NHS international intelligence scanning service

As the general election campaigning enters its final week, it shouldn’t have come as a surprise to anybody that the discourse around the NHS has focused on the big-ticket items of the elective waiting list, the NHS estate and the 8am scramble for GP appointments that consume much debate around the performance of the service. However, this does not diminish the significance of interventions and innovations that do not capture the headlines quite so easily. In this spirit, the June edition of the international scanning service focuses on three examples of innovative practice that feature less prominently in the manifestos and campaign trails of the major parties that any incoming government would rightly seek to emulate to deliver on their pledges. 

The Conservatives

The Conservative Party has committed to ensuring: “...that procurement opportunities are focused on SMEs in their local economies where possible and practical.”

In this instance, the Conservatives can look to the Australian state of Victoria where the state government is financially backing a new training programme that will see more assistive health tech designed and manufactured locally, which ranges from mobility aids to voice controlled home appliances. The training programme, which is led collaboratively by Swinburne University, Bendigo Kangan Institute of Technical and Further Education and organisations from the health and manufacturing industries is intended to reverse Australia’s dependence on imported technology that is less readily available and fit for purpose for individuals. The initiative plans to combine increasing the availability of a growing market of high-quality jobs while delivering better outcomes for those who rely on assistive health tech.  

Labour

Meanwhile, while it does not feature explicitly in the Manifesto, Labour’s previously stated ‘Missions’ have explicitly referenced the importance of virtual wards for shifting resources into primary care and community services: “NHS to expand ‘hospital at home’ services, like virtual wards, (which) are also vital for delivering the healthcare of the future by bringing hospital standard care into the home using technology.”

This Canadian review on the use of virtual wards for supported early discharge, is the first of its kind in Canada to comprehensively examine the use of virtual wards across numerous countries and will likely hold key insights for their further use in the NHS. The review considers virtual wards' ability to reduce mortality, length of stay, hospital readmission and costs to health care providers. Overall, the review identifies that virtual ward programmes can improve comfort and satisfaction for patients, but the high technological use does risk placing additional burden on patients and care givers at the risk of excluding some.  

Liberal Democrats

The Liberal Democrats have made a link between air pollution and health as part of their commitments to improving public health: “Tackling air pollution and poor air quality in public buildings with a Clean Air Act”.

The NHS contributes 40% of public sector carbon emission, 5% of the nation’s total carbon emissions and will find itself at the sharp end of managing the negative impacts climate change has on the health of the population. Action is needed therefore, but climate change is not contained to a single nation and therefore global, coordinated action is required. To that end, the NHS Confederation hosted a session at our recent NHS ConfedExpo that explored the various forms of international engagement that can support the NHS to achieve environmental sustainability and how local and national organisations can act as global leaders to support other systems to achieve this too.

Featuring Chris Gormley, Chief Sustainability Officer at NHS England, Sonia Roschnik, Executive Director at the Geneva Sustainability Centre, and Alex Giles, Head of Innovation at Gloucestershire Hospitals NHS FT, the need for NHS led collaboration and leadership was brought into stark context by Sonia Roschnik when she revealed that the vast majority of health systems supported by the Geneva Sustainability Centre (part of the International Hospitals Federation) haven’t begun taking any action towards environmental sustainability. 

Chris Gormley painted a more positive picture though when he discussed how the Greener NHS team’s collaboration with the WHO meant that the NHS was able to support the 30 other countries that have set similar NetZero commitments for their healthcare systems, encouraging others to make a similar commitment, and crucially learn from the best practice of other systems.

Alex Giles discussed the tripartite approach that Gloucestershire Hospitals has taken in their role as a local organisation by combining the trust's commitment to environmental action with a focus on Artificial Intelligence development across the trust and international partnerships that are led by objectives for commercial development that expand trust revenues. For NHS trusts facing significant fiscal constraints, the ability to align their NetZero commitments with revenue generating activity can potentially alleviate cost pressures that could slow further action.

