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Take a look at a selection of our recent media coverage:
22nd October 2024
The Government is launching a ‘major crackdown’ on waste in the NHS to save millions of pounds a year. Ministers say the savings will be ‘redirected to frontline services’, and the waste reduction and recycling programme will help the NHS become net zero by 2045.
The new ‘Design for Life Roadmap’ strategy lays out 30 actions such as scrapping the use of single-use medical devices and reducing reliance on foreign imports. It includes the Government incentivising UK-based MedTech companies to produce sustainable products and train NHS staff on how to use them.
The proposals will initiate the shift to circular methods of reuse, remanufacture and recycling, keeping resources close to where they are needed and generating economic opportunities within the UK, helping to ‘transform the country into a life sciences superpower’ and creating ‘thousands more UK jobs’.
Reliance on high-volume products imported from overseas can make patient care vulnerable to global supply shocks and these plans to support UK manufacturing will limit this impact.
What’s more, single-use devices substantially contribute to the 156,000 tonnes of clinical waste that the NHS produces every year in England. Reusing medical devices will reduce the UK’s carbon footprint and plastic pollution and preserve precious metals such as platinum and titanium, which are often used in medical devices and currently end up in landfill.
Devices like walking aids and surgical instruments are currently thrown away after just one use, but the Government hopes to encourage innovation to safely remanufacture a wider range of products.
The roadmap gave examples of where innovations are currently being made. These included harmonic shears – a surgical device that seal wounds using ultrasound waves – which are £500 per device but 90% of them are thrown away after one use. However, some companies are purchasing these devices and remanufacturing them at a lower price.
At Northampton General Hospital NHS Trust, an Ophthalmology department saved 1,000 pairs of disposable scissors and £12,000 in a year by switching to reusable pairs, while Leeds Teaching Hospitals Trust saved £76,610 purchasing 604 remanufactured electrophysiology catheters, and generated £22,923 by selling used devices for collection.
Health and social care secretary Wes Streeting said: ‘The NHS is broken. It is the mission of this Government to get it back on its feet, and we can’t afford a single penny going to waste.
‘Every year, millions of expensive medical devices are chucked in the bin after being used just once. We are going to work closely with our medical technology industry to eliminate waste and support homegrown MedTech and equipment.’
Professor Sir Stephen Powis, national medical director of NHS England, said: ‘While the NHS is treating record numbers of patients, we know there is much more to do to ensure taxpayers get value for money.
‘The NHS made a record £7.25bn worth of efficiency savings last year and is targeting a further £9bn of savings for 2024/25. But we are rightly still looking for ways to get our money’s worth for every penny we spend.’
More than 80 stakeholders from the UK MedTech industry, the health and care system and research organisations helped to create the Design for Life Roadmap.
The Royal College of Physicians (RCP) welcomed its publication, saying the current over-reliance on single-use med-tech products is ‘expensive, wasteful, not sustainable and leaves us vulnerable to supply chain issues’.
Dr Mark Harber, the RCP’s special adviser on healthcare sustainability and climate change, said: ‘The NHS, like most health services, generates a huge amount of waste related to day-to-day practice. Only a relatively small proportion of this waste is recycled with most of it either going to landfill or incineration, both of which have very major environmental impacts.
‘Shifting towards a circular system for medical devices that enables them to be reused, remanufactured, or recycled will have a significant effect on the environmental impact of the NHS without compromising patient care.’
In the summer, the RCP released its Green Physician Toolkit suggesting a range of everyday steps physicians can take to help the NHS reach its net zero goal and mitigate the risks of climate change.
This came after the International Hospital Federation’s Geneva Sustainability Centre launched a platform in October 2023 to digitally empower hospitals and healthcare leaders to drive sustainable, low-carbon, equitable and resilient healthcare.
21st October 2024
Education programmes for healthcare professionals involved in the management of atrial fibrillation can increase adherence to guidelines and improve patient safety, according to a recent trial.
Researchers found that current adherence to treatment guidelines for atrial fibrillation is low across six European countries. They concluded that increased efforts are needed to improve the implementation of guidelines and to optimise the care of patients with atrial fibrillation to prevent the high rate of adverse outcomes.
The STEER-AF trial involved 739 healthcare professionals and 1,732 patients with atrial fibrillation in 70 treatment centres across France, Germany, Italy, Poland, Spain and the UK between May 2022 and February 2023. The average age of participants was 69 years, and 37% were female.
Researchers randomly assigned treatment centres to one of two groups to determine whether a structured educational programme could improve adherence to guideline recommendations and the care of patients with atrial fibrillation.
In the intervention group, a total of 195 healthcare professionals received a structured education programme delivered over 16 weeks, targeting stroke prevention, rhythm control and integrated care. Healthcare professionals spent an average of 9.2 hours on the online learning platform and expert local trainers provided learning support. This was in addition to any existing continued professional development.
In the control group, healthcare professionals received only their existing educational activities.
The researchers tracked how well healthcare professionals followed the European Society of Cardiology (ESC) guidelines, in particular adherence to ESC Class I (strongly recommended treatments) and Class III recommendations (treatments that are not recommended) at baseline and six to nine months later.
The study observed a significant improvement in guideline adherence for rhythm control, with adherence increasing from 21.4% to 33.9% in the intervention group and from 20.5% to 22.9% in the control group.
There was no significant improvement in guideline adherence for stroke prevention, which changed from 63.4% to 67.5% in the intervention group and from 58.6% to 60.9% in the control group.
There was also a significant improvement in the patient-reported secondary outcome that assessed eight domains of integrated atrial fibrillation management, improving to 77.0% with the intervention and to 71.0% in the control group. All results were statistically significant and had a reliable confidence level.
The findings of this study are incorporated into the 2024 ESC Guidelines for atrial fibrillation management, which were presented at the ESC Congress 2024.
