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The five year forward plan seeks to improve preventative measures, that have been lacking previously. Taking action on obesity, smoking and alcohol are among the focuses. Prevention is not only cost effective way of providing healthcare but the process of preventing illness and disability where it can could reduce unemployment, and the need for social care and help people live and/or manage full or fuller lives. The impact of prevention ripples throughout society. Integrating services within the community as it mentions will enhance this. The five year plan speaks about more patient choice and control over their services and individualised budgets have shown this to not only offer agency, but to be both cost effective- who but the individual and their loved ones knows what is best and/or needed for them. There is also support added for carers who have been neglected for too long. Carers are vital for the system to work and need to be cared for enough to be able to care. other areas the plan mentions - The organisation of services through specialist community providers -targeted to local and for the diverse communities and their needs. There is also an aim to bridge the gap between physical and mental health services and to budget more efficiently. 

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The five year forward plan seeks to improve preventative measures, that have been lacking previously. Taking action on obesity, smoking and alcohol are among the focuses. Prevention is not only cost effective way of providing healthcare but the process of preventing illness and disability where it can could reduce unemployment, and the need for social care and help people live and/or manage full or fuller lives. The impact of prevention ripples throughout society. Integrating services within the community as it mentions will enhance this. The five year plan speaks about more patient choice and control over their services and individualised budgets have shown this to not only offer agency, but to be both cost effective- who but the individual and their loved ones knows what is best and/or needed for them. There is also support added for carers who have been neglected for too long. Carers are vital for the system to work and need to be cared for enough to be able to care. other areas the plan mentions - The organisation of services through specialist community providers -targeted to local and for the diverse communities and their needs. There is also an aim to bridge the gap between physical and mental health services and to budget more efficiently. 

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Five Year Forward View - One year on

The Five Year Forward View outlines the current and future challenges facing the NHS and details a shared view of what needs to change to overcome them by 2019.

Although there is widespread support for the Five Year Forward View from government and senior healthcare leaders, we know that staff below board level are not as aware of the 5YFV and its impact. If the NHS is to reach its full potential then we need to make sure that all staff throughout the NHS fully understand and support its vision.

One year on from its launch, we summarise what the 5YFV is about, what's been done so far, and provide a presentation and infographic to help you communicate the 5YFV and outline the part your organisation and its staff need to play to ensure its success.

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Have a read of this easy-read version...

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Have a read of this easy-read version...

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Using this and what you already know about the challenges facing the NHS leading up to it's publication in 2014, make a list of reasons why the NHS needed to change. Post your answers below:

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Cure the NHS was formed after Julie Bailey lost her mum to the poor care at Mid-Staffs. The organisation formed their own paper presented in this link - a blueprint of recommendations to prevent this happening again

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The name of this group was deliberately chosen to express it's ambition, to cure the NHS. Cure it of what? Of the malaise that has gripped it in recent years, particularly in the way that it treats the vulnerable and elderly, so clearly set out in the evidence to the Public Inquiry from Cure the NHS members and other witnesses...

That requires three fundamental transformations in the way the NHS, principally the acute sector operates. These transformations can and should apply equally to services delivered by care homes, in fact to all provision of healthcare services, state and private.

A transformation of the way the NHS behaves minute by minute with its patients to rebuild the culture of care, and embed in it a culture which focuses solely and continuously on the safety of patients, and on the quality of the care they are receiving. To ensure that all patients in the UK whether of the NHS or any other provider receive their care right first time with

ii. A transformation in the way the NHS operates day by day in its implementation of all the disciplines which keep patients free from harm during hospital treatment, which by its very nature has many inherent hazards, "Patient Safety Management System"

A transformation in the way the NHS (a) defines the standards " best practice" for each and every element of the treatment and care it provides, the "quality" of care, (b) how it delivers those standards to each and every patient during every minute of their stay, "right first time with zero harm", (c) how it monitors and measures how well it is delivering those standards, "quality assurance", (d) how it makes changes to fill gaps and draw in new ideas, "continuous improvement"; in total a "Patient Care Quality Management System ". This will mean a well-ordered system of guidance without duplication which does not deflect staff from their primary task of patient care.

iii. A transformation of the regulatory structure to assure patients and the public that all providers of health services have the " capability" to deliver safe care to these standards of quality, have been delivering it, are continuing to deliver it, and will be able to deliver it in the future, by consolidating the activities of the many disparate elements of healthcare regulation into one regulatory body.

We recommend that the Health Secretary needs to get on with (should have got on with years ago) :-
i. Rebuilding the culture of safety and care ii. Implementing Two Essential Systems - safety management and quality management iii. Establishing a Single Regulatory Body iv. "Stop and Make Safe" - Assuring Patients and Communities v. Re-establishing Clinical Leadership of the NHS vi. A Rapid End to Whistleblowing vii. Drawing Coroners into the Assurance of Patient Safety and Quality of Care viii. Complaint Handling ix. Investigation of Healthcare Failures x. Giving HealthWatch a Stronger Voice xi. Putting the Nursing back in Nurses

Download this article as a PDF

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Blueprint for the NHS | Cure the NHS - Mid Staffs hospital inquiry

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The name of this group was deliberately chosen to express it's ambition, to cure the NHS. Cure it of what? Of the malaise that has gripped it in recent years, particularly in the way that it treats the vulnerable and elderly, so clearly set out in the evidence to the Public Inquiry from Cure the NHS members and other witnesses...

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1. What is the Mid Staffs scandal?2. Why is it in the news again now? 3. How did the poor care come to light? 4. The public inquiry5. The first Francis inquiry: what was care like?6. What did the Healthcare Commission find?7. Why was care so bad?8. So who failed to spot problems at Stafford and/or do enough to stop them? 9. How will the Mid Staffs scandal affect the NHS?
1. What is the Mid Staffs scandal?
2. Why is it in the news again now?
3. How did the poor care come to light?
4. The public inquiry
5. The first Francis inquiry: what was care like?
6. What did the Healthcare Commission find?
7. Why was care so bad?
8. So who failed to spot problems at Stafford and/or do enough to stop them?
9. How will the Mid Staffs scandal affect the NHS?
1. What is the Mid Staffs scandal?

A disputed estimate [see footnote] suggested that between 400 and 1,200 patients died as a result of poor care over the 50 months between January 2005 and March 2009 at Stafford hospital, a small district general hospital in Staffordshire. The report being published on 6 February 2013 of the public inquiry chaired by Robert Francis QC will be the fifth official report into the scandal since 2009, and Francis's second into the hospital's failings.

The often horrifying evidence that has emerged means "Mid Staffs" has become a byword for NHS care at its most negligent. It is often described as the worst hospital care scandal of recent times. In 2009 Sir Ian Kennedy, the chairman of the Healthcare Commission, the regulator of NHS care standards at the time, said it was the most shocking scandal he had investigated.

It is commonly known as the Mid Staffs scandal because Stafford hospital was and is run by the Mid Staffordshire NHS hospital trust, which in 2008 acquired foundation trust status, making it semi-independent of Department of Health (DH) control. Decision-making and especially cost-cutting as part of its pursuit of that status was later cited as a key reason why poor care took hold and was allowed to persist for so long.

2. Why is it in the news again now?

On Wednesday 6 February Francis will publish the report of his 31-month-long public inquiry into the scandal. His first report, published in February 2010, was an independent report under the NHS Act rather than a full-blown public inquiry. It examined the quality of care at Stafford hospital in 2005-09 and the many reasons why it was so bad, such as inadequate staffing, and produced devastating conclusions.

The public inquiry began in July 2010. Its remit was to investigate what a wide range of commissioning, supervisory and regulatory bodies and systems in the NHS had done to detect poor care at Stafford and to intervene. As such it probed the role of the bodies and individuals all the way from the hospital itself - including the trust's board and its patient liaison group - up to the most senior figures at the Department of Health in Whitehall, including ministers, senior civil servants and key figures in the NHS.

Its brief included its duty "to examine why problems at the trust were not identified sooner; and appropriate action taken. This includes, but is not limited to, examining the actions of the Department of Health, the local Strategic Health Authority, the local primary care trust(s), the Independent Regulator of NHS Foundation trusts (Monitor), the Care Quality Commission, the Health and Safety Executive, local scrutiny and public engagement bodies and the local coroner."

3. How did the poor care come to light?

Although care was poor from at least the start of 2006, concerns about that only began emerging in mid-2007. At that time the Healthcare Commission (HCC), the then NHS care regulator, became anxious that Stafford seemed to have unusually high death rates, drawing on information from Professor Brian Jarman, an expert in patient safety and hospital death rates at Imperial College London.

By January 2008 the watchdog had identified seven different patient safety alerts at Stafford: warning signs that there were problems. Dissatisfied with the hospital's explanation for the apparently high mortality rate - that it was down to "coding errors" - the HCC told a team of its investigators under Heather Wood, renowned as its "hard cases woman", to get to the bottom of what was happening at the hospital. That was the first of the five inquiries.

Julie Bailey, whose 86-year-old mother Bella died in the hospital as a result of poor care in late 2007, also played a key role in exposing the Mid Staffs scandal. She quickly came across other families who had lost a loved one, realised there was a problem and, with other bereaved relatives, formed the campaign group Cure The NHS to demand a public inquiry and hold those reponsible to account.

4. The public inquiry

Andrew Lansley, the then health secretary, commissioned the full public inquiry in June 2010, soon after the coalition took power. It was held under the Public Inquiries Act 2005. Labour in 2009 and 2010 had refused to accede to persistent requests from relatives of victims of the Mid Staffs scandal to hold such an inquiry. Instead ministers commissioned the first Francis report as well as two other, separate inquiries into specific aspects of how the hospital and local healthcare system operated. They were led by Professor George Alberti, the DH's national clinical director for emergency care, and Dr David Colin-Thome, his counterpart at the DH for primary care. They reported in April 2009.

Francis began gathering evidence in July 2010. He initially hoped to deliver a report to ministers by early 2011. Instead it became a particularly in-depth and long-running inquiry. The inquiry took oral evidence from 164 witnesses over the 139 days it sat between November 2010 and December 2011, and also received 87 witness statements and 39 provisional statements, and over a million pages of evidence in total.

Tom Kark QC, counsel to the inquiry, and Francis himself questioned witnesses.

5. The first Francis inquiry: what was care like?

Francis's report into care at Stafford hospital in February 2010, based on evidence from over 900 patients and families, was scathing. "I heard so many stories of shocking care," he said. "They were people who entered Stafford hospital and rightly expected to be well cared for and treated. Instead, many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives."

Francis cited a litany of failings in the care of patients. "For many patients the most basic elements of care were neglected," he said. Some patients needing pain relief either got it late or not at all. Others were left unwashed for up to a month. "Food and drinks were left out of the reach of patients and many were forced to rely on family members for help with feeding." Too many patients were sent home before they were ready to go, and ended up back in hospital soon afterwards. "The standards of hygiene were at times awful, with families forced to remove used bandages and dressings from public areas and clean toilets themselves for fear of catching infections." Patients' calls for help to use the toilet were ignored, with the result that they were left in soiled sheeting or sitting on commodes for hours "often feeling ashamed and afraid". Misdiagnosis was common.

6. What did the Healthcare Commission find?

Care at Stafford was "appalling", the watchdog's report said. The Guardian reported at the time that it found "inadequately trained staff who were too few in number, junior doctors left alone at night and patients left without food, drink or medication as their operations were repeatedly cancelled. Receptionists with no medical training were expected to assess patients coming in to A&E, some of whom needed urgent care."

The then health secretary Alan Johnson said there had been "a complete failure of management to address serious problems and monitor performance, [which] led to a totally unacceptable failure to treat emergency patients safely and with dignity". Bruce Keogh, the NHS's medical director, condemned the trust's "complete failure of leadership". HCC chairman Sir Ian Kennedy said its report was "a shocking story ... of appalling standards and chaotic systems for looking after patients. These are words I have not previously used in any report."

7. Why was care so bad?

"A chronic shortage of staff, particularly nursing staff, was largely responsible for the substandard care," Francis found in his first report.

In addition, morale was low and "while many staff did their best in difficult circumstances, others showed a disturbing lack of compassion towards their patients", he added. "Staff who spoke out felt ignored and there is strong evidence that many were deterred from doing so through fear and bullying."

He laid much of the blame on the trust's ruling board. The action they took to investigate and resolve concerns "was inadequate and lacked an appropriate sense of urgency". Its members also "chose to rely on apparently favourable performance reports by outside bodies, such as the Healthcare Commission, rather than effective internal assessment and feedback from staff and patients". He was particularly critical of the trust's failure to take patients' complaints seriously enough.

Crucially, Francis also highlighted the key impact of the trust board's decision to try to save £10m in 2006-07, as part of its desire to gain foundation trust status. "The board decided this saving could only be achieved through cutting staffing levels, which were already insufficient." It also ignored staff's concerns, he added.

He also mentioned that "many people expressed alarm at the apparent failure of external organisations to detect any problems with the trust's performance" and recommended a separate inquiry look into that.

That led directly to the latest Francis inquiry, which reports on Wednesday 6 February.

8. So who failed to spot problems at Stafford and/or do enough to stop them?

The report of the public inquiry is likely to find that almost every link in what should have been the NHS's chain of monitoring and scrutinising hospital care, and intervening if necessary, did not do its job properly. He has investigated the actions of scores of bodies and individuals, both locally and nationally. The record, performance and reputation of many of them are likely to face detailed criticism, including the management and board of the hospital itself, the various regulators involved (Healthcare Commission, its successor the Care Quality Commisision and Monitor) and senior figures at the Department of Health.

As Francis's first report said, that inquiry heard evidence "that none of them [external organisations charged with overseeing the trust], from the PCT to the Healthcare Commission, or the local oversight and scrutiny committee, detected anything wrong with the trust's performance until the HCC investigation." The landmark report will, over many hundreds of pages, detail what he then also called "the actions and inactions of the various organisations to search for an explanation of whay the appalling standards of care were not picked up."

His task is to explain why so many people failed so badly, and to make sure it does not happen again.

9. How will the Mid Staffs scandal affect the NHS?

Francis's new report will prompt much soul-searching about why some NHS organisations end up providing inadequate, inhumane and dangerously substandard care to some or many patients. Many people will say in effect "Mid Staffs must never happen again", and Francis will set out how to ensure this is the case. It comes amid rising concern about care, and the behaviour of some of the NHS's huge workforce, which was encapsulated by health secretary Jeremy Hunt that "the crisis in standards of care" - not coping with rising demand at a time of tight budgets or making £20bn of efficiency savings by 2015 or reconfiguring hospital services so more patients can be treated in or near their homes - was the service's biggest challenge.

David Cameron and Jeremy Hunt will doubtless point to initiatives they have taken - such as bringing in a "friends and family" test of hospital care and exploring tough "Ofsted-style" ratings for hospitals - as having at least started to tackle the problems Francis has spent so long pursuing.

But his recommendations are likely to go further than this. Ministers, NHS regulators and the new NHS Commissioning Board are already debating the merits of changes that have been proposed from various quarters such as regulation of healthcare assistants, legal minimum staffing levels on NHS wards, a legally-binding "duty of candour" on all NHS staff to admit to mistakes, a blacklist of failed NHS managers and many others. However, if Francis decides that in effect NHS regulation at the time failed - he can hardly conclude otherwise - then ministers may come under pressure to introduce much more robust regulation. That, though, is opposed by bodies such as the NHS Confederation, which represents hospitals, and National Voices, an alliance of 130 charities.

* This article was amended on 4 November 2015 to make clear that subsequent investigations into the poor care at Stafford hospital, including the two reports by Sir Robert Francis​ QC​, said that this disputed estimate​​, which appeared only in a draft report from 2009 by the Healthcare commission​ and was based on mortality statistics​, was ​an ​unreliable​ measure of avoidable deaths​.​ ​The Francis report of February 2013 concluded that it would be unsafe to infer from ​these​ statistics that there was any particular number of avoidable or unnecessary deaths at the trust.​

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Mid Staffs hospital scandal: the essential guide

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1. What is the Mid Staffs scandal?2. Why is it in the news again now? 3. How did the poor care come to light? 4. The public inquiry5. The first Francis inquiry: what was care like?6. What did the Healthcare Commission find?7. Why was care so bad?8.

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“Parts of the NHS are hiring only one nurse for every 400 jobs advertised, show new figures that reveal the extent of nursing staff shortages in England.”

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http://www.nationalhealthexecutive.com/Health-Care-News/nhs-nursing-shortages-risk-becoming-a-national-emergency

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https://www.theguardian.com/society/2018/sep/11/nhs-suffering-worst-ever-staff-cash-crisis-figures-show

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The NHS was short of 41,722 nurses – 11.8% of the entire nursing workforce. That is the highest number yet and a big rise on the 35,794 vacancies seen at the end of March.

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Patients are dying alone on hospital wards because staff do not have enough time to care for them, nurses say.

