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Take a look at a selection of our recent media coverage:

Further treatment option for episodic migraine as NICE approves novel oral drug rimegepant

2nd June 2023

Draft NICE guidance has approved rimegepant, a novel oral drug for preventing migraine, which it said could become available to 145,000 NHS patients.

Rimegepant is the first drug of its class to come in pill form, with other similar medications administered as injections. The calcitonin gene-related peptide (CGRP) receptor antagonist was also the first of its class to be reviewed by NICE.

The draft guidance recommends rimegepant, made by Pfizer and traded under the name Vydura, as an option for preventing episodic migraine in adults where at least three previous preventive treatments have failed.

NICE has also published draft guidance for consultation that does not recommend rimegepant for treating acute migraine, although Pfizer said it was providing additional evidence in a bid to overturn the interim decision.

One of a range of suitable migraine treatments

Episodic migraine is where a person has fewer than 15 migraine days each month and NICE’s draft guidance recommends rimegepant for adults who have at least four migraine attacks per month but fewer than 15.

NICE said current treatments for preventing migraine – including beta-blockers, antidepressants and epilepsy medications – can have significant side effects and be ineffective.

Currently, treatments offered after these have been tried include injections erenumab, fremanezumab or galcanezumab.

NICE draft guidance said that if rimegepant is considered to be one of a range of suitable treatments, the least expensive option should be used following discussion with the patient about advantages and disadvantages of all the options.

NICE expects to publish final guidance next month (5 July), if it receives no appeals from Pfizer, patients or professional groups.

‘Welcome and more convenient’

NICE director of medicines evaluation Helen Knight said: ‘Each year the lives of millions of people in England are blighted by migraine attacks. They can be extremely debilitating and can significantly affect a person’s quality of life. In comments received during consultation on the previous draft guidance, patients and carers described migraine as an invisible disability that affects all aspects of life including family, social activities, mental health, finances and education.

‘Rimegepant is the first oral treatment for migraine to be recommended by NICE and for many thousands of people it is likely to be a welcome and more convenient addition to existing options for a condition that is often overlooked and undertreated.’

She added: ‘Today’s draft guidance demonstrates our commitment to focusing on what matters most and getting the best care to people while ensuring value for the taxpayer.’

The Migraine Trust highlighted that as opposed to conventional acute treatments such as triptans, non-steroidal anti-inflammatory drugs and other painkillers, the group of drugs that rimegepant belongs to (commonly called the gepants) do not seem to cause medication overuse headache.

It said medication overuse headache is a significant problem for people with migraine, with a 2019 survey of 1,800 people by the Trust finding that migraine medication had caused medication overuse headache in a third (34%) of patients.

The Trust also said it hopes NICE will reconsider its draft decision not to recommend rimegepant for acute migraine, highlighting that the Scottish Medicines Consortium recently approved it for this use within NHS Scotland.

It is thought that over 5.6 million people in England have episodic migraines, with an estimated 190,000 migraine attacks experienced every day.

A version of this story was originally published by our sister publication Pulse.

Two-thirds of patients correctly diagnosed with promising cancer blood test

A new blood test detecting over 50 types of cancer has shown promising results in a recent NHS clinical trial, according to researchers. 

The SYMPLIFY study was set up in 2021 to trial the Galleri blood test on over 6,000 patients in England and Wales who had been referred by their GP for diagnostics following identification of potential cancer symptoms.

The results, which were presented at the American Society of Clinical Oncology meeting in Chicago on 3 June 2023, showed ‘strong performance’ of the multi-cancer early detection (MCED) test. 

The study was run by the University of Oxford and supported by GRAIL, the US-based company that developed the Galleri MCED test. 

Of the 5,461 evaluable patients, the test correctly identified two-thirds (66.3%) of those who were diagnosed with cancer through normal care procedures.

This sensitivity increased with age and late cancer stage, with 95.3% accuracy for stage IV cancer. 

After a positive MCED test, Galleri correctly identified the origin site of the cancer in 85.2% of cases.

Expediting cancer diagnosis

The NHS patients involved in the study were those who had been referred by their GP for urgent imaging, endoscopy or other diagnostic tests to investigate symptoms of potential gynaecological, lung, lower GI or upper GI cancer, or who had non-specific symptoms. 

Alongside completing these investigations, patients provided a blood sample so that the MCED could be performed. 

