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The HealthPad team extends its sincerest best wishes to you, your families and loved ones during these unprecedented times caused by the coronavirus CoVID-19 pandemic. We trust that you all stay safe and well.

To everyone working long and stressful hours on the frontline of healthcare; thank you for the sacrifices you’re making every day to help others in their moments of need. Your dedication, commitment and courage have our deepest gratitude and admiration.

Also, our heartfelt thanks go to all key workers who are unselfishly providing essential services, which are helping all of us through this coronavirus outbreak. Your resolution and mettle make a huge difference to our daily lives and we hold you in the highest esteem.

 

#coronavirus #CoVID-19  #frontlinehealthcareworkers #keyworkers #healthcare

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  • The coronavirus CoVID-19 has created the greatest health-cum-economic-cum-societal crisis in history and put unprecedented pressure on overstretched and unprepared healthcare systems
  • Before the coronavirus outbreak, primary care in England already was in crisis, fuelled by an aging population, a large and increasing demand for its services and a shrinking supply of health professionals
  • In 2019, before the outbreak, 75% of primary care doctors (GPs) across 540 clinics in England were over the age of 55 and nearing retirement and a large percentage of newly trained GPs were seeking employment abroad
  • Patients who could not get GP appointments used A&E departments as convenient drop-in clinics for minor ailments, which significantly increased healthcare costs and burden
  • For decades successive UK governments have tried in vain to transform the nation’s primary care services predicated upon face-to-face patient-doctor consultations
  • Several well-funded long-term national plans advocated increased digitization of some routine primary care services
  • But before the coronavirus outbreak only 1% of all primary care consultations were online
  • What these national plans could not achieve in decades appears to have been achieved in days by the UK’s NHS’s response to the coronavirus outbreak
  • Today, millions of patients in England are having face-to-face appointments with their GPs replaced by telephone or video consultations
  • Could CoVID-19 transform the UK’s traditional primary care model?

 

Introduction
 
The UK’s National Health Service’s (NHS) response to the coronavirus CoVID-19 outbreak might improve the nation’s crisis ridden primary care service. This became evident in March 2020, when the UK government ordered all citizens except key workers to stay at home. At the same time, NHS England announced its ‘battle plan’ for CoVID-19, which recommended that England’s 7,000 primary care clinics start conducting as many remote consultations as soon as possible.  In a matter of days, millions of patients had face-to-face appointments with their GP replaced by telephone or video consultations. If this shift to online consultations becomes permanent then the NHS’s response to the coronavirus would have achieved in days what well-funded national healthcare plans, such as the NHS Digital First Primary Care drive, could not achieve in decades.
 
Future healthcare is digital
 
For years, the benefits of online doctor-patient consultations have been advocated by  Devi Shetty, a world-renowned heart surgeon and  founder and chairman of Narayana Health, one India’s largest hospital groups.  According to Shetty, “The next biggest thing in healthcare is not going to be a ‘magic’ pill, a faster scanner or a new operation but information technology (IT). IT will dramatically change the way a health professional will interact with a patient. Every step of patient care will be informed by a protocol embedded in a smartphone. This will make healthcare safer for the patient and remove a lot of traditional dace-to-face healthcare activities and shift healthcare away from the clinic and into the home. Doctors and patients don't need to be together; they could be in their respective homes and effective consultations could take place online.” (see video below)
 
The next ‘big thing’ in healthcare
 
The coronavirus CoVID-19
 
In December 2019, initial reports of a new coronavirus - CoVID-19 - emerged  when patients from Wuhan, the sprawling capital city of China’s Hubei province, which has a population of some 11m, presented with pneumonia of unknown origin. By December 2019 the virus had spread to other countries and on 11th March 2020, the World Health Organization characterised the outbreak as a pandemic. CoVID-19 is an illness caused by a member of the coronavirus family that has never been encountered before but is believed to come from animals.There have been other coronaviruses. For example, severe acute respiratory syndrome (Sars) and Middle Eastern respiratory syndrome (Mers) are both caused by coronaviruses that came from animals. In 2002, Sars spread virtually unchecked to 37 countries, causing global panic, infecting more than 8,000 people and killing about 800, but it soon ran itself out. Mers first emerged in 2012, cases of which have been occurring sporadically since. Mers appears to be less easily passed from human to human, but has greater lethality, killing 35% of about 2,500 people who were infected. CoVID-19 is different to Sars and Mers in that the spectrum of disease is broader, with around 80% of cases leading to a mild infection. There may also be many people carrying the disease and displaying no symptoms, making it even harder to control. CoVID-19 affects your lungs and airways and can cause pneumonia. So, people with an  inflammatory lung disease that causes obstructed airflow from the lungs, such as asthma and chronic obstructive pulmonary disease (COPD), are particularly vulnerable; as are people with weak immune systems, which make them susceptible to infections that might be more severe or harder to treat. In January 2020, China’s national health commission confirmed human-to-human transmission of CoVID-19, and there have been such transmissions in countries throughout the world. Those who have fallen ill are reported to suffer a general feeling of being unwell, fever, dry cough, tiredness, breathing difficulties and a loss of taste and smell. In roughly 14% of cases the virus causes severe disease, including pneumonia and shortness of breath. In about 5% of patients it is critical, leading to respiratory failure, septic shock and multiple organ failure. As this is viral pneumonia, antibiotics are of no use. The antiviral drugs we have against flu will not work. Recovery depends on the strength of your immune system. Many of those who have died were already in poor health. Initially, scientists were challenged to accurately assess how dangerous CoVID-19 was because there were inadequate data. A challenge  to  collecting data was because of a shortage of tests and also because people who had contracted the coronavirus were emitting, or “shedding,” infectious viruses early in the progression of the illness; sometimes before they develop symptoms.

The 1918 Spanish Influenza 
remains the most devastating virus in modern history. The disease swept around the globe and is estimated to have caused between 50m and 100m deaths. A cousin of the same virus was also behind the 2009 swine flu outbreak, thought to have killed as many as 0.58m. Other major viral outbreaks include the Asian flu in 1957, which led to roughly 2m deaths and the Hong Kong flu, which killed 1m people 11 years later. 

 
In this Commentary
 
This Commentary is produced by HealthPad, which is an online health solutions company. (see below). We begin the Commentary by briefly describing the underlying reasons for the UK’s primary care crisis, which include: (i)  the changing and aging population and the consequent increased demand for healthcare, (ii) the shrinking supply of health professionals, and (iii) failing national initiatives to improve the provision of primary care. We then draw attention to some well funded national plans, whose intentions have been to harness the power of information and digital strategies to reform and improve primary care services in England. We also cite research, which suggests that these plans have failed. The Commentary briefly describes a number of innovative online healthcare solution companies, (HealthPad is one).  The majority of these are private initiatives, which have taken advantage of the UK’s high smartphone penetration rates and advanced wireless networks to enter the UK’s healthcare market with an intention to transform the sector. Notwithstanding, to-date the overall impact of these companies has been marginal, due in part, to the general resistance of private enterprises playing a significant role in England’s public NHS, which offers free healthcare to all citizens at the point of care. However, they represent a nascent UK online healthcare solutions market, which is well positioned to benefit from the nation’s response to the coronavirus outbreak, which has forced more primary care services to be delivered online. To increase their footprint these companies, which are largely driven by technology, will need to become more strategic and consolidate. And this will take time. We conclude the Commentary by looking to China and WeDoctor to understand the potential that online services can make to the delivery of healthcare in England. WeDoctor is a Chinese mobile app launched in 2010 to help patients book doctor appointments. Over the past decade it has added more functions to help unclog China’s fragmented and bureaucratic healthcare system and has become a US$5.5bn healthcare company, which connects some 210m registered users with 360,000 doctors.
 
UK’s primary care crisis
 
There are three drivers to the UK’s primary care crisis: (i) the changing and aging population, which increases the demand for healthcare, (ii)  the shrinking supply of healthcare professionals to a point where GP workloads are becoming unsafe, and (iii) failing national initiatives to improve the provision of primary care. Let us briefly describe these.
 
Changing and aging population
 
The UK’s population is changing and aging, which is fuelled by improvements in life expectancy and a decrease in fertility. According to the UK’s Office of National Statistics, in 2016, there were 12m UK residents aged 65 years and over, representing 18% of the total population. 25 years before, in 1991, there were 9m, accounting for 16% of the population. By 2040, it is projected that there will be an additional 8m people aged 65 years and over in the UK: a population roughly the size of present-day London, which will account for 25% of the total population.
 
A report by Deloitte,  a consultancy, suggests that as people age so their propensity for illness increases and more than a quarter of the UK’s population of some 66m have long-term chronic illnesses. This places a significant extra burden on the nation’s overstretched primary care services by utilizing about half of all GP appointments. Deloitte’s analysis is supported by a British Medical Association’s 2019 GP Patient Survey, which found that GP clinics are now caring for 0.72m more patients than they were in 2018. Findings of a 2016 report by the UK’s Royal College of General Practitioners (RGCP), suggest that GPs see 1.3m patients a day and do more than 370m consultations annually: 60m more than in 2010. A research study on GP productivity carried out by the King’s Fund and also published in 2016, suggested that between 2010 and 2015 the total number of telephone consultations increased by 15%, but still only accounted for 1% of all patient-doctor consultations.
 
Shrinking supply of GPs
 
As the UK’s population has grown and aged and the consequent demand for healthcare has increased, so there has been a sustained fall in the number of GPs. This  dynamic is described in a Nuffield Trust report published in May 2019, which confirms the findings of a joint report from the Institute of Fiscal Studies and the Health Foundation for the NHS Confederation, which concluded that, “The fall in GPs per person reflects insufficient numbers previously being trained and going on to join NHS England, failure to recruit enough from abroad and more GPs leaving for early retirement”. As to the future, a  2019 report by three leading think tanks - the Nuffield Trust, the Health Foundation and the King's Fund - predicts that GP shortages in England will almost triple to 7,000 by 2024. According to NHS Statistics, Facts and Figures, currently there are just over 42,000 GPs working in England, down by nearly 1,500 since 2016.
 
