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14th October 2024
Recommendations to mitigate burnout among the oncology workforce have been shared by the European Society for Medical Oncology (ESMO). The paper outlines how to manage psychosocial risks, optimise wellbeing, and reduce burnout among oncology healthcare professionals (HCP) to support staff, improve efficiencies and help maintain the delivery of optimal cancer care.
The series of 11 recommendations targets improvements in three areas: information and training to support HCPs development and practice, resources to safeguard HCPs psychological and physical health, and activism and advocacy to support the wellbeing of the oncology workforce. The proposals are aimed at individual healthcare professionals, institutions and national and international societies.
A diverse, multinational panel of interprofessional experts developed the evidence-based plan designed to address the growing pressures placed on the profession and mitigate the threat they pose to the quality and equity of cancer care. The recommendations are based on the key findings from three previously reported ESMO Resilience Task Force (RTF) surveys, which included more than 3,700 responses from professionals in over 100 countries.
The measures include providing more training and individualised mentoring to support HCPs, allowing them to restore control over their career development. In addition, plans to ensure manageable workloads and offer more flexible working conditions are suggested, as well as the need to create more pleasant working environments with suitable equipment and the time and space to communicate with colleagues and reduce isolation.
ESMO stated that the recommendations are ‘fundamental’ for the future of cancer care. They warned that failing to make the necessary changes would cause the quality of cancer care to deteriorate across Europe, whilst global health inequalities would increase as high-income countries deplete the medical workforces of low- and middle-income countries to try to meet their labour needs.
For each area of action, the paper highlights various initiatives that ESMO is undertaking to help address the issue and provide tangible support to practitioners, including efforts to push for necessary political measures to protect the oncology workforce.
Commenting on the recommendations, Dr Jonathan Lim, member of the ESMO RTF and consultant medical oncologist in advanced immunotherapy and cell therapy at the Christie NHS Foundation Trust in Manchester, UK, said: ‘As oncologists on the ground, we see every day that morale is low and that the workforce is in crisis. Our hope is that this work will now serve as an evidence basis that individuals can use as leverage to advocate for change within their institutions, taking from the recommendations what is most valuable and feasible within their respective countries, cultures and working environments.’
In June, the Royal College of Radiologists warned that escalating workforce shortages were causing ‘growing delays’ in cancer diagnosis and treatment in the UK and ‘putting patients’ lives at risk’.
11th 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. Learn about how the Royal Free London NHS Foundation Trust is approaching this longstanding issue through the use of a discharge lounge as Kathy Oxtoby delves into the second of four case studies.
An extensive refurbishment of the Royal Free Hospital’s discharge lounge has improved patient flow, by allowing more medically fit patients to be transferred from the ward while they wait to be discharged.
Since its refurbishment last year, the usage of the lounge has increased from an average daily attendance of nine patients per day to 31 patients per day, the Royal Free London NHS Foundation Trust says.
Located on the ground floor near the front of the hospital, the lounge has TVs, magazines, newspapers, a full a la carte menu available to patients to receive hot and cold meals, and a self-serve refreshment station, giving it the feel of stepping into an “Upper Class” airport lounge.
All patients leaving hospital don’t need to wait on the ward for transport, medication, or paperwork – they can come to the lounge and wait in comfort, allowing their vacated ward bed to be made ready for a new patient coming into the hospital.
The lounge is staffed with two registered nurses, two health care assistants and an administrator who can help with transport bookings, new and existing.
Since the refurbishment the lounge has much more capacity. Kyle Harding, assistant operations manager, says: ‘We have the capacity to see up to 26 patients which we can turn over every three to four hours.’
Capacity ranges from high, mid and low back chairs, electronic reclining chairs, a dedicated bariatric electronic chair and a trolley space.
Almost all (98%) of patients have positive experiences with the discharge lounge service as reported through friends and family tests.
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:
This case study was originally published by our sister publication Healthcare Leader.
10th October 2024
Statins are cost effective and improve health outcomes for the over-70s with or without previous cardiovascular disease, a large UK modelling study has concluded.
The findings support their routine use in most people in this age group, the team from the University of Oxford concluded.