Reference
Sterliński, M et al. Design and deployment of the STEEER-AF trial to evaluate and improve guideline adherence: a cluster-randomized trial by the European Society of Cardiology and European Heart Rhythm Association. EP Europace 2024; Jun 28: DOI: 10.1093/europace/euae178.
Francine de Stoppelaar is co-founder of Project Asclepius – an excellence platform driving digital transformation and automation of medication management processes – as well as an honorary associate professor at the University of Leicester and an associate at Deloitte for digital transformation of hospital services and medicines optimisation. She speaks to Saša Janković about her trailblazing work in this area and where she sees the biggest potential.
With a background in clinical pharmacology and over 25 years’ experience across the NHS, private healthcare and academia, Francine de Stoppelaar’s career exemplifies the intersection of clinical expertise, innovation and strategic leadership.
As the co-founder of Project Asclepius and former chief pharmacist at Cleveland Clinic London, she has become a leading voice in the digitalisation of hospital processes – particularly in the realm of pharmacy and medication management – and has laid the groundwork for a future where technology and healthcare professionals work in partnership to deliver safer, more efficient patient care.
A long-time champion of the broader potential for multidisciplinary collaboration and the use of digital tools to address unmet patient needs, Francine’s passion for digital transformation in healthcare was ignited during her time at Cleveland Clinic London, which she joined in 2018.
As well as being chief pharmacist, she led the operational activation of the hospital prior to its 2022 opening, in a role that encompassed everything from building, procurement and hiring teams to the integration of equipment and new systems – all of which she spearheaded alongside the added challenges of Brexit and the Covid-19 pandemic.
However, her primary focus remained on pharmacy, where she oversaw the development and implementation of a fully digitalised, closed-loop medicines management system that leveraged digital and automated solutions to enhance patient safety, workforce efficiency and sustainability.
The first of its kind in the UK, this groundbreaking digital pharmacy system included automation at every stage – from prescription verification to bedside administration – allowing for real-time monitoring of medications and dramatically reducing the risk of errors.
‘In fact, after two years the hospital reported only two incorrect administration errors in over one million medication administrations, both of which had no damaging effect to the patient and were easily corrected,’ Francine recalls.
Nonetheless, since most medicines management processes in hospitals across Europe are still based on manual operations to some extent, Francine admits projects like these are ambitious and uncommon.
‘State of the art technologies and innovative solutions are readily available, but their adoption is still limited, partly due to highly fragmented practices and workflows, but also because they are complex and costly,’ she says. ‘That’s why many hospitals in the UK and Europe still rely on outdated analogue systems, but these can lead to inefficiencies and medication errors, which is why it is essential that we bridge the gap between what’s technologically possible and what’s being implemented on the ground.’
This vision has been foundational to Francine’s work with Project Asclepius – an initiative she cofounded with Patrick van Oirschot and Patrick Koch after leaving Cleveland Clinic London at the start of 2024.
‘While some European countries are further ahead than others in managing medication effectively in a hospital setting, there are no consistent cross-European guidelines or effective ways to share best practice,’ says Francine.
‘The aim of Project Asclepius is to contribute to a faster and safe adoption of digital and automated medication management systems in hospitals across Europe, initially by focusing on best medication management practices enabling personalised therapies based on unit doses, with other areas of medication management to follow in future.’
The key to its success, according to Francine, lies in the integration of technology and human expertise. ‘Digitalisation doesn’t remove the human factor,’ she explains. ‘Rather, it enhances our ability to work smarter, not harder, by reducing repetitive tasks and allowing healthcare professionals to focus on patient care.’
One of Francine’s driving motivations has always been improving patient safety.
‘As the healthcare landscape becomes increasingly complex, with workforce shortages and rising costs, the need for more efficient and safe systems becomes critical,’ she says. ‘For example, medication errors in the UK alone are responsible for the loss of approximately 1,700 lives each year.’
For Francine, addressing this through the automation and digitalisation of hospital processes is an ethical imperative. ‘By integrating technologies such as automated dispensing cabinets and real-time scanning at the bedside, we have helped to create systems where every step of the medication process is tracked and checked digitally,’ she says. ‘This approach minimises the possibility of errors, whether from a lack of human oversight or system inefficiencies, because if a medication hasn’t been verified and dispensed by a pharmacist, it simply can’t be administered.’
Through Project Asclepius, she advocates for the wider adoption of such ‘closed-loop’ systems, which not only improve patient outcomes but also have significant impacts on workforce efficiency. For instance, nurses and pharmacists can spend less time on manual tasks and more time focusing on direct patient care. As Francine points out, ‘automation doesn’t eliminate jobs but rather redeploys skilled workers to areas where they are most needed, thereby improving both patient experience and operational flow’.
Another recurrent theme in Francine’s work is the importance of collaboration. ‘Effective healthcare cannot be siloed, and this is especially true when it comes to pharmacy,’ she says, adding that: ‘Pharmacy is the red thread running through a hospital, so that while pharmacy teams handle ‘back office’ tasks such as procurement, logistics and stock management, their work always directly impacts clinical care.’
The challenge, however, is that many hospitals operate in a disjointed way, with different departments using incompatible systems. ‘In my consultancy work with Deloitte I’ve seen numerous inefficiencies resulting from this lack of interoperability, including duplicative processes and wasted staff hours,’ she says.
Her solution is to ensure that all digital systems within a hospital – whether for stock management, prescribing, patient records or anything else – are able to connect and ‘talk’ to each other.
However, she stresses that this requires buy-in not just from pharmacy leaders but from the entire multidisciplinary team. ‘Physicians, nurses, IT specialists and hospital managers must all be aligned in their approach to digital transformation and leaders need to bring everyone on board,’ she insists. ‘Without the support of senior management and the wider clinical team, even the best digital tools won’t succeed.’