Cancer was diagnosed through usual NHS procedures in 368 patients, and the MCED detected a cancer signal in 323 people, 244 of whom had been diagnosed. 

This means 75.5% of those testing positive with Galleri were found to have cancer, and 2.4% of those testing negative were found to have cancer.

Professor Brian D. Nicholson, a GP, associate professor at the University of Oxford and co-lead investigator for the study, said new tools are needed to ‘expedite cancer diagnosis and potentially avoid invasive and costly investigations’.

Of the results, he added: ‘The high overall specificity, positive predictive value and accuracy of the cancer signal detected and cancer signal origin prediction that was reported across cancer types in the SYMPLIFY study indicate that a positive MCED test could be used to confirm that symptomatic patients should be evaluated for cancer before pursuing other diagnoses.’

Dr David Crosby, head of prevention and early detection research at Cancer Research UK, said: ‘The findings from the study suggest this test could be used to support GPs to make clinical assessments, but much more research is needed in a larger trial to see if it could improve GP assessment, and ultimately patient outcomes.’

While this study showed a strong performance for the use of MCED with symptomatic patients, the NHS is also running a study with around 140,000 volunteers aged 50-77 to trial the Galleri test alongside existing cancer screening for asymptomatic patients.

In May, NHS England tasked hospitals with turning around diagnostic test results for suspected cancer within 10 days.

A version of this story was originally published by our sister publication Pulse.

European hospitals at risk from phishing attacks, research reveals

31st May 2023

Fewer than one in 10 European clinics and hospitals have adequate protection from phishing and spoofing, putting highly sensitive data at risk of ransomware attacks, according to new research.

Only 144 (7.2%) of the 2,000 healthcare facilities included in the research by email security provider EasyDMARC were found to have correctly implemented and configured security policies to flag, report and remove outbound phishing emails.

Some 645 (32%) of the organisations had implemented the domain-based message authentication, reporting and conformance (DMARC) standard established in 2012. This standard enables the automatic flagging and removal of receiving emails which are impersonating senders’ domains.

A total of 361 organisations (18%) had implemented DMARC but had not configured it to deal with impersonating emails, while 140 (7%) had configured it to send such emails into quarantine. As a result, these organisations lacked visibility into any phishing or impersonating emails received or blocked.

Susceptible to breaches of sensitive data

Commenting on the research, Gerasim Hovhannisyan, EasyDMARC CEO and co-founder said: ‘Impersonating email domains is one of the most effective ways cybercriminals bypass organisational cyber defences through phishing, spoofing, and ransomware attacks. Far too many organisations are overlooking a vital tool in effectively preventing this present and persistent danger.

‘With stories of ransomware attacks increasingly dominating headlines, the apparent absence of domain authentication renders these organisations susceptible to breaches of highly sensitive, valuable and potentially costly data. Without the adoption of DMARC or similarly effective policies, the sector will continue to see an increase in cyber events and subsequent disruptions and losses.’

Internationally, 54% of the top 100 global clinics and hospitals have adopted and implemented DMARC.

Emergency medicine staffing crisis imminent unless Government acts, RCEM warns

30th May 2023

Burnout, retirement and a reliance on locum staff are among a host of concerns raised in a new report from the Royal College of Emergency Medicine (RCEM), which urges the UK Government to take action to support and maintain the emergency medicine (EM) workforce.

The report, entitled ‘Emergency Medicine Workforce in England’, published on 28 May, reveals the extent of the capacity and staffing issues experienced by emergency departments, which is having a negative impact on staff morale and retention, as well as on patient care.

For example, there should be one whole-time equivalent consultant for every 4,000 annual attendances, but the report states that this ratio currently stands at 1:7052. What’s more, some 45% of the total EM workforce is made up by trainee doctors, posing a potential threat to service provision, especially out of hours.

Another particularly pressing issue, the RCEM notes, is the ageing pool of consultants employed within emergency departments. Some 29% of its consultant members are now aged over 50. Many are doing fewer hours during this stage of their careers, and ‘with a third of the workforce approaching retirement age at the same time, we may witness a mass exodus of experienced senior clinicians’, the report states.

These issues have resulted in an overreliance on locum staff, which takes a significant percentage of the wage bill.

Extra EM training places needed

Highlighting that the system is stretched beyond capacity and requires the next generation of EM doctors to bolster it, the RCEM’s president Dr Adrian Boyle said: ‘You have to keep the topping up the team, and that is why we are urgently calling on the Government to commit to ensuring there will be at least 120 extra training places for EM doctors every year for at least six years.’