With an ageing population, the over-70s age group now makes up around 30% of people over the age of 40 in the UK, yet despite their increased cardiovascular risk, statins use in this older group is lower, the researchers noted in the journal Heart.
The study used an up-to-date cardiovascular disease model developed from UK populations, including a Biobank cohort, which included information on statins safety and effectiveness in older people.
Projected cardiovascular risk figures including on survival, quality-adjusted life years (QALYs) and healthcare costs of statins use were calculated in 5,103 people with previous cardiovascular disease and in 15,019 without.
Use of statins was found to be cost-effective with the cost per QALY gained below £3,502 for standard therapy and below £11,778 for higher intensity therapy.
The team did note that there was a larger degree of uncertainty among older people without previous cardiovascular disease where risk reductions were substantially smaller.
There are two ongoing statin trials in older people without cardiovascular disease which ‘will add valuable data’ particularly in those over the age of 75 years, the researchers said, but added that their findings were robust enough to recommend statin treatment in this age group now.
Lead study author Borislava Mihaylova, an associate professor at Oxford Population Health, said: ‘Lifetime statin treatment increased quality-of-life-adjusted survival in older men and women and, at UK cost of generic statins, was highly cost-effective for all, irrespective of their CVD history or LDL-C level.
‘Higher intensity statin therapy was the strategy likely to bring the highest health benefits cost-effectively, although standard statin regimens would achieve most of these benefits.’
She continued: ‘While further randomised evidence will be helpful, the robustness of these findings indicates that older people are likely to benefit cost-effectively from statin therapy and should be considered for treatment.’
Dr Gavin Stewart, reader in interdisciplinary evidence synthesis at Newcastle University, said: ‘The finding that statins are cost effective and linked to better health outcomes in older people is likely to be robust.
‘It is based on sound analysis and interpretation of well conducted individual patient data meta-analysis and modelling.
‘Notwithstanding the uncertainty associated with modelling observational data, it appears that statins are likely to improve health in average older people.’
A version of this article was originally published by our sister publication Pulse.
9th October 2024
The first evidence of breastfeeding being safe and feasible after breast cancer was presented in two international studies at the recent European Society for Medical Oncology (ESMO) Congress 2024.
No increase in recurrence or new breast cancers was observed in women who breastfeed after being treated for breast cancer, the studies found.
The first study looked at breastfeeding after breast cancer in young mothers who carried BReast CAncer (BRCA) susceptibility genes. The international retrospective cohort study included women diagnosed with stage 1-3 invasive breast cancer at age 40 or younger between Jan 2000 and Dec 2020.
Using statistical analysis, the researchers compared whether breast cancer returned and how long individuals lived, with or without cancer, in women with the BRCA gene and those without.
Nearly 5,000 women participated in the study, resulting in 659 pregnancies and 474 women delivering a child. After delivery, 23.2% of the women breastfed for a median duration of five months, 14.4% did not breastfeed and 47.5% were unable to breastfeed due to undergoing a double mastectomy before pregnancy. The remaining participants (14.9%) had unknown breastfeeding status.
After a median follow-up of seven years, there was no significant difference in the number of locoregional or contralateral breast cancer recurrences between women who breastfed and those who did not (adjusted sHR=1.08, 95%CI 0.57-2.06, p=0.82). In addition, breastfeeding had no impact on disease-free survival (adjusted HR=0.83, 95%CI 0.49-1.41, p=0.49) or overall survival (OS), with nine OS events in patients that breastfed and three in those who did not breastfeed.
In the second study, part of the POSITIVE trial, the researchers investigated a secondary endpoint of breastfeeding in women with hormone receptor-positive early breast cancer who had temporarily interrupted treatment to attempt pregnancy after receiving 18-30 months of adjuvant endocrine therapy.
The primary endpoint had been whether this temporary interruption of treatment was safe, and the researchers found no increase in short-term risk of breast cancer events in these women.
At a median follow-up of 41 months, 317 patients had given birth, of whom 196 (62%) breastfed a total of 232 babies.