Looking ahead, Francine believes that standardisation across hospitals and pharmacies will be key to addressing both workforce and patient safety challenges.
Through Project Asclepius, she is pushing for pan-European standards that would allow hospitals to adopt best practices for digitalisation more easily, which she says ‘includes everything from standardised unit doses and barcoding systems to harmonised procurement processes’.
But she is also realistic about the challenges. A survey by the European Association of Hospital Pharmacists concluded that most hospitals still don’t have plans to implement automation systems, and Francine acknowledges that ‘this is a long game, with huge complexities, particularly in terms of funding and policy’.
But, she says, ‘the potential benefits – fewer errors, better patient outcomes, and a more efficient healthcare workforce – are enormous.’
Ultimately, Francine’s approach to digitalisation within a hospital setting is both visionary and pragmatic. While she is passionate about the potential of technology to transform healthcare, she is also deeply aware of the human factors involved. At the heart of her work is a commitment to ensuring that digital systems serve not just patients, but also the healthcare professionals who care for them.
Consultant clinical oncologist Dr John Conibear speaks to Kathy Oxtoby about the changing treatment landscape of non-small cell lung cancer, durvalumab’s latest approval by the MHRA for the resectable form, and his hopes for the future management of the condition.
The UK has one of the worst five-year survival rates for lung cancer in Europe, and new treatment options are urgently needed to offer patients a better chance of long-term survival.
This July, the Medicines and Healthcare products Regulatory Agency (MHRA) granted marketing authorisation in Great Britain for durvalumab (brand name Imfinzi) for the treatment of adults with resectable non-small cell lung cancer (rNSCLC).
This anti-programmed death ligand 1 monoclonal antibody is now indicated in combination with platinum-based chemotherapy as a neoadjuvant treatment before surgery, followed by durvalumab as adjuvant monotherapy after surgery, in those who have no known epidermal growth factor receptor mutations or anaplastic lymphoma kinase rearrangements or aberrations.
This joins durvalumab’s existing indication for the treatment of adult patients with locally advanced, unresectable NSCLC, meaning the drug is now approved in Great Britain for both resectable and unresectable forms.
The latest approval from the MHRA is based on positive data from the AEGEAN Phase III trial in rNSCLC, which showed that durvalumab-based treatment before and after surgery reduced the risk of recurrence, progression events or death by 32% versus neoadjuvant chemotherapy alone.
Dr John Conibear is a consultant clinical oncologist and clinical director for thoracic oncology at Barts Cancer Centre, London, and oncology lead for the National Lung Cancer Audit (NLCA). He says the AEGEAN Phase III trial represents ‘a promising step forward in the management of patients with resectable lung cancer’.
‘The trial demonstrates that the combination of immunotherapy with traditional chemotherapy, in both the neoadjuvant and the adjuvant setting improves pathological response rates and disease-free survival,’ he says. ‘That could potentially lead to better long-term outcomes and increased survival rates for these resectable patients.’
The use of durvalumab in combination with chemotherapy for treating rNSCLC is still pending approval from the National Institute of Health and Care Excellence (NICE) and is currently not recommended by the organisation in its initial draft guidance, which has been out for consultation and is now being considered by the committee.
Dr Conibear says the results of the trial show that ‘the addition of this drug does seem to reduce the relapse of patients with lung cancer in this resectable setting, and it increases the rates of complete responses’. For him, there is ‘clearly synergism between chemotherapy and immunotherapy in this setting’, and Dr Conibear is in favour of durvalumab being available on the NHS for routine use in this patient group.
‘From a clinician’s point of view, I want to do what’s best for my patients, and it’s a shame if durvalumab is considered unsuitable on the basis of financial availability rather than clinical benefit,’ he says.
Whether NICE changes its current stance, only time will tell.
Dr Conibear’s insight into the importance and value of durvalumab for lung cancer patients comes from more than 20 years of working in oncology, including thoracic oncology.
It was during the early part of his training as a junior doctor in 2003 that he chose this specialism. ‘As a medical specialty, oncology is dynamic, and always seems to evolve, because of the nature of the treatment we can offer patients,’ says Dr Conibear.
Patients with cancer require ‘a compassionate and thoughtful approach to their care’, he says. ‘Oncology fuses both the science and compassion of medical care into one specialty, which I find attractive.’
His particular interest in thoracic oncology was sparked towards the end of his oncology training. ‘I was involved in clinical trials looking at improving outcomes in patients with locally advanced lung cancer, and through that I began to appreciate the complexities in diagnosing and treating lung cancers.’
During the last decade since Dr Conibear became a consultant, the treatment landscape of NSCLC, in both the UK and Europe, has evolved significantly. ‘That’s been driven by advancements in targeted therapies, immunotherapy and the more personalised approach to patient care,’ he says.
Understanding the molecular biology of NSCLC has made a huge difference, with clinicians ‘now able to identify specific gene mutations, which allows us to use specific targeted therapies, and these offer better efficacy and often fewer side effects compared to traditional chemotherapy’.
Then there is the advent and evolution of immunotherapy. ‘This has revolutionised NSCLC treatment, both in the early, locally advanced and metastatic settings. This has become the standard of care for many patients with NSCLC, and led to significant improvements in survival rates,’ he says.
‘Through these advances in treatment, and the combination of these treatments, whereby you create a personalised multimodality approach, we’ve seen improvements in patient survival. We see patients not only cured of their disease, but also living with their disease for much longer than we ever saw in the past,’ he adds.
However, in the UK, what is clear from ongoing data analysis – such as the National Lung Cancer Audit’s ‘State of the Nation 2024’ report – is that much more needs to be, and potentially can be, done. ‘There is still an unmet need when it comes to treating patients with both early and advanced lung cancer in regard to the number of patients who don’t seem to be receiving optimal cancer-driven care’, Dr Conibear says.