This recommendation from the report, which would see more than 700 new trainee EM doctors being trained between 2024 and 2030, aims to help achieve safe staffing levels, ease pressure on existing staff and support capacity and resilience in emergency departments.

Dr Boyle concluded: ‘We are still waiting for the long-promised NHS workforce plan. And it is becoming increasingly important that this is published as soon as possible to avoid the crisis in the NHS worsening; and that it contains specific numbers, details and costings. Nothing less would be a disservice to our members, their colleagues, to patients and the public.’

Staffing shortages are being seen across the UK and Europe, with a mass-exodus of hospital and healthcare staff being widely reported. In the UK, the much-anticipated NHS workforce plan has indeed been delayed once again as rumours circulate around its prohibitively high cost.

Cost concerns further delay NHS workforce plan

The Government’s long-awaited NHS workforce plan appears to have been delayed as rumours circulate that it is too expensive.

According to deputy chief executive of NHS Providers Saffron Cordery, the plan, which was expected for publication today (30 May), has been delayed further. 

Speaking on BBC Radio 4’s Today programme, Ms Cordery said the plan will require ‘a very significant commitment of funding’ from the Government. 

Health secretary Steve Barclay declined to provide a deadline for publication during interviews over the weekend, according to The Guardian.

The workforce plan, which has already been delayed from last year, is expected to put forward solutions to address NHS understaffing, including expanding medical school places and potentially training apprentice doctors directly on the job.

Ms Cordery said: ‘We know that when it comes, it will be a very significant commitment of funding from the Government because what we’re talking about is setting out the number of training places and the number of staff that the NHS needs over the next decade or so.’

Of the delay, she added: ‘What everyone has been calling for, and what Jeremy Hunt committed to in his autumn statement last year and indeed talked about in the spring budget, was a fully-funded and fully-articulated workforce plan for the NHS. 

‘So I think that we are talking about something to do with the funding of this plan.’

The Times has also reported that disagreements over cost, which is believed to be in the tens of billions, have delayed publication of the plan.

A senior NHS source was quoted by the newspaper as saying that Prime Minister Rishi Sunak and chancellor Jeremy Hunt ‘can’t agree the financial commitment’ and that it ‘was all set to go this week and now the PM wants to run through it in detail’.

In March, reports of the plan revealed it would highlight that the health service is already operating with 154,000 fewer full-time staff than it needs and that number could balloon to 571,000 staff by 2036 on current trends.

The leaked report also said that without ‘radical action’, the NHS in England will have 28,000 fewer GPs, 44,000 fewer community nurses and an even greater lack of paramedics within 15 years. 

There have recently been calls from cancer professional organisations highlighting capacity and workforce challenges compromising patient safety and quality of care.

A version of this story was originally published by our sister publication Pulse.

AI tool aids heart attack diagnosis speed and accuracy, say researchers

Heart attack diagnosis could be achieved quicker and more accurately via the use of a new artificial intelligence algorithm developed by the University of Edinburgh.

Tested on 10,286 patients in six countries, the algorithm – named CoDE-ACS – was able to rule out a heart attack in more than double the number of patients compared to guideline-recommended pathways, and with an accuracy of 99.6%.

The tool was also found to identify those whose abnormal troponin levels were due to a heart attack rather than another condition.

It performed well regardless of age, sex or pre-existing health condition, which the authors say reduces the potential for misdiagnosis and inequalities across the population.

‘Enormous potential

Funded by the British Heart Foundation (BHF) and the UK’s National Institute for Health and Care Research, the study was published in the journal Nature Medicine.

Its lead author, Professor Nicholas Mills, BHF professor of cardiology at the Centre for Cardiovascular Science, University of Edinburgh, said: ‘For patients with acute chest pain due to a heart attack, early diagnosis and treatment saves lives. Unfortunately, many conditions cause these common symptoms, and the diagnosis is not always straight forward. Harnessing data and artificial intelligence to support clinical decisions has enormous potential to improve care for patients and efficiency in our busy emergency departments.’

CODE-ACS was developed using data from 10,038 patients in Scotland who had arrived at hospital with a suspected heart attack. It uses routinely collected patient information, such as age, sex, ECG findings and medical history, as well as troponin levels, to predict the probability that an individual has had a heart attack. The result is a probability score from 0 to 100 for each patient.