Failure to stop or slow these trends means today, primary care services in England struggle with staff shortages and a rising demand for care. A 2019 Pulse Magazine survey found that  GPs in England are seeing more patients than is safe. A probe undertaken by The Times in 2019 suggested that the  national shortage of GPs has left some surgeries with one permanent doctor caring for as many as 11,000 patients and one in 10 GPs are seeing up to 60 patients a day, double the number considered safe.
 
GPs across the UK work an average 11-hour day. In that time, they typically see patients for 8 hours and spend the other 3 on administrative tasks such as checking test results and reading letters sent by hospitals.  A 2019 British Medical Association survey found that more than 80% of GPs said the pressure to attend to multiple tasks at once meant they were unable to guarantee safe care, while 91% said excessive workload was the main reason the NHS was struggling to recruit enough staff. The situation has resulted in patients having to wait longer - up to three weeks - for a GP consultation. It seems reasonable to suggest that GPs with too many patients and using traditional face-to-face delivery methods will fail in their duty of care, which obliges them to inform patients about their health and reach shared clinical decisions about treatments. This requires that patients understand their condition/s and are well informed. In many cases, a 10-minute  face-to-face GP consultation might not be the best way to achieve this.
 
Failing national initiatives to improve primary care
 
Subsequent UK governments have struggled to reduce the primary care crisis with well funded national plans. In 2019, the British Medical Journal published findings of a survey to report UK GPs’ views and experience of national healthcare initiatives introduced in England to address the workforce crisis in general practice. The survey was conducted in the same region as a similar survey undertaken in 2014. This allows for a comparative analysis to see how GPs’ views have changed over time. Findings confirm that primary care in England remains in crisis and suggest that numerous national initiatives to improve general practice are perceived by GPs as, “reactive in approach”. To reduce the primary care crisis, respondents suggested, “more GPs and better education of the public". 
 
The UK’s NHS
 
Healthcare in the UK is mainly provided by the National Health Service (NHS), which is a vast public institution funded largely from general taxation to the tune of some £134bn (US$161bn) a year. Created in 1948, the NHS  provides free health services at the point of care for everyone living in the UK and has become the largest single payer health system in the world, and the biggest employer in the UK with 1.2m full time equivalent (FTE) workers, which is the fifth-largest workforce in the world. NHS England is a vast bureaucratic and fragmented organisation, which has proven difficult to change. Private provision of NHS services has always been controversial, even though some services, such as dentistry, optical care and pharmacy, have been provided by the private sector to the NHS for decades and most GP practices are private partnerships. It is challenging to determine how much the NHS spends each year on the private sector because central bodies do not hold detailed information on individual contracts with service providers, especially where these contracts may cover relatively small amounts of activity and spending. Notwithstanding, estimates suggest the share of the NHS’s total revenue budget that is spent on private providers is about 7.3%. 

National plans to improve the NHS
 
The planning and authorising of NHS services is the responsibility of regional Clinical Commissioning Groups (CCGs). Although CCGs are constantly changing because of mergers, as of 2019, there were 191 CCGs in England supporting about 7,000 primary care clinics, some 42,000 GPs and about 15,800 FTE nurses who work in GP clinics, and 1,257 hospitals, which include NHS Trust-managed hospitals and private hospitals that provide services to the NHS. In total, the NHS employs around 150,000 doctors  and over 320,000 nurses and midwives.
 
Successive UK governments have been aware of the impact of technological advances, changing healthcare needs and societal developments on healthcare and have introduced a succession of well-funded national plans to change and improve the NHS. For example, in June 2018, the UK’s Prime Minister announced a new five-year funding settlement for the NHS that amounted to an extra £20.5bn (US$25.2bn) between 2019 and 2024, which represents a 3.4% real average annual increase.
 
NHS long term plan to transform primary care
 
To unlock the funding, national bodies were asked to develop a long-term plan to help the NHS cut costs and improve services. The suggested plan articulated the need to integrate care in order to meet the needs of a changing population and was in line with the Forward View, a planning document published in 2014 and the General practice forward view,which was first published in 2016 and updated in subsequent years. The long-term plan committed the government to an extra £2.4bn (US$3bn) a year to speed up the transformation of primary care and suggested GP clinics join together to form networks typically covering 30,000 to 50,000 patients and provide them with multidisciplinary integrated care. The plan also suggested ‘significant changes’ in the existing performance management and payment of NHS GPs [the Quality and Outcomes Framework (QOF)] in order to encourage more personalised care.
 
NHS long term plans and private online healthcare solution companies have delivered little change
 
Three of five principal objectives of the latest NHS long term plan are to: (i) “give people more control over their own health and the care they receive”;  (ii) “increase the contribution to tackling some of the most significant causes of ill health, including new action to help people stop smoking, overcome drinking problems and avoid Type 2 diabetes”, and (iii) “provide more convenient access to services and health information for patients”.

The plan emphasises the importance of developing digital services, and recommends that within five years, all patients should be able to access GP consultations via a telephone or online. This goal is supported by NHS Digital, which is the national information and technology partner to the UK’s health and social care system. Its mission is to harness the power of information and technology to improve healthcare. Over the past decade there has been an increasing number of innovative online private  healthcare solutions companies entering the market. (see below). Notwithstanding, these and the NHS’s well-funded national plans, have failed to dent the primary care crisis by slowing the vast and escalating demand for healthcare and reversing the shrinking supply of healthcare professionals. So, for the past two decades at least, the NHS has tended to operate on the cusp of a crisis.
 
The death of distance
 
According to Deloitte, the UK has more than 90% smartphone penetration. The main driver of high smartphone adoption rates is the take-up among older age groups. By 2023 smartphone ownership among 55-to-75-year-olds will reach 85% in the UK, and the difference in smartphone penetration by age will disappear. Further, the UK’s smartphone market has seen a greater variety of choice of models and the introduction of faster and more reliable wireless networks. This has benefited the online private healthcare solution companies, which have entered the UK market to provide varying degrees of qualified online healthcare information, consultations, networking opportunities, triage and Q&A. According to Shetty, “A doctor only needs to touch a patient if s/he is going to operate on that patient. If a doctor doesn’t need to operate, a doctor-patient consultation can take place remotely. For a patient-doctor communication distance doesn’t matter.” (see video below)
 

 A doctor only needs to touch a patient if s/he is going to operate on that patient
 
Innovative online healthcare solution enterprises
 
The new online healthcare solution enterprises are a combination of private, public and charitable initiatives, which are well positioned to contribute to the transformation of the UK’s traditional primary care model and include: Babylon Health, which provides remote consultations with doctors and healthcare professionals via text and video; BioBeatsa workplace wellbeing platform designed to empower and improve mental health; Docly, a digital messaging healthcare service, which is a spin-off of Min Doktor; Doctorlink, which partners with payers, healthcare professionals and pharmacists to provide a 24-7 platform for NHS patients to assess symptoms; DrDoctor, a patient engagement platform, which enables patients to book, change and cancel their appointments; EggPlant, a software testing and monitoring company, which helps to streamline patient activities; Dr Fox, an online primary care clinic and pharmacy service; Gogodoc, an online GP video consultation service with possible follow-up home visits; Healthcare Communications UK, which provides appointment management software and patient experience surveys; HealthPad, an online platform that manages and distributes healthcare video information between health providers and patients in order to improve outcomes and cut costs, and has accrued a proprietary content library of over 6,000 short videos contributed by leading clinicians that address peoples FAQs across some 30 therapeutic pathways, (HealthPad is the publisher of this Commentary).  HealthTalksOnline, an events and community portal for health; HealthUnlocked, a social networking service that offers peer support to help people manage their health; Healum provides healthcare professionals with a software, which enables them to support and motivate their patients to better manage their conditions; LIVI, provides GP video consultations; Medshra platform for medical professionals to discover, discuss and share clinical cases and medical images; Microtest Health, a health informatics company that provides practice management systems for NHS GP surgeries. MSKnote Limited creates clinical applications for healthcare professionals and patients with a focus on musculoskeletal conditions; MyWay Digital Health provides advice and solutions to help patients better manage diabetes; NHS.uk/conditions provides online text-based information and advice about medical conditions; NHS 111, a free-to-call medical helpline; the Now Healthcare Group, a GP video consultation platform and tele-pharmacy; Patient Access, which started by enabling patients to book GP appointments online and order repeat prescriptions and has evolved to allow patients to connect with their GPs remotely and access their medical records online; Patientinfo provides patients and health professionals with online health information. PatientAccess and Patientinfo are subsidiaries of EMIS Health, a leading supplier of  software used by NHS England; Patients Know Best, a social enterprise, which provides patients with access to their medical records and information about treatments; PatientsLikeMe, an online service that helps patients find people with similar health conditions in order to take actions that are expected to improve outcomes; Push Doctor, an online video consultation service; SaySo Medical is a digital communications agency, which connects people in order to improve their health; SystmOne, a centrally hosted computer system that provides primary care professionals with electronic patient health records in real time at the point of care; uMotif, a platform that captures electronic patient-reported outcomes data across a range of conditions and works with pharmaceutical companies to measure patient’s health, outcomes and experience; Unminda workplace mental health platform designed to  empower organisations and employees to improve their mental wellbeing; Visiba Care, a digital solutions company, which provides communication and administration software for healthcare practices; VisionHealth provides NHS primary care professionals with software solutions; VisualDX provides clinical decision support systems to enhance diagnoses and therapeutic decisions in order to improve patient safety; WebMD, an online publisher of healthcare news and information, and Zava, an online GP and pharmacy service.
 
