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When we talk about the National Health Service it is all too easy to think of some large and impersonal entity. But talk to any individual and they are far more likely to talk about ‘my doctor,’ ‘my local hospital,’ ‘my physiotherapist.’ And that quasi-one-to-one relationship sits at the heart of delivering effective healthcare.

The need for a more personalised local response runs strongly through the Chartered Society of Physiotherapy’s (CSP) community rehabilitation plan. First launched in October 2022, the plan has hit the headlines more recently with a version being launched in Northern Ireland at the beginning of May 2023. The plan opens with a simple statement:  

“Rehabilitation makes people’s lives better. Many of those who would most benefit from rehabilitation, however, face barriers to accessing services.”

Those barriers can lead people to come back time and time again to require core NHS services rather than being supported in a more appropriate way. For some individuals that support may come from Social Services, whilst others may be better helped vial community hospitals or care homes, or through the provision of physiotherapy, occupational therapy or other interventions.

Importantly, delivering community rehabilitation in this way not only reduces the demand for NHS in-patient services but also can improve the lives of individuals; helping them to live with, manage, or improve their conditions. But for community rehabilitation to work the CSP recommends that it is delivered as an integral part of an integrated care system (ICS) which looks to “include primary, secondary, tertiary health care, mental health, social care, independent and third sector providers.” 

Underpinning the delivery of an effective community rehabilitation plan, the CSP recommends that:

• Referral processes are explicit, easy, efficient and equitable
• Rehabilitation interventions are timely, co-ordinated and prevent avoidable disability
• Rehabilitation interventions meet patient needs and are delivered in an appropriate format
• Rehabilitation pathways should meet needs and be delivered locally with access to specialist services
• Rehabilitation Programmes should enable optimisation, self-management and review
• Rehabilitation services are well led, adequately resourced and networked to other services
• Rehabilitation Services involve Families

That desire to involve families and local providers in the delivery of coordinated rehabilitation demonstrates the importance of localised and personal health delivery which is tailored to the individual. Importantly it also draws in all providers of health services into an integrated patient-centric network. It’s one reason why the use of technology is revolutionising health delivery. Even something as simple as the ability to digitise patient notes helps with the sharing of information across organisations. This not only helps to speed up referrals but also to provide a more targeted treatment plan, particularly in those who may need multi-disciplinary treatments.

At the Northern Ireland launch of the community rehabilitation plan Marie-Therse McDonald, CSP professional adviser for Northern Ireland said: “Without access to high quality community-based rehab, people will continue to be driven towards the most expensive parts of the health and social care system.” She went on to add “We know that what tends to work is care close to home, person centred, specialist, integrated and supports self-management principles.’”

“Integrated care systems (ICSs) represent the best opportunity in a generation for a transformation in our health and care system.”

The executive summary from The Rt Hon Patricia Hewitt’s review into integrated care systems leads with that bold vision of the future of health provision within the UK. However, the subsequent sentences carry a warning to the effect that effective change will require new structures and changed cultures in which “everyone needs to change, and everyone needs to play their part.”

With local government, social care providers, community and other organisations all linking together with NHS services; integrated care systems are designed to improve the lives of local people; helping them to live healthy and independent lives through the provision of support at the point of need. With so many organisations all coming together to provide that support, there is though a danger that silo practices or too narrow a focus on delivery could get in the way of the project.

That is why the review was so important; identifying best practices and potential points of failure. To that end, the review has identified six key areas which will need to be addressed in order to deliver thriving integrated care systems. These are:

• collaboration within and between systems and national bodies;
• a limited number of shared priorities;
• allowing local leaders the space and time to lead;
• the right support;
• balancing freedom with accountability; and
• enabling access to timely, transparent and high-quality data.

That last area of focus has also highlighted the importance of the use of data and data management which is relevant and timely. One of the conclusions of the report is that an excessive focus on targets can in fact lead to poorer patient outcomes. That is because leaders are focused more on ‘gaming the system’ in order to meet targets rather than in finding ways to provide viable treatment plans for individuals. Accordingly the report recommends that there be a significant cut in the number of national targets with integrated care systems instead introducing a suite of priorities based on local need.