Breastfeeding did not impact the breast cancer-free interval (BCFI) with few reported events in women who breastfed (n=9/196). Two years after the first live birth, the cumulative incidence of BCFI was 3.6% and 3.1% in the breastfeeding and non-breastfeeding groups, respectively.
It was concluded that while longer follow-up is warranted, both studies provide key evidence for clinicians and women with breast cancer who wish to pursue pregnancy and breastfeed.
Indeed, commenting on the findings, Dr Maria Alice Franzoi, medical oncologist and researcher at Gustave Roussy, Villejuif, France, who was not involved in the studies, said: ‘Data from these two studies will be extremely useful to guide our practical discussions with young women diagnosed with breast cancer.
‘We should start thinking and discussing about survivorship care planning – including fertility preservation, pregnancy and breastfeeding for women who want to consider these options – at the time of diagnosis, so that they are prepared and empowered across the entire breast cancer journey for shared decision making.’
References
Blondeaux, E et al. Breastfeeding after breast cancer in young BRCA carriers: results from an international cohort study. Abstract 1815O, presented at the ESMO Congress 2024; Sept 14, Proffered Paper Session on Saturday, 14 September, 14:45-16:25 (CEST) in the Pamplona Auditorium – Hall 3.
Azim, HA et al. Breastfeeding in women with hormone receptor-positive breast cancer who conceived after temporary interruption of endocrine therapy: Results from the POSITIVE trial. Abstract 1814O. presented at the ESMO Congress 2024; Sept 14, Proffered Paper Session on Saturday, 14 September, 14:45-16:25 (CEST) in the Pamplona Auditorium – Hall 3.
8th October 2024
The rapidly developing area of technology and artificial intelligence (AI) within respiratory medicine and science was under the spotlight at this year’s European Respiratory Society (ERS) Congress, including the use of artificial neural networks (ANNs) in detecting bronchopulmonary dysplasia (BPD) in preterm infants.
ANNs can be trained to detect BPD in preterm infants by analysing their breathing patterns, Swiss researchers reported at the ERS Congress.
There is difficulty in identifying BPD with current lung function tests as they require sophisticated equipment, the study authors said.
ANNs are mathematical models which, once trained with large amounts of data, can be used for classification and prediction.
Lead author Professor Edgar Delgado-Eckert, adjunct professor at the Department of Biomedical Engineering at the University of Basel said: ‘Until recently, this need for large amounts of data has hindered efforts to create accurate models for lung disease in infants because it is so difficult to assess their lung function.’
For this study, the researchers used a simpler and non-invasive alternative: measuring an infant’s inspiratory and expiratory air flow during tidal breathing to yield a large amount of sequential flow data which could be used to train an ANN.
Professor Delgado-Eckert’s team studied a group of 139 term and 190 preterm infants who had been assessed for BPD, recording their breathing using a soft face mask and sensor for 10 minutes while they slept.
Among the 190 preterm infants, 47 were diagnosed with mild BPD, 54 with moderate BPD and 31 with severe BPD.
For each infant, 100 consecutive regular breaths, carefully inspected to exclude sighs or other artefacts, were used to train, validate and test a long short-term memory recurrent ANN.
The data was randomly split into 60% for training and 20% for validation, with the remaining 20% given to the model unseen to test if it could identify infants with BPD.
On the unseen test data, the model achieved 96% accuracy, 100% specificity, 96% sensitivity and 98% precision for detecting BPD.
Professor Delgado-Eckert said: ‘Our research delivers, for the first time, a comprehensive way of analysing the breathing of infants, and allows us to detect which babies have BPD as early as one month of corrected age – the age they would be if they had been born on their due date – by using the ANN to identify abnormalities in their breathing patterns.’
ERS Congress co-chair Professor Judith Löffler-Ragg said the research presented at this year’s event under the theme of ‘Humans and machines: getting the balance right’ was pioneering and should guide future developments.
‘It is extremely important that we view developments in technology, and specifically AI, with an open mind but also a critical eye,’ she said.
‘Our vision is to advance personalised medicine through the responsible use of AI, continuously improving respiratory medicine.’
7th October 2024
Women with asthma are more likely to need fertility treatment to conceive than women without the condition and are also more likely to miscarry, a large Danish study has found.
