H. Omer TONTUS
From reducing stillbirths to diagnosing cancers earlier but the principal concept of the plan for NHS England is to do more with less
What is the NHS long-term plan about?
The NHS does not have enough money to keep doing what it does, treating the growing number of patient and often elderly people, many of whom live in the less welloff communities of the country. The Long-term plan (LTP), published on 7th January 2019, and part of a deal with the government to end the political noising about the overloaded NHS, is about doing more with less.
The NHS-long term plan is attempting a gradual transformation of the NHS as tightening up and smartening up. New ideas have been tested in a few areas of the country as “trial projects” and those that worked will be in use.
The LTP calls for legislation to “create publicly accountable integrated care locally, to streamline the national administrative structures of the NHS, and remove the overly rigid competition and procurement regime applied to the NHS”1.
What does and How does the NHS intend to do that?
In the first place, NHS is intended to stop people from getting sick. The central drive of the plan is to keep people well and to pick it up early if they get ill, because it’s much cheaper to treat cancer or heart disease before it’s progressed. The focus has to be on primary care and people will have responsibilities to improve their own health, for instance, by stopping smoking or taking more exercise
The NHS will open a digital “front door” of new technology. Consulting a GP online will save both sides time and encourage more people with potential problems to get checked out. Hopefully, the plan will cut A&E admission by digital consultations, plus rethinking the support given to those arriving at A&E so they are routed to the urgent care centre or somewhere more appropriate to their needs. This will decrease 30m visits to the hospitals and will save £1bn.
The NHS is going to fund prevention programmes for obesity and smoking, and promote its already successful weight-loss support for people with type-2 diabetes. NHS will interact with 1 million people a day who are sick and need some kind of information. With help of given information, people will rethink what they are doing about their health. Surely, these are not to be enough to sort out the pressures on the NHS. The NHS is being distressed by the merging of several intractable problems. Poor diet and inactivity caused obesity is one of them. Another one is growing numbers of elderly frail people who are in and out of hospital which there is no social care package for them. Social care for the elderly is a very difficult area. It is vital to sort out, however it will cost a lot of money. The NHS and its plan are in risk until that happens
Local authorities are responsible for public health programmes on obesity, smoking cessation and alcohol, as well as unnumbered other vital services and they are not getting sufficient money. The NHS plan is focused on supporting people at their GP practice and in their community to adopt healthier behaviour. Some of the budgets of NHS England will be directed to areas on the basis of their local needs, in a bid to tackle health inequalities.
LMP is intended to reduce stillbirths, mother and/or child deaths during birth by 50%. Women, particularly those from a BAME (Black, Asian & Minor Ethnic) community and/ or deprived background will see greater continuity of care from their midwife as this has been shown to reduce the chances of losing a baby. Pre-term birth clinics will be encouraged to help those at risk, including younger mothers and those from deprived backgrounds. The long-term plan also talks about minimising unnecessary intervention, improving fetal heartbeat monitoring and reducing smoking during pregnancy.
LMP is intended preventing up to 150,000 heart attacks, strokes and dementia cases over the next 10 years. Cardiovascular diseases are seen as the single biggest area where the NHS can save lives over the next decade. The public will be offered increased opportunities to be tested for high blood pressure and other high-risk conditions. There will also be expanded access to genetic testing for familial hypercholesterolaemia (FH), which causes early heart attacks. Defibrillator networks will be built to improve survival from out of hospital cardiac arrest1
One of the most important targets of LMP is saving 55,000 more lives a year by diagnosing more cancers early. There will be a big emphasis on diagnostics testing to detect cancer early such as new tests for bowel cancer, mobile lung cancer screening units and rapid diagnostic centres that yield a result on the same day. Bowel cancer screening age will be lowered from 60 to 50.
The personalised and risk-stratified screening will be use and test for family members of cancer patients will begin. All children with cancer will be offered genetic testing to enable more comprehensive and precise diagnosis and access to more personalized treatments. Advanced CAR-T and protonbeam therapy will be available to children in England.
NHS will take active action for people with learning disabilities and autism. The LTP aims to increase specific health checks for people with a learning disability and for people with autism. There will be action to tackle over-medication and NHS staff will receive training on supporting people with a learning disability and/or autism. NHS England is also aiming to reduce waiting times for specialist services to facilitate speedier diagnosis and to increase investment in community support services.
At least £ 2.3 billion more will be spent per year for mental health care.
An estimated 345,000 more children and young people will be treated via NHS funded mental health services and school or college-based mental health support teams over the next five years. Children will get access to mental health support in schools, in the hope of preventing depression and anxiety escalating into adulthood. Over the same period, an extra 380,000 adults will be accessed to talking therapies. Mental health liaison services will be available in all A&E departments and ambulance staff will be trained to respond effectively to people experiencing a mental health crisis. When people have physical health problems, mental health issues will also be investigated.