Cross-party

Looking at cross-party commitments, all three parties have outlined some form of commitment to address the consumption of vapes, and they would be wise to look to a new Bill set to be passed by the Australian Senate on the 1st July that will prohibit the sale of all vapes in any location other than pharmacies. The move means that anybody wishing to purchase a vape will need to do so for therapeutic purposes and will need a GP’s prescription before purchasing one from their local pharmacy. 

Given the prominence voters give to the NHS, it will never come as a surprise that all parties have made a variety of commitments to the service and wider public health; however, as NHS Confederation CEO, Matthew Taylor, discusses in the latest episode of Health on the Line, there is a dearth of detail on how these commitments will be funded. In these instances, the next government will need to look to tried and tested approaches to derisk their interventions in such a fiscally-constrained operating environment. 
 

Wednesday (22 May) brought to an end months of speculation about when the next general election would be held. Soon to fill the void among the health policy profession is not if, but to what extent, the NHS will become a political football.  

Manifestos will of course be launched imminently, making each party’s plans much clearer, but for now we are able to get a sense of their commitments based on the extensive public debate into the policy the NHS needs that has already occurred. Therefore, in this month’s international scanning service, we’ll be looking at the commitments the major parties have already made and the international examples each could include further in their thinking.  

Starting with the incumbents, the Conservative government has pledged to cut waiting times and has implemented various policies while in government in an attempt to address the NHS’s issues.  

Further lessons can be found in Italy for addressing the the growing backlog of elective care, now at ~8 million. Based on OECD data, Italy has a comparably strong performance on elective waiting times, but domestically waiting times are a point of long-term political debate. In 2015, the region of Emilia-Romagna implemented a plan for reducing waiting times for elective procedures. The plan took a demand and supply approach to reducing waits, including reducing requests for services that didn’t require an elective intervention and non-presentation among patients, as well as removing perverse incentives for some procedures among some providers.  

In the first four years of the plan's implementation, the ambition for 90% of specialist consultations to be undertaken within 30-days, and 60 days for diagnostic tests was exceeded. Despite this, Emilia-Romagna remained an outlier in Italy’s regional approach to health system devolution and in 2019 this resulted in the establishment of the National Observatory on waiting times.  

The Labour party's mission to ‘Get the NHS back on its feet’ also includes commitments to reduce the elective waiting list, as well as improving waiting times for cancer patients, improving access to primary care and dentistry, and improving access to community mental healthcare.  

If they’re not already, the Labour Party will want to keep an eye on Australia, where this week Cancer Australia, the national agency for cancer control, has announced the launch of the Australian Comprehensive Cancer Network (ACCN). Australia is recognised by the OECD as having a particularly strong performance on 5-year survival rates, despite the higher-than-average instances among the OECD; however, inequalities in access and outcomes pervade across the country, especially in rural and remote regions and among Aboriginal and Torres Strait Islander communities. The ACCN will build upon commitments made in the 2023 10-year Australian Cancer Plan by linking cancer services across the country. Participants in the ACCN will work together to a set of standards focused on comprehensive cancer care, equitable access, research excellence, data collection, and workforce development. The ACCN will benefit from the announcement of $1.8bn in new investment into health and medical research in Australia, that includes $1.4bn for research into the reduction of health system disparities and incidences of low survival rates among cancer patients.  

Meanwhile, the Liberal Democrats have committed to guaranteeing everyone the right to see their GP within seven days or 24 hours if it is deemed urgent. They, and other parties, are probably right to focus on their retail offer on primary care. While data from NHS Digital indicates that a significant proportion of patients are already seen with 1 week of booking an appointment, last year's British Social Attitudes survey showed waiting times for GP appointments is a significant factor in the declining satisfaction with the NHS.

All political parties can look to the work of the European Observatory on Health Systems and Policies and their new report Implementing the Primary care Approach for inspiration on this topic. At 504 pages, the report is a comprehensive compendium of the levers that can be exerted in primary care including governance, estates, and digital health and data that draws upon the insights of over 70 experts and the experiences of over 50 health systems.  