The report also strongly promotes the provision of integrated approaches which look towards holistic healthcare and prevention. Commenting that ‘for too long we have mistaken NHS policy for healthcare policy’ the report cites an initiative which looked to support physical activity and address social isolation in Wigan. So successful was this community-led initiative that it resulted in a seven-year increase in life expectancy in the most deprived wards in Wigan. It’s an example of the way in which a simple step outside of core health provision can result in a significant improvement in health outcomes.

Commenting on the report the Chair of the Health and Social Care Committee Steve Brine MP said: 

“This is a key moment for Ministers and for NHS England. We have found genuine enthusiasm for the potential of Integrated Care Systems to make a real change, not only in how health and social care is delivered but in prioritising the needs of local populations and preventing ill-health.”

The news that nine percent more deaths were recorded in 2022 than in 2019 (the last year before the pandemic) has naturally given rise to a fair amount of debate. It may well be that we have to wait for the results of in depth studies before we see a more definitive indication of the causes of excess mortalities. In the meantime, various theories have been put forward as to why the second half of 2022 in particular saw more deaths than would otherwise be expected.

During the course of the pandemic, concerns were raised that patients were delaying approaching their doctors or finding it difficult to receive an accurate diagnosis when consultations were managed at a distance. It was therefore recognised that the potential for untreated conditions to require greater intervention, once diagnosed, than would otherwise be the case could lead to excess deaths. For example, a recent BBC report, highlighted a reduction in the number of new prescriptions for blood pressure medication or statins during the covid period.

The ongoing effect of having had covid has also been put forward as another potential reason for people dying earlier than expected. One study reported in the BMJ [1] concluded that “Individuals discharged from hospital after covid-19 had increased rates of multiorgan dysfunction compared with the expected risk in the general population.” This includes an increased risk of cardiovascular disease following covid infection.

This theory is bolstered by another BMJ report [2] which highlighted the fact that whilst an analysis of the ‘underlying cause of death’ for conditions such as heart disease and stroke have not shown an increase, this changes dramatically when looking at the wider causes of death mentioned on death certificates. In particular, death certificates mentioning cardiovascular disease and diabetes have been seen to be substantially in excess of the norm since April 2022.

The ongoing pressures on the health service have also been put forward as a potential reason for some excess deaths. From delays in seeing a GP and starting treatment to pressures on the ambulance and emergency services; it is inevitable that pressures on the health service have the potential to affect patient outcomes.

This is one reason why there is an increasing emphasis on the part played by pharmacists and other health practitioners in delivering healthcare solutions. The more that healthcare professionals across the board can contribute to delivering patient outcomes, the greater the potential for improved acute patient outcomes. Of course, that spreading of the burden is only effective if it can be done without over-stressing other elements of the healthcare service. In part that means finding ways to work smarter rather than harder, to optimise patient consultation times without adversely affecting patient care.

Strategies such as digitising patient records can help here, enabling patient notes to be shared across healthcare professionals as required. Not only does this reduce delays in referrals, it also avoids needless time spent in requiring the patient to repeat their history to each successive healthcare professional. 

The problem of excess deaths isn’t confined to the UK. Speaking to Sky, NHS England chief strategy officer Chris Hopson highlighted that countries such as Germany, Spain and Italy are also experiencing higher mortality rates than normal. That’s why further research is required to identify the underlying factors and put mitigation strategies in place. Pending that research, the more that can be done to spread the excess healthcare workload, the better.

[1] https://www.bmj.com/content/372/bmj.n693

[2] https://www.bmj.com/content/379/bmj.o2524

“When health as a fundamental human right is upheld by all countries and all sectors, we lay a strong foundation for building the world we all want and deserve.”

That quote from the World Health Organisation (WHO) perfectly illustrates why in 2017 it decided to launch International Universal Health Coverage Day. The day, which is held on 12^th December each year, aims to showcase international efforts to prioritise health care for all people, communities and organisations across the world.

The theme for 2022 is: “Build the world we want: A healthy future for all.” According to the WHO primary health care which is based on a ‘whole of society’ approach is the most effective way to bring health and well-being closer to people. Accordingly, the WHO is calling for societies and economies to be designed to prioritise everyone’s health.

The WHO comments that improvements have been made in the delivery of universal healthcare since it first started to promote the idea of health care for all some seventy-five years ago. However, the WHO also acknowledges that inequalities in service coverage and financial hardship still exist in many countries, especially among vulnerable and hard to reach populations.