An extra 24,000 women with moderate to severe perinatal mental health difficulties and a personality disorder diagnosis will get care each year. Care provided by specialist perinatal mental health services will be expanded to be available from preconception to 24 months after birth1.
Key conclusion at a glance,
The biggest problem is staffing and it will be worsened by Brexit. The plan talks of taking the pressure off staff in A&E and hospitals generally. Online consultations will be expected to help GPs, too. But there will still be rising numbers of elderly people and a need for treatment, which is costly and really requires an expanding workforce. The nursing shortage will sharpen and the plan proposes support to train more and more staff. But the workforce issues are unlikely to be solved.
How NHS-LTP will affect Medical Tourism?
Although health services are dependent on technology and infrastructure and are generally a part of the service sector at macro level, it is not possible to achieve success unless the staff shortage eliminated.
In addition to the length of the training period of health professionals, the fact that specialization has segmented to the micro level. The NHS providing services with around 40 specialization areas has reached 120 fields of expertise which has a negative effect on the insufficiency of professional healthcare personnel.
Additionally, with the lack of healthcare personnel, the increasing elderly population and increasing A & E applications prevent the provision of NHS services in a fair and timely manner. In general, it would be a dream to hope that the LTP would shorten the waiting times for the next few years.
How to eliminate the waiting list of 4.3 million people stated by Denis Campell3 in his article dated July 13, 2018, does not appear in the plan content. For example, in May 2018, 211,434 patients had been on the waiting list for “more than six months”, up from the 197,067 who were in that position a month before. NHS England data showed that 25475 operations were cancelled at the last minute just only 3 months in January-March 20186.
Growing numbers are having to wait for more than the supposed maximum of 18 weeks (126 days) for planned non-urgent surgery such as cataract removal or hip or knee replacement. The 18-w eek referral-to-treatment standard for planned care has not been met since February 2016, the A&E four-hour standard since July 2015 and the 62-day cancer standard for more than three years5. Imagine that, your GP informs you about cancer suspicion for your wife/husband or child and you should wait for an appointment for more than 2 months. How would you feel about that?
According to NHS-LTP, there may be some optimism about the decrease in the waiting list in the long term with the help of preventive health services. However, the growth rate of the elderly population will overshadow this optimism.
The maximum waiting time for suspected cancer is two weeks from the day your appointment is booked through the NHS e-Referral Service, or when the hospital or service receives your referral letter. Referrals for investigations of breast symptoms where cancer is not initially suspected are not urgent referrals for suspected cancer, and therefore fall outside the scope of this right4. In a sense, the medical center or hospital which you were referred by your doctor for further examination will not evaluate you before 2 weeks and you will not know how long you will wait to be investigated, even if there is a mass in the breast
Let’s imagine, technology-oriented social life is an important part of daily routine thanks to smartphones and tablets that enable “exploring and reading”. Such activities stop or slowing due to cataract disease. Additionally, examples such as prosthetic surgery, some cancer treatments (Prostate Ca.) or non-urgent orthopedic surgery can be given, too. When we look at the sociological impact of 18-24 months waiting time for cataract surgery or 6-9 months waiting time for renal stone disease surgery, medical tourism is still a priority for the British
Although many patients, especially from the MiddleEast, treated in the UK through at medical centres and clinics in London, in particular, some patients should be expected to leave the UK such as for eye surgery (especially for patients with cataracts), orthopaedic surgery (for knee and hip prostheses), cancer diagnosis services and oncologic surgery.
1 The NHS Long Term Plan https://www.longtermplan.nhs.uk/wp-content/ uploads/2019/01/nhs-long-t erm-plan.pdf
2 Haroon Siddique https://www.theguardian.com/ society/2019/jan/07/what-will-the-nhs-long-term-planmean-for-patients
3 Denis Campbell https://www.theguardian.com/ society/2018/jul/13/nhs-oper ation-waiting-lists-reach10-y ear-high-at-43m-patients
4 NHS official https://www.nhs.uk/using-the-nhs/ nhs-services/hospitals/guide-to-nhs-waiting-times-inengland/
5 Siva Anandaciva & James Thompson https://www. kingsfund.org.uk/publications/articles/nhs-waiting-times
6 Iacobucci Gareth. NHS waiting times: number of patients waiting 1 8 weeks for treatment rises sharply BMJ 2018; 361 :k2114
7 Sarah Boseley Guardian Health editor https://www. theguardian.com/society/2019/jan/07/what-is-the-nhslong-term-plan-and-can-it-achieve-its-aims