 Technologically heavy and strategically light
 
Despite a significant number of online healthcare solution enterprises entering the market and the fact that some provide services to millions of people in the UK, this market segment is in its infancy and fragmented. All the initiatives mentioned above have been advantaged by the NHS’s response to the coronavirus outbreak. Notwithstanding, to permanently increase their footprint and significantly influence primary care in England, barriers to private enterprises and to online services will need to be reduced; and private companies in this segment will need to act more strategically and consolidate.
 
Most of these online healthcare service providers are technologically heavy and strategically light. For private companies in this market to grow and increase their influence on the NHS they will need to increase their focus on profitability and scale, which will require them to become more strategic and develop merger-integration skills. To become a dominant player, a company will have to successfully consolidate. Speed and merger competence are paramount. Companies that capture critical ground early and move up the consolidation curve the fastest will be successful. Enterprises that are slow to consolidate will become acquisition targets and disappear. Companies that stay out of the consolidation contest altogether will not survive.

A Chinese example
 
History has shown that many short-term emergency measures have a tendency to  become permanent fixtures. Thus, the UK’s response to the coronavirus CoVID-19 outbreak might permanently reduce the barriers to moving routine primary care tasks to innovative private online enterprises.
 
In an attempt to fully appreciate the potential of increasing online primary healthcare services in England, consider WeDoctor, a Chinese mobile app launched in 2010 by artificial intelligence expert Jerry Liao. Originally called Guahao (Mandarin for “booking”), WeDoctor started as a simple booking platform that made it easier for patients to make appointments with doctors. From these humble beginnings WeDoctor grew by adding extra functions such as reminders for regular medical checks, screening, prescriptions and online diagnoses and consultations. This helped to unclog China’s fragmented and bureaucratic healthcare system and made quality healthcare more accessible to the average person.
 
WeDoctor secured backing from Tencent Holdings, a Chinese multinational conglomerate, Sequoia Capital, the Goldman Sachs Group and the insurer AIA Group. In 2018, the company raised US$0.5bn in a private financing round at a valuation of US$5.5bn. Today, WeDoctor has more than 210m registered users mainly in China for its online appointment booking, prescription and diagnosis services and is linked to about 3,200 hospitals and 360,000 doctors. In March 2020, at the height of the CoVID-19 pandemic, it was reported that, in the latter half of 2020, WeDoctor intends to raise HK$1bn in an IPO on the Hong Kong Stock Exchange at a valuation of HK$10bn.
 
Although NHS England is much smaller than China’s healthcare provision, it is similarly fragmented and bureaucratic. The UK online solutions enterprises described in this Commentary have significant potential simply by helping to reduce GPs large and increasing burden of administration while increasing the connectivity between patients and GPs. This will help GPs to concentrate on what they have been trained to do and improve healthcare for people in most need.
 
Takeaways
 
Over the past two decades, legacy primary care systems and attitudes in the UK have slowed the uptake of online healthcare solutions. Notwithstanding, the NHS’s response to the coronavirus CoVID-19 outbreak might prove to have helped to transform the UK’s traditional face-to-face primary care model by making GPs deliver some of their services online. In a recent interview with the New York Times, Dr Bruce Aylward, Assistant Director-General of the World Health Organization, stressed how the Chinese had responded to the coronavirus outbreak by significantly increasing the amount of medical care the nation provides online.  In light of the discussion in this Commentary, be minded that in Mandarin the word “crisis” is denoted by two characters: 危机, one means ‘disaster’ and the other means ‘opportunity’.
 
 
#coronavirus #coVID-19 #NHSEngland #NHS #pandemic #primarycarecrisis #ChinaWeDoctor #WeDoctor #DigitalHealthcare 
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  • International study shows that while British cancer survival has improved over the past 20 years the UK’s cancer survival rates lag behind the European average in 9 out of 10 cancers
  • 10,000 cancer deaths could be prevented each year if the UK hit the European average
  • Analysis shows that some British cancer survival rates trail that of developing nations such as Jordan, Puerto Rico, Algeria and Ecuador
  • Since the inception of the NHS in 1948 policy makers and clinicians have viewed the problem as the NHS being under staffed and underfunded
  • But the answers to the cancer care challenge in the UK are not that straight forward
  • The world has changed and is changing while policy responses to challenges have remained static
 
UK cancer care lags that of other European nations: reasons and solutions
Part 1

 

This Commentary is in 2 parts
Part 1 focusses on cancer care in the UK, but much of its substance is relevant to other advanced nations with aging populations and large and escalating incidence rates and costs of cancer. Before drilling down into cancer care in Britain we briefly describe the etiology of cancer, the epidemiology of the condition as it relates to the UK and other wealthy nations, mention immunotherapy as indicative of evolving and significant new therapies, which give hope to cancer sufferers. We then describe the CONCORD-3 study reported in The Lancet in 2018. This is a highly regarded and significant international study, whose findings are widely recognised as the “gold standard” of comparative cancer care. It reports that although 5-year cancer survival rates (the internationally accepted indicator of cancer care) have improved in Britain over the past 2 decades, the UK is still trailing that of most large European countries. We conclude Part 1 with a brief description of UK initiatives to close its cancer-gap with other European countries.
 
Part 2, which will be published in 2 weeks, is an analysis of the cancer-gap between Britain and other European countries. We suggest that for decades, healthcare providers, policy makers and leading clinicians have suggested that the UK cancer-care gap is because of the lack of funding and the lack of healthcare professionals. Since the inception of the NHS in 1948 a policy mantra of “more” has taken root among policy makers, providers and clinicians: predominantly, “more money”, “more staff”, and “the government should do more”. We suggest that, over the lifetime of NHS England, a combination of Britain’s economic growth, its historical ties with Commonwealth countries and, since 1973, the reduction of barriers to the flow of labour between European countries, has given UK policy makers a convenient “get-out-of-jail-card” because they could always provide more money and more staff. Over the past 2 decades, this option has become less and less effective because of a combination of the slowdown of world economic growth, the rise of emerging economies such as India, and more recently Brexit.
 
We conclude with some thoughts about why a significant cancer care gap has opened between the UK and other European nations, and briefly describe some UK initiatives to close the gap. We suggest that the world has changed quicker than the thinking of policy makers and quicker than structural changes in the UK’s healthcare system. Improving cancer care in the Britain will require more than inertia projects. It will require more innovation, more long-term planning, more courage from policy makers, more focus on actual patients’ needs rather than what we are simply able to provide. Since 1948, the healthcare baton in the UK has been with an establishment comprised of policy makers, providers and leading clinicians. Over the past 70 years this establishment has become increasingly entrenched in past and narrow policy solutions. It has failed because the world has changed while It has remained static. It is time that the healthcare baton is passed to people with less self-interest at stake, who are less wedded to the past, and understand the new and rapidly evolving global healthcare ecosystem.

 
The UK’s cancer challenge

While British policy makers and health providers appear keen to stress that trends in the 5-year cancer survival rates (the internationally accepted measure for progress against cancer) have improved over the past 20 years, there is an element of “economy with the truth” in what they say. The UK is being left behind by significant advances in cancer survival rates in other nations. Treatment for 3.7m UK cancer patients diagnosed since 2000 is struggling to progress, especially for people diagnosed with brain, stomach and blood cancers. Further, your chances of dying after being diagnosed with prostate, pancreatic and lung cancer in Britain is significantly higher than in any other large European nation. This is according to CONCORD-3, the largest ever international cancer study reported in the January 2018 edition of the The Lancet.
 

The emperor of all maladies
 
Cancer is the uncontrolled proliferation of cells. In his 2010 Pulitzer Prize winning book, ‘The Emperor of All MaladiesSiddhartha Mukherjee, professor of oncology at Columbia University Medical School in New York describes cancer cells as, "bloated and grotesque, with a dilated nucleus and a thin rim of cytoplasm, the sign of a cell whose very soul has been co-opted to divide and to keep dividing with pathological, monomaniacal purpose." Cancer occurs when a cell starts to divide repeatedly, producing abnormal copies of itself, rather than dividing occasionally just to replace worn out cells. If the immune system fails to destroy these cells, they continue to reproduce and invade and destroy surrounding healthy tissue. A number of forces can trigger these cell divisions, such as certain chemicals (carcinogens), chronic inflammation, hormones, lack of exercise, obesity, radiation, smoking, and viruses. ‘The emperor of all maladies’ is not just one disease. There are over 200 different types of cancer, each with its own methods of diagnosis and treatment. Most cancers are named after the organ or type of cell in which they start: for example, cancer that begins in the breast is called breast cancer. Cancer sometimes begins in one part of the body and can spread to other parts of the body through the blood and lymph systems This process is known as metastasis.
 
