes. He continued: “So you will be hearing more about what I am calling ‘the GP one-stop programme’, looking at areas like diabetes, end-stage renal, and many others. We are going to go through, situation by situation, condition by condition, and ask what barriers we can remove centrally to allow more of this work to happen in general practice.” He admitted that this meant asking GPs to “do more work” but said that they would be “paid for doing that” and argued that it would also “make life more rewarding for doctors”. Aside from being more satisfying for GPs, Hunt said the model will allow patients to be seen more quickly.

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Patients could get advanced treatment quicker, says NICE: Cost effective treatments could be offered up to three months faster under plans unveiled by the standards body and NHS England, reported Health IT Central. The National Institute for Health and Care Excellence (NICE) has come up with proposals for a new “fast-track” appraisal system to accelerate patient access to new technologies. NICE will also consider requests from NHS England which show that the budget impact of introducing a new technology “would compromise its ability to properly fund other areas of its work”. The plans, drawn up in collaboration between NICE and NHS England, are also claimed to offer the NHS much more value for money. “NICE and NHS England believe these proposals represent a fair approach to the significant challenge of providing faster access to innovative, cost effective treatments alongside the need to safeguard future financial sustainability,” said Sir Andrew Dillon, NICE’s chief executive. The idea is that health technologies deemed to be of a cost per QALY (quality adjusted life year) of up to £10,000 would be assessed more rapidly than happens now under a special “lighter touch” process. That would mean patients would get such treatments and help from new tech quickly, with final guidance being published by NICE upon regulatory approval – and NHS Funding made available within 30 days instead of the current 90. In parallel, a new “budget impact threshold” of £20m per year is also being looked at to help better manage the introduction of treatments known to be cost effective but have a very high cost.

Opt-outs have been honoured – NHS Digital: NHS Digital has said it is now complying with rules about sharing patient information, after the deadline imposed by the Information Commissioner’s Officer (ICO) passed on Wednesday, reported Last month it was reported that some patients who had opted out of sharing their data beyond direct care, known as a type-2 opt-out, had not yet had their wishes respected. In an undertaking agreed in April, the ICO had given NHS Digital until 19th October this year to honour the opt-outs. The failure to do so years after patients requested their information not be shared was “unfair”, the ICO said. This week an NHS Digital spokeswoman said the organisation was “now respecting type 2 opt-outs robustly and consistently across all our disseminations and we are confident that we have met both the spirit and the letter of the undertaking, and we await the ICO’s review of our response”. Since April, NHS Digital has been processing type-2 opt-outs centrally and removing them from datasets but until recently some opt-outs at the fringes were still not being honoured. A report to NHS Digital in September showed that some research bodies and other organisations that have received data from opt-out patients had yet to destroy it. NHS Digital had contacted 151 customers, which have received data since 2014 on patients that have since exercised a type 2 opt-out, to request they destroy this data. As of 23rd August, 58 organisations had yet to respond. However the NHS Digital spokeswoman said all organisations that had held personal data about type-2 opt-out patients had now confirmed this data has been deleted.

NHS England offers £400,000 for mental health digital innovation: New funding will be available for digital innovations to improve mental healthcare as part of the programme of NHS reforms, reported the National Health Executive. Six to eight innovators will take part in the Digital Development Lab, for which NHS England is providing £400,000 funding. The innovations must address one of the following areas: early intervention and improving access; parenting; perinatal health; transitions to adulthood; and employment, education and training. Juliet Bauer, director of digital experience at NHS England, said: “There are lots of digital technologies claiming to help people manage their mental health but it is hard for practitioners to assess their effectiveness and their safety for use. Using this fund we can rapidly develop and scale currently available, evidenced based tools. The lab’s successes will mean more people can manage and care for their mental health using a set of high quality, evidence-based and safe digital tools with NHS endorsement. We’re particularly interested in tools that support the mental health of young people and families.” Increased support for digital technology is part of the Mental Health Forward View, published after the Mental Health Taskforce found serious failings in NHS mental healthcare provision.

NHS Fife praised for pioneering tech trial: NHS Fife has been given an award for a pioneering piece of technology it has been using since 2015, reported Kingdom FM. It is the first health board in Scotland to pilot the Patientrack system, which monitors patients’ vital signs at their bedside. The health board said the number of cardiac arrests in the medical admissions acute unit alone has dropped by two-thirds since the system was introduced at NHS Fife. Dr Gavin Simpson, a consultant in critical care and anaesthetics, said: “Patientrack has helped us achieve an immediate and significant reduction in cardiac arrests in one of the busiest areas of the hospital, by up to two thirds. Any clinician can now instantly see the profiles of the sickest patients in the hospital. Patientrack has helped us introduce some of the biggest and most immediate changes in clinical practice I have ever seen.”