This year’s event is overshadowed by the impact which the Covid pandemic had on universal healthcare with the effects having been exacerbated by the current global economic recession. These, the WHO say are likely to halt progress seen in recent times, particularly among disadvantaged populations.

Even in a country such as the UK which, thanks to the NHS, has had a primary healthcare system since 1948 we have seen the effects of Covid on healthcare delivery. The combination of delayed treatments and the ongoing health impacts of those affected by long covid have helped to put the service under even more strain than before.

But universal health provision is not simply a matter of treating existing conditions. Prevention too plays an important part. Take the Chief Medical Officer’s recent call for the UK to do more to reduce air pollution. Recognising the progress which has been made towards tackling outdoor air pollution, Professor Chris Whitty comments that we should not ignore the impact which indoor air pollution can have on health.

We spend around 80% of our time indoors and yet indoor air pollution is still in many instances not seen as a priority in designing and managing buildings; particularly public spaces. In order to address this the Chief Medical Officer has called for work to be undertaken to find ways of ensuring effective ventilation in indoor spaces whilst minimising energy use and heat loss. Research, the CMO says, should also look at ways of reducing indoor air pollution including reducing the sources of that pollution.

Taken together indoor and outdoor air pollution have been linked with a range of health conditions including lung cancer, cardiovascular problems and asthma. It’s a perfect illustration of why the WHO sees health provision in terms of societies and economies; with every agency uniting to deliver health coverage for all.

As we slide past the middle of November we have to admit that, so far, autumn has been a fairly mild affair. So much so that Armistice Day 2022 was the warmest on record. Is this warm autumn going to continue or should we be preparing for storms ahead?

According to the Met Office’s long range forecast it’s a bit of a good news, bad news scenario. On the positive side, although the Met office doesn’t rule out the chance of stormy weather at times, they say that the risk of strong winds and storms is less than normal. However, whilst we may see fewer strong gales than in recent years, the risk of excess rainfall is being supplanted by a greater chance of a colder winter.

If the Met Office is right, that means more frost and ice. And if that happens then potentially there will be an increasing demand on health services as pedestrians slip and fall and traffic slides in the icy conditions. And it’s not just physical health which can be affected; with a Met Office survey released in October 2022 revealing that 41% felt their mental health was affected by winter weather.

Planning for such eventualities means finding ways to deliver continuing care without unnecessarily tying up vital resources. Truth be told, at the time of writing there is no way to be certain when this colder weather will arrive. As the Met Office’s Chief Meteorologist, Professor Paul Davies, commented “the science, as yet does not allow for specific detail on, for example, the number of nights of frost, rain or snow over the coming months or when specifically severe weather may occur.” 

That can make planning difficult. How do you agree holiday leave or structure shifts based on likely demand/resource matrices if you don’t know when that demand is likely to occur? And is it really the best use of scares resources to take on extra staff just in case they might be needed when poor weather hits?

One solution could be to develop processes which can be flexed as demand requires. For example, a health practice might decide to appoint a call answering service such as that provided by Clinic Appointments. Available either on a permanent or ‘at need’ basis; having calls answered by an external agency helps to relieve administration burdens, particularly when resources may be stretched. With calls answered in the name of the health practice, clients need not know that you have outsourced the call function.

Our call handlers can screen out unwanted sales calls and answer general enquiries leaving you free to concentrate on patient treatments. Add in the diary management option and we can also book and update appointments as well as send out appointment reminders if required. Over 97% of calls are answered within three rings, providing a professional response for health patients.

Best of all with the option of an overflow or permanent services, health practices have a potential call management solution which can flex as the needs of the business change in response to the weather or to any other factor. The Met Office may not be predicting storms this winter but flexible planning solutions could help health practices to weather any other seasonal pressures that this winter may bring.

Last month we wrote about a campaign to reduce the stresses which health practitioners encounter on a daily basis. In our article we highlighted a few coping strategies suggested by the BMA. And we looked at how even simple administration changes such as sending out appointment reminders by SMS text or taking credit card details at the time of booking could help to reduce the number of missed appointments; a potential source of stress for practitioners and patients alike.