A practitioners’ views

According to Whitfield Growdon, an oncological surgeon at the Massachusetts General Hospital and Professor of Obstetrics, Gynaecology and Reproductive Biology at the Harvard University Medical School, Cancer is a complicated set of events, which can happen in any cell in your body. Your body is comprised of tiny cells, which have the ability to grow, stop growing and to re-model, which is necessary to do all the functions that are required for living. But every cell in nature has the potential to lose control of its growth. It is this uncontrolled growth of an individual cell, which we call cancer. Cells can grow, they can spread, and if the cell growth is uncontrolled it can invade other tissues, which can lead to you losing the ability to perform vital functions that are required for your life,” see video below:
 
 
Epidemiology

There is scarcely a family in the developed world unaffected by cancer. But, this has not always been the case. Cancer only became a leading cause of death when we began to live long enough to get it. In 1911, the prevalence of cancer was low compared to what it is today. Then life expectancy in the UK was 51.5 and 52.2 years for males and females respectively. Similarly, in the US, at the beginning of the 20th century, life expectancy at birth was 47.3 years. Today, the median life expectancy in the UK is 81.6 and in the US 78.7.  Significantly, the age at diagnosis for prostate cancer today is 67 and 61 for breast cancer. Approximately 12% of the UK population are aged 70 and above and account for 50.2% of the total cancers registered in 2014. 87% of all cancers in the US are diagnosed in people over 50.
Late diagnoses
 
Every 2 minutes in Britain someone is diagnosed with cancer, and almost 50% of these are diagnosed at a late stage. Every year in the UK there are more than 360,000 new cancer cases, which equates to nearly 990 newly diagnosed cancers every day. Taking a closer look at the UK data, we notice that since the early 1990s, incidence rates for all cancers combined have increased by 12%. The increase is larger in females than males. Over the past decade, incidence rates for all cancers combined have increased by 7%, with a larger increase in females: 8% as opposed to 3% in males. Over the next 2 decades, incidence rates for all cancers combined in Britain are projected to rise by 2%. Incidence rates in the UK are lower than in most European nations in males, but higher in females.

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Can AI reduce medical misdiagnosis?
 
 
Incidence rates of specific cancers in the UK

In 2015, breast, prostate, lung and bowel cancers together account for some 53% of all new cancer cases in the UK. Over the past decade, thyroid and liver cancers have shown the fastest increases in incidence in both males and females.  Incidence rates of melanoma, small intestine, and kidney cancers have also increased markedly in males over the past 10 years. Over the same period, Incidence rates of kidney, melanoma, and head and neck cancers have also increased markedly in females. Despite the rise in incidence rates, in recent years mortality rates from cancer in England and Wales have fallen. Between 1994 and 2013, mortality rates from cancer for males and females fell by 30% and 22% respectively.
 
New therapies: immunotherapy/biologics
 
What gives hope to people living with cancer is partly new and innovative therapies. Over the past few decades immunotherapy, also called biological therapy, is an evolving treatment, which has become a significant part of the management of certain cancers. Immunotherapy is any form of treatment that uses the body's natural abilities that constitute the immune system to fight infection and disease or to protect the body from some of the side effects of treatment. This may be achieved either by stimulating your own immune system to attack cancer cells specifically, or by giving your immune system components to boost your body’s immune system in a general way. Immunotherapy works better for some types of cancer than for others. It is used by itself for some cancers, but for others it seems to work better when used with other types of therapy.

According to Hani Gabra, Professor of Medical Oncology at Imperial College, London, and Chief Physician Scientist and Head of the Oncology Discovery Unit at AstraZeneca, UK, “Biological therapies are treatments gaining importance globally as we progress with the management of cancer. Understanding the biology of cancer has enabled us to understand the targets that go wrong in those cancers. We have successfully used many treatments that hit directly those cancer targets in order to inhibit or “switch-off” the cancers. These biological therapies either can be useful on their own or more commonly, combined with standard treatments such as chemotherapy, surgery and radiotherapy.” See video below:

 
 
Why is the CONCORD-3 study significant?

CONCORD-3 reported in a 2018 edition of The Lancet is an international scientific collaboration designed to monitor trends in the survival of cancer patients throughout the world, and involves 600 investigators in over 300 institutions in 71 countries. The study compares the overall effectiveness of health systems to provide care for 18 cancer types, which collectively represent 75% of all cancers diagnosed worldwide. The study is specifically designed to: (i) monitor trends in the survival rates of cancer patients world-wide to 2014, (ii) inform national and global policy on cancer control, and (iii) enable a comparative evaluation of the effectiveness of health systems in providing cancer care. The study is the third of its kind and supports the over-arching goal of the 2013 World Cancer Declaration, to achieve “major reductions in premature deaths from cancer, and improvements in quality of life and cancer survival”.
 
CONCORD’s evidence base
 
The evidence base of the CONCORD-3 study is significant and is predicated upon the clinical records of 37.5m patients diagnosed with cancer between 2000 and 2014. Data are provided in over 4,700 data sets by 322 population-based cancer registries from 71 countries and territories; 47 of which provided data with 100% population coverage. The analysis is centralised, based upon tight protocols and standardised quality controls, and employs cutting-edge methods. The 71 participating countries and territories are home to a combined population of 4.9bn (UN figures for 2014). This represents 67% of the world's population (7.3bn). The 322 participating cancer registries contributed data on all cancer patients diagnosed among their combined resident populations of almost 1bn people (989m), which is 20% of the combined population of those countries. CONCORD-3 contributes to the evidence base for global policy on cancer management and control.
 
CONCORD-3 data base drives national and global policies on cancer control

Despite the care taken of the data management processes, no study is perfect, and It is reasonable to assume that a study the size of CONCORD-3 will have weaknesses. Notwithstanding, the study is “best in class” and its results are comparable within the limits of data quality. The international trends in cancer patient survival reported in the study reflect the comparative effectiveness of health systems in managing cancer patients. The findings of CONCORD-3 form part of the evidence that drives national and international policies on cancer control. For example, the International Atomic Energy Agency use the findings in its campaign to highlight global inequalities in cancer survival. The Organisation for Economic Co-operation and Development (OEDC) use the results of CONCORD as indicators of the quality of healthcare in 48 countries in its Health at a Glance publications, and the European Union use the findings in its Country Health Profiles for EU Member States.
 
Overall cancer survival is improving

Overall findings of the CONCORD-3 study suggest that the prospects for cancer patients are improving throughout the world and survival rates are increasing for some lethal cancers. Several cancers show significant increases in 5-year survival, including breast (80% to 86%), prostate (82% to 89%), rectum (55% to 63%) and colon (52% to 60%); reflecting better cancer management. Notwithstanding, there are significant differences in cancer outcomes between nations.
 
UK has worse cancer survival rates compared with other European nations

Despite the fact that increasingly more people are surviving cancer, British adult cancer patients continue to have worse survival rates after 5 years compared to the European average in 9 out of 10 cancers. Research comparing 29 countries shows survival rates in Sweden are almost 33% higher than in the UK. For ovarian cancer, which affects 7,400 British women each year, the UK comes 45th out of 59, with only 36.2% sufferers surviving 5 years. Some countries achieve nearly double this survival rate. When the largest 5 European countries - Germany, France, Britain, Italy and Spain - were compared for the 3 most common cancers, Britain came bottom for 2 of them. Britain’s survival rates were worse than the other 4 European nations for lung and prostate cancer, and second worst for breast cancer. With regard to pancreatic cancer British patients had just a 6.8% chance of survival, compared to 7.7% in Spain, 8.6% in France, 9.2% in Italy and 10.7% in Germany. This puts the UK 47th out of the 56 countries that had full data for this cancer. Studies suggest 10,000 deaths could be prevented each year if the UK were to keep up with the European average. The UK only exceeds the European average in melanoma. See table below.
 
 
Takeaways

Here we have introduced and described the findings of CONCORD-3, which suggests the UK lags significantly other European nations with regard to cancer survival rates.  This sets the scene for part 2 of this Commentary, which will briefly describe some of the UK’s cancer initiatives to reduce premature death from cancer and enhance the care of people living with the disorder. Much has been achieved and over the past 2 decades, cancer mortality rates in the UK have been significantly reduced. Notwithstanding, more innovative and effective policies, which address the actual needs of patients rather than provide “more money and more staff” will be required if the UK is to reduce the cancer-care gap.
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  • International study shows that while British cancer survival has improved over the past 20 years the UK’s cancer survival rates lag behind the European average in 9 out of 10 cancers
  • 10,000 cancer deaths could be prevented each year if the UK hit the European average
  • Analysis shows that some British cancer survival rates trail that of developing nations such as Jordan, Puerto Rico, Algeria and Ecuador
  • Since the inception of the NHS in 1948 policy makers and clinicians have viewed the problem as the NHS being under staffed and underfunded
  • But the answers to the cancer care challenge in the UK is not straightforward
  • The global healthcare ecosystem has changed and is continuing to change faster than national policy responses
  • The UK’s cancer care challenges require more innovation not just more reports, more money and more staff
  
UK cancer care lags that of other European nations: reasons and solutions
Part 2

Part 1 of this Commentary  described the CONCORD-3 study reported in the January 2018 edition of The Lancet, which suggested that although 5-year cancer survival rates (the internationally accepted indicator of cancer care) have improved in Britain over the past 2 decades, the UK lags behind most large European countries in cancer care.
 
This is part 2 of the Commentary, which begins by describing some of the UK’s initiatives over the past 20 years to improve cancer mortality rates, speed up diagnoses and enhance the quality of cancer care for people living with the disease. All arrive at similar conclusions: that UK cancer care strategies have reduced cancer mortality rates over time, but there is still more that can be done. They do not compare Britain’s cancer mortality rates with other European nations. Notwithstanding, there appears to be some consensus among leading clinicians and policy makers that the UK’s failure to close the cancer care gap with other European nations is because NHS England is underfunded and understaffed. While this explanation might provide part of the answer it does not tell the whole story. The answer might be less to do with extra funds and extra staff, and more to do with the fact that the global healthcare ecosystem has changed quicker than the thinking of UK policy makers and quicker than structural changes to NHS England. To the extent that this is the case, improving cancer care in Britain may not require more money and more staff, but more innovation and more focus on actual patients’ needs rather than on what policy makers can provide politically.
 
National cancer initiatives: resolving patients’ needs or perpetuating the status quo?
 