However, most women with asthma are able to have children, according to the research presented at the European Respiratory Society (ERS) Congress in Vienna, Austria, this month.
Lead author Dr Anne Vejen Hansen, from the department of respiratory medicine at Copenhagen University Hospital, Denmark, said previous research had found women with asthma took longer to become pregnant when undergoing fertility treatment.
Previous research had also showed that women with asthma who succeeded in becoming pregnant were more likely to have used fertility treatment than the general population.
‘But most existing studies focused on women who had become pregnant, so we wanted to examine fertility outcomes on a national scale, to also include those that might not become pregnant at all,’ Dr Vejen Hansen said.
Using a Cox regression model adjusted for age, calendar year and education, the study analysed the reproductive outcomes of all Danish women born between 1976 to 1999 (769,880 women), following them from 1994 to 2017, with a median follow-up of 10.8 years.
Women who repeatedly redeemed anti-asthmatic drugs were classified as having the condition, with asthma severity stratified per 2018 Global Initiative for Asthma (GINA) guidelines.
Overall, 77% of women gave birth over the follow-up period, irrespective of asthma status, the researchers reported.
However, women with asthma experienced a higher degree of foetal loss compared with controls (17.0% vs 15.7%) and used more fertility treatment (5.6% vs 5.0%), researchers reported.
Risk of fertility treatment was significantly higher in women with asthma (HR 1.12), researchers reported.
Furthermore, Dr Vejen Hansen noted women with more severe asthma and those who experienced more flare-ups were especially likely to need fertility treatment.
Women classified as GINA criteria step 4-5 had the highest risk of needing fertility treatment (HR 1.62), while women with three or more prior exacerbations also had an increased risk (HR 1.38).
Dr Vejen Hansen said the drivers behind these associations were unclear, but they could be related to systemic inflammation throughout the body, including women’s reproductive organs.
‘The numbers also show that these same women who redeem asthma medication still have as many live births in the end as women who don’t,’ she said.
‘This suggests that most women with asthma probably do manage to become pregnant and have babies in the end.’
Commenting on the research, Professor Lena Uller, chair of the ERS Airway Pharmacology and Treatment Group, said it was reassuring to see that women seemed to have the same live birth rate regardless of their asthma.
Nevertheless, Professor Uller, who is also head of the Respiratory Immunopharmacology Research Group at Lund University, Sweden, said the study underscored the importance of managing the condition in reproductive-aged women.
‘The fact that the more severe the asthma, the more the problems with fertility, suggests that uncontrolled asthma is the problem and we should be helping women to get their asthma under control,’ Professor Uller said.
Dr Vejen Hansen and colleagues have previously published a large case-control study showing the proportion of women conceiving by fertility treatment was higher among women diagnosed with asthma than in the general population, with the association particularly pronounced among women aged 35 years and older.
The prevalence of fertility treatment preceding live births was 12.2% among women with asthma compared with 7.7% in the control group, with the association remaining significant after adjusting for a range of factors including age, body mass index and smoking status.
When they assessed fertility treatment after stratifying cases and controls into two age-groups (women <35 years and women ≥35 years), no significant association was found between asthma and fertility treatment in the younger age group.
But among women ≥35 years of age, the prevalence of fertility treatment was 24.8% among women with asthma compared with 13.4% in the control group, which also remained statistically significant after adjusting for confounders.
Dr Vejen Hansen and colleagues now plan to conduct a registry-based study to investigate the possible effect of male asthma on fertility.
Dr João Gonçalves PhD provides expert commentary on a recent study demonstrating real-world evidence of the feasibility and efficacy of a personalised peptide vaccine for glioblastoma – one of the most malignant primary brain tumours in adults.
The goal for cancer vaccines is straightforward: to harness what has been achieved for infectious diseases and their antigens to focus the immune system on eradicating cancer cells.1
A better understanding of the range of tumour-associated antigens and technological advances in neoantigen prediction, in vivo genetic and pharmacological models, and spectroscopic methods have facilitated improved designs for therapeutic cancer vaccines over the last decade.2,3
Despite these developments, glioblastoma remains one of the most formidable challenges in oncology, with current treatment modalities offering limited survival benefits. Regardless of advances in surgery, radiotherapy and chemotherapy, the prognosis for glioblastoma patients remains poor, with nearly all patients experiencing recurrence.