There is another reason why something as simple as SMS text reminders could make a marked difference to some individuals; the menopause. Whilst every individual’s experience of the menopause is personal to them, cognitive difficulties are relatively common. So much so that research conducted for World Menopause Day on 18^th October by the Chartered Institute of Personnel and Development (CIPD) revealed that nearly two thirds of women who were experiencing menopause symptoms found they were less able to concentrate. No wonder therefore that the theme for the 2022 day is ‘cognition and mood.’

A paper released by the International Menopause Society highlighted some of the cognitive difficulties experienced by those transitioning menopause including disturbances in daily life, trouble concentrating, and forgetting appointments and events. With that in mind, even something as simple as SMS text reminders can make it easier for individuals to manage their daily lives without missing out on important health checks. From this writer’s personal experience, another source of stress is the fear that appointments have been written down incorrectly. This has led to a need to phone the health practitioner to double check, something which could have been avoided had SMS texts been issued.

This leads us on to another important issue, the effect which the menopause could have not just to patients but also to those working within health practices. The CIPD research mentioned above also revealed that sixty percent of those surveyed found that menopause symptoms had a negative impact on their work. When everyday actions can seem stressful, the more that processes can be automated the better. For example, digitising patient records might seem like a simple solution. But being able to retrieve information at the touch of a button rather than searching through paper files can help to relieve stress; particularly if there is a concern that ‘brain fog’ might have led to mis-filed information. Solutions such as these may go some way  towards helping the more than 50% of people who reported increased stress levels during the menopause.

Finally, it is important to be clear that every individual’s journey will be personal to them and that symptoms may come and go over time. The effect on friends, family, and colleagues cannot be underestimated. As the NHS employer’s website commented: “Menopause is not just a gender or age issue; it is an organisational issue.  It can impact on colleagues both directly or indirectly. Awareness on this topic is fundamental and reducing the stigma attached to it is vital so that more people will talk openly about it so it can begin to be normalised and people can get the support they need.”

How are you? Three simple words which convey a wealth of meaning as expressions of enquiry, of concern, and of genuine care. Of course, in the spirit of the stiff British upper lip the instinctive answer is to say that you are OK. But there are times when giving that answer is to deny yourself and to deny the people around you the chance to help.

Quite simply, it’s OK to not be OK.

Acknowledging this, the BMA’s General Practice branch has come up with a ten point plan to help their colleagues to manage in stressful times. Quite frankly, many of the suggestions could equally apply not only to practitioners across the health service but in other walks of life as well.

The plan includes some of the more obvious coping strategies such as providing access to support groups, pairing less experienced staff with more experienced colleagues, and rotating staff between high and low stress activities. But it also stresses the need for people to check in with each other, for individuals to feel able to speak up if they are struggling and for senior staff to stress the message that it is OK to not be OK.

The overall message is simple, health practitioners cannot provide the best levels of care for patients if they are in need of care themselves. And right now that’s a challenge. Statistic after statistic demonstrate just how much strain the health service is under. A BMA analysis in September 2022 talks about a growing backlog of care with one in eight people in England waiting for treatment.  

And despite the announcement of some thirty-five thousand new healthcare support workers having signed up to join the NHS in 2022, the pressure to provide the highest level of care for patients still remains. That’s’ why statistics which were released earlier in 2022 with revealed that across the country there were more than one million missed appointments each month are so disconcerting. When demand for services is already high, optimising face-to-face or face-to-screen time is key to ensuring that as many people as possible are able to receive the treatment they need as early as possible.

In response to these statistics the then Chancellor, Rishi Sunak, floated the idea of charging no-shows £10 a time. The response to this proposal was mixed; but there are other ways of helping to ensure that people are more likely to attend booked appointments. Simple solutions such as sending out appointment reminders by SMS text have been shown to reduce the number of missed appointments. And for those health practitioners who charge for their services, being able to take credit or debit card details at the time of booking and to charge a fee if the patient fails to turn up for their appointment has proved to be another way of boosting attendances.

What do simple steps such as these have to do with practitioner health? Well, when the pressure is on, sitting waiting for a no-show whilst being aware that you could have been treating someone else can be a source of frustration and stress. Taking even simple steps to optimise patient access may not seem like much but they could have positive results for patients and for health practitioners alike.  

“The National Health Service and the social care sector are facing the greatest workforce crisis in their history.” Parliament’s ongoing inquiry into workforce: recruitment, training and retention in health and social care didn’t pull any punches as it issued its latest report into the sector in July 2022. Setting out the levels of shortage across doctors, nurses, and midwives, the report goes on to highlight the ever increasing demand on the health and social care sector which will result in a further 475,000 positions in health and 490,000 in social care within a decade.