The mounting pressure across the UK is also leading to medicines being given late and patients being left in pain.

The issues have been brought to light after the Royal College of Nursing canvassed front-line staff about their experiences of their last shift.

But ministers said despite the concerns raised it was investing in nursing to ensure there were enough staff.

The numbers working in the NHS have increased since 2010, but the RCN maintains this has not been enough to keep pace with demand.

A report earlier this year by the union found one in nine posts were vacant.

Some 30,000 staff, including midwives and health care support workers from across the UK, took part in this new online research.

The RCN described some of the stories as "desperately sad".

'Out of my depth'

Staff revealed how they had ended up parachuted into departments they were unfamiliar with to provide emergency cover at the last minute.

For example, one nurse described how care had been compromised when cardiac nurses were sent to a stroke unit.

Another nurse, who works on an elderly care ward, said she felt "useless, unsafe and out of my depth" when she was sent to A&E.

Others described how the demands on them had compromised care and left them in tears after their shift.

And there were reports of situations where patients had died alone on their watch because they simply did not have time to do everything that was needed.

The RCN said it knew of a number of hospitals which had been forced to rope in volunteers to sit with patients at the end of life.

Among the other problems highlighted were:

Medicines for sepsis, diabetes and Parkinson's not being given on time

Patients being left in pain because nurses were too busy

Child patients going without food as staff had to prioritise treatment

Patients not being moved, putting them at risk of bed sores

Patients left in corridors because all the beds were full

Community staff complaining they were not able to do everything asked of them

One nurse told the RCN: "I often go home in tears. I love being a nurse but I feel I am unable to do my job properly."

The nurses all took part on an anonymous basis.

But one nurse who was willing to be named was Chris Perry, a former director of nursing in the south-west of England who retired earlier this year.

She said the stories in the report were "sadly all too familiar".

She described how she found herself having to "scrabble around" trying to find staff to fill gaps and said despite being willing to pay the most expensive agency prices, she could still not fill rotas.

She said it had now reached "crisis" point.

"We are seeing patient care suffer," she added.

The RCN said more than a third of those who took part in the online survey in May reported having to leave elements of patient care undone because of a lack of time, while two-thirds worked extra time unpaid.

RCN general secretary Janet Davies said: "When this many professionals blow the whistle, they cannot be overlooked."

But the Department of Health, which is responsible for the health service in England, said it was investing in nursing.

It pointed out the numbers in training are increasing - there will be another 10,000 more nurses by 2020 - while the overall number on wards had increased over the past seven years.

"We are helping the NHS to make sure it has the right staff, in the right place, at the right time to provide safe care," a spokeswoman added.

The Scottish government said it had committed to enshrining safe staffing in law and creating about 2,600 extra nursing and midwifery training places over the next four years.

Scottish Health Secretary Shona Robison said: "The link between safe and sustainable staffing levels and high quality care is well established.

"Scotland has led the UK in the development of nursing and midwifery workload and workforce planning tools, ensuring we have the right number of staff, with the right skills, in place."
Read more from Nick Follow Nick on Twitter

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Patients are dying alone on hospital wards because staff do not have enough time to care for them, nurses say. The mounting pressure across the UK is also leading to medicines being given late and patients being left in pain.

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https://youtu.be/fKEtM6EIbZY

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Vacancies for nurses and midwives were over a fifth higher at the end of last year compared to two years ago, with a total of 133,660 vacant posts advertised in 2017.

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“It has never been busier but is shedding experienced nurses quicker than it can find new ones”

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The statistics, released today by NHS Digital, reveal that the number of vacant nursing jobs reached a new high in the three months to the end of September 2017.

"It has never been busier but is shedding experienced nurses quicker than it can find new ones"

Janet Davies

At that point there were 34,260 nursing and midwifery posts advertised, which is nearly 2,500 more than the previous quarter and more than 2,600 up on the same period in 2016.

The data also shows that, as of September 2017, nursing and midwifery had the highest percentage of unfilled whole-time equivalent (WTE) roles out of all NHS staff groups, accounting for 40%.

The figures come amid mounting concern over the number of nurses leaving the NHS, with the rate of departures outstripping the number entering the profession.

A breakdown according to trust type shows the highest number of nursing and midwifery vacancies at acute trusts. with more than 24,000 nursing jobs unfilled in the quarter up to September 2017.

There were nearly 7,500 vacancies in mental health trusts, nearly 2,250 in community providers, 217 vacancies in clinical commissioning groups, and 91 in commissioning support units.

As of September 2017, the highest number of WTE vacancies in nursing and midwifery were for band 5 roles at more than 6,700, followed by 2,650 band 6 roles and more than 1,000 band 7 jobs. There were more than 360 vacancies in nurse roles at band 8a and above and six vacant "senior manager" roles.

"It is particularly worrying to see the drop in numbers of community nurses"

Phillippa Hentsch

In addition, the latest available data on recruitment shows the NHS filled one nurse job for around every seven posts advertised across England in the three months up to June 2017.

However, some areas fared worse than others with the Thames Valley region hiring just five nurses for 1,957 advertised posts - roughly one new nurse appointment nurse for every 400 empty roles.

Meanwhile NHS organisations in the West Midlands NHS managed to fill the greatest number of posts, hiring 1,196 nurses and midwives for 2,817 roles advertised.

The second worst recruitment rate was seen in North West London with 42 nurses recruited for 2,545 posts - about one for every 60 vacancies.

Across the capital, the figures suggested there is just one nurse for every 24 or so jobs. But the Royal College of Nursing warned the situation was likely to be "much worse" as multiple vacancies were often advertised and recorded as single posts.

Bernell Bussue

RCN London regional director Bernell Bussue said the statistics painted a "shocking picture", with thousands of posts remaining empty "despite hospitals desperately advertising to fill them".

"The problem is not the willingness of providers to employ nurses, but the fact that they are having to fish from an ever shrinking pool," he said.

Nationally, RCN chief executive and general secretary Janet Davies said nurses were being driven away from the profession by low pay and stressful working conditions.

" The next generation of British nurses has been deterred by the current whirlwind tearing through the NHS - record pressure, lack of funding and poor pay for staff," she said.

"It has never been busier but is shedding experienced nurses quicker than it can find new ones," she said. "Earlier cuts to training places are exacerbating the problem just as long-serving staff feel demoralised and pushed to leave nursing."

Ms Davies called on the government to invest in the profession and ensure robust workforce planning. "When the government allows nursing on the cheap, patients can pay the highest price," she said.

"It is time to draw a line under this false economy with urgent investment in services and those who provide them - including a pay rise above inflation - and legislation to make ministers accountable for workforce planning and safe staffing levels," she added.

Responding to the vacancy statistics, the head of analysis at NHS Providers, Phillippa Hentsch, said: "These figures are a further reminder of the difficulties trusts face in recruiting and retaining nurses.

"They show that overall nursing and midwifery vacancies in the NHS rose by 19% in the last two years," she said. "It is particularly worrying to see the drop in numbers of community nurses."

She added: "We urgently need a sustainable approach to securing and developing an NHS workforce that is able to respond to growing and changing demand."

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Extent of nurse shortages revealed in new recruitment figures

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The statistics, released today by NHS Digital, reveal that the number of vacant nursing jobs reached a new high in the three months to the end of September 2017.

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https://www.independent.co.uk/news/health/brexit-latest-eu-nursing-shortage-hospital-social-care-nhs-a8618976.html

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the kings fund released a statement. saying that the nutse shortages are “symptomatic of a long term failure in workforce planning, which has been exacerbated by the impact of brexit snd short sighted immigration policies”.

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https://www.cnbc.com/2017/05/05/where-the-jobs-are-rural-hospitals-desperately-need-more-nurses.html

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https://www.bbc.co.uk/news/health-45837563

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costing NHS 1.5bn a year on agency nurses due to their own staff leaving.

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London hospital drops chemotherapy due to nursing shortage

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Patients at King George hospital will have to go elsewhere as NHS trust centralises care

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This has charts and statistics on the drastic falls of nurse and midwife applications.

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Brexit is set to exacerbate the NHS staffing crisis and a new report estimates that as many as 51,000 nursing staff will be needed by the time time the UK leaves in 2021 after its transition period.

This would mean the health services is missing the equivalent of 45 hospitals' worth of nurses, according to the report by the Cavendish Coalition, an alliance of 36 health and social care organisations which is urging government to step up recruitment and training to mitigate the loss of EU staff.

The latest NHS workforce figures have revealed a "grim" and growing gap in key staff with 41,722 nursing roles unfilled in June.

Brexit is set to exacerbate these gaps, particularly in the harder to fill specialties like social care nursing, and is likely to have added 2,700 from lost EU staff already.

Extrapolating this over the potentially three year Brexit transition period the report estimates Brexit could contribute to as many as 10,000 additional nursing vacancies

The report was written by the National Institute of Economic and Social Research, and it warns waiting times for patients are also increasing fastest in NHS Trusts which are losing more European workers, particularly nurses.

"These startling figures should be taken extremely seriously by those negotiating our departure from the EU," said Danny Mortimer, co-convenor of the coalition and chief executive of the NHS Employers organisation.

"The health and social care sector is deeply reliant on talented colleagues from across Europe and the rest of the world so it is deeply disheartening to see these projected workforce gaps at a time of rising demand for services."

The report makes a series of recommendations including: a call for an "uncomplicated" immigration process, a review into workforce planning for the health and social care sector and a call for the Home Office to guarantee that its settled status programme for EU nationals will be honoured in the event of a no-deal Brexit.

Commenting on the report, Nigel Edwards, chief executive at the health think tank the Nuffield Trust, said: "This is an extensive and credible report which should trouble everyone who cares about the future of health and care in the UK. Our own calculations have shown that with no further net migration or improvements domestically, social care could face a gap of up to 70,000 workers by 2025.

"The Government's reported plan to stem all immigration of less qualified people after Brexit, and the repeated ducking of tough choices on social care, make this worst case scenario look worryingly plausible."

Councillor Kevin Bentley who chairs the Brexit taskforce of the Local Government Association said councils were particularly concerned about the gaps.

"Eight per cent of social care staff are non-UK EU nationals and therefore represents one of the sectors most vulnerable to changes in migration rules.

"With people living longer, increases in costs and decreases in funding, adult social care is at breaking point. The recent report of the Migration Advisory Committee reinforces the need to improve pay and conditions for social care staff in order to attract the workforce that is needed.

A Department of Health and Social Care spokesman said: "We greatly value the contribution of nurses to the NHS and we hope those from the EU will take up the early opportunity to secure their future in the UK.

"There are 11,900 more nurses on our wards since 2010, 52,000 nurses currently in NHS training and we have made more funding available to increase university training places.

"Later this year, we will also set out plans to reform the adult social care system to make it sustainable for the future, including how better to attract and retain staff."
Additional reporting by PA

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NHS nursing vacancies could top 51,000 by the time UK leaves EU, report warns

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Brexit is set to exacerbate the NHS staffing crisis and a new report estimates that as many as 51,000 nursing staff will be needed by the time time the UK leaves in 2021 after its transition period.

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Shorter training period from 3years to 2years and bring back the NHS bursary 

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Shorter training period from 3years to 2years and bring back the NHS bursary 

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The NHS are only hiring one nurse for every 400 jobs advertised. Bernell Bussue: “The problem is not the willingness of providers to employ nurses, but the fact that they are having to fish from an ever shrinking pool”.

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The NHS are only hiring one nurse for every 400 jobs advertised. Bernell Bussue: “The problem is not the willingness of providers to employ nurses, but the fact that they are having to fish from an ever shrinking pool”.

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https://www.nursingtimes.net/news/workforce/extent-of-nurse-shortages-revealed-in-new-recruitment-figures/7022928.article

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Staff shortages will lead to more waiting times and delays in surgeries

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Staff shortages will lead to more waiting times and delays in surgeries

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Article with information about shortages with interesting statistics.

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The NHS in England has nearly 100,000 jobs unfilled, a situation described as "dangerously" understaffed.

The total represents one in 12 of all the posts in the health service and would be enough to staff 10 large hospitals.

It includes 35,000 nurse posts and nearly 10,000 doctor vacancies.

The figures have been revealed in a finance report, showing NHS services are heading for a £931m deficit this year, twice what was planned.

The overspend by hospitals, mental health trusts and ambulance services has been partly blamed on the need to cover the vacancies with overtime and temporary staff.

The accounts to the end of December also show higher than expected spending on paying the private sector to see NHS patients in an attempt to relieve the pressure on hard-pressed A&E units.

Despite the overspend, the forecast is still some way short of the record £2.45bn deficit accrued in 2015-16.

If you can't see the NHS Tracker, click or tap here.

Nigel Edwards of the Nuffield Trust think tank said the NHS was "dangerously" short of staff.

"In some ways, the lack of crucial workers in the NHS is an even bigger problem than the lack of funding.

"We can sign a cheque and bring back more money on-stream if the will is there, but there is no button to push which will suddenly bring us tens of thousands of qualified extra staff."

Royal College of Nursing general secretary Janet Davies added: "All the evidence shows that standards of patient care rise and fall as nurse numbers do.

"That was the lesson from Mid Staffordshire and we cannot afford to forget it."

Ian Dalton, head of NHS Improvement, the regulator that released the accounts, said the health service was working hard to tackle the problems.

He said staff deserved "heartfelt thanks" for their hard work.

A Department of Health and Social Care spokesman said: "We are supporting staff to improve work/life balance by working more flexibly and have announced the biggest ever expansion of training places for both doctors and nurses."

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NHS 'dangerously' short of 100,000 staff

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The NHS in England has nearly 100,000 jobs unfilled, a situation described as "dangerously" understaffed. The total represents one in 12 of all the posts in the health service and would be enough to staff 10 large hospitals. It includes 35,000 nurse posts and nearly 10,000 doctor vacancies.

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The NHS is hireing 1 nurse for every 400 jobs advertised. Nursing tomes

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The number of NHS vacancies have risen by almost 10% in the first quarter of this year and are expected to continue rising with experts warning that "widespread and growing nursing shortages now risk becoming a national emergency."

NHS Improvement's quarterly performance report showed that in England there were 107,743 NHS vacancies at the end of June, up from 98,475 back in March which bucks the downward trend seen over the past year.

The regulator has published the latest figures for the April to June period, showing over 40,000 nursing vacancies in total.

Independent think tank The King's Fund released a statement, saying that the nursing shortages are "symptomatic of a long-term failure in workforce planning, which has been exacerbated by the impact of Brexit and short-sighted immigration policies."

Siva Anandaciva, chief analyst at The King's Fund, added: "The right to start treatment within 18 weeks is enshrined in the NHS Constitution, yet three and half thousand people have now been on hospital waiting lists for more than a year and waiting lists stand at their highest levels in over a decade.

"This is unacceptable and the review of waiting time targets currently underway must ensure that patients not treated within initial time limits are protected from lengthy waits for treatment."

Around 1.1 million full and part-time staff are currently employed by the NHS, according to figures from NHS Improvement, with 9.2% of all posts not filled.

Between April and June NHS trusts spent £805m on bank staff, £102m more than planned, and an additional £599m on agency staff, £32m over budget.

Anandaciva added: "With hospitals and other NHS providers once again forecasting a significant end-of-year deficit, it is clear that the NHS finance regime is broken, with financial targets routinely missed and huge financial problems in some NHS organisations offset by surpluses in others.

"Today's report is a reminder that the forthcoming NHS long-term plan must focus on reform and investment in new ways of delivering services otherwise the NHS will be trapped in a perpetual winter crisis."

Responding to the Q1 financial and performance report, NHS Providers chief executive Chris Hopson said: "NHS trusts are doing all they can to respond to a triple challenge of rapidly increasing demand, growing workforce shortages and continuing pressure on NHS finances.

"But however hard they run, they don't seem able to outpace the increase in demand.

"Trusts tell us they are most worried about the workforce shortages they face, and it's a real concern that these figures have shown such a big increase in vacancy levels. It's worrying that this problem is getting worse rather than better."
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NHS nursing shortages risk becoming a 'national emergency'

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The number of NHS vacancies have risen by almost 10% in the first quarter of this year and are expected to continue rising with experts warning that "widespread and growing nursing shortages now risk becoming a national emergency."

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risk of becoming a national emergency

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Kings Fund: the health care workforce in England: Make or Break:

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Kings Fund: the health care workforce in England: Make or Break:

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15th November 2018

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Test 1: Is there a funded and credible strategy to address the immediate workforce shortages - including addressing forecast critical shortages in job specialties and specific geographic areas?

There are significant staff shortages across the NHS. There are over 100,000 vacancies across NHS trusts (1 in 11 posts) with the vast majority of these vacancies filled by bank or agency staff. In addition, the staff that are in post are under increasing stress: the latest NHS staff survey showed that 38% of staff had felt unwell during the previous 12 months due to work-related stress.