‘We’re trying to explore the reasons behind that – the potential biases and inequalities that are causing these differences to occur, both within regions of the UK, and also the UK compared to our European brothers and sisters.’
The AEGEAN Phase III trial is evolving the treatment landscape further, says Dr Conibear.
Durvalumab has become ‘a cornerstone in the management of unresectable locally advanced NSCLC’, and ‘the AEGEAN trial potentially, as the data matures, could reveal durvalumab to have a similar role in resectable patients,’ he suggests.
Until now, treatment has been focused on just the neoadjuvant use of chemoimmunotherapy in resectable patients before they have surgery.
‘What this trial demonstrates is expanding that treatment beyond surgery, so that patients then come back after surgery to receive further immunotherapy,’ Dr Conibear says. ‘Essentially, we’re intensifying the patient’s treatment to see an improved long-term outcome – we hope.’
Dr Conibear would like durvalumab to ‘translate into a meaningful improvement in long-term survival and push the bar higher in what we consider to be standard outcomes for these patients’, and he believes there is certainly potential for this to happen.
While clinicians and multidisciplinary teams (MDTs) working in lung cancer care understand the role of durvalumab in treating patients with unresectable lung cancer, Dr Conibear says ‘there is a knowledge gap now for people in those teams to understand the role of durvalumab in that resectable patient group, following the results of the AEGEAN trial’.
If NICE’s final ruling is in favour of durvalumab for treating rNSCLC ‘then there will be a need to target education towards these clinicians to expand that knowledge base’, he says. This could include educational initiatives such as workshops, seminars and webinars focused on the role of durvalumab in non-small cell lung cancers. And guidelines and protocols will need to be updated to reflect these evolutions of approaches to patient care.
Ongoing professional development should be encouraged, ensuring that the MDT attends training sessions to stay up to date with the latest practices and treatment recommendations, he says.
As patients are becoming increasingly complex in terms of the personalised approach required for their care, Dr Conibear sees a greater need for case discussions and the sharing of ‘knowledge and experience between multidisciplinary team meetings’. There is also a role for direct peer-to-peer learning and encouraging experienced oncologists to share insights through mentorship programmes or peer-led discussions, he adds.
‘And what mustn’t be forgotten is the dissemination of information to patients, arming them with the knowledge of what’s available, and what’s potentially suitable for them so they can also be an advocate for their own care,’ he says. ‘Patient education and advocacy are also important to dispel the limitations on what we offer our patients.’
As to further developments in the management of NSCLC beyond durvalumab, attention is turning to new mutations, which Dr Conibear says are ‘potentially druggable’ and ‘could form further aspects of that personalised approach to patient care in the resectable and unresectable lung cancer setting’.
Then there are advances in diagnostics, in particular liquid biopsies – the ability to collect and analyse circulating tumour DNA and circulating tumour cells. ‘We can use these measures to understand resistance patterns to treatment so that we potentially have a more dynamic and adaptive treatment plan that we can offer our patients,’ he says.
‘We can see at a microscopic level whether the treatment is working or not, so that we can make clinical management decisions more quickly than we have done historically.’
Dr Conibear also highlights the integration of artificial intelligence and machine learning into clinical practice. ‘These tools are capable of analysing large data sets, including imaging, genomic data and clinical data,’ he says. ‘It seems with the right algorithms you’re capable of predicting patient outcomes and responses to therapy, and possibly even unwanted adverse events or effects more accurately. This technology could help us to enhance this personalised treatment approach to patients.’
And with the AEGEAN trial showing the benefit of immunotherapy and chemotherapy before, and now also after surgery, ‘it’s demonstrating, again, the importance of a multimodality approach to these patients’, Dr Conibear says. ‘As we move on, we’ll see the potential of other treatments added into this approach.’
It’s no secret that Dr Conibear would like durvalumab to be available to real-world rNSCLC patients who are eligible for the treatment. ‘And it would be great to not see it as the final step, but a stepping stone in terms of improving things further for these patients,’ he says.
‘Ultimately, I hope durvalumab plays a pivotal role in advancing lung cancer treatment, thereby contributing to higher survival rates, improved quality of life and pushing the bar higher on the idea of a personalised approach to these patients’ care. I’m optimistic we’ll see that.’
18th October 2024
More patients are experiencing delayed discharges from hospitals, but integrated care boards are working with system partners to develop new and innovative ways to address this. Mid and South Essex ICB and Mid and South Essex NHS Foundation Trust are approaching this longstanding issue with a home-first ethos as Kathy Oxtoby explains in the third of four case studies.
High demand for services, more patients with complex care needs, and making sure there is sufficient flow in discharge services, are some of the main challenges facing the integrated care board (ICB) and hospital trust when managing patient discharge.
The hospital trust works jointly with the three local authorities to promote a home-first ethos.
System challenges are being addressed through ‘shared thinking, shared responsibility, and putting patient outcomes at the heart of all decision making’, the ICB and trust say.
In Mid and South Essex, there is an established Stewardship programme, which is about forming teams that bring together perspectives from the whole cycle of care – from across all services supporting residents moving through the health and care system, from before they enter, to after they step out.
Ageing Well stewards have co-designed a common assessment tool to help identify and meet the needs of older people who often have complex needs. Results have seen more than 12,000 new people with frailty/dementia/end of life needs identified in the first year alone, and more than a 50% reduction in older people with more than three unplanned hospital admissions in their last 90 days of life.
Schemes such as Urgent Community Response Teams, can provide two weeks of intensive treatment in a person’s home or care home, are ensuring more urgent care in the community.
Supporting people to get home and become as independent as soon as possible has also been a focus. This has been done through continued partnership working with system partners to offer ‘at home’ reablement and virtual ward services to support people to go home if they are able for ongoing assessment.