As a result of the existing and future anticipated shortage the report comments that nearly 90% of BMA members think the Government’s aim to tackle the Covid backlog with the existing workforce is either “totally or mostly” unachievable. Of greater concern is the toll which the report indicates is being put on the health of NHS workers, leading either to the need to take time off or to individuals leaving the profession. In response the Royal college of Physicians called for ‘better workforce planning informed by patient demand.’

The shortage of trained doctors and nurses is not confined to NHS surgeries or hospitals. A BBC report at the beginning of August 2022 revealed that ninety percent of dental practices are not accepting new NHS adult patients with eighty percent not taking on children. Commenting on the report The British Dental Association commented that NHS dentistry was at a ‘tipping point.

Statistics such as these demonstrate the challenge facing the health sector. In a bid to overcome that challenge, in recent years we’ve seen the rise of smart systems which are designed to take some of the administrative burden away from health practitioners. Simple solutions such as SMS texting have already resulted in a measurable decrease in appointment no-shows whilst the ability to make appointments online has helped to improve patient accessibility. Other innovations such as digitising patient notes have not only saved administration time, they have also enabled clinicians and health professionals to better share information; collaborating in order to improve patient outcomes.

And these are only the tip of the iceberg. Innovations in patient treatment and care have been seen across a range of services; from apps which enable people to be monitored whilst living at home to robot-assisted surgery which enables surgeons to perform surgical procedures with a greater level of control than before. Innovations such as these are designed to improve patient outcomes and speed up recuperation whilst reducing the day to day burden on health services.

The Parliamentary report made seventy-three recommendations across health and social care. These covered areas such as workforce planning, recruitment, training, and the retention of staff. This last area considers the availability of flexible working patterns alongside pay and working conditions. Working culture including the challenges faced by those who are recruited overseas also came in for a number of recommendations as did the need to ensure continuity of care for individuals across health and social care systems.

An amber extreme heat warning covering must of the country has been issued by the Met Office. Coming almost exactly one year on from the first ever amber warning, this extreme heat  warning which was originally only in force for Sunday 17^th July has now been extended to take in Monday 18^th and Tuesday 19^th July 2022.

With daytime temperatures climbing into the 30s and night time temperatures also higher than normal, the amber weather warning should not be taken lightly. The Met Office warns that ‘population-wide adverse health effects are likely to be experienced’ which could potentially lead to serious illness or danger to life. Importantly, it’s not just those who are already seen as vulnerable who may be affected.

Accordingly, the Met Office has reiterated the standard Government advice that 999 services should be used in emergencies only. However, it is worth noting that even before the amber heat warning was issued, all ten ambulance services across England had already declared a critical incident meaning that response times are likely to be stretched.

So what can health providers do to help their patients at this time. It is worth noting that the Met Office warn that transport delays are likely, with road closures and cancellations to rail travel expected due to the effects of heat on infrastructure. Even moderate delays, the Met Office say,   could lead to ‘significant welfare issues’ for those stuck in traffic or on trains. And it won’t just be patients affected with staff too being potentially caught up in the delays.

With the standard advice being not to travel unless necessary it may therefore be worth considering a review of appointments booked for the days affected. This, with a view to rearranging appointment times or days, particularly for the most vulnerable patients.

Admittedly there will be some appointments which should not be delayed. But is there any scope for being a little more flexible on times, perhaps shifting appointments due to take place in the hottest parts of the day to earlier in the morning or later in the evening? Remember, excess heat can not only lead to irritability it can also affect our ability to concentrate on mental or skilled tasks. So moving appointments may not only help your patients as they travel to your practice, it might also help to ensure that your service to patients is not affected by the heat.

 And whilst it may be too late to check that any air conditioning is working well, it might be worth ensuring that staff and patients have access to chilled water and a cool area within the building. This cool area could also be used for patients who wish to delay their journey home until the hottest part of the day has passed.

Finally, make sure that your people are aware of and can react to and appropriately treat the symptoms of heat exhaustion and heat stroke. The link to the NHS advice on these conditions can be found here. [1]

[1] https://www.nhs.uk/conditions/heat-exhaustion-heatstroke/