Clinical trials are now underway in Scotland to assess whether the AI tool can help doctors reduce pressure on overcrowded emergency departments.

Government commits to easing pressure on NHS through commercial clinical trial investment

26th May 2023

The UK Government has announced five funding commitments totalling £121m to accelerate commercial clinical trials, making it easier for revolutionary healthcare treatments to reach patients and helping to cut NHS waiting times.

The commitments include measures to make the approvals and set up of trials quicker, with the aim of approving all trials within 60 days, and improving trial recruitment through increased transparency and accessibility of clinical trial data. This will make it easier for people to find trials via real-time information and for NHS organisations to contact patients who could benefit from ground-breaking treatments.

A joined-up approach to clinical trials across the country will also be established through the creation of Clinical Trial Acceleration Networks. These will focus on accelerating priority areas of research, creating exemplars for delivering trials in key areas, such as cancer and infectious disease, to improve delivery of all trials based on best practice.

The Government acknowledged clinical research as the single most important way to improve healthcare – by identifying the best way to prevent, diagnose and treat conditions – and identified clinical trials as part of the solution for reducing strain on the NHS.

O’Shaughnessy Review into clinical trials

The announcement comes in response to the publication of the Lord O’Shaughnessy Review into commercial clinical trials in the UK.

This much-anticipated independent review, commissioned by the Government in February 2023, offers 27 recommendations, addressing eight problem statements, on how the Government should work to resolve key challenges in conducting commercial clinical trials in the short and longer term.

This includes the need for clinical research to be be systemically prioritised by or within the NHS, and for incentives to offered to doctors, nurses and NHS organisations to take part in clinical research, especially when it is commercially funded.

Indeed, evidence shows hospitals which undertake research have better patient care outcomes, improved staff retention and it benefits the whole health and care system.

The Government has welcomed all recommendations from the Review, with health and social care secretary Steve Barclay saying: ‘This investment is another significant step in harnessing UK innovation to help cut waiting lists  one of the Government’s five priorities and build a stronger NHS.

“We will take forward Lord O’Shaughnessy’s recommendations to speed up the delivery of clinical trials and boost patient involvement in research, so people getting NHS care can benefit from cutting-edge treatments faster, supported by £121m in government funding.’

The Review also highlights the potential for commercial clinical trials to take place in primary care and at-home settings and the need for regulators to produce guidance to support these decentralised trials.

A report into the progress of the Government’s commitments to Lord O’Shaughnessy’s recommendations, as well as responses to those recommendations requiring further research, will be published in autumn 2023.

Stakeholders respond

Richard Torbett, chief executive, Association of the British Pharmaceutical Industry, said: ‘Lord O’Shaughnessy is right that making the UK an attractive destination for industry clinical trials requires regulatory reform, speedier study set-up and approvals, and improved access to data. Implementing his proposals, alongside these other announcements, can be a springboard to delivering on the UK’s ambition to be a science superpower, and we now must press forward with delivery at pace.’

Executive director of policy, information and communications at Cancer Research UK, Dr Ian Walker, said: ‘The O’Shaughnessy Review has rightly recognised that the UK’s clinical trials system needs to change. The system has been under pressure for many years, but has been pushed close to breaking point by the pandemic and related pressures on the NHS.

‘Many of the review’s recommendations recognise the value that medical charities like Cancer Research UK bring to clinical trials, offering patients early access to innovative new treatments. Taking trials to sites outside of hospitals and cutting red tape will help get more trials up and running, get more patients joining trials and make faster progress towards new treatments. 

‘But fundamentally we must urgently address the lack of time and capacity available for research within the NHS. Right now, staff within cancer services are overstretched, struggling to set aside time to deliver promising clinical trials which could ultimately make smarter use of the NHS.’

Dr Samantha Walker, Director of Research and Innovation at Asthma + Lung UK, said: ‘I’m pleased Lord O’Shaughnessy’s review highlights the areas where clinical trials aren’t currently working in the UK and that the Government proposes to accept his recommendations. Clinical trials are an essential part of developing new and better treatments for people. However, without a consistent way to connect people in need of treatment with the appropriate trial, the system supporting clinical research in the UK breaks down and faces collapse.’

Scientific innovation

Mr Hunt’s ‘Life Sci for Growth’ package, announced on 25 May 2023, brings together 10 policies to ‘fire up the UK’s life sciences sector’, backed by cross-government package of £643m.