Transfer of care hub teams have been working on making sure community services information can be accessed by wards – which is being trialled in a small number of wards on two of the hospital sites – and with support from community matrons to highlight what support community teams can provide on discharge. ‘This is having a positive impact on ward teams’ confidence in discharging residents with complex issues to home, rather than to short term bedded care,’ the ICB and trust say.
Charis Shop provides hospital discharge teams with immediate access to funds to help them discharge a person safely home. The scheme came about to support the delivery of a one-off discharge support package that could help reduce unnecessary discharge delays. It allows those with low level needs to be supported with essential items such as food and fuel vouchers, bedding, small appliances and phone top ups.
Using the fund in this way supports people – who might otherwise have had an extra day or two in hospital waiting for assessment or support from other agencies – to be discharged and receive a follow up from statutory or voluntary services if needed once they are home.
Within the last year, the Integrated Discharge Teams have supported the distribution of more than £19,000 of grants to 155 people through the Charis fund.
Michelle Stapleton, integrated care operations group director for Mid and South Essex NHS Foundation Trust says: ‘We now focus on a patient’s discharge journey from the moment they are admitted. Using same day emergency care services has enabled us to treat and transfer or discharge at the front door, reducing the need for stays in hospital. Work to reduce length of stay is important in increasing flow across the hospital and we can only do this by working in an integrated way with our wider health system partners.
‘There have been some bumps along the way, but we must remember our ethos of home first. Patients will always feel better if they can recover with support in their own homes,’ she says.
Dr Matthew Sweeting, executive medical director for NHS Mid and South Essex, says: ‘Supporting effective discharge is not a one-size-fits-all process, and as a system we are focussed on ensuring smooth and timely discharges that consider the holistic needs of patients and maximise health outcomes.
‘We know that beds in residential settings are not always the answer to supporting people to get home at the right time. We need to continue to support our community teams across health and social care to work together and have strong networks to help our residents to remain or regain independence after a stay in hospital. It’s important to reduce unnecessary admissions by having care at home and using community home-based services such as our Urgent Community Response teams (UCRT) and virtual hospital.
‘We recognise that discharge planning starts on admission and that in working with our partners across the system, we need to ensure our discharge pathways flow well and that teams can work together to problem solve and support our residents. One team cannot solve this on their own,’ he says.
Read more about tackling delayed hospital discharge and improving patient flow in this analysis, and discover some of the other inspirational work being done across England in the other case studies in this series:
Look out for the final hospital discharge case study next week.
This case study was originally published by our sister publication Healthcare Leader.
17th October 2024
Hospital Healthcare Europe (HHE) is delighted to welcome respiratory consultant Dr Zaheer Mangera as a speaker on the diagnosis and management of lung cancer at the upcoming Clinical Excellence in Respiratory Care event on 21 November 2024.
Dr Mangera, who is the lung cancer lead at North Middlesex University Hospital NHS Trust, will touch on guidelines from the National Institute for Health and Care Excellence as he considers the importance of early diagnosis and indications for chest radiotherapy, helping patients to understand what their risk factors are and what interventions are available to them, plus the effectiveness of diagnostic and staging investigations.
This session complements his contribution to the previous Clinical Excellence in Respiratory Care event in May 2024 in which he joined a panel discussion on the use of diagnostic imaging for respiratory conditions, with a particular focus on lung cancer.
Dr Mangera will also join colleagues from Sheffield Teaching Hospitals NHS Foundation Trust and Royal Brompton Hospital for a panel discussion on the management of pulmonary hypertension as a multidisciplinary team.
Find out more about the upcoming Clinical Excellence in Respiratory Care event and register for free to hear the latest from Dr Mangera on lung cancer and more.
This latest event in HHE’s Clinical Excellence series brings together renowned experts from recognised Centres of Excellence and other key institutions to share best practice and explore the latest advances in respiratory care including diagnosing lung cancer, personalised approaches to asthma and COPD treatment and managing pulmonary hypertension and sleep disordered breathing.
Providing the opportunity to gain CPD hours, the day-long event will also focus on how to best use multidisciplinary teams (MDT) and improve patient care in this area. The agenda has been created by HHE with guidance from industry experts to offer respiratory physicians and members of the wider MDT a comprehensive overview of this broad clinical area.
To coincide with this event and others in the Clinical Excellence series, a whole host of additional content and interviews with prominent clinicians from Centres of Excellence and beyond have been published on the HHE website – look out for the orange Clinical Excellence tag in the Cardiovascular and Respiratory zones.
This includes a summary of a fascinating session from cardio-oncologist Dr Rebecca Dobson on the need and demand for cardio-oncology services, how they’ve developed over time and the current state of play in this evolving field.
The Clinical Excellence schedule for 2025 will be announced soon, including new clinical areas, so watch this space.
16th October 2024
Patients who are waiting for planned trauma and orthopaedics and ear, nose and throat services are facing the longest waiting lists in the NHS system, according to a report by the Nuffield Trust and Health Foundation.
As of May 2024, these two specialisms made up almost one fifth of the total waiting list size (11.0% and 8.6% respectively) for planned hospital care. They are waiting an average of 15.4 and 17.6 weeks respectively.
The report said trauma and orthopaedics services are more likely to treat people requiring overnight admission and longer lengths of stay in hospital than other specialities, which limits their capacity to treat patients.
However, it added that the Covid-19 pandemic may have also negatively affected access to these services more than others, as there were ‘greater relative drops’ in the number of admitted patients compared to non-admitted patients.
Oral surgery has the longest median waiting times, with 17.7 weeks, however it is only the thirteenth largest waiting list overall.
The report also highlighted that respiratory medicine and gynaecology services had the largest increases in waiting list sizes over the past 10 years.
Respiratory services, which currently has one of the smaller waiting lists compared to other specialisms, had a 263% increase between May 2014 and May 2024. Gynaecology had the second largest increase, with 223% uplift over the same period.