One of the greatest challenges lies in nursing. One in eight posts is vacant, with 36,000 nurse vacancies in the NHS. There are worrying increases in numbers of nurses leaving the NHS, particularly at younger ages: in 2016/17, 5,000 more nurses left NHS employment than in 2011/12.15 Had the rate remained at 2012 levels through to 2017, there would have been 16,000 more nurses working in the NHS - almost half the currently vacant nurse posts filled.

Brexit has created additional risks in both the short and medium term. Already, a net inflow of nurses from the EU into the NHS has turned into a net outflow: between July 2017 and July 2018, 1,584 more EU nurses and health visitors left their roles in the NHS than joined.

Finally, a reduced cohort of young people leaving school and the loss of bursaries for nursing places has seen the number of applicants for nursing courses decline, with an 18% drop (11,750 fewer applicants) between 2016 and 2017 - the biggest fall in nursing applicants on record. The anticipated expansion in the nursing training pipeline of 10,000 additional nurses has not materialised.

There are also challenges in medicine, particularly in some specialties and geographical areas. GP practices are struggling to recruit and retain doctors such that the number of GPs has fallen in recent years. Similar issues are faced in psychiatry, and core psychiatry training is now on the Migration Advisory Committee shortage occupation list. A recent survey by the Royal College of Physicians found that 53% of consultants and 68% of trainees said that there were 'frequently' or 'often' gaps in hospital medical cover that raised significant patient safety issues.

As the Care Quality Commission highlighted in their recent State of care report, workforce shortages are having a direct impact on the quality of people's care. These shortages must be addressed.
Action needed
In the short term, it is critical that there is concerted action to improve retention and active support for international recruitment. While NHS Improvement is actively engaging with trusts on improving retention from a national perspective, the local picture is variable. Moreover, international recruitment of health professionals has been constrained by a restrictive immigration policy compounded by Brexit, lack of national coordination, and a number of regulatory hurdles from some professional bodies. Addressing these issues will be key to addressing the immediate workforce challenges.

Test 2: Is there a funded and credible long-term strategy to deliver a sustainable workforce over the next 10 years?

Our projections suggest that without significant remedial action, the current gaps in the NHS workforce will increase significantly and undermine the future sustainability of services.

Given the ageing population, increasing dependency ratios and a growing burden of chronic diseases and multimorbidity, demand for health care services will grow. In order to keep up with these pressures alone, the Institute for Fiscal Studies and the Health Foundation calculate that acute activity in England would need to increase by 40%, and health spending would need to rise by 3.3% per year on average.

If current models of care and staffing continue, this would see the need for health care workers in the NHS increase to over 1.5 million FTE staff. Current estimates of trends in supply suggest that available staff will not increase by anywhere near that rate. Our projections estimate that by 2030, the gap between supply of and demand for staff employed by NHS trusts could increase to almost 250,000 FTE posts.

This position could be further exacerbated if the emerging trends of clinical staff leaving the NHS well before retirement age continue and international migration is unable to support the short-term gaps. The nursing workforce is also ageing: nearly a third of qualified nursing, midwifery and health visiting staff are over 50 years old, with one in three expected to retire in the next 10 years.

While international recruitment is a useful short-term fix, it is not a long-term solution, and there are ethical concerns about taking trained workers from developing countries. The World Health Organization has projected workforce demand across 31 of its member countries, with the results suggesting that by 2030 all countries could experience shortfalls of about 50,000 midwives, 1.1 million nurses and 750,000 doctors. As with all such projections the results must be treated with some caution, but they are consistent with other evidence of rapid global growth in demand for health care professionals, which is increasing at a faster rate than supply.

If the emerging trend of staff leaving the workforce early continues and the pipeline of newly trained staff and international recruits does not rise sufficiently, this suggests a worst-case scenario of a shortage of more than 350,000 FTE staff in NHS trusts by 2030, according to our projections (see Figure 1).

Gaps of this size will require significant action over and above that suggested for addressing shortages in the short term. The domestic training pipeline will need to secure adequate numbers of clinical staff to meet growing needs, with allowance for a worst-case scenario. Traditionally, the NHS has been keen to avoid an oversupply of clinical professionals, and has relied on overseas migration to fill workforce gaps. But in the context of major global workforce shortages, it would be prudent to plan for a degree of oversupply.

The government has increased numbers in the pipeline for doctors and we are now slightly above the OECD average for doctors in training. But numbers of nurses in training are low by international standards - half that of the United States or Australia - and the promised 10,000 increase, as mentioned previously, is not yet evident.
Action needed
The priority, then, should be to expand the number of student nurses and look beyond traditional routes to maximise the opportunities offered through alternative routes, such as apprenticeships, and under-represented groups. Achieving the necessary level of expansion will require the government to review and improve the targeted incentives on offer, financial and otherwise, to students entering the profession, and to employers looking to become more directly involved in supporting education opportunities.

Test 3: Is there a funded and credible strategy to support new ways of working across the health care workforce?

Rapidly changing patient needs, alongside medical and technological advances, will require all frontline staff to acquire new skills and adopt new ways of working over the next 10 years. But at present the NHS struggles to make full use of the capabilities of its staff and new technologies, and progress is far, far too slow.

For example, access to and effectiveness of primary and secondary care could be significantly improved through enhanced contributions from nurses and allied health professionals working in advanced roles as part of multidisciplinary teams alongside doctors and other staff. This would also help to achieve better workload balance, with staff contributing at the optimum level of their skill set.

This is already happening in isolation in some parts of the system, but it needs to happen at greater scale and pace. For example, pharmacists can take on medication reviews and some elements of long-term condition management. Likewise, with musculoskeletal conditions making up around a fifth of the GP workload, enabling patients to self-refer to a physiotherapist has been shown to be a safe, cost-effective alternative. One estimate suggests that up to a quarter of a GP's overall time could be saved through new ways of working, with greater use of other staff.

Technological developments, including the widespread use of digital tools and intelligent devices, also have significant implications for the roles and functions of the health workforce. The long-term plan needs to focus clearly on the mechanisms for adoption and deployment of new technologies and their implications for the workforce. Staff need to be equipped with new technologies and the necessary digital skills and be supported to work differently to maximise the potential benefits. At present, this is only taking place in a piecemeal way. It is largely being left to individual organisations, leading to patchy implementation and adoption and limiting the scope for realising the benefits at scale.
Action needed
The central investment in ongoing training and development for existing staff is now a third of its 2014/15 value. The £84m dedicated nationally to workforce development in the NHS32 in 2018/19 is wholly inadequate to equip this huge workforce with the skills and capabilities it needs to be as productive as possible.

A significant uplift in investment is required to deliver a step-change in capabilities at local level. But solutions are about more than money. In primary care in particular there needs to be greater support to equip staff with the time and space to develop new skills and ways of working.

Test 4: Is there a credible strategy for addressing inequalities in recruitment, pay and career progression by gender, ethnicity and occupation?

The 2017 NHS staff survey showed that one in eight staff had experienced discrimination at work during the past 12 months and one in six did not believe that their organisation provided equal opportunities for career progression or promotion. While the NHS has made progress in addressing unwarranted inequalities in pay, there is evidence that disparities still exist.

In 2017, for directly employed NHS staff in the health service in England - 77% of whom are women and 23% men - the estimated median basic FTE pay gap between men and women was 8.6% in favour of men.

The gap is significantly worse for women in some ethnic groups. Asian/ Asian British and Chinese women experience the largest gender pay gap at 21.3% and 20.9%, respectively, followed by those of mixed ethnicity (13.5%), white women (6.1%) and women of any other ethnic background (2.1%). The gender pay gap only favours women in the case of black/ black British staff (2.2%).

There are also significant ethnicity pay gaps within some major staff groups. For Asian/Asian British managers (including senior managers) and nurses, the pay gap in favour of white staff is 10.8% and 8.5%, respectively.
Action needed
A complex array of factors drive differences in earnings, and more research will be needed to understand them. But we know that under-representation at senior levels of any group of staff is not beneficial for organisations. Many studies have shown that a motivated, engaged and valued workforce helps deliver high-quality patient care, increased patient satisfaction and better patient safety.37 Addressing gender, race and other inequalities must be a key feature of national and local workforce strategies. This must be accompanied by a commitment to inclusive leadership and developing cultures that engage staff and result in high-quality, compassionate care.

Test 5: Is there a plan to strengthen workforce and service planning at all levels of the system, including alignment of the institutional accountabilities and responsibilities for these?

A litmus test for the credibility of the long-term plan is whether it addresses the workforce implications of the proposals it contains in addition to estimating the staff needed to meet rising demand. Service leaders have acknowledged that proposals will only be deliverable if the workforce required to deliver them is put in place. For example, long-standing objectives to reach parity of esteem between physical and mental health will fail if the NHS cannot overcome the existing deep shortages in mental health staffing.

NHS history is sadly littered with examples of policy ambitions that were not underpinned by robust workforce strategies - the most notable being the desire to shift care out of hospitals. Despite the overarching policy commitment to move care away from hospital and towards primary care,38 in the period from 2006 to 2014 the number of hospital consultants increased by almost a third (32%) compared with just a 5% increase in GP numbers. This trend has been exacerbated over the period since 2014, during which the number of GPs has actually fallen. Meanwhile the number of nurses in community services has fallen by around 14% since 2009, and the number of district nurses has declined by 45% over the same period. Unsurprisingly, the anticipated shift has not taken place.
Action needed
Alongside specific policy changes and investment, the long-term plan needs to establish a new system and approach to workforce issues. At the heart of this should be a much more coherent and transparent national-level approach to workforce planning and strategy across the health and care system. Health Education England and NHS Improvement recently announced plans to work together more closely. This may help, but falls short of what is really required, which is a stable platform for workforce policy and planning, based on a strategic approach, agreed and coordinated responsibilities and allocated functions.

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In advance of the publication of the NHS long-term plan, this briefing highlights the scale of workforce challenges now facing the health service and the threat this poses to the delivery and quality of care over the next 10 years.

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is NHS really free with so much privatising?

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is NHS really free with so much privatising?

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Ageing well: whose responsibility is it?

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Growing numbers of older people are not a burden or a threat - but they do need the services and support to ensure they age in better health and inequalities are reduced, says David Oliver

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Threatened social worker: 'Was he going to follow me?'

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Threatened social worker: 'Was he going to follow me?'

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'I worried he was going to follow me home'

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Social workers have been traced on social media with some needing police protection, representatives claim.

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NHS suffering worst ever staff and cash crisis, figures show

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NHS suffering worst ever staff and cash crisis, figures show

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NHS suffering worst ever staff and cash crisis, figures show

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Number of vacancies at record high in England as underlying deficit of £4.3bn revealed

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Rise in attacks on NHS workers blamed on lack of staff and delays

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Rise in attacks on NHS workers blamed on lack of staff and delays

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Rise in attacks on NHS workers blamed on lack of staff and delays

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Hospital trusts in England reported 56,500 assaults in 2016-2017, up 10% on year before

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Please watch this short video about privatisation in the NHS

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Please watch this short video about privatisation in the NHS

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Add your comments, thoughts or questions below

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Privatisation of the NHS: Allyson Pollock at TEDxExeter

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The Kings Fund (2013): Predictions for the future of Health & Social Care (Produced in 2013)

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The Kings Fund (2013): Predictions for the future of Health & Social Care (Produced in 2013)

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Future of health and social care 2013-2033

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An ageing population simply means that, on average, we are living to an older age, and the NHS and health and social care are effectively the key influences behind this. The knowledge and research which has been obtained and undertaken since these services were first introduced has led us to where we are today, with a growing population which is staying alive and healthier for longer. However, with the growing and ageing population comes the result of more illnesses and diseases, and the funding to research and treat these, in order to again keep us healthy and alive for longer. This has effectively created a spiraling cycle of living longer due to research, then needing more research, and so on, which has, and will cause a strain on the services and the ways it's funding can be stretched.

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What are your thoughts on their predictions?

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What are your thoughts on their predictions?

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The public opinion on health and social care services fall quite broadly, however, it is clear that much of the public believe that although there has been improvement throughout the years, there is due to be a downfall due to funding issues which have been experienced during recent years. Therefore, some members of the public agree that an increase in tax payments, by the public, would be beneficial in keeping health and social services afloat and ensuring their efficiency and effectiveness in it's service provision.
https://www.health.org.uk/sites/health/files/Polling2017_web.pdf

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This report suggests that in 2017 satisfaction fell to its lowest level since 2007. Lack of funding streams through as a main reason for the dissatisfaction and awareness of this pressure is high. There is a feeling that there are not enough nurses and that money is wasted and at the same time not enough money was being spent. Satisfaction lies with the quality of care, the staff and their behaviour, the range of services/treatments and the fact that it is still free at the point of use.

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Since 1983, NatCen Social Research's British Social Attitudes (BSA) survey has asked members of the public about their views on, and feelings towards, the NHS and health and care issues generally. The latest survey was carried out between July and October 2017 and asked a nationally representative sample of 3,004 adults in England, Scotland and Wales about their satisfaction with the NHS overall, and 1,002 people about their satisfaction with individual NHS and social care services.

In the analysis that follows, the differences highlighted are statistically significant at the 95% level unless otherwise stated.

Key findings

Satisfaction with the NHS overall

Public satisfaction with the NHS overall was 57% in 2017 - a 6 percentage point drop from the previous year. At the same time, dissatisfaction with the NHS overall increased by 7 percentage points to 29% - its highest level since 2007.

Older people were more satisfied than younger people: 64% of those aged 65 and over were satisfied with the NHS in 2017 compared to 55% of those aged 18 to 64. Between 2016 and 2017, satisfaction fell among all age groups.

The four main reasons people gave for being satisfied with the NHS overall were: the quality of care, the fact that the NHS is free at the point of use, the attitudes and behaviour of NHS staff, and the range of services and treatments available.

The four main reasons that people gave for being dissatisfied with the NHS overall were: staff shortages, long waiting times, lack of funding, and government reforms.

Satisfaction with NHS and social care services

Satisfaction with GP services fell to 65% in 2017 - a 7 percentage point drop from the previous year. This is the lowest level of satisfaction with GP services since the survey began in 1983 and the first time that general practice has not been the highest rated service.

Satisfaction with outpatient services was also 65% in 2017. The change from the previous year was not statistically significant.

Satisfaction with inpatient services was 55% in 2017, down by 5 percentage points from 2016.

Satisfaction with accident and emergency (A&E) services was 52% in 2017. The change in satisfaction from 2016 was not statistically significant.

Satisfaction with NHS dentistry services was 57% in 2017. The change from the previous year was not statistically significant.

Satisfaction with social care services was 23% in 2017. The change from the previous year was not statistically significant. At the same time, dissatisfaction with social care services increased by 6 percentage points in 2017 to 41%.

How satisfied is the British public with the NHS overall?

In its 70th year, polling shows that the NHS remains a treasured national institution that is a key part of the British national identity. The public is unwavering in its support for the underlying principles of the NHS and consistently prioritises the health service for extra government funding, above other public services like education and welfare.

Yet while support for the founding principles of the NHS changes little over time, the public's satisfaction with the service is not as constant, fluctuating in response to changes in issues like waiting times, patient experience, funding and the political environment.

For 35 years, the BSA survey has asked a sample of the public 'how satisfied are you with the way the NHS runs nowadays?'. Responses to this question have provided a unique insight into how public views on the NHS change over time.

In 2017, satisfaction with the NHS was 57% (combining the percentages of 'very' and 'quite' satisfied responses). This is 6 percentage points lower than the previous year.

At the same time, public dissatisfaction with the NHS grew to 29% in 2017, a 7 percentage point increase from the previous year, and the highest level of dissatisfaction with the NHS since 2007. Dissatisfaction with the NHS has risen rapidly over the past three years: between 2014 (when dissatisfaction was at an all-time low) and 2017, the level of dissatisfaction almost doubled, rising from 15% to 29%.

Because of these changes, net satisfaction (calculated as satisfaction minus dissatisfaction) was 28% in 2017 - its lowest level since 2007.

Why is the British Social Attitudes survey so important?

There is a lot of different polling about people's views and attitudes towards the NHS. What are the differences, and where does the British Social Attitudes survey fit in?

Surveys that differ in their findings often do so because of different question wording or approaches to conducting the survey. For example, large-scale patient experience surveys ask people about their experiences of using the service. Their results are relatively stable over time, usually changing by only a small amount each year. This is partly because participants tend to have a particular experience of care (for example in maternity or cancer services), and often a long-standing relationship with a clinician or health care organisation, in their mind when responding.

Polling on public attitudes is different, because people tend to focus on wider issues as well as their experience of care when responding. Not everyone responding to a public poll will have used the NHS recently.

Public polling about the NHS asks a range of questions that explore subtly different aspects of satisfaction. For example, a recent Ipsos MORI survey found that 62% of people thought the NHS would get worse over the next few years. This measures optimism about the future and so is not the same as the BSA survey question about current satisfaction with how the service is run.