As well as focusing on clinical trial improvements, other health-related policies include up to £48m of new money for scientific innovation to prepare for any future health emergencies, and £154m to increase capacity of the UK’s biological data bank.

Plans were also unveiled to plans to relaunch the Academic Health Science Network as ‘Health Innovation Networks’ to boost innovation by bringing together the NHS, local communities, charities, academia and industry to share best practice.

Mental health was another priority, with £42.7m of investment for the ‘Mental Health Mission’, which will go towards the research and delivery of novel treatments for early intervention in psychosis, depression and mental health in children.

Mr Barclay added: ‘We’re also accelerating research into mental health, backed by over £42 million of investment in clinical research centres across the UK – including in Birmingham and Liverpool – to improve the speed and accuracy of diagnosis and increase the use of technology for treatment.’

Biobank pilot to be launched by MHRA to better understand genetics and medicines safety

A genetic ‘biobank’ will be launched on 1 June 2023 by the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) to understand how a patient’s genetic make up can impact the safety of their medicines.

Known as the Yellow Card biobank, the biobank will contain genetic data and patient samples and be used by scientists to determine whether a side effect from a medicine was caused by a specific genetic trait.

A joint venture with Genomics England, the genetic research resource is the first of its kind to be launched by a drug safety regulator.

Operating alongside the MHRA’s existing Yellow Card reporting site for suspected side effects and adverse incidents involving medicines and medical devices, the new venture forms part of a long-term vision for more personalised medicine approaches.

Targeted prescriptions

By understanding the underlying mechanism of an adverse drug reaction (ADR), it is hoped that pharmacogenetic testing strategies could be developed so that ADRs could be prevented rather than requiring a reactive approach.

In turn, this will enable doctors to target prescriptions so UK patients will receive the safest medication for them, based on their genetic makeup.

‘We are excited by the upcoming launch of the Yellow Card biobank, which demonstrates that we are at the absolute forefront of innovation in the field of drug safety monitoring,’ said Dr June Raine, MHRA Chief Executive. ‘Almost a third of adverse reactions to medicines could be prevented with the introduction of genetic testing… This has the potential to transform our safety monitoring activities – enabling us to meet a real need by using high-quality patient data to reduce side effects of medicines.’

Participant recruitment

Recruitment for the biobank will commence on 1 September and participants will be visited at home by a nurse who will take a blood sample to be added to the biobank. The sequencing of participants’ genetic material will begin in spring 2024. Initial research findings are due to be published in 2025.

The pilot phase will start by looking at allopurinol and related rare, severe skin reactions including Stevens-Johnson syndrome and toxic epidermal necrolysis. Other topics of focus for the pilot phase will be confirmed in due course.

Genomics England will support the MHRA with the sequencing and storage of genetic material through use of its well-established and secure infrastructure.

Commenting on the ‘transformative partnership’ with the MHRA, Professor Matt Brown, Chief Scientific Officer for Genomics England, added: ‘Many [severe ADRs] are influenced by underlying genetic risk factors, substantially heightening an individual’s vulnerability.

‘By joining forces with the MHRA, we are poised to gain greater understanding of these genetic influences – discoveries that will be vital if we are to move to harness the power of genomics to proactively protect patients from these harms.

‘Together, we hope that this is the first step towards redefining the future of drug safety.’

ADRs continue to be a significant burden on the NHS and account for one in 16 hospital admissions.

Understanding the intricacies of tube feeding with Stephen Taylor

25th May 2023

Stephen Taylor PhD is a critical care and research dietitian based in the ICU department at Southmead Hospital, North Bristol NHS Trust. He has spent many years exploring the use of enteral feeding and more recently on optimising the insertion of feeding tubes, which he stresses should be deemed a specialist rather than routine procedure based on the associated high level of risk.

With around 6% of hospital patients requiring invasive nutritional support, particularly with nasogastric feeding, tube insertion has become a relatively common intervention.

This, according to Stephen Taylor PhD, critical care and research dietitian at Southmead Hospital, North Bristol NHS Trust, means that the procedure is deemed to be of low risk, which is simply not the case. ‘Most people don’t realise that placing a nasogastric tube, the easiest to do, has about the same morbidity and mortality as a tracheotomy,’ he says.

Dr Taylor believes that in an ideal world, there should be small teams and who are ‘expertly trained in guided tube placements, either electromagnetic, direct vision or both.’