The report said: ‘For respiratory medicine, this might be a consequence of increasing emergency care needs diverting resources away from planned care as a result of direct Covid-19 infections or exacerbations of respiratory diseases due to changes in the occurrence of respiratory viruses post pandemic, such as respiratory syncytial virus (RSV).
‘In addition, with the emergence of long Covid, the respiratory medicine workforce are caring for a whole new group of patients suffering long-term symptoms following a Covid-19 infection.’
Meanwhile one in 20 waits for gynaecology services were more than 52 weeks, which is the third largest number across the services.
‘The 2022 Elective Recovery Plan for the NHS focused on prioritisation based on clinical need and to reduce long waits over 65 weeks. This has been criticised as not effectively prioritising these services and may have resulted in waits for gynaecological services not improving as much as orthopaedic services which had more of the very longest waiters,’ the report said.
However, it added that waiting lists have increased across all specialities apart from general internal medicine and mental health services.
It comes after health secretary Wes Streeting said the Government plans to get hospitals running like a ‘Formula 1 pit stop’ to deliver up to four times more operations than normal.
The report also looked at waits for emergency services, with patients with psycho-social or behavioural problems waiting longer than other patients, with an average of 11 hours and 59 minutes for those who were admitted and seven hours 19 minutes if not admitted.
It also looked at the demographics of patients waiting longer in A&E and found that more people from deprived areas attend A&E but waiting times are similar across all levels of deprivation.
However, children from Black, Asian and mixed ethnicities were seen to wait longer than white children.
The report said: ‘When we look at the youngest age group (those aged 19 and under), patients of Black ethnicities waited longer – on average three hours and 41 minutes – compared to white children and young people, who waited approximately three hours and 20 minutes on average.
‘Further analysis by 10-year age bands revealed longer waits for Black patients up until the age of 40. Amongst patients who were admitted, Black people of all ages were found to wait longer than white people.’
A version of this article was originally published by our sister publication Healthcare Leader.
15th October 2024
Hospital Healthcare Europe’s Clinical Excellence in Respiratory Care event is back this November with a jam-packed agenda looking at the latest advances in clinical care – and registration is now open.
Taking place on 21 November, this one-day respiratory event for the multidisciplinary team brings together renowned experts from recognised Centres of Excellence and other UK and EU hospitals to share their experiences of clinical innovations, examples of best practice and how they are improving patient care.
This time, topics include the NICE guidance on the management and diagnosis of lung cancer with insights from Dr Zaheer Mangera, respiratory consultant and lung cancer lead at North Middlesex University Hospital NHS Trust, and an overview of sleep disordered breathing from Dr Alanna Hare, consultant physician, Department of Sleep and Ventilation, Royal Brompton and Harefield Hospitals.
Florence Schleich, respiratory physician, Department of Pneumology, University of Liege, Belgium, will share her take on personalised medicine approaches in managing respiratory conditions including asthma and chronic obstructive pulmonary disease (COPD).
Dr Mangrea will also be involved in a panel discussion on the management of pulmonary hypertension as a multidisciplinary team with David Kiely, consultant respiratory physician at Sheffield Teaching Hospitals NHS Foundation Trust, Colm McCabe, respiratory consultant in pulmonary hypertension, and Heba Nashat, consultant cardiologist in pulmonary hypertension – both at Royal Brompton Hospital.
This year’s autumn respiratory care offering has been developed by the team at Hospital Healthcare Europe and Hospital Pharmacy Europe with guidance from industry experts.
The event is free to attend and comprises individual presentations, panel discussions and sponsored sessions delivered virtually live and on-demand, all tailored to provide maximum convenience and work around your busy schedule.
Select sessions most relevant to your clinical practice, specifically tailoring the day to your needs, and gain CPD hours from the comfort of your computer.
With a whole host of fascinating insights and inspiration for improving patient care, it’s not to be missed. Register now to join us for Clinical Excellence in Respiratory Care on 21 November and on demand.
To coincide with this event, a whole host of additional content and interviews with prominent clinicians from Centres of Excellence and beyond has been published on the HHE website – look out for the orange Clinical Excellence tag in the Respiratory zone.
This content includes an inspirational conversation with Professor Andy Bush, consultant paediatric chest physician at London’s Royal Brompton Hospital, about his career highlights, his passion for improving children’s respiratory health and campaigning to ban the promotion of e-cigarettes to young people, and his research into the early origins of asthma.
And Professor Mona Bafadhel discusses a new tool that has identified COPD as a crucial cardiovascular disease risk indicator. She explains how she hopes it will impact health inequalities and ensure better access to preventative therapies.
The Clinical Excellence schedule for 2025 will be announced soon, including new clinical areas, so watch this space.
The use of shared decision-making in dermatology is varied despite a desire for it to be embedded into routine clinical practice in the UK. A recent retrospective, single-site study explored the extent to which shared decision-making was documented in medical records for those undergoing immunosuppressant treatment for a dermatological indication.
The King’s Fund’s 2011 publication ‘No decision about me, without me’ noted that the Government wants shared decision-making to become the norm in the NHS.1
There have been various definitions of shared decision-making over the years. Guidance from the National Institute for Health and Care Excellence (NICE) defines it as ‘a joint process in which a healthcare professional works together with a person to reach a decision about care’.
In general, shared decision-making involves choosing tests and treatments based on evidence and the person’s preferences, beliefs and values. Discussion and information sharing ensure that the person understands the risks, benefits and possible consequences of the available options.
This joint process empowers people to make decisions about their care that are right for them at that time, with the options of choosing to have no treatment or not changing what they are currently doing always included.2 Shared decision-making is most appropriate when more than one reasonable option is available, with trade-offs between potential benefits and harms.