Previous studies for glioblastoma therapeutic vaccines have suggested that few neoantigens could be targeted in glioblastoma due to low mutation burden. However, a recent study by Latzer and colleagues offers real-world evidence and a promising glimpse into the potential of personalised peptide vaccines targeting tumour-specific neoantigens to extend survival in glioblastoma patients.3
This retrospective study involved 173 patients with isocitrate dehydrogenase (IDH)-wildtype glioblastoma, treated with a personalised neoantigen-derived peptide vaccine between 2015 and 2023.3
The personalised approach, tailored to the specific somatic mutations within each patient’s tumour, aims to harness the immune system by inducing a targeted T-cell response against the tumour. The median overall survival (OS) for the entire cohort was 31.9 months – a notable improvement compared with the historical median of approximately 15 months observed with the current standard of care.
The importance of this study lies in its demonstration of the feasibility, safety and potential efficacy of such personalised vaccines in a real-world setting.
The ability to generate a vaccine within 16 weeks of tumour tissue acquisition and observe a robust immune response in 88% of the patients underscores the practicality of this approach. Moreover, the study shows a clear correlation between the strength of the vaccine-induced immune response and patient survival, with those exhibiting multiple vaccine-induced T-cell responses achieving a median OS of 53 months.
This study provides compelling evidence for clinicians and researchers that personalised peptide vaccines could significantly advance the treatment of glioblastoma. The fact that most patients tolerated the vaccine well, with only grade 1 or 2 adverse events, suggests that this approach could be integrated into clinical practice without adding undue toxicity.
However, the study also highlights several challenges. First, the heterogeneity of the patient population, including primary and recurrent glioblastoma cases, introduces variability that could confound the interpretation of results. Additionally, the study’s retrospective nature and the absence of a randomised control group limit the ability to draw definitive conclusions about the vaccine’s efficacy relative to standard therapies.
The study’s reliance on patients who could afford the cost of the vaccine and travel to Germany introduces a potential socio-economic bias, which may limit the generalisability of the findings.
The study’s focus on the immunogenicity of personalised vaccines provides valuable mechanistic insights. The detection of vaccine-induced T-cell responses in most patients and the association of these responses with prolonged survival support the hypothesis that effective anti-tumour immunity can be achieved through personalised vaccination strategies.
This is particularly relevant in glioblastoma, a tumour type often considered immunologically ‘cold’ due to its low mutational burden and immunosuppressive microenvironment.
Moving forward, exploring the factors contributing to variability in patients’ immune responses will be critical. The study noted that 10% of patients did not mount a detectable T-cell response, which raises questions about the potential barriers to effective immunisation in these individuals. Understanding the role of factors such as the tumour microenvironment, immune checkpoint expression and patient-specific immunogenetic factors will be essential in refining this approach.
Additionally, the study opens the door to further exploration of combination therapies. The observation that adding bevacizumab, a vascular endothelial growth factor inhibitor, was associated with reduced survival suggests that careful consideration is needed when integrating personalised vaccines with other therapies. Combining immune checkpoint inhibitors or other immune response modulators to enhance the vaccine’s efficacy may be beneficial.
The promising results of this real-world study set the stage for prospective, randomised clinical trials that can more rigorously assess the efficacy of personalised neoantigen vaccines.1,2,4 Such trials should aim to control for the heterogeneity seen in this study by focusing on more homogeneous patient populations. Moreover, they should investigate the optimal timing and sequencing of vaccine administration relative to other treatments, such as surgery, radiotherapy and chemotherapy.
Given the significant resources required for the development of personalised vaccines, future efforts should also focus on streamlining the production process. Advances in next-generation sequencing and bioinformatics will be vital in reducing the time and cost associated with vaccine development, making this approach more accessible to a broader patient population.5,6
Another critical area of investigation will be the long-term immune monitoring of patients who respond to the vaccine.7 The durability of the immune response and its ability to prevent recurrence in the long term are essential considerations for the overall success of this treatment strategy. The study’s indication that vaccine-specific T-cells can persist and continue to provide protection suggests that long-term benefits may be achievable.