Over the past 20 years the UK government has commissioned a number of strategies, taskforces and reports all aimed at improving cancer diagnoses, treatments, and management, and enhancing the quality of life of people living with the disease and reducing premature deaths. In 2000, NHS England launched a National Cancer Plan, which was, “committed to addressing health inequalities through setting new national and local targets for the reduction of smoking rates, the setting of new targets for the reduction of waiting times, the establishment of national standards for cancer services, and investment in specialist palliative care, the expansion and development of the cancer workforce, cancer facilities, and cancer research.” This was followed in 2007 by the Cancer Reform Strategy, which was designed to build, “on the progress made since the publication of the NHS Cancer Plan in 2000, and sets a clear direction for cancer services for the next five years. It shows how by 2012 our cancer services can and should become among the best in the world.”

 
Independent cancer taskforce
 
In January 2015, an Independent Cancer Taskforce was launched by NHS England, “to develop a five-year action plan for cancer services that will improve survival rates and save thousands of lives.” The NHS established the taskforce on behalf of the Care Quality Commission, Health Education England, Monitor,  Public Health England and theTrust Development Authority. The taskforce was chaired by Harpal Kumar, then, CEO of Cancer Research UK, and was comprised of representatives from a cross section of the cancer and healthcare communities.

In July 2015, the Independent Cancer Taskforce published a report entitled: Achieving world-class cancer outcomes: a strategy for England 2015-2020. The report identified key elements of a world class cancer care system and suggested that this is what British cancer patients should expect and what NHS England should aim to provide by 2020. The strategy included, “effective prevention (so that people do not get cancer at all if possible); prompt and accurate diagnosis; informed choice and convenient care; access to the best effective treatments with minimal side effects; always knowing what is going on and why; holistic support; and the best possible quality of life, including at the end of life.” According to the report such a strategy would achieve world-class cancer outcomes and save 30,000 lives a year by 2020.

 
2nd National Cancer Strategy

Two months before the publication of the Taskforce’s report, in May 2015, the UK government launched a National Cancer Strategy. This was its second 5-year program to implement a world-class cancer strategy designed to increase the prevention of cancer, speed up its diagnosis, and improve the experience of people with the condition. It suggested that rapid progress had been made in a number of key and high-impact areas, and stated that, “if someone is diagnosed with cancer, they should be able to live for as long and as well as is possible, regardless of their background or where they live. They should be diagnosed early, so that the most effective treatments are available to them, and they should get the highest quality care and support from the moment cancer is suspected.”

Report of the National Cancer Transformational Board
 
In December 2016, a National Cancer Transformation Board, led by Cally Palmer, the Cancer Director for England, published a number of specific steps to improve cancer care, and reported that over the past decade, 5-year cancer survival rates in the UK have improved across all main cancers, and at the end of 2016, cancer survival rates in Britain were at a record high with 7,000 more people surviving cancer compared to 2013.
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Interim report of the 2nd National Cancer Strategy

In October 2017, NHS England published an interim report of its 2015 National Cancer Strategy, which suggested that, “Survival rates for cancer have never been higher, and overall patients report a very good experience of care. However, we know there is more we can do to ensure patients are diagnosed early and quickly and that early diagnosis has a major impact on survival. We also know that patients continue to experience variation in their access to care, and this needs to be addressed. Early diagnosis, fast diagnosis and equity of access to treatment and care are central to the ‘National Cancer Programme’ and the transformation of services we want to achieve by 2020-21.” According to an NHS spokesperson, “Figures show that cancer survival is now at an all-time high in England, as a result of better access to screening, funding for effective new treatments and diagnostics and continued action to reduce smoking.”
 
Why cancer mortality rates in Britain lag other European countries
 
If you look at similar European countries the proportion of GDP (Gross Domestic Product) the UK has spent on health in the last 10 to 15 years is low and has increased less than the others,” says Michael Coleman, Professor of Epidemiology and Vital Statistics at the London School of Hygiene & Tropical Medicine and co-author of the international cancer study reported in the March 2018 edition of The Lancet. UK healthcare spending fell from 8.8% of GDP in 2009 - when it averaged 10.1% in leading European countries - to 7.3% in 2014-15. “This difference between the likes of Germany and France is likely to explain some of what we are seeing,” says Coleman and he also suggests that, “The number of medical specialists who deal with these diseases [cancer] tends to be low compared to other similar countries,” [Our emphasis]. Let us examine the relative European healthcare spends and levels of staffing in NHS England.
 
Comparative GDP spends on healthcare

The OECD’s November 2016 Health at a Glance report suggests that in 2013 (the latest year for which data have been published) the UK spent 8.5% of its GDP on public and private healthcare. And, a 2016 report from the King’s Fund, a charity, suggests that projected spending on NHS England as a proportion of the UK’s GDP in 2020-21 is 6.6%, just 0.3% above what it was in 2000.
 
Challenges comparing healthcare spends

Notwithstanding, linking cancer mortality rates to the proportion of GDP nations spend on healthcare is not straightforward. This is partly because of, (i) different nations have different sources of healthcare funding, and (ii) a person’s purchasing power is different in different countries. Fluctuations in relative national economic growth make such comparisons over time and between nations challenging. According to The Health Foundation, a higher percentage of UKhealthcare spending is publicly funded compared to other European countries. For example, “In 2012, publicly funded spending accounted for 84.0% of UK healthcare spending. This is the third highest level in the EU-15 (average: 76.5%).  In 2012, UK public spending on healthcare was slightly higher than the EU-15 average of 7.6% of GDP”. Between 2008 and 2012 the average annual change in healthcare spending per person was lower for the UK than most EU-15 countries, which was largely the result of Greece, Ireland and Portugal making significant cuts to their healthcare spending. The rising prevalence of cancer and other chronic long-term diseases, is a significant driver of increased healthcare costs. According to OEDC data, UK spend on chronic lifetime conditions is similar to the European average. However, the UK spends less than other European countries on pharmaceuticals and out-of-pocket payments. Further, on average, UK patients spend less time in hospital and generally use fewer resources (measured in terms of staff and beds).
 
A 2017 paper published by the Nuffield Trust suggests that, when taking into consideration different sources of healthcare funding and purchasing power parity, the UK’s healthcare spend actually might be keeping up with that of other European nations.
 
NHS “dangerously” understaffed

Let us now consider staffing. In 2017, The Royal College of Emergency Medicine reported that primary and emergency care doctors, which are crucial for the early diagnosis of cancer, were experiencing significant recruitment and retention challenges. According to 2018 figures, NHS England has nearly 100,000 jobs unfilled, which include 35,000 nursing posts and 10,000 doctor vacancies.  The total vacancies represent 1 in 12 of all NHS posts, which is enough to staff about 10 large hospitals. Further, the high number of unfilled NHS posts coincides with 0.25m more people visiting A&E in the first quarter of 2018 than in the equivalent period in 2016. According to Saffron Cordery, the director of policy and strategy for NHS ProvidersThese figures show how the NHS has been pushed to the limit. Despite working at full stretch with around 100,000 vacancies and a real risk of staff burnout, and despite treating 6% more emergency patients, year on year in December (2017), trusts cannot close the gap between what they are being asked to deliver and the funding available”. A February 2018 finance report suggests that NHS England is heading for a £931m deficit in 2018 and is "dangerously" understaffed. This year-on-year deficit was revised to a projected £1.3bn shortfall, which is 88% worse than planned.
 
Reasons for shortages of health professionals

The NHS staffing challenges are aggravated by the fact that British trainee primary care doctors are dwindling, newly qualified doctors are moving abroad, and experienced doctors are retiring early. Over the lifetime of NHS England, the UK has trained significantly fewer healthcare professionals than it needed, and the supply of qualified young British people has consistently outstripped the number of places in medical schools and nurse training. According to data from the General Medical Council (GMC), between 2008 and 2014 an average of 2,852 certificates were issued annually to enable British doctors to work abroad. A 2015 British Medical Association (BMA) poll of 15,560 primary care doctors, found that 34% of respondents plan to retire early because of high stress levels, increasing workloads, and too little time with patients.  Further, it is estimated that 10% of doctors and 7% of nurses employed by NHS England are nationals of other European countries. The uncertainties of Brexit (a term for the potential departure of the UK from the EU) add to NHS’s recruitment and retention challenges of healthcare professionals. According to a 2017 Health Foundation Report, in 2016, more than 2,700 nurses left the NHS; an increase of 68% since 2014.
 
UK policy approach to healthcare shortages has not changed

Notwithstanding, NHS staff shortages are not new. In the 1960s, NHS hospitals in Britain introduced mass recruitment from Commonwealth countries, and this has influenced staffing policies ever since. Being able to recruit doctors and nurses from foreign countries provided NHS England with an “easy” solution to staff shortages. However, over the past 2 decades the global healthcare ecosystem has changed significantly, while UK healthcare staffing policies have not kept pace with the changes. Today, there is a substantial gap globally in the supply and demand of healthcare professionals. Countries such as India, which traditionally could be relied upon to provide healthcare professionals for NHS England, have changed and the pool of potential Indian recruits have shrunk. Over the past 2 decades, the Indian economy has improved and the nation has developed a number of world-class hospital groups such as Apollo, Fortis and Narayana Health, which offer internationally competitive terms and conditions to Indian doctors and nurses. Increasingly Indian hospitals retain more of the nation’s healthcare professionals, and indeed attract doctors working in the UK and the US to return. Further, NHS England has tended to be staffed on the basis of what successive governments can afford rather than what NHS patients’ actually need.
 
Challenges of planning healthcare needs

Although there is a significant shortage of healthcare professionals in NHS England, it is not altogether clear that, (i) significantly increasing the number of NHS health professionals in the short to medium term will be possible, and (ii) simply increasing staff numbers will improve cancer care. Over the past 2 decades, as technologies and demographics have changed, so the demands on cancer professionals have changed. It is not necessarily the case that the NHS has the right mix of staff with the right mix of skills to deal effectively with changing conditions.  Changing traditional roles rather than simply boosting numbers might contribute more to reducing cancer mortality rates and improving the quality of cancer care. Further, it seems reasonable to suggest that, with the aforementioned challenges, a greater proportion of the UK’s annual healthcare spend might be more effective were it directed at cancer prevention rather than “diagnosis and treatment”.
 