Other than when there may be time-challenging acute contacts with patients, it is argued that all significant healthcare decisions should be based on a dialogue that incorporates both the healthcare professional’s experience and expert knowledge of illness and health, as well as the patient’s experience, values and preferences for their own lives.3 Patients are no longer seen as passive recipients in healthcare, and healthcare professionals are not transmitters.3
The General Medical Council (GMC) Decision making and consent guidance notes that all patients have the right to be involved in decisions about their treatment and care and to make informed decisions, if they can. It also states that the exchange of information between clinician and patient is essential to good decision-making.4
In addition, Good medical practice guidance for all GMC-registered doctors highlights the need to support patients in making decisions about treatment and care and sharing information with patients.5
Within the NHS in England, the NHS Standard Contract includes Service Condition 10 on Personalised Care, which states: ‘In planning and reviewing the care or treatment which a service user receives, the provider must employ shared decision-making, using supporting tools and techniques approved by the co-ordinating commissioner.’
Furthermore, shared decision-making is driven by the duties of NHS England to promote individual participation in decisions about care, treatment, tests and prevention of illness; promote patient choice; and exercise its functions to secure continuous improvement in the quality of services.6
Dermatology is a specialty particularly suited to shared decision-making as the severity of most dermatologic diseases is defined by patients’ experiences of symptoms and adverse psychosocial impact.7
A shared decision-making approach in dermatology has been described in several publications across different countries and conditions.8-10 A survey assessing the extent of shared decision-making in atopic dermatitis and psoriasis in the Netherlands found that despite the dermatologists’ optimistic perspective, patients experienced a limited extent of shared decision-making.9
At Royal Cornwall Hospitals NHS Trust, we wanted to ascertain the extent to which shared decision-making is documented in medical records as having occurred for patients who commenced an immunosuppressant for a dermatological indication.
Royal Cornwall Hospital is a 750-bed acute teaching district general hospital in the south-west of England. The dermatology unit provides routine and emergency assessment, treatment and surgery for patients with skin conditions and diseases.
In conditions for which an immunosuppressant would be prescribed, the patient is typically referred from primary care, sees a senior dermatology doctor and then attends a nurse-led clinic for any baseline tests and education on the treatment. The first prescription for the treatment is usually provided through the outpatient pharmacy.
This was a retrospective, single-site study in an acute teaching district general hospital.
A convenience sample of patients prescribed one of the three target oral immunosuppressants (azathioprine, ciclosporin or methotrexate) from dermatology was identified by searching the outpatient dispensing database (see Table 1).
Table 1. Patient characteristics of those prescribed target immunosuppressants
We used the NICE shared decision-making guideline,2 choosing prompts from section 1.2 to formulate our questions, having decided not to include information relating to whether:
The date of initial dispensing for a specific patient was used to search for any correspondence to the GP or patient on our patient administration system. Such correspondence was examined for any text relating to the questions in Table 2. The patient characteristics of gender, age and indication for treatment were also recorded. Data were entered and analysed in Microsoft Excel.
Table 2. Questions arising from NICE shared decision-making guidance
Health Research Authority criteria for research and service evaluation were considered. This was a retrospective assessment involving no changes to the service delivered to patients, and we used the NHS Health Research Authority tool, which helped confirm that no ethical approval was required for this project.
Patient data were used in accordance with local NHS hospital policy, and this assessment was recorded on the Trust’s clinical effectiveness database.
We reviewed the correspondence records for 30 patients from late 2021 to early 2024 (see Table 2 above).
Only in a minority of patients (n=3) was there documented evidence that different available options had been shared with the patient. Overall, in 19 of the 30 cases, it was documented that there were different treatments in the pathway, although the correspondence typically described prior treatments tried or possible future treatments in the pathway rather than expressing how the patient was helped to choose between possible options.
For three of the 20 patients with eczema who were commenced on either azathioprine, ciclosporin or methotrexate, one of the alternative options was named in the correspondence as having previously been tried. In one further case, methotrexate was restarted.
In only three of the remaining 16 cases of eczema was an alternative drug – other than what was prescribed – named in the correspondence as having been mentioned to the patient. For the four psoriasis patients on methotrexate, only prior treatments were documented in the correspondence.
For all 30 cases, a treatment review period was noted. In nearly two-thirds of instances, the correspondence explicitly provided a dermatology department telephone number, although contact details for the hospital switchboard would have been in the letter.
We found that some aspects of the NICE shared decision-making recommendations were documented in correspondence to a greater extent than others. Our study found that 26 patients (87%) were given a British Association of Dermatologists leaflet; this would have been after the medication choice had been made.
This leaflet is not a decision aid, as patient decision aids go beyond standard brochures, educational pamphlets or websites by describing evidence, helping patients think about their preferences and identifying steps to support a decision.10 Furthermore, NICE advises offering a resource before a discussion to encourage the patient to think about what matters to them, what they hope will happen as a result of the discussion and what questions they would like to ask.2
We found that in nearly two-thirds of correspondence, different options in the treatment pathways were mentioned. However, this usually describes what has previously been used or what might be a future treatment. There were only three cases when it was documented that different options had apparently been explained to the patient.
Hence, for this cohort of 30 patients, it is unclear how the decision to commence a specific drug – such as the decision between ciclosporin or azathioprine in eczema – is reached and what, if any, patient input there is into this decision.
It may be that the choice is influenced by prescriber experience and familiarity and not after a person-centred discussion. However, any clinical bias that does exist when suggesting options to patients, though possibly based on personal experience or familiarity, may not necessarily be a bad thing if the drugs are similar in effectiveness and risks.
If shared decision-making is to be embedded into practice, there should be consideration of how choosing between the three treatment options for eczema mentioned above, for example, can become more formalised for both the prescriber and the patient. Principles of how such a decision aid might be constructed are reported in the published literature.11
Decision aids are effective strategies for improving shared decision making between people and their health professionals.12 Examples in dermatology include those for actinic keratosis,13 although one scoping review, with a search strategy up to 2020, reported there have been few published and validated decision aids in dermatology.14 That review also argues for the exploration of the reluctance of dermatologists to include shared decision-making in their practice.