Surveys may also yield different results because they use different methodologies, cover a different population or ask questions in a different order.

The BSA is widely viewed as a robust survey that uses a randomly selected sample of the British public, and it is conducted using a 'gold standard' survey methodology that involves a face-to-face interview with multiple follow-ups with non-responders. The survey is conducted the same way every year and the data provides a rich time trend going back to 1983, adding a depth and context to the findings that no other measure of NHS satisfaction can give us. As a result, when satisfaction falls in the BSA survey, we are as confident as we can be that it reflects a genuine change in public attitudes.

Who is most satisfied with the NHS?

Figure 2 shows how satisfaction with the NHS differs between groups in the population. For each group, we have included black bars showing the 95% confidence interval around each value. These show the range of values that, based on the survey data, we can be 95% certain include the true satisfaction level for each group. Where the confidence intervals overlap, we cannot be
confident that the true satisfaction levels differ between groups.

Satisfaction levels differ depending on the respondent's age and ethnicity. Younger respondents under the age of 65 report lower levels of satisfaction (55%) than those aged 65 and older (64%). Respondents aged 75 and older report even higher levels of satisfaction (69%).

Looking at the data on ethnicity, respondents who identify as Black report lower levels of satisfaction (44%) than respondents who identify as White (58%). Satisfaction among respondents who identify as Asian (54%) was lower than among White respondents, but the difference was not statistically significant. Patient experience surveys also find that patients from minority ethnic groups report more negative experiences, and this may be a contributing factor to differences in the satisfaction levels reported in the BSA survey.

The differences in satisfaction levels between men and women; across different income groups; between those who have and haven't had recent contact with NHS inpatient services in the past year; between those who voted to remain or leave in the 2016 EU referendum; and between supporters of different political parties are not statistically significant (although supporters of the Liberal Democrats have a significantly higher level of satisfaction than respondents who support no political party).

The grey diamonds in Figure 2 show the results for the 2016 BSA survey. Between 2016 and 2017, levels of satisfaction reduced in every group that we looked at, although not all of the changes are statistically significant. The only group who reported a higher level of satisfaction in 2017 compared to 2016 was people in the lowest income quartile (although again the change was not statistically significant).

How satisfied is the British public with different NHS and social care services?

The survey also includes a set of questions that explore public views about specific health and social care services. When interpreting this data, it is important to remember that this is not a patient experience survey. It is a survey of public views, and many respondents may not have used the service they are being asked to comment on in the past year. Because of this, the survey asks respondents to draw on 'your own experience, or from what you have heard', meaning the experiences of family and friends and information from other sources such as the media are likely to influence their responses.

Of the six questions on satisfaction with individual health and care services, GP satisfaction is the closest that the BSA survey gets to an experience measure. Most of the people who responded to the survey will have visited their general practice in the past year, either for themselves or with a family member.

In 2017, satisfaction with GP services fell to 65%, the lowest level in the survey's 35-year history (Figure 3). Satisfaction dropped by 7 percentage points between 2016 and 2017, which is the biggest one-year change since the survey began. In line with this, dissatisfaction with GP services was at an all-time high in 2017, jumping 6 percentage points to 23%.

NHS England's national GP patient survey (which covers England, rather than Britain) includes a similar question that provides a useful comparator for these results ('Overall, how would you describe your experience of your GP surgery?') . In a similar way to the BSA satisfaction measure, the proportion of patients who describe their experience as 'good' has steadily decreased
in recent years, from 89% in July 2012 to 85% in July 2017. The proportion describing their overall experience of making an appointment as 'good' also decreased from 79% to 73% over the same period.

Satisfaction with NHS dentistry was 57% in 2017, 4 percentage points lower than the previous year, but the change was not statistically significant (Figure 4). Satisfaction with dentistry services remains at one of the highest levels seen this century. As we discussed last year, the relatively high rates of satisfaction compared to the mid-2000s is likely to be partly explained by efforts to increase access to NHS dentistry services over the past 10 years. NHS England's GP patient survey also asks respondents about their overall experience of NHS dentistry services. It reported no change in patient satisfaction between 2016 and 2017, but there has been a small increase since 2012 (from 83% to 85%).

The BSA survey also asks about satisfaction with social care services (Figure 4). For the past six years, this question has defined social care as 'personal support services provided by local authorities for people who cannot look after themselves because of illness, disability or age'. In 2005 and 2007, the question was worded slightly differently, not mentioning local authorities in its definition of social care. Figure 4 shows that levels of satisfaction with social care have been declining since 2007. In 2017, satisfaction with social care services was 23%. Although the change
in satisfaction from the previous year was not statistically significant, satisfaction was 7 percentage points lower than in 2012. Dissatisfaction with social care services increased by 6 percentage points in 2017 to 41%.

The survey also asks about satisfaction with hospital services (Figure 5). Satisfaction with inpatient services dropped by 5 percentage points in 2017 to 55%, following four years in which there was no statistically significant change. Meanwhile, satisfaction with outpatient services remains relatively high, historically speaking, at 65%, and the change from the previous year was also
not statistically significant. Satisfaction with A&E services, which was 52% in 2017, has not changed significantly for the past three years.

Levels of satisfaction with the three hospital services included in the survey broadly follow the same trend as satisfaction with the NHS overall. This is perhaps because these are services that the public has less personal experience of, so - as is likely the case with overall NHS satisfaction - respondents draw on a range of sources to inform their views about the NHS, from friends, family and elsewhere.

Figure 6 brings together public satisfaction data for health and social care services and the NHS overall in 2017. As in previous years, satisfaction with the social care services provided by local authorities is far lower than satisfaction with health care services.

A higher percentage of respondents say that they 'don't know' what their satisfaction level is or provide a neutral answer that they are 'neither satisfied nor dissatisfied' with social care compared to other services. This is likely to reflect a lower level of understanding among the public about what social care services actually are, coupled with less experience of using them.

In 2017, net satisfaction with social care services (calculated as satisfaction minus dissatisfaction) was -18%, whereas net satisfaction with the NHS overall and individual NHS services ranged from +28% to +52%.

Figure 7 presents trends for all of the BSA survey's health and social care satisfaction measures since 1983. It shows that, throughout the survey's history, general practice has received higher satisfaction ratings from the public than other health and care services and the NHS overall. The difference was most stark in the 1990s and early 2000s, when satisfaction with general practice was around 20 percentage points higher than satisfaction with hospital-based services and the NHS overall. However, the steady decline in satisfaction with general practice in recent years (from 80% in 2009 to 65 per cent in the latest data) and increases in satisfaction with hospital-based services have led to a convergence in satisfaction rates across services. In 2017, for the first time since the survey began, general practice was not the highest-rated service: outpatient services received the same satisfaction rating (65%) as general practice.

Figure 7 also shows that between 1983 and 2003, satisfaction with the NHS overall was lower than satisfaction with individual NHS services. From 2004 onwards, improvements in overall satisfaction brought it closer to satisfaction with individual services. (Overall satisfaction was higher than satisfaction with A&E, inpatient and dentistry services and lower than satisfaction with GP and outpatient services for most of the period from 2004.)

What drives public satisfaction?

Over the last few years, we have asked some additional questions to try to better understand the responses to the BSA survey's question about satisfaction with the NHS overall. We know that the public draw on more than their experience of NHS services when reporting their satisfaction level, but understanding why satisfaction changes from year to year is not a precise science. To explore this further, we ask respondents why they said they were either satisfied or dissatisfied with the NHS overall. The question presents people with nine possible reasons to explain their response, and asks them to select up to three. The lists of reasons were developed with a group of respondents who were asked an open-ended question about why they were either satisfied or dissatisfied.

Figure 8 shows that the 57% of respondents who were either 'very' or 'quite' satisfied with the NHS overall in 2017 selected five main reasons to explain their responses. The majority told us that they were satisfied with the NHS because of the quality of care provided and because the service is free at the point of use. Positive feelings about NHS staff and the range of services available were
selected as reasons for satisfaction by just over two in five, and the length of wait for general practice and hospital appointments was selected by almost a third.

While reasons for satisfaction mainly centred on quality and the underlying structure of the NHS (free at the point of use, with a wide range of services available), reasons for dissatisfaction mainly related to resourcing issues. Figure 9 shows that, among the 29% of respondents who were dissatisfied with the NHS in 2017, the majority put this down to long waiting times, lack of funding or a lack of staff in the NHS. Around a third of dissatisfied people said this was because of government reforms to the health service, and a quarter said their dissatisfaction was due to money being wasted in the NHS. This shows that dissatisfaction was driven by negative views about decisions on resourcing, rather than negative views about the core principles of the NHS.

It is interesting that very few people gave 'stories in the media' as a reason for expressing either satisfaction or (in particular) dissatisfaction with the NHS - despite widespread media coverage about pressures on NHS services (see 'Media coverage of the NHS in 2017' box below.). It may be that media stories have an indirect impact on underlying attitudes that is not immediately obvious to the respondent.

The survey has included these additional questions since 2015, which means that changes in responses can now be tracked over time. Figure 10 shows changes in the five most popular reasons for dissatisfaction with the NHS in 2017, over the past three years.

Between 2015 and 2017, the proportion of respondents who were dissatisfied because the government 'doesn't spend enough money on the NHS' increased from 39% to 51% and the proportion who were dissatisfied because there are 'not enough NHS staff' increased from 44% to 52%. At the same time, the proportion who were dissatisfied because they felt that 'money is wasted in the NHS' decreased from 35% to 25%. This suggests that the increase in dissatisfaction over the past three years (from 23% to 29%) can be partly explained by a view among the public that extra resources are needed for the health service.

There has also been a significant increase over the past three years in the proportion of respondents who are dissatisfied because of 'government reforms that affect the NHS' (up from 20% of dissatisfied respondents in 2015 to 32% in 2017).

The 2017 BSA survey took place against a backdrop of significant high-profile media coverage for the NHS, and at a time when the public ranked the NHS as the biggest issue facing the country, reporting their highest level of concern in 15 years.

The year started with a striking image on the front page of the Daily Mirror of a sleeping toddler in A&E lying on two pushed-together chairs. During the same week, the Red Cross said that winter pressures meant the health service was witnessing a 'humanitarian crisis'.

During the build-up to June's snap General Election, the subject of social care caused problems for the Conservative Party when their social care manifesto policy was coined by the media and critics as a 'dementia tax'. For several days after the policy was announced, social care and the debate on care for older people more generally were pushed to the top of the news agenda.

When Britain experienced three terrorist attacks between March and June, praise for the emergency services, including NHS staff, was echoed strongly across the media by victims, politicians, journalists and the general public. From 20 June to 11 July, BBC2 broadcasted 'Hospital', a four-part fly-on-the-wall documentary following the staff of St Mary's Hospital in Paddington, London, with the first episode showing how they responded to the Westminster terrorist attack.

In August, while the survey was being conducted, the number of people waiting for surgery in England topped four million for the first time in 10 years, leading to extensive coverage across print and broadcast media. Calls for increased funding for the NHS have continued to receive regular media coverage.

Conclusion

The BSA survey has now been monitoring public views for half of the 70-year life of the NHS. This data provides its richest insights when viewed over decades, rather than years. Looking at the 2017 data through that long-view lens reminds us that overall NHS satisfaction levels remain higher than they were in the 1990s and early-to-mid-2000s. Nevertheless, the statistically significant fall in satisfaction (and rise in dissatisfaction) in 2017 took net satisfaction to its lowest level since 2007. With an increase over the last few years in the proportion of survey respondents reporting lack of funding as a reason for their dissatisfaction, it seems the public is increasingly aware of the reality of funding pressures that the NHS has experienced over the last seven years. With equally small increases in funding planned over the next few years and NHS performance on key headline measures worsening, it is hard to see the public's satisfaction with the NHS improving in the near future.

Footnotes

1. The 2017 BSA survey questions on satisfaction with the NHS reported here were jointly sponsored by the Nuffield Trust and The King's Fund. (Back to text)

2. If a difference or change is statistically significant at 95%, we can be 95% confident that the survey result reflects a real change or difference in public views, rather than being down to chance. Where a difference or change is not statistically significant, we cannot be confident that it reflects a real change or difference in public views. (Back to text)

Methodology

Sample and approach

The 2017 survey consisted of 3,988 interviews with a representative sample of adults in England, Scotland and Wales. Addresses are selected at random and visited by one of NatCen Social Research's interviewers. After selecting (again at random) one adult (aged 18 and over) at the address, the interviewer carries out an hour-long interview. The participant answers most questions by selecting an answer from a set of cards.

The sample size for the overall NHS satisfaction question reported here was 3,004 in 2017; for questions about satisfaction with other NHS services the sample size was 1,002. The data is weighted to correct for the unequal probabilities of selection, and for biases caused by differential non-response. The weighted sample is calibrated to match the population in terms of age,
sex and region. The margin of error in 2017 for the health care questions was around +/-1.4 to 3.7 percentage points.

The majority of fieldwork for the 2017 survey was conducted between July and October, with a small number of interviews taking place in November.

Topics

The topics covered by the survey change from year to year, depending on the identities and interests of its funders. Some questions are asked every year, some every couple of years and some less frequently.

Funding

The survey is funded by a range of charitable and government sources, which change from year to year. The survey is led by NatCen Social Research. NatCen carries out research in the fields of social and public policy, uncovering the truth about people's lives and what they think about the issues that affect them. As an independent, not-for-profit organisation, NatCen focuses its time
and energy on meeting clients' needs and delivering social research that works for society.

Acknowledgements

Many thanks to Eleanor Attar Taylor from NatCen for her assistance with data analysis, to Kirsty Ridyard from the Nuffield Trust for her analysis of media stories during the field period and to all of our colleagues at The King's Fund and Nuffield Trust who provided helpful comments on earlier drafts and helped with the editing, digital content and launch of this report. Most importantly, we would like to thank members of the British public for the time they took to complete this survey and for providing us with this fascinating dataset.

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Public satisfaction with the NHS and social care in 2017: Results and trends from the British Social Attitudes survey

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Since 1983, NatCen Social Research's British Social Attitudes (BSA) survey has asked members of the public about their views on, and feelings towards, the NHS and health and care issues generally.

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What does the public think of current H&SC services?

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More GP consultations via Skype and barcode tracking of patients and their treatments in hospitals - these are two of the uses of technology the new health and social care secretary was enthusing about in his first speech since taking on the job.

Matt Hancock sees the tech agenda in the NHS as one of his early priorities.

He arrived at the department after Jeremy Hunt moved to the Foreign Office.

Less than a fortnight later he was setting out his stall in front of an NHS audience at the West Suffolk Hospital.

Technology, as he acknowledged, is his passion and he has already launched his own app for communicating with constituents.

He went out of his way to praise the online NHS service, known as GP at Hand, run by the private provider Babylon.

This was launched in Greater London in 2017 and offers patients the chance to have a video consultation with a GP within two hours, or a face-to-face appointment the same day or next day, Monday to Saturday.

Mr Hancock argued that this online service "works brilliantly for me" and he wants to "see more technology like this available to all, not just a select few in a few areas of the country".

This appeared to be giving local NHS leaders and GPs the green light to develop partnerships with Babylon and other tech companies for online patient consultations.

Advocates of GP at Hand, like the secretary of state, argue that it is convenient for a commuting population who don't want to have to stay off work to get an appointment at a local surgery.

They also say that the service will help reduce pressure on GP practices by absorbing some of the patient demand.

But opponents, including the British Medical Association, point out that traditional surgeries will be left to deal with the sickest patients with long-term conditions, while younger and healthier sections of the population are cherry-picked by online services.

GP practices are paid a fee for every patient regardless of their state of health, and they lose this payment when a patient switches to a different provider.

Diagnosis concerns

Concerns about GP at Hand have been raised, including suggestions that symptoms of some conditions could be missed and that there is a tendency to over-diagnose.

Jeremy Hunt wrote to the Commons Health and Social Care Committee in early July, noting that while digital services were increasingly being brought forward there was a need to safeguard patients and the wider system.

To that end, Mr Hunt said there was an independent evaluation under way with an interim report in October, which would inform future policy in this field.

Less controversial in the digital health arena is a scheme highlighted by Matt Hancock to allow better tracking of patient care and the use of medical devices.

The Scan4Safety scheme involves barcode readers familiar in the retail world.

These involve scanning of patient wristbands as they move through hospitals and use certain products as part of their care, making it easier to track and trace equipment and drugs which are faulty.

Mr Hancock says this is saving NHS money and improving patient safety, though so far it has been on trial in only six trusts in England.

Winter test

Technology in the NHS will only go so far, and the new secretary of state is well aware of that.

Looming ahead of him is his first winter in the job and the inevitable pressures which will engulf the system.

He has indicated that he is open to amending key NHS targets, such as the four-hour A&E benchmark.