Preventing cancer
 
A substantial proportion of cancers can be prevented including cancers caused by tobacco use, heavy consumption of alcohol, and obesity. According to the World Cancer Research Fund about 20% of all cancers diagnosed in the developed world are caused by a combination of excess body weight, physical inactivity, excess alcohol consumption, poor nutrition, and tobacco use, and thus could be prevented. Certain cancers caused by infectious agents such as the human papilloma virus (HPV), hepatitis C, (HCV), and human immunodeficiency virus (HIV) can be prevented by human behavioural changes, vaccination or treatment of the infection. Further, many of the 5m skin cancer cases worldwide (16,000 in the UK), which are diagnosed annually could be prevented by protecting skin from excessive sun exposure and not using indoor tanning machines.
 
Cancer screening
 
Screening is known to reduce the mortality of cancers of the breast, colon, rectum, cervix, and lung. Screening can help colorectal and cervical cancers by allowing for the detection and removal of pre-cancerous lesions. Screening also provides an opportunity for detecting some cancers early when treatment is less expensive and more likely to be successful. Early diagnosis is an important factor in improving cancer outcomes. Currently, the UK offers 3 national screening programs for bowel, breast and cervical cancer. Notwithstanding, recent reports suggest that these programs are not being fully utilised. For example, in 2017 the percentage of women taking up invitations for breast cancer screening was at the lowest level in a decade, dropping to 71%. Over 1.2m women in the UK (25% of the eligible population) did not take up their invitation for cervical screening. Further, a heightened awareness of changes in certain parts of the body, such as the breast, skin, eyes and genitalia may also result in the early detection of cancer.
 
Reconciling bureaucracy with innovation
 
We have described how UK cancer strategies are determined from the top. Cancer care professionals conform to internationally accepted standard processes, which facilitate and reinforce control. ‘Control’ and ‘conformism’ are in the DNA of cancer healthcare professionals and provide the cultural norms of NHS cancer care programs. NHS managers ensure conformance to clinical procedures, medications, targets, budgets, and quality care standards. This describes a classic “bureaucracy”, which is the technology of control and conformism, and the 70-year old command and control structure of NHS England. While control, alignment, discipline and accountability are very important to cancer care programs, innovation is equally important. If NHS England’s cancer mortality rates are to be compatible with those of other European healthcare systems we will have to find a way to reconcile the benefits of bureaucracy - precision, consistency, and predictability - while making the architecture and culture of our cancer care programs more innovative and more compatible with the demands of rapidly evolving 21st century science and technology.
 
Takeaways

Cancer is a vexed and profoundly challenging disorder. As soon as you read about a breakthrough you have news that the cancer has outwitted the scientists, hence the name, “the emperor of all maladies”. Cancer care in the UK has improved, but still the majority of British cancer patients would faire significantly better in other European countries. When reflecting on the myriad of cancer strategies, reports, and taskforces over the past 2 decade you cannot help but think that NHS England suffers from an element of bureaucratic inertia: the inevitable tendency of the NHS to perpetuate its established procedures and modus operandi, even if they do not reduce cancer mortality rates to those experienced by other European nations. The UK policy debate to resolve this problem tends to be dominated by “more”: more money, more doctors, more nurses. Historically this has provided successive governments with a “get-out-of-jail-card” because circumstances meant that the NHS could always provide more. This is not the case today. The global healthcare ecosystem has changed quicker than UK cancer strategies and quicker than structural changes in the nation’s healthcare system. Improving cancer care in the UK will require more than inertia projects. It will require more innovation, more long-term planning, more courage from policy makers, more attention to actual patients’ needs rather than providing what is politically available. The UK healthcare establishment should be minded of Darwin who suggested that, “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.”
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  • Narayana Hrudayalaya (NH) is an innovative Indian healthcare provider
  • In just 15 years NH has become one of India’s leading hospital groups
  • Founded by Dr Devi Shetty, a heart surgeon, NH treats nearly 2m patients a year
  • NH has built an international reputation for affordable quality healthcare
  • A number of large institutional investors are betting that NH can grow
  • Is NH’s model of affordable quality healthcare replicable outside of India?

Will Devi Shetty have a major influence on global healthcare?
 
 
PART 1
 
Dr. Devi Shetty, founder and chairman of Narayana Hrudayalaya (NH), an innovative Indian healthcare provider, wants to transform the way healthcare is delivered across the world. Can he do it?
 
This Commentary is in three parts. Part 1 is a general introduction to NH and its 2015 initial public offering. It describes some of NH’s internal challenges and suggests that it is reasonable to assume that these will be overcome given its position within a buoyant Indian healthcare market. Part 2 describes some key aspects of NH’s model for affordable quality healthcare. In particular, it shows how Shetty has embraced information technology and some aspects of scientific management to create mega hospitals in India that delivers sustainable high-volume affordable quality care. Part 3 discusses some of the challenges associated with replicating the NH model outside of India. It briefly describes Shetty’s initiative to create a medical city in the Cayman Islands to capture share from the North and South American healthcare markets. It discusses some of the barriers to replicating the model in the UK and other developed markets and suggests that besides India; Africa, - despite its complexities and challenges - might offer NH growth opportunities. It also suggests that NH could play a leading role in training a new generation of healthcare professionals specifically attuned to the vast and escalating healthcare needs of developing economies, and this could be commercially valuable.
 
London-based financial institution CDC and a number of others think Shetty can provide the world with a new model of affirdable healthcare. In December 2015 the CDC Group, owned by the British government, with an investment portfolio valued at £2.8bn, backed NH’s initial public offering (IPO) with an investment of US$48m. The IPO valued NH at US$1bn. The issue was 8.6 times oversubscribed, with most of the demand coming from foreign institutional investors. Beside CDC, other anchor investors included the government of Singapore, Morgan Stanley, Nomura, BlackRock, and Prudential.
 
Dharmesh Mehta, former managing director and CEO of Axis Capital, one of the bankers to the issue, said:  “We got one of the best anchor books, with several long-term investors supporting it. Investors are bullish about the Indian healthcare space, especially hospitals, and Narayana Hrudayalaya has a unique business model, and the backing of good quality management.”
 
In the video below Shetty argues that, “Healthcare of the future will not be an extension of the past.” Shetty has a good understanding about how technology is revolutionizing the way healthcare is delivered and changing its structure and organization to such an extent that the future of healthcare will be dramatically different from what it is today. Healthcare is moving beyond the hospital towards patient self-knowledge and empowerment. Home-healthcare services facilitate enhanced doctor-patient connectivity where it had not been previously possible.

 
 
(click to play the video)
 
Narayana Hrudayalaya
 
Shetty, who has more than three decades of experience as a cardiac surgeon both in the UK and India, founded NH in 2000. Since then, it has become one of India’s leading healthcare service providers; with a network of 23 multi-specialty, primary and tertiary healthcare facilities, eight heart centers, and 25 primary care facilities, across 32 cities, towns and villages in India. Currently, NH has 5,600 operational beds, which it intends to increase to 30,000 by 2020. NH employs some 12,500 people, including 818 doctors, 5,400 nurses and about 1,660 visiting consultants.

In fiscal year 2015, Narayana provided care to nearly two million patients and undertook more than 51,456 cardiology procedures, 14,000 cardiac surgeries - which accounted for 10% of the national figure - and 184,443 dialysis procedures. Narayana posted revenues of US$219m for fiscal year 2015 and profit after tax of $2m. For the four fiscal years that ended March 31, 2015, the company’s revenues grew at a compounded annual rate of 30%.
 
Access to healthcare for millions of poor people
 
NH has one of the world’s largest telemedicine networks with 150 centers including 50 in Africa, where Shetty sees further expansion opportunities for NH. The service is free-of-charge and enhances the connectivity between remote health facilities and consultants at Narayana. Shetty, a vocal advocate of affordable healthcare, helped design the Karnataka State government Yeshasvini scheme, which is one of the largest self-funded micro healthcare insurance programs in India. It covers about 2 million people who previously did not have access to healthcare. Participants pay US$1.40 per year, which provides them with free access to over 800 surgical procedures in 400 hospitals. In the past 10 years, 85,000 peasant farmers have used the insurance to have surgery.
 
Challenges

NH faces some challenges. Its profit margins are low and its revenues are mainly derived from three of its largest hospitals, which concentrate on cardiac care and cardiology. As of March 2015, the company’s recent acquisitions and expansion into the Cayman Islands, where it opened a 130-bed tertiary hospital, were making losses.

However, NH’s acquisitions and expansion are strategic and their pay-offs are expected to accrue over the next four years. Also, higher yields from value-added therapies such as oncology, neurology and gastroenterology are anticipated to improve Narayana’s average revenue per operating bed (ARPOB). The company’s strategy to focus on the mid-income segment of the market is predicted to increase its utilization, given that this is a large, rapidly growing and immediately addressable market. Narayana is also advantaged by its history of efficient use of capital: it has a debt-equity ratio of only about 0.3. 

 
Market drivers

In 2015 investors might have been influenced by the falling gold, oil and real estate markets and the relative attraction of the Indian healthcare sector, buoyed by changing demographics, rising incomes and a large and expanding middle class, greater health awareness, changes in disease profiles and a rising penetration of health insurance. By 2020 India is expected to be the world’s third largest middleclass consumer market behind China and the US. By 2030 India is projected to surpass both countries with an aggregated consumer spend of some US$13 trillion. A 2019 study by the McKinsey Global Institute (MGI) suggests that if India continues to grow at her current pace, average household incomes will triple over the next two decades, making the country the world’s fifth-largest consumer economy by 2025, up from the current 12th position.