National exemplars should include non-acute – Gordon: The next round of “exemplars” should be expanded to include non-acute trusts, the chairman of NHS Digital has said, reported Noel Gordon, who both chairs NHS Digital and sits on the NHS England board, said: “I would like to see more diversity in the national exemplars.” This could include mental health, ambulances or even emerging integrated care organisations, he said. While no decision had been made at NHS England, Gordon said he would be arguing at the board for a wider range of trusts to be included. “Overall, I would like to mix it up.” Health secretary Jeremy Hunt recently revealed 12 acute trusts that would be funded for up to £10m each to become “a global digital centre of excellence”. The model of funding is aligned with US ‘digital doctor’ Bob Wachter’s review of NHS IT, which recommended splitting NHS trusts into three groups, and funding the most digitally advanced trusts, or group A, first and the least digitally advanced trusts, group C, last, with minimal support until they were further advanced. So far, £100m has been set aside for global exemplars, but Gordon said he hoped more money would be made available for national exemplars.

UCL Institute of Digital Health to work with Cerner UK: The University College of London (UCL) Institute of Digital Health has signed a partnership with Cerner UK to “close the gap between what is learned in research and what is delivered in healthcare partnership” reported The institute is a network of researchers, projects and research centres with an interest in the potential of digital technologies to improve health and wellbeing; particularly at a population level. Its website says its key ambition is to “advance research in digital health that is technologically leading and socially relevant”. In a statement, Ann Blandford, the institute’s director said: “UCL has a long-standing relationship with Cerner, in both research and teaching, and this is a great opportunity to build on past collaborations to deliver future research that makes a real difference in practice.” Specific aims of the partnership include closing the gap between research and practice, developing the future healthcare workforce and making sure it has appropriate IT skills, and reducing the time to market for digital health innovations. Geoff Segal, general manager for Cerner UK and Ireland said: “With this partnership, not only will we focus on what the health and care of the future should look like, we will also make sure that this care is delivered to care providers as soon as possible, and that their workforces are ready for it.”

NHS launches patient, staff-led twitter account: NHS England has launched an @NHS Twitter account that will each week be controlled by a different patient or member of staff, in a pioneering new initiative designed to “lift the lid” on the service through voices on the frontline, reported the PharmaTimes. The three-month pilot scheme aims to tap into the experiences of users and providers of NHS care and channel their stories “far and wide”, handing over sole control of the account to @NHS curators so that they can share their thoughts and opinions with anyone on Twitter. The first is Richard Orchard, current non-Hodgkin’s lymphoma cancer patient at Barking, Havering and Redbridge University Hospitals Trust. He said: “It’s been an eventful time in my life being diagnosed with non-hodgkin’s lymphoma and I’m looking forward to sharing my journey with others for the week – with all its highs and lows. I hope some of my experiences with strike a chord with fellow cancer patients, to let them know they’re not alone in this.” Also commenting on the move, Jane Cummings, chief nursing officer for England, said it is a “fantastic opportunity for our much valued patients and NHS staff to hold a magnifying glass up to the system, so we can learn from their experiences, as we continue with our ambition to improve the way that care is delivered”. The NHS is partnering with Twitter on the initiative, which has pledged to promote the @NHS account to its 15 million users in the UK.

Keith McNeil joins CCIO advisory panel: Keith McNeil, the NHS’s first chief clinical information officer (CCIO), has become a member of the national CCIO Network Advisory Panel, reported McNeil joined the panel, which is chaired by Dr Joe McDonald, a practising NHS consultant psychiatrist and CCIO at Northumberland, Tyne and Wear NHS Foundation Trust. Its two vice chairs are Anne Cooper and Jonathan Kay. The advisory panel provides the governance, strategy and direction for the network, which is dedicated to promoting the development of CCIOs across the NHS, greater collaboration and best practice. The CCIO Network, established four years ago, grew out of Digital Health’s campaign to introduce the CCIO role to the UK. It aims to support the CCIOs that are now in post and encourage young clinicians to think of a career in health informatics. The network runs national and regional events, most notably the CCIO Summer School, and a private collaboration online community. McDonald said: “The CCIO Network was extremely pleased at the appointment of the first NHS CCIO and it is great news that Keith has now accepted the invitation to join the CCIO Network Advisory Panel”. When McNeil took up the national CCIO role, he stressed that: “Introducing and embedding new technology takes time, and is always challenging. This is particularly so in hospitals and healthcare. However, the rewards are great – getting it right transforms the way we care for patients, improves patient outcomes and saves time and money for the NHS.”