This has been suggested by the head of NHS England, Simon Stevens.

That might sound fine in theory, as they have been repeatedly missed, but changing the goalposts as winter approaches may not be good politics.

We will hear a lot more of the NHS technology agenda - Mr Hancock's enthusiasm for it will be welcomed.

But the test for most patients will be the length of time they have to wait for care by GPs or hospital staff.

That is how he will be judged.

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Tech an early priority for health secretary

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More GP consultations via Skype and barcode tracking of patients and their treatments in hospitals - these are two of the uses of technology the new health and social care secretary was enthusing about in his first speech since taking on the job.

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Ted talk exploring the technology and how it can change healthcare.

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Ted talk exploring the technology and how it can change healthcare.

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The Empowered You: How Healthcare Is Evolving With Technology | Daniel Kraft | TEDxBeaconStreetSalon

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As we learn more and more about the role of the Gut microbial system  and how it affects our health and wellbeing, research continues on the potential for Fecal transplants. It is what it suggests, the transplantation of fecal matter from a healthy, screened donor into the body of a compromised gut microbial system. The potentials are far reaching with suggestions that it can help with conditions such as inflammatory bowel disease to allergies, to diabetes and obesity and even depression.
The possibilities, if carried out very carefully could be far reaching.
I found one case of a patient treated successfully with c-diff, an infection caused by antibiotics obliterating the microbial system, who had suffered with alopecia that started growing hair as a side effect.

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Aug. 1, 2018 -- Madelynn Hernandez was in a battle. The California teenager loved to draw, dance, and study math, but her Crohn's disease was seriously getting in the way.

"I had so much nausea, and my head was often spinning," she says. "Sometimes I had good days and I was fine, but on the bad days, I just wanted to stay at home and lie on the couch. I was missing a lot of school."

So last fall, when her doctor talked to her about being part of a study of new treatments for young people with bowel diseases, Hernandez jumped at the chance, even if it meant having someone else's fecal matter put inside her body.

At the time, Hernandez was taking more than a dozen pills and supplements a day, and never knew if during the school day she would have to run to the bathroom to deal with diarrhea.

"I wanted to help other kids, and I was willing to try anything that would help me feel better," Hernandez says.

Her doctor, Sonia Michail, MD, a pediatric gastroenterologist and researcher at Children's Hospital Los Angeles, got Hernandez enrolled in a clinical trial to determine the safety of fecal transplants for Crohn's patients.

It's part of a 5-year, 10-person study sponsored by Children's Hospital LA, in which fecal transplants are used to treat inflammatory bowel diseases like Crohn's and ulcerative colitis, as well as autism.

Crohn's disease is a chronic condition that for unknown reasons causes the body's immune system to attack the intestines.

Changing the Gut to Change the Immune System

Fecal transplants are one of the hottest areas of new medical research, as scientists have come to understand the role the microbiome -- the billions of bacteria that live in and on the body -- plays in health.

Though researchers are still trying to understand how the microbiome works, evidence has been mounting that the makeup of the microbiome affects the body's immune system.

A fecal transplant is like an organ transplant, in that biological material from a healthy person is given to a sick person to replace something they lost.

Scientists theorize that what has been lost in the sick patient is good bacteria. Stool from a healthy donor, transplanted into a sick person, can change the balance of bacteria in the gut and restore it to health.

Fecal transplants are delivered through colonoscopy, enema, pills, or a tube that is inserted through the nose and travels to the small intestine.

More than 200 studies, almost 20 of which focus on children, are examining whether they can be used to treat diseases. The research involves a range of conditions from inflammatory bowel diseases, like Crohn's disease, to peanut allergies, according to clinicaltrials.gov, a database of global public and private clinical trials maintained by the National Library of Medicine.

In January 2018, the American Gastroenterological Association, with funding from the National Institutes of Health, enrolled its first patient in one of the largest fecal transplant research efforts to date, called the Fecal Microbiota Transplantation National Registry. The registry enables researchers in various studies to pool their data and to track 4,000 fecal transplant patients over 10 years. The aim is to find out risks and long-term benefits of fecal transplants.

"There is still a lot of unknowns with fecal transplants," says Stacy Kahn, MD, of the Inflammatory Bowel Disease Center at Boston Children's Hospital. She leads two studies looking at fecal transplants to treat Crohn's disease and ulcerative colitis, a condition in which the immune system attacks the colon. Risks of a fecal transplant include infection, diarrhea, stomach discomfort, and flare-ups of symptoms.

"A number of case series have shown promising results, but much more research is needed, especially in children," Kahn says.

There have been a few randomized, controlled trials of fecal transplants for inflammatory bowel disease, she says. Each of them, however, has been different in some way, making it difficult to compare results.

"Right now we just don't know what works and what doesn't," she says.

There isn't a cure for Crohn's disease or ulcerative colitis. About 5% of the more than 1.6 million Americans that are diagnosed with inflammatory bowel disease each year are children, according to the Crohn's and Colitis Foundation.

The cause is also unknown, though some data point to genes playing a role. Researchers theorize that patients' genetic makeup can lead to a reduction in certain bacteria that help the gut work smoothly.

The standard treatment involves a lifetime of taking multiple drugs aimed at reducing intestinal inflammation. Many of the drugs have serious side effects, like fatigue, nausea, and vomiting, driving many to seek alternative treatments like fecal transplants.

Special Push to Help Children

Children in the U.S. cannot get a fecal transplant except through a clinical trial. The FDA permits fecal transplants as an "investigational new drug" that can be used to treat people with severe and recurring infections caused by Clostridium difficile (C. diff), if standard treatments have failed. A group of lawyers, researchers, doctors, patient advocates, and fecal transplant banks are working to change the FDA rules to make it easier for patients to access fecal transplants for not only C. diff, but to treat other diseases.

C. diff can cause symptoms from severe diarrhea to life-threatening inflammation of the colon. It can thrive when antibiotics have killed off other healthy bacteria in the gut. About 500,000 Americans, including children, get sick from C. diff each year, and as many as 29,000 people die from it, according to 2011 statistics from the CDC.

Over the past decade, dozens of studies have shown that a fecal transplant has cured about 90% of adult C. diff patients. The overall cure rate for children with repeated C. diff infections was 87% with a fecal transplant, according to preliminary results of a study Kahn co-wrote. The data are decisive enough that the Infectious Diseases Society of America in February 2018 updated its guidelines and recommended that doctors consider using the procedure for people with C. diff who have not been cured by standard treatments, such as antibiotics.

The C. diff data have encouraged doctors like Michail to look into whether the benefits extend to other diseases. Michail is leading the three clinical trials at Children's Hospital LA.

"So far, fecal transplant seems to be the most effective way to appropriately change the microbiome for health," she says.

Since receiving her fecal transplant, Hernandez's Crohn's disease remains in remission, and she has stopped taking most of her medications. In the next few months, the now 16-year-old expects to eliminate all of them.

"I feel so much better," Hernandez says. "No stomach pain, no diarrhea."

Sources

Madelynn Hernandez.

Tania Hernandez.

ClinicalTrials.gov.

News release, American Gastroenterological Society.

Sonia Michail, MD, pediatric gastroenterologist and researcher, Children's Hospital Los Angeles.

Stacy Kahn, MD, Inflammatory Bowel Disease Center, Boston Children's Hospital.

InflammatoryBowelDisease.net: "Statistics."

University of Minnesota Center for Infectious Disease Research and Policy: "Experts call for new approach to regulating fecal transplants."

CDC: " Clostridium difficile Infection."

Cochrane Library: "Fecal transplantation for treatment of inflammatory bowel disease."

Annual meeting of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Las Vegas, Nov. 1-4, 2017.

Clinical Infectious Diseases: "Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)."

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Research Flourishes on Promise of Fecal Transplants

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Aug. 1, 2018 -- Madelynn Hernandez was in a battle. The California teenager loved to draw, dance, and study math, but her Crohn's disease was seriously getting in the way. "I had so much nausea, and my head was often spinning," she says.

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Virtual world could help those with psychosis in the real world

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Virtual world could help those with psychosis in the real world

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Mindtech is involved with a researching the use of immersive
use of immersive virtual reality (VR) therapy to enable people with psychosis to practice skills in a computer-simulated world to reduce problems in real life. The hope is that it will help the many that experience difficulties with social situations and withdrawal that can result in physical health problems and mental health deterioration. With only 5% of people with psychosis receiving psychological therapy, and that therapy rarely aiding social withdrawal this treatment could offer a chance to make a real difference to their lives.
I believe that this technology could help other groups of people, in fact anyone, for whatever reason is struggling with having difficulties with social situations, social anxiety etc and the social withdrawal or limitations.

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MindTech is a national centre focussing on the development, adoption and evaluation of new technologies for mental healthcare and dementia.

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may contribute to job losses but may also provide more advanced research towards uncommon illnesses and even cures.

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may contribute to job losses but may also provide more advanced research towards uncommon illnesses and even cures.

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It's been eight years since the launch of these pocket-sized devices we now know so well. We take them for granted but our phones combine: computing power that could steer a spacecraft, a connection to the internet, a host of sensors for health-relevant data like movement and location tracking, plus a touch-screen interface.

Two-thirds of Britons use them to access the internet ( Ofcom Technology Tracker 2015), and few would regard these devices as 'new', yet the smartphone's potential is yet to be realised in health and care.

Apps

App stores already feature thousands of health apps, though their uptake for health and care has been patchy. Efforts to curate the best quality apps, for example in the NHS App Library, have had little success so far ( Huckvale et al 2015).

One of the more sophisticated apps in use in health care is Ginger.io. In this depression programme, people track their own mood and this is combined with data collected from the sensors in the smartphone about their movements, social app or telephone use. The data can be shared with clinicians and offers people an intervention when their data suggests they might benefit from support.

Hubs

Smartphones can serve as the hub for sophisticated new diagnostic and treatment technologies. So, for example, people with type 1 diabetes dissatisfied with the progress of medical technology companies are driving the development of an artificial pancreas. This links continuous glucose monitoring and insulin-delivery systems that are all controlled by the smartphone. It will adapt its algorithms for insulin delivery to a person's physiology.

Large-scale research

Smartphones are highly effective data collection devices and they can record a lot of detail about people's lives. As well as tracking their own health status, people can also help researchers gather large amounts of data on health problems and their determinants using their smartphones.

The first long-term and large-scale opt-in disease studies are just beginning. Apple seeks to support large-scale studies using patients' iPhones by providing its 'ResearchKit' software platform for researchers to tackle any research question. uMotif is seeking eventually to build a 100,000-person study into Parkinson's disease, tracking variables using a smartphone app.

Devices cheap enough or portable enough to be transported to people's homes to provide diagnostic information aren't new - think of a GP doing home visits armed with a stethoscope. But recent innovations mean that devices previously only kept in a hospital or a GP surgery are now portable or cheap enough to be located in people's homes, and used by patients themselves.

Hospital-level diagnostics in the home

These include portable x-ray machines, blood-testing kits and other technology that can provide more and more of the diagnostics required to support health care, with profound consequences for the way we configure our health care system.

At a recent conference at The King's Fund on emerging primary and acute care systems, Dr Michael Montalto described how these technologies and others enable the safe, high-quality acute care service that his team has provided for people in Victoria, Australia, in their own homes for 20 years. One recent innovation in this area is the AliveCOR ECG embedded in a smartphone case that helps interpret test results via an app and facilitates secure sharing with clinicians ( NICE evidence review).

Smart assistive technology

Many people with disabilities or long-term conditions use assistive devices to help them perform tasks or activities made harder for them by their disability or their condition. These are often available as part of NHS and social care packages. The prospect of using these to gather information in addition to achieving a specific task is motivating several new developments.

Verily (formerly Google's life sciences arm) has invested in a tremor spoon already on the market for use by people with Parkinson's disease, for example. By incorporating sensors and deploying its data analytic expertise, the aim is to provide people or health professionals with information about how someone's tremor characteristics and severity change over time - and to understand more about the disease across a population. Smart inhalers like those in development by Propeller Health work on a similar idea, passively detecting each use, location and the surrounding air quality, allowing insights into what triggers asthma attacks.

We know that between a third and a half of all medication prescribed to people with long-term conditions is not taken as recommended ( Nunes et al 2009). Several technologies in development could enable patients and care professionals to monitor and improve adherence to a prescribed drug regime either through automation or providing better information about medication usage.

Smart pills

One company has developed sensor technology so small it can be swallowed and combined with drugs in pill form. When the pill dissolves in the stomach, the sensor is activated and transmits data to a wearable patch on the outside of the body and on to a smartphone app. This enables patients and their clinicians to see how well they are adhering to their prescription.

Proteus Digital Health began the US Food and Drug Administration (FDA) regulatory process for this technology in 2015. The treatment now undergoing review combines the technology with an anti-psychotic drug, raising questions about how health systems could use the technology and how privacy and autonomy for patients will be affected. The company are also investigating other potential applications including assisting those with long-term conditions such as dementia and Parkinson's disease to remember to take their medications.

Implantable drug delivery

New automated drug delivery technology is under development by a firm set up by researchers and engineers from the Massachusetts Institute of Technology (MIT). They are developing an implantable device with hundreds of tiny, sealable reservoirs that open when a small electric current controlled by an embedded microchip is applied ( Farra et al2012). The team developing the device say it could provide a way to automatically release doses for more than 10 years from a single chip. They are developing the technology for long-term condition medication as well as for contraception.

Digital therapeutics are health or social care interventions delivered either wholly or significantly through a smartphone or a laptop. They effectively embed clinical practice and therapy into a digital form. At a minimum, these interventions combine provision of clinically curated information on a health condition with advice and techniques for dealing with that condition.

Many digital therapy platforms include a way for people to connect with peers and share their experience, or to connect with health professionals remotely. Whether they are fully automated or blend automation with supervision, the therapy offered can be tailored to the needs of the specific user. Digital therapeutics are often cited as a solution to help manage long-term conditions that call for behaviour changes or to prevent diseases in the long run.

Computerised cognitive behavioural therapy

The use of computerised cognitive behavioural therapy (CBT) in the NHS has a relatively long history. Two recent independent studies looking at early-generation computerised CBT suggested that the main limitations in effectiveness were due to people failing to complete the course. ( Gilbody et al 2015, Smith et al 2015)

Recently, a new generation of automated digital therapies based on CBT has been developed that aims to deliver CBT at scale with better engagement. Sleepio is one example, a six-week tailored programme delivered via the web, designed to treat insomnia, and in doing so help alleviate anxiety and depression. There have been positive early results in randomised controlled trials ( Espie et al 2012, Pillai et al 2015). The therapy is personalised in response to data provided by the patient and by using the latest practice in design and delivering the therapy via an animated avatar, the course is made more engaging. Design and personalisation are key elements likely to improve engagement, and therefore outcomes, in digital therapies of all types.

New preventive digital therapies

Another class of digital therapies are in development to help people make changes to reduce the risk of developing long-term conditions. Interventions to change lifestyles through regular coaching and group sessions can reduce the risk of developing diabetes. Sean Duffy, CEO of Omada Health, which delivers online therapies for a range of conditions, gave a presentation at The King's Fund Annual Conference, showing how the company has achieved positive results in its early evaluations in the United States.

Advances in genome sequencing and the associated field of genomics will give us better understanding of how diseases affect different individuals. With the genetic profile of a person's disease and knowledge of their response to treatment, it should be possible to find out more about the likely effectiveness of medical interventions such as prescribing drugs to treat a disease (pharmacogenomics).

Falling sequencing costs

Twenty years have passed since the first complete genome sequence of a living organism was produced and twelve since the first human genome was sequenced. In that time, the economics of genome sequencing has changed significantly. The US National Human Genome Research Institute estimates that the marginal cost of sequencing a single person's genome has now come down to $1,000. However, the upfront costs are still high and likely to remain so for a long time.

The cost of sequencing could fall further thanks to new sequencing techniques using nanopores developed over the past few years. Nanopores are very small holes that DNA molecules can pass through. When an electric current is induced through the pore, variation in the current as DNA molecules are passed through can be used to infer their make-up. Oxford Nanopore Technologies uses this approach to offer very small genome sequencing devices, far more portable than the larger, fridge-sized machines used in traditional laboratory-based sequencing.

Population-level studies

Major projects are under way internationally to gather large databases of genomes and analyse them to find relationships between genetic make-up, people's disease risk and experience, their physical characteristics and their behaviour.

In the United Kingdom, the government is sponsoring the 100,000 Genomes project in England. Human Longevity Inc in the United States promises to build a database featuring 1 million genomes by 2020 and currently has 20,000 sequenced genomes linked to other data about the person's physical characteristics. Verily aims, with its Baseline study (a research collaboration between the company and Stanford and Duke medical schools), to analyse large amounts of volunteers' linked genome, lifestyle and physical data to develop a better understanding of how all that data looks when a person is healthy and identify the changes that indicate disease at an earlier stage.