Interestingly, he cites published data showing that centres with a low use of electromagnetic tube placement have ‘a worse rate of undetected misplacement than blind placement’. However, the overall use of guided-tube placement results in a lower incidence of pneumothorax than blind placement. This is because in most cases misplacement is detected during placement, when most complications occur.

Regulatory barriers

Unfortunately, regulatory bodies only permit pH and X-ray as the end-of-procedure checks. Despite the success of guided-tube placement, these methods are really only perceived as acceptable ‘add-ons’ that increase the overall procedural costs. But, as Dr Taylor explains, this serves only to discourage clinicians from using them even though these are the only techniques that ‘prevent those lung complications and oesophageal misplacements that would otherwise happen and would only be detected at the very end.’

Evidence from studies where these more sophisticated techniques have been used by untrained hands, ‘has led to major complications’, says Dr Taylor. As a result, rather than mandating high quality training, regulatory authorities have simply suggested that these techniques cannot be relied upon.

Correct tube insertion

So, how does a clinician know if they have inserted a tube correctly? Dr Taylor first highlights the importance of tube tracking. After all, once it ‘hits the greater curvature of the stomach it could then coil back towards the oesophagus’, he says. Hence, without some means of tracking, it is impossible to know the precise location of a tube.

While it seems intuitive and rather obvious that some form of tube tracking is required, Dr Taylor describes how ‘more than 95% of tubes in most centres are placed blindly’ – that is to say, unguided. Once a tube is placed beyond the mouth or nose, ‘you no longer know where the tube is’, Dr Taylor explains. He adds that although sophisticated tracking devices are available, ‘such devices are used in less than 5% of all the tubes that are placed’.

Although a patient’s response, such as coughing, quickly alerts a clinician that a tube may be traveling down the respiratory tract, there remains uncertainty over the precise location of the tube. In the absence of a tracking system, several end-of-procedure checks are used to help identify tube misplacements, for instance, if a tube has inadvertently entered the thorax, by which time a pneumothorax may have occurred or, at the least, the tube must be re-positioned and re-confirmed,’ Dr Taylor says.

End-of-procedure checks

One check, for example, relies on determining the pH of the surrounding fluid. A small amount of fluid is aspirated and the pH checked with the acceptable range – set s anywhere between a pH of 4.0 and 5.5. At his own centre, Dr Taylor and his team use a pH of 4.0 simply because this indicates that the tube is more likely to be within the stomach and not the distal oesophagus where, in practice, the pH might be above 4.0.

An alternative end of procedure check is the use of X-rays, which are deemed the gold standard. Sometimes, clinicians will also use a mid-procedure X-ray check, which allows the operator to identify whether the tube has become lodged in the respiratory tract rather than the alimentary canal.

Although this mid-procedure x-ray has some value, Dr Taylor thinks that a downside to these additional checks, which require movement of the patient to the X-ray room and a slightly higher exposure to radiation, is that it will delay the medication and feeding by hours, sometimes a day.

Another increasingly used mid-procedure check relies on the measurement of carbon dioxide. After insertion of the tube by only 30-35cm, the tube is aspirated to check for CO2 with either colorimetric paper or a meter. If the CO2 reading is high, this is a clear indication that the tube is within the respiratory tract, allowing the operator to withdraw the tube.

Electromagnetic tracking can also be used. This more sophisticated technique allows the operator to visualise the path followed by the tube on a computer screen. Additionally, several direct visual methods are also available.

Currently, pH and chest X-ray checks are the standard practice to prevent undetected misplacements, Dr Taylor confirms.

Risk of damage from blind tube placement

End-of-procedure checks designed to ensure that a feeding tube has reached its intended location are the only checks mandated and endorsed by regulatory authorities.

Nevertheless, Dr Taylor feels that the focus on detection of tube misplacements ignores a more important problem: the damage that might occur during blind tube placement. ‘Undetected misplacements occurs in only 0.015% of tube placements,’ says Dr Taylor. While these can result in a pneumothorax, pneumonia and even death, they represent a small proportion of tube-related respiratory complications. The current end-of-procedure checks fail to recognise any direct damage from respiratory placement.

Bu comparison, ‘some 1.6% of tubes enter the respiratory tract resulting in 0.49% causing a pneumothorax,’ Dr Taylor says, ‘so 97% of tube-related major complications and/or death. These cannot be prevented by using an end-of-procedure – pH or X-ray – checks because they have already occurred before checking.’ In other words, end-of-procedure checks only ensure that food, water or medications are delivered to the correct location. Such checks cannot identify any trauma caused by insertion of the tube.