While recognizing the challenges for India’s healthcare sector, investors must have thought that NH is well positioned to take advantage of the expected explosion in India’s middleclass consumer market. Narayana has a strong brand name and it is one of India’s leading healthcare companies, with significant revenue growth over the past four years. Its services appear cheaper than those of its competitors, such as Chennai’s Apollo Hospitals Limited, which has about four times the revenues of NH and Delhi’s Fortis Healthcare, which is about three times bigger in revenue terms. This suggests that NH has scope for substantial growth. 


 
PART 2
 
International attention
 
Healthcare systems worldwide consume a large and escalating share of national incomes and costs and quality of care are the two most hotly debated issues among healthcare professionals. Does Shetty have an answer?
 
For many years, Shetty has attracted international attention. For example, in 2010 a UK prime ministerial delegation visited NH’s Medical City in Bengaluru. Vince Cable, then the UK’s Business Secretary, said: “What we're trying to do in the UK is to get more for less. Dr Shetty has shown us a model by which we do not need to accept inferior healthcare because there's less money, but actually how to get more out of the system for less resource,” Cable described his visit as “inspirational” and went on to say, "I just found it overwhelming. NH combines what we always see in a good health system, which is humane humanitarian behaviour, with sound economics."
 
The Henry Ford of heart surgery
 
Worldwide, the demand for healthcare services is rising faster than its supply. By focusing on an endeavour to make doctors more effective, NH has demonstrated that it can deliver what healthcare systems need: enhanced patient outcomes for less money.  “We have invested in infrastructure. Similar infrastructure in the UK and the US is used for about eight to nine hours a day. Ours is used for 14 to 15 hours a day, which allows us to perform the high volume of procedures,” says Shetty. In 2009 the Wall Street Journal referred to him as “the Henry Ford of Heart Surgery”.
 
In a similar way Henry Ford used large factories and mass-production techniques to manufacture a large number of quality cars, which many ordinary people could afford; so, Shetty developed large hospitals and a significant skill base, which he used to improve the quality of surgical procedures and reduce costs. This enabled him to offer large numbers of people access to affordable high-quality healthcare. 
 
NH doctors, who are on fixed salaries, work in teams. Each team comprises a specialist, a number of junior doctors, trainees, nurses and paramedics. A bypass surgery typically takes about five hours. The actual grafting, which is the critical part, takes only an hour and is performed by an experienced specialist surgeon, while harvesting of the veins/arteries, opening and closing of the chest, suturing and other procedures are carried out by junior doctors. Nurses and paramedics handle the preparation and the aftercare of the patient. This Henry Ford-type process leaves the specialist free to perform more surgeries. As the volume of surgeries increase, outcomes improve, and costs are reduced. A heart surgery at NH costs less than US$2,000 per operation.
 
NH’s lower costs have not come at the expense of quality. Narayana’s mortality rate for coronary artery bypass procedures is 1.27% and its infection rate 1%, which are as good as that of US hospitals. Incidence of bedsores after cardiac surgery is anywhere between 8% and 40% globally, whereas at NH it has been almost zero in the last four years.
 
It can’t be done!
 
When we started our journey, we were discouraged by people saying that, ‘there is no such thing as low-cost high-quality healthcare’, and that ‘healthcare is expensive and will always be expensive’. Only when people become wealthy, they can afford quality healthcare . . . . . When I grew up, I looked at some of the richest countries in the world, struggling to offer healthcare to its citizens and quickly realized that even if India became a rich country, it still would not be able to guarantee healthcare to everyone. We had to change the way we were doing things and this is what we’ve done,” says Shetty.
 
Socializing the P&L
 
UK doctors and health providers often talk about reducing the costs of healthcare, but, says Shetty, “doctors usually have no idea how much they are spending”.  In contrast, at noon every day all NH doctors receive an text with NH’s previous day’s revenue, expenses and EBIDTA (earnings before interest, depreciation, taxation and amortization). According to Dr. Ashutosh Raghuvanshi, NH’s CEO, “When you look at financials at the end of the month, it’s a post-mortem. When you look at them daily, you can do something to change things”. The daily data doctors receive describes their operations, and the various levels of reimbursement. “It’s not just a cheap process, it’s effective,” says Raghuvanshi.
 
In the video below Shetty suggests that a key factor for the future success of NHS England will be its ability to re-invent itself, increase its focus on costs and outcomes, benchmark key functions with successful international comparators and instil strict financial discipline in doctors, “because they represent the biggest spend in healthcare systems,” says Shetty.
 
      
 (click to play the video)   
 
Information technology
 
Healthcare systems require radical change at every level in order to reduce the vast and upward trajectory of unsustainable costs, improve patient experiences and outcomes, speed the translation of research into therapies and make healthcare accessible to everyone. Information technology helps in these regards. NH regularly mines data to raise the quality of care and patient outcomes. Its business intelligence activities manage real-time data on 30 different parameters that track and support efficiency improvements. Those related to clinical outcomes are then reviewed at a weekly meeting, where all major clinical procedures are discussed among doctors and best practices shared. This way NH maps the cost effectiveness of each doctor.
 
PART 3
 
Affordable quality healthcare outside India
 
An example of Shetty’s model of affordable quality healthcare working effectively outside of India is Narayana Health Cayman Islands. The Cayman government has given Shetty a 200-acre site and New York investors have backed him to develop and operate a Health City. In 2014 NH opened its first phase, a 130-bed tertiary hospital targeting the elective surgery markets of North and South America. “Narayana Health City Cayman will demonstrate how over-priced and inefficient US hospitals actually are and show that lower costs and better outcomes can be achieved outside of India just as well as in Bengaluru,” says Shetty.
 
The UK
 
There are numerous barriers to adopting the Shetty model in the UK and in other developed economies. NHS England has its innovators and there are efforts to roll-out innovations nationally, but they have limited success, mainly because innovations tend to be isolated and local and not widely known across different NHS functions or beyond sector boundaries. The lack of centralised expertise in NHS England skews perspectives and limits resources. This presents a significant obstacle to the adoption of compelling healthcare innovations, such as those demonstrated by Narayana.
 
Further, there is doctor-resistance to innovations in the UK. Doctors are trained to identify and implement proven and recommended treatment protocols for various disease states. To deviate from this is to run the risk of litigation. Further, health professionals in the UK are increasingly time-pressed, with the result that acquiring and adopting new and innovative pathways of care takes a back seat. See, Meeting the challenges of affordable quality healthcare. and, The end of doctors.
 
Medical tourism
 
"Medical tourism" refers to traveling to another country for medical care. The world population is aging and becoming more affluent at rates that surpass the availability of quality healthcare resources. In addition, out-of-pocket medical costs of critical and elective procedures continue to rise, while nations offering universal care, such as the UK, are faced with ever-increasing resource burdens. These drivers are forcing patients to pursue cross-border healthcare options either to save money or to avoid long waits for treatment.

In 2015 it was estimated that the worldwide medical tourism market was between US$50bn and US$65bn and growing at an annual rate of between 15%-25%. In 2015 some 1.5 million US residents travelled abroad for care, up from 0.5 million in 2007. Two of their top destinations were Costa Rica and India. Costa Rica can yield savings on standard surgical procedures of between 45% and 65%, and India, between 65% and 90%.

Beyond the US, the OECD estimates that there are up to 50 million medical tourists worldwide annually. The most common procedures that people undergo on medical tourism trips include heart surgery, dentistry and cosmetic procedures. People are attracted to well-known, internationally accredited hospitals, which have a flow of medical tourists, internationally trained experienced health professionals, a sustained reputation for clinical excellence and a history of healthcare innovation and achievement.

Already, NH attracts medical tourists from over 50 countries, it has an international reputation for excellence, many of its top health professionals have been trained and have gained clinical experience in the US and Europe and it has a significant track record in high demand areas, particularly heart surgery. This suggests that NH is well positioned to take advantage in the future growth of medical tourism and this is probably something taken into account by NH’s anchor investors. 

 
Africa
 
Because of entrenched obstacles to change in the healthcare systems of developed economies, Shetty has indicated an interest in Africa. In the past, private healthcare providers have neglected African healthcare; it has been underserved by governments, and mostly reliant on irregular help from abroad. However, this is about to change, and there is some evidence to suggest that healthcare reform in Africa is beginning. A 2016 African Healthcare Summit suggested that African healthcare spending is expected to grow to 6.4% of GDP in 2016, making it the second highest category of government investment. A Report from the International Finance Corporation (IFC) of the World Bank suggests that, over the next 10 years, there will be, “considerable African demand” for investment in hospitals, medicines and health professionals and meeting this demand, “can deliver strong financial returns.”
 
Healthcare providers also can take heart that a number of African countries are trying to establish or widen social insurance programs to give medical cover to more of their citizens. Further, there are six African countries with projected compounded annual growth rates (CAGR) for 2014 through 2017 of between 7.12% and 9.7%. These are: Rwanda, Tanzania, Mozambique, Cote d’Ivoire, the Democratic Republic of the Congo, and Ethiopia.
 
Notwithstanding, Africa is facing a dual challenge of communicable and parasitic diseases such as malaria, TB and HIV/AIDS and growing rates of chronic conditions such as diabetes, hypertension, obesity, cancer and respiratory diseases. Increased urbanisation in many African countries, along with growing incomes and changing lifestyles, have led to a rise in the rate of chronic conditions, which are projected to overtake communicable diseases as Africa’s principal health challenge by 2030. This suggests that despite the fledging signs of change, over the next decade African healthcare will still be challenged. However, over the past 15 years, NH’s has demonstrated capabilities to meet and overcome similar challenges in India, which positions it well to succeed in Africa where it already has a non-trivial telemedicine presence.
 