We recognise some limitations with this small-scale study. Some aspects of the shared decision-making process may have happened in the patient consultation but were not documented. Furthermore, the choice of a specific immunosuppressant will also be based on patent-specific factors such as co-morbidities that may not be detailed in the correspondence. For example, someone with a high alcohol intake may not be offered methotrexate. These factors may mean that there is, in effect, only one drug to choose.
This small study identified varying degrees of documentation for some critical aspects of shared decision-making for dermatology patients.
To support shared decision-making, an information leaflet highlighting the differences and contraindications of the three drugs, including their benefits and risks, could be given by the clinician to all patients so they can read through it in their own time before a treatment decision is made. This might improve the patient experience, but it might also confuse some patients and reduce satisfaction in those with poor or limited health literacy.15
Alternatively, such a leaflet could be offered to all but given selectively to patients who wish to have a more active role in choosing the drug to be prescribed. However, it is unclear now how this extra step would fit into the workflow of a busy department without causing undue delay in instigating treatment.
Michael Wilcock MPhil
Pharmacy Department
Ersa Tsoutsoura MPharm
Dermatology Department
Lisa Haddon MBBS BSc MRCP
Dermatology Department
All of Royal Cornwall Hospitals NHS Trust, Truro, UK
14th October 2024
As United European Gastroenterology (UEG) launches a new report on enhancing transitional care in digestive health, members of its public affairs group discuss the challenges and opportunities around transitioning children from paediatric to adult care and UEG’s new recommendations to optimise care during this crucial time.
Over 332 million people in Europe live with digestive disorders, many of which begin early in life and demand lifelong management.1 A significant number of these people must therefore transition from paediatric to adult care at some point in their journey, which can feel daunting for both the patient and their caregivers.
‘Prioritising transitional care is essential for healthcare systems across Europe to prevent patients being left in limbo during this critical phase,’ says Professor Patrizia Burra, UEG Public Affairs Group chair.
A new United European Gastroenterology (UEG) report, ‘Enhancing Transitional Care in Digestive Health’, shines a light on transitional care challenges and offers a comprehensive roadmap for addressing them.1 Drawing on the expertise of leading European specialists, the report makes it clear that early, structured and coordinated transitional care is needed to safeguard patients’ futures.
The UEG report identifies four primary challenges that provide opportunities to drive optimal support for those transitioning from paediatric to adult healthcare.
1. Late initiation of transitional care
‘One of the most significant challenges we face is the late initiation of the transition process,’ says Dr Jorge Amil Dias, from the European Society for Paediatric Gastroenterology Hepatology and Nutrition. ‘Many adolescents enter adult care abruptly at 18, often feeling unprepared and unsupported. We need to start these conversations earlier, ideally by age 12, to ensure a smoother transition.’
The UEG taskforce is calling for early disease-specific education to prepare patients and parents, as well as structured programmes supported by multidisciplinary teams.
2. Care coordination gaps
There is an urgent need for improved communication between paediatric and adult care providers. ‘Enhanced collaboration is vital,’ says Dr Amil Dias. ‘Transitional Care Coordinators play a crucial role in ensuring a seamless transition.’
The report outlines the need for the appointment of these coordinators early on, fostering joint care through regular appointments, use of transition readiness assessments and involving patients in their own care decisions.
3. Recognising life-stage impact
Adolescence is marked by physical, mental and social development, which can make transitional care particularly challenging. ‘We recommend a stepwise, skills-based training programme that is tailored to each individual’s needs and closely monitors treatment adherence,’ says Hans Törnblom, European Society of Neurogastroenterology and Motility representative, UEG Public Affairs Group. ‘Providing emotional support and using modern communication tools, such as telehealth and the MyHealth Passport, can empower young adults to take an active role in their care journey.’
4. Managing disease characteristics
One of the main challenges in managing disease characteristics is the risk of differences in treatment guidelines between paediatric and adult healthcare that can disrupt treatment continuity, as well as the varying behavioural differences between adolescents and adults. The transition to adult care must be carefully timed to align with periods of disease stability.
‘There needs to be a consensus on treatment regimens between paediatric and adult healthcare professionals,’ says Joana Torres from the European Crohn’s and Colitis Organisation. ‘Continuous education and training, as well as treatment regimen consensus among paediatricians and adult healthcare professionals, are crucial for managing evolving diseases effectively.’
Dr Amil Dias adds: ‘Incorporating essential skills into the training of both paediatric and adult gastroenterologists is crucial. This ensures that when patients transition to new providers – whether due to relocation or other circumstances – they continue to receive care from physicians who are fully equipped to manage the complexities of their condition.’
‘Despite a growing body of evidence and consensus on its critical role in supporting continuity of care and treatment adherence for patients affected by digestive diseases, transitional care has often been overlooked by both the medical community and broader society,’ says Professor Burra. ‘Our overarching recommendation is that the current gaps in transitional care practices must be bridged. This is not just about transferring patients from one care team to another; it’s about equipping them with the skills and knowledge they need to manage their health independently. A skills-based approach that addresses both medical and non-medical support can help achieve this.’
Improving transitional care in digestive health requires a coordinated effort from healthcare professionals, policymakers, patients and advocacy groups. The stakes are high, and the costs of inaction are even higher.
As Dr Gauden Galea, strategic adviser to the regional director at the World Health Organization’s Regional Office for Europe, states of the UEG recommendations: ‘By advancing these initiatives, we can transform gastrointestinal healthcare and improve the lives of countless patients. Let us move forward with determination and commitment to ensure the optimal health and wellbeing of all people throughout their lives.’1
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