Until recently, computers weren't especially good at recognising patterns in messy data. Or rather, the way we programmed them meant they weren't very good. New techniques have now been developed in the applied mathematics and computer science fields that have allowed more effective use of computers for tasks like this. Machine learning is one such field. It is a type of artificial intelligence that enables computers to learn without being explicitly programmed, meaning they can teach themselves to change when exposed to new data.

New insights into big datasets

Several new businesses hope to use these techniques to provide diagnostic support. Enlitic in the United States has created a tool for radiologists that uses previous findings and other data associated with existing images in its databases to spot patterns in images and the data to help spot likely mistakes and rule out extremely unlikely options. Both IBM's Watson and Google's DeepMind - the two most famous artificial intelligence organisations - have started to explore potential applications in health care. For example, IBM Watson is studying whether applying machine learning to large amounts of unstructured data like clinical guidelines, scientific literature and treatment protocols could help optimise cancer treatment.

Here at The King's Fund, we are working with colleagues at Demos' Centre for Analysis of Social Media to see what is practical and ethical in terms of applying machine learning techniques to user-generated content on the internet. We are hoping to understand the insights that health systems can glean about patient need and how services meet that need.

Blockchains were conceived in 2008 and the most well-known application is the digital currency Bitcoin. The technology has potential uses in a wide range of other fields, particularly financial services and government functions, where it is already being deployed.

Blockchains are decentralised databases, secured using encryption, that keep an authoritative record of how data is created and changed over time. Their key feature is they can be trusted as authoritative records even when there is not a single, central, respected authority updating them and guaranteeing their accuracy and security. This derives from the mathematical properties of the way the data is recorded and the difficulty it would take to break the rules and successfully alter the record.

Decentralised health records

Electronic records for health care are now widely used, but they are stored on centralised databases, secured and provided by a small number of suppliers. Some commentators have described how a decentralised database using blockchain technology to contain all or some of patients' health information would work, with the patient or clinician given the keys to control who else sees the data.

They argue that the system would be more resilient as no single organisation houses the data and that switching to or incorporating blockchains into existing systems could help to speed up the transition to interoperable patient records. The technology could be applied to create accurate records of health interventions and eventually verified outcomes, which could be used as the basis for reimbursing providers for the health outcomes they achieve for their local population.

Behind all technologies, there are people. The internet and the devices and technology it has enabled have facilitated the development of many communities, bringing together people around a common interest, a shared identity, a social movement, or even just hashtags.

Peer-to-peer support networks

Connected communities for health are growing in their membership and their diversity. Several platforms bring together people with interests in health and care within countries and across the world to support each other, share learning and even provide a platform for tracking their health data or helping them manage their condition.

MedHelp, PatientsLikeMe and HealthUnlocked are just three of these social networks for health. Alongside these dedicated networks, platforms such as Twitter and Facebook that dominate the social network market in the United Kingdom have also become key places for disseminating and discussing health and care information and best practice - as Daniel Ghinn of Creative Health told our Digital Health and Care Congress in 2015.

Communities contributing to research

Some online communities are already contributing to research about their health conditions, offering people the chance to be 'data donors' and providing a simple way to share their data with researchers. PatientsLikeMe has already been used to contribute to nearly 70 published studies, including a study credited with new discoveries about the disease progression of amyotrophic lateral sclerosis (ALS).

Healthbank offers a different model, and is described as 'the world's first citizen-owned health data transaction platform'. Members pay a one-off fee to store health data securely and control who it is shared with. The organisation is a co-operative, so profits made using the patient data are paid out in dividends to its members.

With new technologies like these come new opportunities for our health and care system: improving the accuracy and usefulness of information we can gather on our health as citizens and patients; changing how and where care is delivered; and offering new ways to prevent, predict, detect and treat illness.

But along with these opportunities come challenges:

how to ensure universal access to any benefits through the NHS, ensuring the system doesn't get left behind by a consumer market and fail to provide poorer or excluded citizens with their benefits

how to encourage uptake of new care methods and models built around them throughout our system

how to deal with the great volume of health information these technologies can generate.

The technologies we've highlighted here are not an exhaustive set. Many of them could transform health and care but more evidence is needed on their costs and benefits to deliver on their promise. Ask too much or give too few opportunities for real-world testing and we risk protecting an outdated status quo. Ask too little and we risk spending public money on something ineffective.

Above all we must not lose sight of the people behind the technology and their needs - the patients, citizens and communities for whom it will be put to work.

The authors would like to thank the following: Eric Topol for his insights into blockchain and new directions for digital health; Craig Venter, Ruby Gadelrab and Brad Perkins for a vision of the future of genomics; Pat Saxman, Peter Hames and Sean Duffy for their insights into digital therapeutics; Donald Jones for his insights on drug delivery and patient-driven data; Michael Pellini, Luke Hutch and Joon Yun for helping develop our thoughts on precision medicine; Nick Dawson, Rebecca Hope, Chris Natt and Scott Noppe-Brandon for their expertise on innovation. Rupert Dunbar-Rees and David Ewing Duncan for reviewing early drafts and providing valuable feedback; and Vishal Gulati, Jack Kreindler and Daniel Kraft for their support and assistance in the research phase.

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It's been eight years since the launch of these pocket-sized devices we now know so well. We take them for granted but our phones combine: computing power that could steer a spacecraft, a connection to the internet, a host of sensors for health-relevant data like movement and location tracking, plus a touch-screen interface.

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Abbott’s New FreeStyle Libre 2 Continuous Glucometer with Level Alarms Cleared in EU

October 1st, 2018 Editors Medicine, Pediatrics

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Abbott won the European CE Mark for its FreeStyle Libre 2 continuous glucose monitor that features low and high glucose level alarms, letting patients know in real-time that they’re falling outside of their normal range.

The system doesn’t require regular and painful finger pricks, instead relying on an upper arm sensor that regularly measures glucose within the interstitial fluid using a tiny built-in needle. The sensor shares its readings with a paired device that looks like a smartphone, which the patient uses to keep a history of readings, set alarms, and manage all kinds of related data. Though this device is important, the sensor will still work on its own and will vibrate or make sounds (depending on the user’s preference) when it’s readings sugar levels outside the norm.

“Enabling patients to have optional alarms with the FreeStyle Libre 2 system provides them with even more freedom in managing their condition,” said Jens Kröger, M.D., specialist of Internal Medicine and Diabetology at the Center of Diabetology Bergedorf in Hamburg, Germany, and chairman of diabetesDE. “For some patients who are unaware of the hypoglycemia episodes they may be experiencing — especially during sleep — having alarms can be important. Or, for the parents of children with diabetes, alarms can provide peace of mind.”

Here’s a short promo video from Abbott for the FreeStyle Libre 2:

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...as discussed in today’s lecture.

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NHS England " NHS Five Year Forward View

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Health and high quality care for all, now and for future generations

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 How will Brexit affect health and health services in the uk?’ 

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 How will Brexit affect health and health services in the uk?’ 

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In a paper in the Lancet titled ‘ How will Brexit affect health and health services in the uk?’ Brexit poses a threat. It is wide-ranging and substantial. The effects range from negative to very negative with few opportunities.

All 3 scenarios of soft, hard and failed Brexit are deemed to pose substantial threat to the health service but the effects depend on the type of Brexit pursued. A soft Brexit would minimise health threats and a failed Brexit would be the riskiest outcome.

Impacts:

·      The workforce- the NHS is heavily reliant on EU staff.

·      Financing of health care for UK citizens in the EU and vice versa is threatened, as is access to some capital funds. wider economic impacts that impact on the state’s ability to fund the NHS.

·      Access to pharmaceuticals, technology, blood, and organs for transplant is jeopardised.

·      Information used for international comparisons is threatened, as is service delivery, especially in Northern Ireland.

A few potential opportunities for improvement in areas such as competition law and flexibility of training were found should the UK Government take them. According to the paper Brexit will reshape all components of the health service.

Table of impacts of 3 types of Brexit on healthcare in the UK

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Brexit will leave UK short of 380,000 care workers by 2026, analysis suggests

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Brexit will leave UK short of 380,000 care workers by 2026, analysis suggests

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One in every six adult social care roles in England is filled by carers from outside the UK. Strict visa limits on low-skilled workers have seriously curtailed the ability of staff from outside the EU to work, so and the EU workforce has increased to fill this gap.

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England will be short of nearly 400,000 carers to look after the booming older population unless it strikes a deal to guarantee the free movement of EU staff on which the sector relies, a new analysis claims.

Using Office of National Statistics data, the think tank Global Future predicts England will have a shortfall of 380,000 workers by 2026 unless low-skilled roles can be filled with people from overseas, something at odds with government Brexit plans.

The UK's 1.34 million adult social care workforces is currently short of 90,000 staff, a vacancy rate of 6.6 per cent - three times higher than the UK labour market average.

Demand for carers is growing as the UK's population ages, with 1.5 million more people over 75 expected in England by 2026 around 420,000 more workers will be needed to keep up.

But chronic underfunding of social care has seriously harmed the sector's ability to recruit from the UK, and without something to enable staff from overseas to come and work it is only likely to get 10 per cent of the growth it needs.

Global Future director Peter Starkings told The Independent the government must not make it harder to attract people to work in the UK after Brexit.

"Ministers have got to stop treating social care as an afterthought and get serious about ensuring our loved ones are properly cared for," Mr Starkings said.

"Keeping free movement in the sector is a first step, but the government has to do more. Without action our care sector faces a staffing shortfall of almost 400,000 by 2026.

"That must not be allowed to happen."

Other requirements to fortify the sector include a national recruitment campaign and opportunities for career progression, which the government says it is planning.

It has yet to commit to pay increases and funding for the sector which has endured nearly a decade of austerity and no end is in sight.

One in every six adult social care roles in England is filled by carers from outside the UK. Strict visa limits on low-skilled workers have seriously curtailed the ability of staff from outside the EU to work, so and the EU workforce has increased to fill this gap.

However, leaked drafts of the governments' Brexit plans suggest similar caps for low-skilled workers from the EU will be introduced when the UK leaves and this could spell disaster for the sector.

If freedom of movement continues after 2019, Global Future predicts the workforce will continue to grow at current rates and will be 115,000 stronger by 2026 - a shortfall of 265,000.

Experts and polling suggests the prospect of Britain crashing out of the EU without a deal increasingly looks like a 50/50 chance, and the uncertainty for workers is making matters worse.

"The government's chaotic approach to Brexit is making the workforce crisis in social care even worse," said Barbara Keeley MP, Labour's shadow minister for social care.

"Ministers should immediately make clear that health and care staff are welcome here to care for our sick and our elderly after Britain leaves the European Union."

The government has said leaving the EU will mean an immigration system that works for the whole of the UK.

A Department of Health and Social Care spokesperson said: "We recognise the invaluable contribution of social care workers and we are confident of reaching a deal with the EU which benefits our health and care workforce.

"We want to promote adult social care as a career of choice and ensure the system is able to meet the demands of our growing ageing population. That's why we are launching a recruitment campaign this autumn to raise the image and profile of the sector."

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Brexit will leave UK short of 380,000 care workers by 2026, analysis suggests

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England will be short of nearly 400,000 carers to look after the booming older population unless it strikes a deal to guarantee the free movement of EU staff on which the sector relies, a new analysis claims. Using Office of National Statistics data, the think tank Global Future predicts England will have a shortfall of 380,000 workers by 2026 unless low-skilled roles can be filled with people from overseas, something at odds with government Brexit plans.

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A hospital serving Dominic Raab's constituents has released an internal document identifying potential Brexit risks, warning that an expectation for a flow of funds into the health service after leaving the EU "may be false".

The paper from Kingston Hospital NHS Foundation Trust - situated in the Brexit secretary's local area - outlines how NHS officials have highlighted the possibility of staff shortages and how "costs may go up".

Specialist equipment or parts sourced from the EU could potentially be "less accessible", IT servers based in the EU may be affected and there could be delays to accessing medicines, the hospital added in details released to the Daily Mirror.

The report, prepared for the hospital's executive management committee in March, mentions risks such as "resource pool shrinkage - already an issue - [which] affects EU nationals and those partnered to EU nationals", and "distraction for staff even if they don't plan to leave - attending meetings, sorting out visas etc".

It also noted: "It was thought that the upsides should also be considered as there may be opportunities from Brexit, such as the return of British nationals."

Dr Andrew Dearden, treasurer of the British Medical Association, told the newspaper: "It is clear from these documents that Brexit could negatively affect every corner of the NHS.

"It's a tragedy that the public were led to believe figures plastered on the side of a bus when many authoritative sources are now saying that there could instead be less money for trusts, limited access to life saving medicines and a Brexit brain drain of much needed staff."

A Kingston Hospital NHS Foundation Trust spokeswoman said that the potential risks identified are "only possibilities and not definite", only relate to its trust and that "various contingency options" are being worked up.

The spokeswoman added: "We can say that to date there has been a definite impact on our workforce where we have already experienced issues with regards to recruitment from the EU and retention with our existing EU staff members.

"However, we have implemented specific plans to support these very important members of our team and help them to continue to deliver the vital care they give our patients. We are pleased to say that these measures have already resulted in a recent stabilisation in numbers of EU staff."

The Independent has launched its #FinalSay campaign to demand that voters are given a voice on the final Brexit deal.

Sign our petition here

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Brexit warnings released by NHS hospital serving Dominic Raab's constituents

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A hospital serving Dominic Raab's constituents has released an internal document identifying potential Brexit risks, warning that an expectation for a flow of funds into the health service after leaving the EU "may be false".

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We will see more cuts to the NHS,, increase in contributions and prescriptions. An increase in staff shortages and the NHS may loose skilled medical professionals.

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i think that it may mean less funding for the NHS in the short term but in the future may provide more independence and make funding more available.

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i think that it may mean less funding for the NHS in the short term but in the future may provide more independence and make funding more available.

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Brexit could have a "potentially catastrophic" impact on the NHS, the authors of a major new report have claimed as they warned they had no confidence the Government was in a position to address the consequences.

Assessing three scenarios - "soft Brexit, hard Brexit, and failed Brexit" - the authors conclude in the Lancet medical journal that each poses a substantial threat to the NHS.

Even a so-called soft Brexit that retains access to the EU's single market while restricting free movement is likely to have a big impact on health care, they claim.

"The workforce of the NHS is heavily reliant on EU staff," the authors write. "Financing of health care for UK citizens in the EU and visa versa is threatened, as is access to some capital funds, while Brexit threatens overall economic performance. Access to pharmaceuticals, technology, blood and organs is jeopardised."

In a withering critique, the researchers add that they have "no confidence" that Theresa May's Government is yet in a position to address the consequences of Brexit on Britain's health service, which they predict risks "overwhelming Parliament and the civil service".

They add: "The future is especially uncertain following the 2017 general election, which left the Government with a minority in Parliament.

"There are deep divisions with the Cabinet and we have no confidence that central Government is yet in a position to address the consequences for health."

Professor Martin McKee, a member of the team from the London School of Hygiene & Tropical Medicine, said: "Our analysis of how Brexit will affect the NHS, although the UK's desired outcome remains unclear, is that Brexit in any form poses major risks to almost every part of the NHS, with a 'no deal' scenario potentially catastrophic.

"The EU has shown that it recognises many of these threats, and we hope that our paper encourages the UK negotiating team to make health issues a priority."

After Brexit it will be increasingly difficult for the UK to recruit sufficient NHS and social care staff, according to the research.

Estimates for 2017 suggest that 60,000 people from the EU work in the NHS and 90,000 are employed in adult social care, with a concentration of staff in London and the south east. These regions would be especially vulnerable to labour shortages, said the authors.

Another risk highlighted in the report was the loss of funding to the NHS, both as a direct result of the European money stream being cut off, and indirectly from impacts on the UK economy.

It comes after Sir Vince Cable, the Liberal Democrat leader, warned earlier this month that Ms May's Brexit plans pose a threat to millions of pounds worth of investment in schools and hospitals across the UK.

An analysis by the party claimed the European Investment Bank (EIB) has provided £380m in investment to schools and £345m in hospitals since 2015 - a vital source of cheap loans for "cash-strapped" local authorities.

"I remain deeply concerned about the effects of leaving the EU on all aspects of the UK's economic, social and cultural life, including health," said professor Tamara Hervey - one of the authors of the study from the University of Sheffield.

"If we must leave the EU, I hope this analysis will help interested stakeholders and our elected representatives to hold our government to account to deliver a 'healthy Brexit," she added.

Another author, Nick Fahy, a former European Commission staffer who is now at the University of Oxford, said: "Health is often thought to be a purely national matter, relatively insulated from the consequences of Brexit.

"That is not the case; as this analysis shows, leaving the EU will have wide-ranging impacts on health and the National Health Service. These must be addressed now if the consequences of Brexit are not to be borne by the sick and vulnerable."
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Brexit 'potentially catastrophic' for the NHS, new study claims

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Brexit could have a "potentially catastrophic" impact on the NHS, the authors of a major new report have claimed as they warned they had no confidence the Government was in a position to address the consequences.