Hospitals cancel hundreds of appointments after ‘critical’ tech crash: Two hospitals in the Midlands had critical internal incidents declared after a major technology failure, which affected all trust IT and telecoms systems. Health Service Journal (subscription required) reported that Peterborough and Stamford Hospitals Foundation Trust had initially said it had cancelled more than 1,700 outpatient appointments at Peterborough City and Stamford hospitals but later said the figure was more likely around 300. The fault affected the trust since around 3am in the morning. Internal phones and communications systems were also down. Clinicians used walkie talkies to keep in contact with wards. Stephen Graves, chief executive, said: “We cancelled appointments in the interest of patient safety. We did not take this decision lightly and sincerely apologise to those patients affected. We will reschedule cancelled appointments as early as possible. Patient safety is our priority; therefore some operations have also been cancelled. Engineers are on site and we were working closely with them (the clinicians) to resolve the issue.”



Uniting organisations and people to deliver new care models
Samantha Jones, director of New Care Models Programme, discusses how vanguards have helped the NHS improve its quality of care for patients, and reduced pressure on the health service.

In an article to the Health Service Journal (subscription required) she said: “Each vanguard has clear plans in place for managing demand more effectively across their local health system and to reduce costs, whilst at the same time improving the care provided to patients.

“This includes reducing avoidable hospital admissions and bed days, releasing back office savings and improving prevention, self-care and the use of technology.

“Each vanguard has clear plans in place for managing demand more effectively across their local health system and to reduce costs

“A local GP has been linked to the home and a pharmacist is working with residents to ensure they only take the medication they need. In March there were no falls – before the scheme there were about eight a month.  Ambulance calls are down more than 30%. 

“In terms of COPD, 108 patients have been seen in a rapid clinic and 30 patients in a severe clinic. This has already led to a reduction in GP and out of hours’ visits, as well as emergency department and hospital admissions, and plans are in place to replicate this model across the county.

“We have already published the first in a series of common frameworks for those wishing to take up the new ways of working.”

The future of digital healthcare
Pooven Maduramuthu, VP of health at Atos, discusses the untapped potential for wearable technology in healthcare.

In an article on IT Pro Portal, he writes: “UK sales of wearable health and fitness monitors were expected to reach over 13 million last year, and the forecast is for more than threefold growth in global sales by 2020.

“What if…we could wear a device that proactively monitored our physiology and alerted us, and our GP, of a change in state to prompt early intervention and the potential to prevent serious illness?

“…this was complemented by a same day (24/7), virtual consultation with our GP to diagnose the condition and set in motion the optimum course of treatment?

“…a single, electronic patient record could then be shared and updated by everyone involved in delivering that course of treatment, the time and cost of treating the patient could be significantly reduced and patient experience and outcomes improved? 

“…the same wearable device that diagnosed the condition could be used to monitor patients during and after treatment, facilitating an early discharge from hospital, in turn addressing the bed-blocking that has such an impact on the NHS today? 

“We know there are major gaps and challenges facing the NHS. Harnessing data can help care professionals to understand and cope with changing needs. In many cases, digital solutions are ready for implementation if there are corresponding cultural and organisational shifts.

“Technology partners who can work hand-in-glove with healthcare managers and clinicians to harness digital technologies will be able to improve patient outcomes and target resources where they are needed most.”

Every 1% saved from chaotic NHS procurement could save £220m
Colin Cram, a public sector consultant and former director of the North West Centre of Excellence, explains how millions could be saved in the NHS if the line over procurement was tougher.

In an article on The Guardian, he writes: “Every 1% reduction in hospital trusts’ annual procurement expenditure of £22bn could pay for more than 4,000 extra junior doctors.

“There have been at least six separate procurement strategies for NHS England since 2000. The result is a chaotic mix of outsourced procurement providers, procurement consortia, and local collaborative initiatives.

“The latest strategy, entitled the future operating model for NHS procurement, should improve matters. The department is seeking providers, private sector firms, for 11 categories of goods and services – effectively outsourcing procurement. Their use will be almost mandatory, thus getting close to maximising purchasing power for items covered by these agreements.

“However, this is not a magic formula. Much more could be done more quickly by focusing on specific areas of spending. For example, reduced costs for NHS trusts of up to £1bn and better patient care could be delivered by tackling certain types of sight loss and patient falls. That would equate to up to 4% of procurement spend by NHS trusts, or enough to cover the earnings of up to an extra 16,000 junior doctors

“NHS procurement needs a coherent, integrated management structure – central, regional and local – on which the category structures could be superimposed. 

“Hunt should require NHS England to set this up and limit Department of Health involvement to monitoring progress and performance. Could this be an opportunity for the recently set-up NHS England commercial team?”


normanlambGuest blog: Norman Lamb: ‘As a minister I was in a mental health fog’
The former care minister recalls his daily fight in the coalition government to keep mental health on Jeremy Hunt’s agenda, and argues that better use of data is now absolutely critical to correct lost momentum and ensure equality in mental health treatment.

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