Dr Taylor airs concern that in reality most of the risks to patients arise from tube insertion and ‘none of the major bodies have addressed this in their guidelines’.

Room for improvement

There is still a need to reduce the level of misplacements, but Dr Taylor believes this will only occur if regulatory bodies accept that risks arise not only from undetected misplacement but also from trauma during respiratory tract misplacement and oesophageal misplacement that pH can fail to detect.

Regulatory authorities need to sanction the use of guided placement by an expert, says Dr Taylor. But this, he adds, would require the regulator to ‘nationally mandate evidence-based guidance and training to attain expertise in guided methods’.

He is hopeful that in future the mid-procedure CO2 screening will become standard, and that guided tube placement will become more common. Drawing a parallel with the insertion of coronary artery stents, which is a guided procedure, he thinks it nonsensical for feeding tubes to be routinely inserted without any such guidance. His hope is for the development of a system that enables direct vision of the tube combined with a tracking system showing the tube’s path.

Though electromagnetic tracking and direct vision have been available for many years, it remains expensive. Dr Taylor thinks that the technology is under-used because the focus of guidelines is on reducing undetected misplacements and not on complications. Nevertheless, while guided techniques are expensive, the costs associated with complications such as a pneumothorax are even higher, and this must be considered.

Finally, Dr Taylor reflects on how for too long the insertion of feeding tubes has become seen as a routine rather than specialist procedure. Consequently, clinical staff remain largely ignorant of the potential risks and complications associated with the procedure and there is an urgent need to change this mindset.

NHS app to offer patients more choice over care provider after GP referral

Patients will be able to choose from up to five different care providers through the NHS app when they are referred by a GP for treatment, the UK Government has announced.

Giving more options of where patients can go for treatment, including NHS care provided in the independent sector, could cut up to three months off waiting times, the announcement said.

Information for healthcare providers – filtered by distance, waiting times and quality of care – will be available to patients after they have spoken to their GP and they can choose which option they prefer through the NHS app or website.

Currently, figures suggest only one in 10 patients exercise their right to choose, which the Government said it wanted to change by providing more information for patients.

From October, patients already waiting more than 40 weeks for an appointment, and patients that have a decision to treat but have not yet been given a treatment date, will also be asked whether they want to switch hospitals, if possible and clinically appropriate.

In April, the Government commissioned Hewitt review said patients should have greater access to their NHS record, including checking their position on waiting lists and removing themselves.

Access and empowerment

Prime Minister, Rishi Sunak, said: ‘Empowering patients to choose where they receive treatment will help cut waiting lists, one of my five key priorities.

‘Our aim is to create an NHS built around patients, where everyone has more control over the care they receive, wherever they live or whatever their health needs are.’

Health and social care secretary Steve Barclay said every patient should be able to easily choose where they go to receive treatment.

‘Millions of people downloaded the NHS app during the pandemic. Increasing use of this fantastic resource will enable them to exercise more choice and get access to essential information about the options for their care including journey time, length of wait and quality of service – all at the swipe of a smartphone screen.’

Amanda Pritchard, NHS chief executive, said: ‘Despite significant pressure, the NHS reduced 18-month waits for care by more than 90% by April and, alongside existing tools like elective hubs, surgical robots and “prehab” checks, this is another way that we are continuing to embrace the latest innovations and tech for the benefit of patients.’

Joe Harrison, Chief Executive at Milton Keynes University Hospital NHS Foundation Trust, commented: ‘Staff at NHS trusts across the country have been working flat out to reduce the amount of time patients are waiting for elective treatment, and are making incredible progress.

‘Giving patients even more access to information about their appointments, and being able to choose where they take place through the convenience of the NHS app, will help trusts continue to provide patients with the best possible care, as quickly as possible.’

While, the Liberal Democrats’ health spokesperson Daisy Cooper MP said: ‘Rishi Sunak is failing on his pledges to cut NHS waiting lists, recruit the NHS staff we need, and fix crumbling hospitals. 

‘This latest gimmick will do nothing to change the fact that under the Conservatives, far too many patients are waiting far too long for the treatment they need.

‘The Government can’t tackle this health crisis until they address the huge staff shortages that blight our local health and care services.’

The Government wants to see 75% of adults in England using the NHS App by March 2024 as the ‘front door’ to the health service.

A version of this story was originally published by our sister publication Pulse.