Of particular interest will be the approach taken by Spain, where just 0.2% of the population report unmet needs as a result of waiting times, and 86% of appointments for non-emergency cases take place within two days of the request. Much of this is the result of reforms in the early 2000’s that decentralised planning and fiscal responsibility of the national health system and placed an emphasis on services being developed around primary care. Primary care centers have been developed across the country that act as the primary contact point for a range of services including general practice and nursing, paediatrics and social services.  

Wherever they look, each party can find excellent practice from a wide range of health care systems. Common across all systems, though, is a long-term approach that recognises the multifaceted nature of the problems facing services and the need for multi stakeholder collaboration and devolution of decision-making to the local level.  

Amid widespread political interest in the productivity of the NHS, the latest round of NHS England planning guidance, published in late March, has placed significant pressure on NHS leaders to deliver stretching targets that seek to improve access to output of services from the elective waiting list to improving the provision of mental health in the community, to children & young people, and the perinatal period. 

It begs the question, to what extent are other health systems struggling to provide timely access for their citizens to such a diverse range of services, what actions are being taken to address this, and how is their focus on short-term access being balanced with the ambition to address the long-term drivers of ill health?

Diagnostics

In the USA, where inequalities in access and uptake of diagnostics pervade across socioeconomic, ethnic and racial divides, policy-makers are thinking differently about how they provide diagnostics that are easier to access, and how to overcome the issue of how communities can be reached. 

In the latest episode of The Dose, The Commonwealth Fund spoke with UCLA Professor of Medicine and Director of the Gastroenterology Quality Improvement Programme, Dr Folasade May. With a dual focus on medical treatment and health equity policy, the podcast concentrates on Dr May’s efforts to improve the methods used for diagnosing colorectal cancers, design bespoke engagement initiatives for diverse communities, and effect national policy interest for a cancer that has become the number one killer of men, and number two killer of women in the USA.  

Access to primary care

NHSE planning guidance also places an emphasis on improving access to primary and community services and places a requirement on ICBs to report on how well trusts are improving the primary-secondary interface. Primary care, and the scale of services it delivers, is often taken for granted in the UK, but for many health systems in similarly wealth nations, an integrated approach to primary care has been lacking for a long time, with poor coordination for patients requiring ongoing care for multiple conditions and significant inequalities in service provision.

Back in the USA, where state spending on primary care is among the lowest in the OECD at 5-7% of total healthcare spending (based on OECD metrics the UK comes in at 16%), the Commonwealth Fund has formed the Primary Care Investment Network alongside The Primary Care Development Corporation and the Milbank Memorial Fund. Made up of representatives from 25 states, and amid a disparate and underdeveloped system, the Investment Network’s task is no mean feat. Their initial task has been to simply define what is and isn’t considered primary care in the American context, before it is possible to go onto address accountability, stakeholder engagement, and evaluation methods. 

Despite this challenging base, the Network has already been able to identify some good practice. In California, a Primary Care Investment Coordinating Group has had success in aligning the interests of  public and private healthcare providers, policy-makers, and patient representatives to agree investment in primary care. 

Germany’s health insurance-based health system, much admired for its comparatively high investment in health and the resulting degree of technical and professional capacity at its disposal, is often criticised for the lack of integration between services and providers. Several steps have been taken over the past decade to rectify this and one such initiative, introduced at a single site in 2017 and now being scaled across the country is Health Kiosks. 

Designed to support socially disadvantaged citizens to easily access comprehensive health services where there is limited access to physicians, Health Kiosks can be established in various settings and act as a source of providing health services, preventative care and general welfare. Since their introduction in 2017, there has been a commitment from central government to expand to over 1,000 kiosks across the country and invest in the expansion of electronic health records and wider digital infrastructure in the Kiosks.

And this is not the only effort being made in Germany to increase integration across primary care. Since 2017, the Robert Bosch Foundation have been investing in Patient-Oriented Centres for Primary and Long-Term Care programmes (PORTs). The intention of PORTs is to develop community health centres that are designed around an ageing, multimorbid population. Integrating prevention and health promotion, POSTs will coordinate treatments for patients and help them manage their own conditions, in acknowledgement of patients wanting to take greater agency in their care.  