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Another good one from the Kings Fund website:

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Another good one from the Kings Fund website:

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A new deadline to achieve, and ratify in parliament, an EU withdrawal agreement of 31 January 2020 was set on 28 October 2019. With a general election approaching and uncertainty as to how events will unfold between now and the agreed deadline, a no-deal Brexit remains a possibility. Over the past year the government and the NHS has put considerable work into preparing for a no-deal Brexit. The Department of Health and Social Care has published guidance for organisations to prepare contingency plans and has established a national operational response centre to lead on responding to any disruption to the delivery of health and care services. The government has also published the Operation Yellowhammer documents, which set out the 'reasonable worst case scenario' impact of a no-deal Brexit. This includes a risk of significant disruption to the supply of medicines and increased instability in the adult social care market. In early October 2019, anticipating Brexit on 31 October, the government published a full overview of its preparations to date in their No-deal readiness report.

While government, the NHS and the social care sector continue to prepare for the possible eventuality of a no-deal Brexit, considerable effort has gone into successfully agreeing a new withdrawal agreement with the EU. If, in due course, parliament ratifies the current withdrawal agreement, it will allow us to move on to the next stage of Brexit, known as the transition period, which will run from the day of exit to December 2020.

During this period, our current relationship with the European Union as a member state will continue, while the government and European Council work towards agreeing what the future relationship around trade and regulation will look like.

If a withdrawal agreement is not passed by parliament by 31 January and a further extension is not granted, we again risk entering a no-deal Brexit scenario, with no transition period to agree the detail of future trading relationships, and the UK's existing relationships with all the European Economic Area (EEA) countries will come to abrupt end. This would have serious implications for the NHS and social care with regards to shortages in supplies of vital medicines, price increases for some medicines, greater difficulty in recruiting international staff, increased demand for services as British emigrants in the European Union return to access health care, as well as the potential for economic disruption which could place further restraints on public spending.

This article focuses on the potential impact that any form of Brexit could have on the provision of health and social care. However, we must remember that Brexit could also impact health outcomes in the short and long term. For example, a no-deal Brexit that impacted on fresh food supplies could affect people's diets and access to nutrition, with potential knock-on consequences on their overall health.

Across NHS trusts there is currently a shortage of almost 100,000 staff (representing 9 per cent of posts), severely affecting some key groups of essential staff, including nurses, many types of doctors, allied health professionals and care staff. Vacancies in adult social care are rising, currently totalling 122,000, with around 9 per cent of care worker roles unfilled. International recruitment is a key factor in addressing these vacancies. Brexit and immigration policy will have an impact on the ability of the NHS and social care providers to successfully fill these vacancies.

The policy of freedom of movement and mutual recognition of professional qualifications within the European Union means that many health and social care professionals currently working in the United Kingdom have come from other EU countries. This includes nearly 65,000 (5.5 per cent) 1 of the 1.2 million workforce of the NHS in England and an estimated 115,000 (around 9 per cent) 2 of the 1.3 million workers in England's adult social care sector. The proportion of EU workers in both the NHS and the social care sector has grown over time, suggesting that both sectors have become increasingly reliant on EU migrants.

The UK has a greater proportion of doctors who qualified abroad than any other European country, except Ireland and Norway. Latest General Medical Council (GMC) data shows that the number of doctors from the EEA joining the medical register is now holding steady (but still down 40 per cent on 2014). A combination of relaxed visa restrictions and active recruitment by trusts means that the number of non-EEA doctors joining the register doubled between 2014 and 2017. However, some specialties not currently on the Home Office's shortage occupation list are still facing difficulties, for example, child and adolescent psychiatry.

The situation in nursing is similar, in 2018/19 only 968 nurses and midwives from the EEA joined the Nursing and Midwifery Council's (NMC) register, a decrease of 91 per cent since 2015/16. This fall has only been partially mitigated by more non-EEA nurses joining the register - their numbers increased by 126 per cent in 2018/19, with 6,157 non-EEA registrants joining during the year. As with GMC registrants the likely causes of these trends are relaxed visa restrictions, nursing being added to the shortage occupation list in 2015 and active recruitment from outside the EEA by trusts.

However, even with both EEA and non-EEA registrants taken into account, these figures are considerably below the peak of around 16,000 international nurses on the NMC register in 2001/02. Although there are other contributing factors, including the introduction of new English language requirements in 2016, Brexit has had a significant impact.

In the longer term, the potential economic impact that Brexit may continue to create could act as a powerful disincentive for health and care staff to work in the NHS and social care. For example, a fall in the value of the pound would mean the money staff earn in the UK is worth less in their home country.

One of the main priorities in the first phase of the negotiations between the United Kingdom and the European Union was clarifying the status of EU citizens currently living in the United Kingdom and of UK citizens living in other EU countries. Any EU citizen currently living in the United Kingdom, including the 165,000 EEA staff already working in health and social care are able to apply for the EU settlement scheme. They will need to apply by June 2021 (or December 2020 in in the event of no deal) in order to be able to stay in the United Kingdom.

The government published an immigration White Paper in December 2018 setting out proposals for a new skills-based immigration system to begin in 2021, which would treat EEA migrants in the same way as non-EEA migrants. It removes the limit on numbers of skilled workers but proposes an annual earnings threshold of £30,000, which is likely to have an impact on the ability to recruit certain health professionals to the NHS. The threshold generated fierce debate - in June 2019 the government commissioned the Migration Advisory Committee (MAC) to carry out an in-depth analysis of potential future salary thresholds. The MAC is due to report back by January 2020 with recommendations as to what level any future salary threshold should be set at.

The White Paper also acknowledges England's reliance on migrants in the social care workforce. However, it proposes that for a transitional period such workers would only be allowed to work for a limited time, with no entitlement to bring dependants. Again, this is likely to impact the ability of the social care system to attract sufficient workers. In the event of a no-deal Brexit, for an interim period EU citizens would be able to enter the United Kingdom as they do now, but if they wish to stay longer than three months they would have to apply for permission under a new European Temporary Leave to Remain scheme. People who obtain this status would be entitled to live, work and study in the country for a further three years.

Separately the Prime Minister has announced that under new rules, international students will be entitled to the right to remain in the UK for two years after graduation. This will allow international graduates in medicine and nursing additional time to secure long-term employment. The previous rules only allowed four months.

Staff shortages across the NHS are a real challenge, for example, our calculations show that the NHS requires an additional 5,000 internationally recruited nurses per year to prevent current staffing shortages getting worse. Any post-Brexit migration policy which impedes this could have serious implications for future staffing of the NHS. The situation in social care is just as serious, with 90 per cent of staff in the sector qualifying for a permanent work visa under the reforms proposed in the immigration White Paper, as they earn less than the £30,000 per year threshold.

In short, the impact of Brexit on the health and care workforce will depend on future migration policy and the barriers or incentives to live in the UK and work in the NHS and social care that are put forward.

Currently, European Union rules govern UK citizens' access to health and care in the European Union, and EU citizens' access to UK services.

EU citizens are entitled to a European Health Insurance Card (EHIC) which gives access to medically necessary, state-provided health care during a temporary stay in another EEA country. 3 The cost of treatment under these schemes can be subsequently reclaimed from the visitor's country of residence via reciprocal health care agreements. Around 27 million people currently hold EHICs issued by the United Kingdom. In addition, under EU rules, people who come from elsewhere in the European Union to live in the United Kingdom, or who leave the United Kingdom to live in another EU country, have access to health care on the same basis as nationals of that country.

Both sides in the Brexit negotiations have agreed, in principle, to preserve reciprocal health care rights until the end of the transition period, at least for those citizens already residing in another EU country. The transition period will run between the day of exit until December 2020 if the withdrawal agreement is passed by parliament. During this time, all existing regulatory arrangements will stay in place while the United Kingdom makes new bilateral agreements with each of remaining EU member states. In the event of a no-deal Brexit there will be no transition period and therefore no guarantee of reciprocal health care rights. However, some member states have already agreed and passed bilateral agreements with the United Kingdom which set out health care rights after the transition period or in the event of a no-deal Brexit.

Until the final outcome is known, uncertainty remains about the future of health care rights. Estimates of the number of people who will be affected differ among the available sources. However, it has been suggested that there are around 1 million British migrants living in other EU countries, compared with around 3 million EU migrants living in the United Kingdom. UK citizens living abroad tend to be older, and therefore more likely to use health and care services, than EU citizens living in the United Kingdom. Significant numbers of UK citizens returning to the United Kingdom would have implications for health and care services.

After Brexit, whether we leave with or without a deal, UK citizens will face new barriers to accessing health care while in the European Union. These barriers will differ between member states, each of which should have its own bilateral arrangements with the United Kingdom in due course. UK citizens may have to provide proof of residency, proof of current or previous employment, enter a social insurance scheme, or take out private insurance to access health care services in the European Union after Brexit.

If we arrive at a no-deal scenario where British citizens face significant barriers to accessing health care in EEA countries, it is likely that British emigrants currently resident within the EEA, particularly those with long-term conditions, will return to the United Kingdom for ongoing treatment. Around 200,000 British citizens currently access an EU scheme that guarantees health care provision to retirees, which risks being lost in the case of a no-deal Brexit meaning they would have to return to the United Kingdom for treatment. It is not known how many of the 800,000 other UK nationals living in EEA nations will be able to access or afford health care in the event of a no-deal Brexit.

To mitigate the potential impact of this, the UK government has proposed to all EU member states that, in the case of no deal, reciprocal health care rights continue for six months after UK exits. The value of this offer depends on which states accept it.

There are a number of EU regulations that impact on the health and care system, including:

Regulation of medicines

EU legislation provides a harmonised approach to medicines regulation across the EU member states. The United Kingdom is currently part of the authorisation system operated by the European Medicines Agency (EMA), which has now moved from London to Amsterdam, and participates in the EU medicines regulatory network (EMRN).

The EMA is responsible for the scientific evaluation of human and veterinary medicines developed by companies for use in the European Union. Under current arrangements, companies can submit a single application to the EMA to obtain marketing authorisation that is valid in EU, EEA and European Free Trade Association (EFTA) countries. Being a member of the EMA also gives the United Kingdom 'tier 1' market status, meaning that pharmaceutical and medical device companies prioritise the United Kingdom as a market for launching their products.

The United Kingdom has its own national regulatory agency, the Medicines and Healthcare products Regulatory Agency (MHRA). However, this currently deals with national authorisations intended for marketing only in the UK.

The EU withdrawal agreement sets out a transition period until the end of 2020, during which time the United Kingdom will continue to abide by all EU rules, to provide time for the United Kingdom to negotiate its relationship with the European Union, which would include the regulation of medicines. The intention is that eventually the MHRA will operate as a sovereign regulator outside the EMA, but with regulatory equivalence and working closely with the EMA and other international partners. There are already precedents for such arrangements - the EMA currently co-operates with regulatory bodies around the world and has specific agreements in place with countries including the United States, Canada and Switzerland. However, if there is no deal, the United Kingdom would cease to participate in the EMRN and the MHRA would take on the functions currently undertaken by the European Union for human medicines on the UK market. The government has passed a statutory instrument which will allow MHRA to take on this role, commencing on the day of exit. If the MHRA is to take on these new functions and do them effectively, it will need a significant increase in resource.

Some have also expressed concern that if the United Kingdom leaves the EMA arrangements and develops its own drug approval system, the United Kingdom may lose its 'tier 1' status and end up at the back of the queue for new medicines. For example, in Switzerland and Canada, which have separate approval systems, medicines typically reach the market six months later than in the European Union.

All medical devices in the United Kingdom are currently subject to EU regulations and must comply with EU standards. Higher-risk devices must be certified by an independent body (called an EU Notified Body) that is designated and overseen by the relevant national authority (the MHRA in the UK), following joint audits by two other national authorities and the European Commission. In the event of a no-deal Brexit the government has said that the United Kingdom will recognise medical devices that have been approved for the EU market, are CE-marked and comply with other EU regulations for medical devices, though will have no formal presence at EU committees in respect of devices.

The United Kingdom faces a similar issue in relation to future access to medical radioactive isotopes, which are used, for example, in the diagnosis and treatment of cancer. In 2018/19 the NHS performed more than 619,000 diagnostic procedures that rely on radioactive material. 4 The European Atomic Energy Community (Euratom) creates a single market for nuclear energy in Europe and is responsible for co-ordinating and regulating access to these materials. The government has stated that when the United Kingdom leaves the European Union it will also leave Euratom, although it hopes to continue working closely with it in future.

Although the government has stated that the United Kingdom's exit from Euratom will not have an impact on the availability of radioactive materials, many are concerned about the impact on future supply, including increased costs and a risk to patients, should access be disrupted.

The supply of medicines and medical devices

There are also concerns that supplies of medicines will be interrupted after Brexit. Around three-quarters of the medicines and more than half of the devices that the NHS uses, come into the United Kingdom via the European Union. The government has asked suppliers of medical goods to build up at least six weeks of extra stocks above usual levels, as government plans show that in the event of a no-deal Brexit there is likely to be significant disruption to cross-channel import routes for up to six months. However, there are some concerns about this approach and the issues are not just about supply routes.

The Operation Yellowhammer document acknowledges that it would be impractical to stockpile for six months, stating that 'DHSC is taking a multi-layered approach to mitigate these risks'. GP practices, hospitals, community pharmacies and patients have been told they should not stockpile medicines beyond usual levels.

NHS England and NHS Improvement board papers note that the health service, internally, is prepared for Brexit and that the anticipated risks to medicine supplies will be realised if public and pharmacist behaviour changes. Shortages will only happen if individuals and pharmacists stockpile.

The Association of the British Pharmaceutical Industry has warned that a decrease in the value of the pound could see existing stockpiles of medication sold off, as traders and wholesalers undertake 'parallel exporting', where medicines are sold across EU borders to maximise profits.

The government has intervened to stop the parallel exporting of some drugs, including hormone replacement therapy. While the government has been clear that this is unrelated to Brexit, it underlines how fragile pharmaceutical supply chains are, irrespective of Brexit.

In the longer term, beyond the immediate disruption to supply, the additional bureaucratic and regulatory burdens that pharmaceutical companies will face, is likely to increase the price of imported medicines and medical devices. The Nuffield Trust estimates that the annual cost of this would be £2.3 billion to the NHS.

Whatever form Brexit takes, it is likely to impact the supply and pricing of medicines and medical devices. A no-deal Brexit could cause serious disruption to supply and even shortages, meaning some people may not be able to access vital medicines. A more orderly Brexit on agreed terms and with a transition period, would mitigate the risk of shortages, but looks likely to increase the bureaucratic and regulatory requirements of importing medicine, which could in turn create price increases.

Competition law

The impact of EU competition and procurement laws on the NHS is contentious. A combination of the Competition Act, provider licences and the Procurement, Patient Choice and Competition Regulations continues to prohibit anti-competitive behaviour by NHS providers and commissioners. Leaving the EU would allow policy-makers to modify these arrangements and other relevant legislation. As the relevant EU directives are incorporated into UK law, the government would need to repeal or amend UK law if it wished to reverse current competition policy so there are unlikely to be changes in the short term.

Many in the NHS would welcome changes in this area. Simon Stevens, Chief Executive of NHS England, has previously remarked that competitive tendering, in which commissioners invite bids from other NHS organisations and private providers, can often create 'frictional cost and dislocation' in the NHS, and has said that the United Kingdom will be in a position to 'shape our own decisions' in this area once the United Kingdom leaves the European Union.

Removing the overly rigid competition and procurement regime currently applied to the NHS is one of a number of recommendations for legislative change proposed by NHS England and NHS Improvement. The changes proposed are to support the implementation of the NHS long-term plan, though this legislation is not dependent on or a result of Brexit.

There has also been discussion about the impact of trade deals with the European Union and with countries outside the European Union, particularly the United States. The government has stated its intention to 'ensure we protect our ability to maintain control of the provision of public services, like the NHS, in new trade agreements'. However, its ability to do so will depend on the United Kingdom's future trading relationship with the European Union and its success in trade negotiations with other countries, which have not yet been agreed.

Working time directive

Among the most contentious pieces of EU legislation affecting the NHS are the European Working Time Regulations - usually referred to as the working time directive. The working time directive was introduced to support the health and safety of workers by limiting the time that employees in any sector can work to 48 hours each week, as well as setting minimum requirements for rest periods and annual leave.

The European Union (Withdrawal) Act 2018 transfers all EU directives into UK law. This fact will remain unaltered whatever the content of the withdrawal agreement or if there is a no-deal Brexit. This means that on the day of Brexit, under any circumstance, worker's rights under EU law will continue, providing continuity to employers and employees in the short term.