Training health professionals
 
The healthcare and wellness sectors are positioned to be significant drivers of the world economy in the 21st century. Healthcare is about a US$6 trillion global market, which is increasing. Advances in medical technology, public health and governance have improved healthcare for about 30% of the world’s population. But billions of people still have no access to healthcare.
 
The WHO estimates that there is a shortage of nearly 13 million healthcare workers globally, but Shetty believes these shortages could be significantly higher. According to the Royal College of General Practitioners the shortage of doctors in the UK is the worst it has been for 40 years. One hundred primary care practices, serving 700,000 patients across Britain, are facing closure and the number of GP-patient consultations is estimated to rise from 338 million in 2013 to 441 million by 2017. UK experts warn that primary care doctors with too many patients will fail to provide adequate healthcare through current delivery methods and they say that this is expected to further drive patients to search online for health-related issues. See: Curing the Problems of General Practice.
 
Such shortages concern Shetty, who believes that the situation will only be improved with a radical change in the way healthcare is delivered. “This”, says Shetty, “will only be achieved with a change in the way health professionals are trained.” Future health professionals need to be trained for a world of e-patients. Digital classrooms will create new connections between students and health professionals and allow for access to the most current information and resources. Shetty advocates the development of a virtual global medical university, with features that include a cross-country curriculum and a reduced training period. “This is the only way we will increase the much-needed pool of healthcare talent,” says Shetty.
 
Takeaways

While change in Western healthcare systems will neither be quick nor easy, NH’s near to medium term growth will most probably come from India, the Caymans, Africa and other developing countries where the need for quality healthcare is high and growing fast, and the barriers to entry relatively low. In time, however, the US and the UK might be able to benefit from some of Narayana’s best practices so that an increasing percentage Americans may have access to high quality affordable healthcare and NHS England maybe reformed to ensure its survival.
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Gordon Moore
Professor, Harvard University Medical School and world renowned authority on the design and implementation of healthcare delivery systems 
 

'Instead of throwing more manpower at their problems, multiple industries are using information technology to offload work to the consumer, connect the participants up in real time, and create smart, real-time process support.'

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Curing the Problems of General Practice

The Royal College of General Practice (RCGP) and the Centre for Workforce Intelligence (CFWI) agree: too small a supply of GPs will meet a rising tide of demand.  In the UK, spotty shortages exist now, but will become widespread over the next decade.

The causes of rising clinical demand are well known:
  • Continued growth of the things medicine can do
  • Surge of lifestyle diseases
  • Burgeoning patient devices that collect data and require monitoring by clinicians
  • Increased public expectations for access to GPs 
  • Aging of the population
  • Emergence of multiple, complex chronic illness
  • Diversion of GPs to management activities such as commissioning

Little analysis of root causes
Less is known about the underlying causes of the shortfall of supply in GPs.   The RCGP cites lagging GP incomes as a source of dissatisfaction, with consequent dampening effects on medical student choices of general practice specialist careers.   The CFWI models GP supply, but offers little analysis of the root causes of the declining intake to GP careers.  

While both the RCGP and the CFWI repeatedly emphasize the need to make general practice more attractive and increase its uptake, they have few suggestions about how to do so other than promoting it better.  In the meantime, they advocate, as does the NHS, that larger, multi-skilled teams must grow to service the increasing need, and that the key barrier to effective teamwork is lack of integration.

Concerns
I want to raise two significant policy concerns about the direction that the UK is taking to mitigate the primary care “crisis”.  First, I postulate that the reason that medical students are not choosing general practice is less a matter of money than of increasing practice complexity and life style.   Second, I suggest that the “solution” of larger, better-integrated teams is unproven and, further, may actually diminish productivity, and worsen, rather than relieve, the stress of work on GPs while their satisfactions further diminish.  

Lifestyle challenges
There is little evidence that medical students will select GP careers if they earned more.  In fact, over the past five years, during the rapid upturn in GP incomes, dissatisfaction among GPs grew and fewer medical students, especially men, chose to enter general practice.  In the US, studies have shown that life style is an important factor in the diminishing number of medical students entering primary care.   At the same time, corporate primary care is growing, and larger practices with more salaried doctors are becoming the work choice of preference. 

This suggests that young doctors are put-off by the complexity, responsibility, the long hours, and the stress of general practice, and seek to transfer those risks to someone else.  Without fixing this, throwing more money at the problem is unlikely to reverse the trend.   Money, of course, is important, but it’s merely an enabler of career choice and a deterrent if too low. Compensation alone doesn't appear to be a sufficient incentive to chose primary care.   

Multi-purpose teams failing
The idea is seductive that integrated, multl-manpower teams are a solution to the GP shortfall. However, early evidence from America doesn’t suggest that the US-version of integrated, primary care teams (the patient-centered medical home) is achieving the efficiencies and improved care that they were touted to deliver.  Recent studies  (see: Friedberg M.W., 26th February 2014, Journal of the American Medical Association) show some small improvements in quality measures, but no change in cost-effectiveness in a group of enthusiastic early adopters.   

There are many reasons to doubt that simple team integration occurs by encouraging it among those working together, and much to suggest that the cost of integration is a major barrier to a cost-effective strategy to increase manpower.   Information technology, as a field, discovered years ago that taking complex tasks and dividing them among many different subgroups was dis-economic.

Additional manpower not the answer
As long ago as 1975, Frederick Brooks in The Mythical Man-Month argued convincingly that by, “adding manpower to a late project makes it later”.  No surprise then that when one counts the cost of personnel, the coordination mismatches, the communication time, the complexity of handoffs, and duplication of services, teamwork is more a theoretical concept than a practical working model. 

Adopt best practice
What, then, might one consider as a possible solution to the increasing stress, complexity, and uncertainty of life as a GP? What is needed to facilitate integration among and between team members and patients?  Surely, we can draw lessons from other industries.  Instead of throwing more manpower at their problems, multiple industries are using information technology to offload work to the consumer (think of Cash Points), connect the participants up in real time, and create smart, real-time process support. 

The role of technology
Digital infrastructure for general practice has failed to keep up with the rest of the world.  The electronic medical record documents what has been done but does little to help doctors and other health workers to do their work. There is no infrastructure to help patients. Information technology should be providing an infrastructure to make general practice easier and better to do. 

Merely throwing non-GP manpower at their problems will make the life of the GP more complicated and less satisfying.   It is time to invest in true infrastructure innovation in the NHS.  It won’t be cheap, but it is the only answer to the threat that general practice will fail to meet the needs of the population in future.    
 
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Evidence from a recent survey of people with diabetes, suggests patient outcomes will improve if GPs provide healthcare information in video clips rather than paper pamphlets.

Traditional patient information is failing
"An indication that the current paper and web-based diabetes information is failing to improve patient outcomes is the fact that the incidence rates of diabetes in the UK are escalating. Currently, a plethora of diabetes information is provided either in paper pamphlets or as digitalized text on websites, but patients want healthcare information in video clips, and greater connectivity with their health providers," says Dr Seth Rankin, managing partner, Wandsworth Medical Centre, who conducted the survey.

Despite the NHS spending £10 billion each year on diabetes care, between 2006 and 2011 the number of people diagnosed with diabetes in England increased by 25%: from 1.9 million to 2.5 million. Today, 3.8 million people have diabetes, and this number is expected to increase to 6.2 million by 2035. In 2013 there were 163,000 new diagnoses of diabetes in the UK, the biggest annual increase since 2008, and the five-year recurrence rates of diabetic foot ulcers are as high as 70%. The population increase over the past decade only explains some of these increases.
 
 
Improving outcomes
Organizations treat the distribution of diabetes information as ends in themselves, and report the quantity of information distributed, but not the impact it has on outcomes.
 
By simply asking patients with diabetes how, when and where they would like to receive information to help them manage their condition provides an important missing social link between health professionals and patients, and can help to improve outcomes.
 
Patients' views neither sought nor acted upon
"When we ask patients living with diabetes," says Rankin, "we get a clear picture of what patients want. The fact that patients' opinions are rarely sought, and even more rarely acted upon, might help to explain why the incidence rates of diabetes are escalating. There's no shortage of resources and technical competences in the UK to treat and manage diabetes. However, communications between doctors and their patients living with diabetes throughout their therapeutic journeys are weak. This inhibits patient education, slows self management and quickens the onset of complications," says Rankin. 
 
Patient survey 
In 2014, 140 people living with diabetes from two London primary care practices participated in a six-week project to improve doctor-patient communications. Patients received regular video clips via email from their health professionals and fellow patients to help them improve the management of their condition. At the end of the project patients' opinions were sought in an email survey, which yielded 51 responses: a response rate of 36%.
 
Findings
  • 65% found video information about diabetes helpful
  • 72% prefer diabetes information from GPs via email
  • 70% want access to healthcare information anytime, anywhere and anyhow 
  • 52% prefer healthcare information in video format to paper pamphlets
  • 68% want more information about their condition
  • 14% visit Diabetes UK's website
  • 53% regularly search the Internet for information about diabetes care
  • Only 19% can distinguish between good and bogus Internet healthcare information
 
Takeaways
"Providing diabetes information in short video clips featuring local health professionals, which can be easily browsed by patients, creates greater connectivity between doctors and patients.
Unlike health professionals and paper pamphlets, video clips never wear out, and are available 24-7, 365 days a year. Further, any number of people can access them at the same time, from anywhere, on any device.
Our survey suggests that videos clips are effective in increasing patients' knowledge of diabetes, and propelling them towards self-management. Video clips could be used for all manner of patient information on all manner of conditions,"says Rankin.
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