Elective waiting lists

The government of New South Wales (NSW), Australia, has been making efforts to reduce their waiting lists for elective surgery. A ‘Surgical Care Taskforce’ was established in May 2023 and initial reporting from the Bureau of Health Informatics suggests that the Taskforce’s initiatives have so far reduced waiting times for elective surgeries by 35%.

The NSW government is now attempting to replicate the success with the establishment of an emergency department taskforce. This comes as new national statistics show that NSW has the highest number of ED presentations in the country (3 million). Official statistics and patient experience reporting show that it should be possible for the taskforce to significantly reduce ED presentations. Almost half of presentations to ED were for the two most minor categories of injury, while 45% of patients reported that they felt they could be treated by a GP. As such, the taskforce will focus much of its efforts on initiatives to reduce unnecessary presentations and efficiently moving patients across the system, so they can be treated in the most appropriate setting. 

NSW is matched in its ambition to reduce elective waiting times by Sweden, where waiting times are increasing, and disparities are emerging between the regions. To combat this, the national government has commissioned the eHealth Agency to develop a new ‘care intermediation system’. The system allows providers of care across the country's regions to identify alternative providers that can deliver elective care to patients in a timelier manner. 

Delivering a balanced financial position

These efforts all come with a significant financial cost attached to them, and NHS leaders may feel some comfort knowing that it is not just they who are facing down the prospect of needing to make significant cost savings. 

Finland, another publicly-funded health system where healthcare is devolved to regional level, has asked its health regions to make significant savings to their healthcare budgets amid a national budget that will see spending fall and taxes rise. Spending across the nation’s public services will fall by £6bn euros and this cut in public spending, alongside the proposed changes to healthcare provision have caused anger among the public and discontent among healthcare and political leaders across the Finnish regions. The resignation of the Managing Director of Wellbeing services in one region and the subsequent loss of confidence in the Chair of the Regional government, by their party, serve as an indication of the degree of fallout. 

Amid the austerity programme is permission from central government to increase debt for investment that will see small health centres and central hospitals close and be replaced by larger social and health care units. Larger than the existing local health centres and smaller than Finland’s central hospitals, social and health care units are expected to provide greater economies of scale, be more attractive places of work for a range of healthcare professionals and remain easily accessible to all patients. 

These plans follow the recommendations of a working group convened by the Ministry of Health that has suggested that the number of central hospitals in Finland be reduced from 15 to between 5-8, with the sites purpose shifted away from the provision of accident & emergency care and elective surgeries, to the ongoing care of an ageing and multimorbid population. It is expected that from 2027 these reforms will save the health service €100 million per annum. 

Conclusion

The latest round of planning guidance has placed NHS leaders in the challenging position of delivering greater access to a wide range of services, with little additional financial support to do so. As the NHS Confederation acknowledged in its response, the ambition is welcome, but successfully meeting this ambition will remain unclear. In the face of such demands, it is hopefully reassuring to NHS leaders that they are not alone in these endeavours and there are international counterparts outside the NHS whose experience and best practice they can share. 

Speaking at this month’s Nuffield Trust Summit, Professor Chris Whitty, the Chief Medical Officer, drew upon his annual report to discuss the challenges posed by an ageing society and how we need to collectively think about ageing differently.  

Whilst praising the advances that have been made in life expectancy, the CMO sought to position ageing from the perspective of increased quality of life, and not just the quantity of years. Currently, the average healthy life expectancy for men in England is 62.4 years and 62.7 years for women, with significant geographical variation across the UK and subject to socioeconomic factors. This is well understood to have profound impacts on the overall wellbeing of individuals, their families, carers, and wider communities who depend on a healthy older population. Additionally, as communities age in poor health, there is an increasingly negative impact on the broader economy and a heavily resource-constrained NHS.  

In his foreword to the report, the CMO chose to highlight that improving healthy ageing is not the responsibility of any one individual or group and that the general public, policy-makers and medical profession all have a role to play. Our focus should be on our ability to influence how well we age, how healthcare planning can reflect the geographies and built environments in which older individuals age, and the increasing incidence of multi-morbidity, not single disease, associated with ageing in the 21st century which must be reflected in service design, and medical provision and research.  