Brexit may allow future governments to amend domestic legislation to change EU directives that have been bought into UK law, should they wish to, although their ability to do so will be subject to wider negotiations regarding access to the single market.

Public health

Public health legislation for a number of policy areas, in particular food safety and nutrition, tobacco, alcohol, radiation, environment, housing standards, and chemicals is drawn from established EU legislation, standards and regulations, with relevant directives transposed into UK legislation.

EU legislation has had a significant impact in some areas, such as air quality, that cannot be successfully controlled at national level alone. In other areas, such as tobacco control, the United Kingdom currently leads the way in Europe, having gone further than required by a recent EU directive by introducing standardised packaging.

In May 2019, during the third reading of the European Union Withdrawal Act, the government signified its intention to transpose key legislation that maintains EU public health regulations, particularly the 'do no harm' duty of the Lisbon Treaty that means the government is required to consider 'a high level of human health' when making policy.

Public health organisations have since called on the new government to reconfirm this intention, though a response has not been received.

On the other hand, decision-making in a community of 28 countries can be cumbersome and slow, and the United Kingdom could choose to take bolder and faster action on public health after leaving the European Union (Faculty of Public Health 2016).

The European Union also operates systems for the early warning of communicable diseases, managed by the European Centre for Disease Prevention and Control (ECDC). These systems facilitate the rapid sharing of information and technical expertise in response to potential pandemics, communicable diseases and other cross-border health threats. Recent examples of collaboration include managing the H1N1 'swine flu' pandemic and efforts to tackle anti-microbial resistance. Leaving the European Union does not necessarily mean the United Kingdom has to leave the ECDC; both Norway and Switzerland (non-EU member states) work with the ECDC, but do not have a formal role in its decision-making. However, the future arrangements for working with the ECDC are not mentioned in the current withdrawal bill.

Research

Members of the academic, pharmaceutical and medical communities have expressed serious concerns about the impact of leaving the European Union on science and research in the United Kingdom (see, for example, Lechler 2016; Mossialos et al 2016). Nobel Prize winner and Chief Executive of the Francis Crick Institute, Professor Sir Paul Nurse, has warned that Brexit could be challenging for science in the United Kingdom because of its impact on the free movement of researchers across Europe and on the ability of UK researchers to attract research funding. We may already be starting to see evidence of this warning being realised, as the Russell Group of universities has published analysis highlighting the impact of Brexit uncertainty on recruitment and retention of academics in UK universities. In the year after the referendum there was an 11 per cent increase in EU academics leaving Russell Group universities.

The United Kingdom has furthered its scientific research agenda through EU collaboration, as a result of access to European research talent and to important sources of funding. For example, between 2007 and 2013 the UK received 8.8 billion euros for research, development and innovation activities while contributing only 5.4 billion euros to EU research and development. NHS organisations benefit from a range of EU funding schemes including Horizon 2020 and the European Structural Investment Fund (ESIF). The government has set an ambition for the United Kingdom to be a world leader in life sciences and medical research, but this will require it to address the loss of EU funding for research and development and the benefit from the collaboration of researchers and scientists across the European Union.

In the short term, the government has committed to honour funding agreements for ESIF projects that were signed before the Autumn Statement 2016, even where these continue after the United Kingdom has left the European Union. Funding for projects signed after the Autumn Statement 2016 will be funded if they provide strong value for money and are in line with domestic strategic priorities. For Horizon 2020 projects, the government will underwrite the funding for all successful bids that are submitted before the United Kingdom leaves the European Union.

In the longer term, arrangements are unclear. However, the government has stated that it wishes to 'establish an ambitious agreement on science and innovation that ensures the valuable research links between us continue to grow '. While it may be possible to continue to participate in some research programmes after the United Kingdom leaves the European Union (non-EU countries are able to participate in Horizon 2020 as associates or third countries, for example), it is unlikely that projects in the United Kingdom would be eligible to receive EU funding and the United Kingdom would have limited influence over work programmes.

Restrictions on the movement of researchers will have a significant effect on research, with about three-quarters of researchers having spent part of their career in a non-UK institution and more than 28 per cent of university academics currently from outside the United Kingdom.

Clinical trials

Clinical trials for new drugs are currently carried out at a national level but are subject to EU regulations, including registration of trials. Revised EU clinical trials regulations will not be in force in the European Union at the time that the United Kingdom exits the European Union and so will not be incorporated into UK law on exit day. The government expects to align, where possible, with these new regulations, subject to parliamentary approval. Any divergence between the United Kingdom and the European Union on the regulation of clinical research would have a number of consequences, including:

an impact on the status of UK-based patients who are participating in multinational EU clinical trials

recruitment issues for clinical trials, especially for rare diseases and paediatric medicine; if the United Kingdom becomes isolated it may be seen as a less attractive option for clinical trials recruitment

an increased burden on researchers and clinical trials sponsors if two different systems operate in tandem in the European Union and the United Kingdom.

Regulations on the transfer of personal data for research (currently overseen through the EU General Data Protection Regulation (GDPR) will also be affected by the Brexit deal.

In the long term, the performance of the wider UK economy will be one of the most important influences on funding for the NHS and social care.

During the referendum campaign, claims were made that leaving the European Union would result in a dividend equalling £350 million per week. This, it was argued, could be used to fund the NHS. As the United Kingdom remains a member of the European Union at this time, we still pay into its budget, hence no dividend has been received. Brexit does not guarantee a dividend. If a withdrawal agreement is achieved and passed by parliament, the United Kingdom may continue to make contributions to the EU budget.

However, since the referendum the government has committed to and set in train a multi-year funding settlement for the NHS, that within five years will see annual spending increases for the NHS of £20.5 billion. To be clear, this spending increase is not a direct result of Brexit - it is funded through existing fiscal measures and tax receipts ( Office for Budget Responsibility 2018; Treasury Committee 2018).

With negotiations over the United Kingdom's exit from the European Union ongoing, it is difficult to predict the economic outlook with any certainty. Indeed, the actual economic consequences of Brexit are hotly contested, with some arguing it will have a long-term positive impact. However, the weight of opinion suggests that the net economic impact will be negative, with a range of independent economic forecasts suggesting that Brexit will limit growth and lead to increased borrowing, whatever form it takes. ( Bank of England 2018; OECD 2019; Office for Budget Responsibility 2019). In the Office for Budget Responsibility's estimation, a no-deal Brexit of medium disruption would cost the UK economy £30 billion per year, while the Institute of Fiscal Studies have forecast that this scenario will see government borrowing almost double to £100 billion a year.

It is important to remember that funding for public services is not directly and intrinsically tied to national economic performance. Funding for the NHS is a political decision and a recession or economic downturn will not necessarily lead to reductions in public spending.

The NHS has benefited from the certainty of a multi-year funding settlement as part of the long-term plan. However, this spending announcement does not cover the health service in its totality, as it does not cover public health, spending on building and equipment or training budgets. It also does not cover the provision of social care, a sector which is fragile and particularly vulnerable to disruption that a disorderly Brexit may cause.

Social care

If there are economic consequences to Brexit which result in lower growth and politicians then choose to reduce public expenditure in response, then the implications for social care could be significant. Its budget is only set for one year ahead, it does not have the five years of certainty that the NHS does.

A no-deal Brexit could have a very damaging impact on social care providers. Operation Yellowhammer reports that increasing operational costs bought about increases in inflation could see smaller social care providers go out of business or hand back council contracts within two-three months of a no-deal Brexit. Larger providers would be affected within four-six months of a no-deal Brexit.

The United Kingdom's decision to leave the European Union has already had an impact on the NHS and social care: for example, the EMA has relocated to Amsterdam and the number of certain groups of health and social care staff joining the workforce from Europe has fallen. It is also absorbing significant time and resources that could otherwise be devoted to the reforming the health and social care system and improving services for patients and service users.

Brexit may present some opportunities for the United Kingdom, in particular the chance to go further and faster on public health regulation and remove rules on competition that are seen to present obstacles to the integration of and collaboration between health services.

However, Brexit also presents the NHS and social care with a number of significant challenges. These include: the potential impact on the health and social care workforces that rely considerably on staff who are EU nationals; the impact on future trading relationships, which could affect the affordability and supply of drugs and other products; a weakening of cross-border co-operation on public health and research; and, of course, the impact on the wider economy, the performance of which will affect future funding for health and social care.

Despite the preparations that have been put in place to manage a no-deal scenario, were it to happen, it could have even more significant consequences for the health and social care system, compounding these threats and potentially causing serious disruption to medical supplies, significant damage to social care provision and the end of reciprocal health agreements, which could increase demand for services as British emigrants with long-term health and care needs return to the United Kingdom and leave British citizens travelling to EU countries to take out private insurance. Alongside this, a no-deal Brexit is forecast to bring significant economic turbulence, in the form of increased borrowing and decreasing growth rates. If this risk is realised, it may put further pressure on public spending and on the overstretched resources of the NHS and, to an even greater extent, social care.

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Brexit: the implications for health and social care

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A new deadline to achieve, and ratify in parliament, an EU withdrawal agreement of 31 January 2020 was set on 28 October 2019. With a general election approaching and uncertainty as to how events will unfold between now and the agreed deadline, a no-deal Brexit remains a possibility.

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A large percentage of nurses (and NHS staff) come from overseas, so due to Brexit and the immigration rules; they may have to leave. This means the NHS will be even more understaffed than currently.

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It is projected that Brexit will reduce the size of the UK economy, and with a weaker economy comes a weaker platform for the NHS and Health and Social Care services. A weakened economy may result in further spending cuts throughout, including staff, medicines, research, operations, etc., and essentially may reduce the overall effectiveness and quality of service provision.

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With the NHS approaching crisis point like never before, and social care suffering from this Government's chronic under-funding, there are many important concerns about the UK's exit from the EU.

Issues such as medicine regulations, reciprocal healthcare and competition rules, which are currently dealt with at European level, will all have to be painstakingly scrutinised. But among these issues, two stand out as by far the most prominent for health and care services: the state of the economy (and therefore the sector's finances), and its workforce.

If a strong economy makes for a stronger NHS, then the recent report commissioned by the Mayor of London to Cambridge Econometrics bears some bad news. The report, " Preparing for Brexit ", examines five scenarios, going from soft to hard Brexit, with the fourth being the closest to the current state of negotiations - that is, no single market or customs union deal and a two-year transition from March 2019.

The projections for the economy get progressively worse with the more severe types of Brexit. According to the report, Brexit will not only reduce the size of the UK economy, but the cumulative change in Gross Value Added (GVA) over time will keep increasing in the long-term.

Compared to what would happen if the UK remained in the single market and customs union, the UK is expected to have a loss of 2.7% (£49.1bn) in GVA by 2030, 13.8% (£41.6bn) in investment and 1.4% (468,000 people) in employment under scenario 4.

However, for example under scenario 2 (two-year transition followed by single market membership without customs union) the loss would be 1.0% (£18.6bn) in GVA, 6.7% (20.2bn) in investment and 0.5% (176,000 people) in employment.

While London is likely to fare somewhat better in terms of economic output, the impacts on population (and so employment) will be noticeably stronger there than in the rest of the UK.

This is due to the higher number of non-UK residents and workers in the capital, who will potentially leave or never come to the UK after Brexit, and also to the potential departure or non-arrival of their dependents (children and elderly parents).

Population growth under scenario two is predicted as 0.78%pa from 2019 to 2030, whereas under scenario four and five the projection is 0.54%.

The health and social care relies heavily on non-UK staff, of which a significant percentage are from the EU. Given this, it is concerning to already see a change in recruitment and retention of NHS and social care staff coming from the EU.

For example, the number of EU nurses and midwives leaving the Nursing and Midwifery Council's register between October 2016 and September 2017 increased by 67% compared to the 12 months before, while the number joining it fell by 89%.

Moreover, a recent British Medical Association survey of EU doctors working in the UK has found that 45% are considering leaving following the EU referendum result, with 18% already having plans to relocate elsewhere.

It's clear that the Government needs to be doing much more to reassure EU citizens that their rights to live and work in the UK will be protected after Brexit.

The health and social care sectors could face a considerable loss of staff if EU migration is limited after Brexit. Modelling from Department of Health projects a shortage in the UK of between 26,000 to 42,000 nurses by 2025/26. Estimates from the Nuffield Trust suggest a shortfall in England of as many as 70,000 social care workers by the same date.

The way Brexit negotiations are currently being conducted is jeopardizing the health and care sector. With the Government pursuing a needless, damaging and extremely hard Brexit, and looking prepared to possibly leave the EU without a deal, they are putting the entire health and social care sector at risk.
By Dr Onkar Sahota, London Assembly Member and Labour's spokesperson for Health, chairing the Health Committee.
Disclaimer:
The views expressed in this analysis post are those of the authors and not necessarily those of the UK in a Changing Europe initiative.
View all analyses

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The impact of Brexit on the health and social care sector - UK in a changing Europe

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With the NHS approaching crisis point like never before, and social care suffering from this Government's chronic under-funding, there are many important concerns about the UK's exit from the EU. Issues such as medicine regulations, reciprocal healthcare and competition rules, which are currently dealt with at European level, will all have to be painstakingly scrutinised.

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Please make sure you have read the following article BEFORE this week's session;

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Please make sure you have read the following article BEFORE this week's session;

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If their predictions are correct, how will they affect your future career?

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If their predictions are correct, how will they affect your future career?

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Use this thread to add any general comments about the module

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Use this thread to add any general comments about the module

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General comments or thoughts on the Kings Fund presentation?

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General comments or thoughts on the Kings Fund presentation?

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The data on which their predictions were based.

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Changes in the size and make-up of the English population, as well as trends in life expectancy, changing households and health inequalities, over the next 20 years.

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Ask people you know to describe UK health and social care services in 5 words 

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Ask people you know to describe UK health and social care services in 5 words 

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Post their responses here:
(Please keep it clean!)

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The group representing hospitals and ambulance services in England has warned of a lack of "contingency planning" to deal with the impact of a no-deal Brexit on the health service.

In a leaked email to NHS England boss Simon Stevens, NHS Providers says leaving the EU without agreement would immediately be a real risk to services.

The group warns it would make it harder to stop the spread of diseases.

NHS England said preparing for every potential Brexit outcome is a priority.

Ministers are to reveal more details of their contingency planning for a no- deal Brexit later this week.

Brexit Secretary Dominic Raab, who will travel to Brussels for the latest round of talks with his EU counterpart Michel Barnier on Tuesday, has said a deal is still the most likely outcome.

But he has said preparations for the failure to reach an agreement this autumn, or Parliament rejecting any deal, is the responsible course of action.

The UK is set to leave the EU on 29 March 2019 and the two sides are currently negotiating the terms of its exit and its future relations in a whole range of issues.

With seven months to go, ministers have said they are stepping up contingency preparations for a no-deal Brexit, while insisting that it is not their chosen outcome.

'Stockpiles and shortages'

But NHS Providers - which represents acute, ambulance, community and mental health services within the health service - has expressed concern about what it says is a lack of engagement with ministers in the email, seen by the BBC.

It has called for NHS England and NHS Improvement - which oversees NHS trusts and providers - to convene a group of trust leaders as a matter of urgency.

In an email sent to NHS chief executive Simon Stevens, also copied in to Mr Raab and Health Secretary Matt Hancock, it calls for a co-ordinated response to confront the challenges that would be presented by a no deal.

Chief executive of NHS Providers Chris Hopson writes that there has been "no formal communication" to trusts from either NHS England or NHS Improvement on this issue.

Without national planning and coordination "there could be both stockpiles and shortages of medicines and medical devices", Mr Hopson says.

He adds that "disease control coordination could also suffer".

'Not unforeseen'

An NHS England spokeswoman said the health service was working with government, planning for different post-Brexit scenarios.

"We will be working with our colleagues and partners across the NHS to ensure plans are well progressed, and will provide the NHS with the support it need," she said.

Last month, Mr Stevens said "extensive" planning was under way to prepare the health service for a no-deal scenario, to ensure the continued supply of medicines and equipment.

While this would not be "desirable", he said that - if such a situation arose - the effects would not be "unforeseen".

A series of technical notices - including advice for businesses, citizens and public bodies about a so-called "hard Brexit" - will be made public over the next month or so.

Downing Street has described the advice due on Thursday as "sensible, proportionate, and part of a common sense approach to ensure stability, whatever the outcome of talks".

On the same day, Mr Raab will make a speech in Westminster to outline the government's plans for the possibility of leaving the EU without a deal.

The UK is seeking "associate membership" of the European Medicines Agency, which evaluates and supervises medicines and helps national authorities authorise the sale of drugs across the EU's single market.

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The group representing hospitals and ambulance services in England has warned of a lack of "contingency planning" to deal with the impact of a no-deal Brexit on the health service. In a leaked email to NHS England boss Simon Stevens, NHS Providers says leaving the EU without agreement would immediately be a real risk to services.

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Can artificial intelligence 'save' the NHS? - BBC Click

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