As other nations contend with similar challenges arising from an ageing population, it makes sense to consider how our peers are approaching this demographic shift, what interventions are being made, and what impact, if any, they are having on the quality of life of older adults and the demands faced by the health and social services supporting them?

Italy

Health system design is one such intervention that needs to be considered, with the CMO noting that health service planning currently doesn’t sufficiently reflect the geographical spread of older adults and how the built environment in these geographies impacts access to care. There is general recognition in England of a need for a ‘left shift’ of resources into community settings, and this is one area where the English NHS could learn from the Italian healthcare system, especially from the northern region of Emilia-Romagna. Counter to the common Italian approach of heavily centralised, specialist hospitals and single doctor primary care clinics, in 2013 Emilia-Romagna (healthcare in Italy is devolved to the regional level) embarked on the development of a series of ‘health homes’ that provide services for all patients who don’t require hospitalisation for complex treatment, with services including psychiatry, dietetics, adult social care, and even beds for those requiring monitoring. This approach came to prominence during the covid-19 pandemic as it proved to be much more adaptable and stress resistant than centralised institutions and has proven far more accessible to Italy’s older adults who, not dissimilar to their English counterparts, are distributed across small towns and villages, and require ongoing and frequent, but non-urgent care for multiple conditions.  

United States

Similar approaches have been taken in the United States to improve services for the rural older population, with providers of health and long-term care services working to improve access to services, overcoming workforce shortages and making facilities ‘age-friendly’. In 2023, the New York based Commonwealth Fund published a report with various case study examples of these interventions. One such example, on a smaller scale than its Italian comparator, comes from Cochise County, Arizona, where one geriatrician has attempted to overcome limitations in Medicare’s funding for primary care provision for rural populations, by initially establishing a solo home-based independent living service. When reviewed by the University of Arizona, the programme was found to have resulted in reduced costs of participants attending specialist clinics, A&E and requiring hospitalisation. In 2017 the programme was expanded, via state grants, to collaborate with paramedics and the employees of local primary care clinics. This extension of the programme resulted in the reduction of 30-day re-hospitalisation rates among participants from 19 percent to 8 percent, with a subsequent push to establish the long-term sustainability of the programme through Medicaid reimbursement.  

Australia

In 2018 the Australian government introduced a $150 million grant programme – The Move It AUS - targeting inactive older Australians, with the ambition to increase participation in sport and activity. Since its launch, the initiatives funded by the programme have resulted in participants almost doubling their weekly physical activity, with the most disadvantaged communities increasing their activity from once a week to almost three times per week.  

Taking control

The CMO's report also highlights the importance of the state supporting individuals to take control of their health and take the necessary action to improve their chances of ageing healthily – such as healthy diet, physical activity and reducing nicotine and alcohol consumption. Examples of national and local initiatives can be found in almost all countries with an ageing society, including Italy and Japan, with the WHO’s Global Database of Age Friendly Practices a key repository of such initiatives.  

STAGE research programme

The CMO’s final call was to the medical and health science professions, highlighting that as adults live longer, but with increasing incidence of multi-morbidity, it will be crucial that general medical skills are retained alongside the development of deep specialisms, and that the medical research community increasingly reflects the incidence of multi-morbidity in their research, in a shift from researching single diseases in a siloed fashion.  

At present, this siloed, single disease approach is creating gaps in our knowledge of how to age healthily and in January this year the STAGE research programme was launched to overcome the resulting dearth of evidence on a European level. A partnership of 22 European organisations which includes universities, SMEs and NGOs (including Imperial College London and the University of Bristol) and funded to the tune of €20 million by Horizon Europe and UKRI funding, STAGE will take a life course approach to understand how the built environment, social conditions and the fundamental biology of ageing allow us to grow old healthily. Ultimately, the project will use increased levels of scientific evidence to co-develop resources with citizens, healthcare providers and policymakers that can inform policymaking on ageing and the creation of age-friendly urban developments.