The study by Latzer et al represents a significant step forward in the development of personalised cancer immunotherapies.3
Demonstrating the feasibility and potential efficacy of neoantigen-targeted peptide vaccines in a real-world setting provides a foundation for future clinical trials that could transform the treatment landscape for glioblastoma and potentially other solid tumours.
However, as with any pioneering approach, further research is needed to address the challenges and refine the strategies that will enable the widespread adoption of this promising therapeutic modality. If successful, personalised peptide vaccines could offer a new avenue of hope for patients with glioblastoma, a disease that has long been synonymous with poor prognosis.
João Gonçalves PharmD PhD
Faculty of Pharmacy, University of Lisbon, Portugal
4th October 2024
More patients are experiencing delayed discharges from hospitals, but integrated care boards (ICBs) are working with system partners to develop new and innovative ways to address this. In the first of four case studies, Kathy Oxtoby reports on how Central London Community Healthcare Trust is approaching this longstanding issue via virtual ward and Quick Start initiatives.
To reduce unnecessary delays to discharge and needless admissions to hospital, Central London Community Healthcare NHS Trust‘s (CLCH’s) Hospital at Home Service in Wandsworth and Merton operates as a virtual ward.
One of the first community trust-led virtual wards in the country, it combines technology and face-to-face visits to allow hospital-level care, including diagnostics and treatment, to be carried out in a patient’s own home.
Through on-the-spot blood testing, remote monitoring and face-to-face visits from advanced nurses at CLCH, frailty patients receive the hospital-level care they need safely and conveniently and closer to their support networks, the trust says.
Since its launch in December 2021, the trust estimates the initiative has saved approximately 4,836 hospital bed days in Wandsworth and Merton (as of August 2024).
This approach helps to ease urgent and emergency care capacity pressures by improving patient discharge rates, or avoiding admission.
The trust’s Quick Start initiative brings together CLCH’s Hospital at Home and discharge services to provide ‘the right care to patients at home’, the trust says. Patients can be provided with therapy, medical or social care support dependent on their needs, preventing admission to hospital and supporting earlier discharge from hospital.
CLCH works with acute services at the point of admission to ensure that the package of care a patient needs at home will be ready for them as soon as they are well enough to leave hospital, preventing delays due to the absence of safeguarding support or equipment to help their recovery, the trust says.
Dr John Rochford, deputy chief medical officer at Central London Community Healthcare NHS Trust says: ‘In collaboration with South West London Integrated Care System – our partners in acute, primary and social care – we provide tailored support to care for our communities at home.’
He says CLCH and the South West London ICB are ‘enhancing patient care through the use of virtual wards with a focus on ensuring seamless integration of services, pre-hospital care to help patient flow and improving patient outcomes through prevention and early interventions’.
‘The partnership around virtual wards exemplifies a shared commitment to delivering high-quality healthcare in many areas, such as digital solutions to support clinicians to make quicker and safe bedside decisions, to meet the needs of the community,’ he says.
‘This innovative way of working means that we are able to support more patients to get better in their own homes, helping them to avoid unnecessary and lengthy admissions to hospital, which can have a detrimental impact on their health,’ says Dr Rochford.
‘Patients fare better in familiar surroundings, when they can sleep in their own bed, eat the food they like and have friends, family and pets around them whenever they wish,’ says Dr Rochford.
Mark Creelman, Merton and Wandsworth place lead at South West London ICB, says: ‘Across South West London, there are four virtual ward – hospital at home – services covering our six boroughs, all with face to face and remote monitoring capabilities to provide hospital level care for patients who would otherwise be on a ward, in the comfort of their own home where it is safe to do so.
‘We now have 415 “beds” with a central remote monitoring hub operating 24 hours a day, seven days a week to support patients’ own monitoring, and we continue developing our virtual wards to improve services, help ease pressures on urgent and emergency care and contribute to reducing avoidable admissions.’
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:
This case study was originally published by our sister publication Healthcare Leader.
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. Kathy Oxtoby reports.
Patient discharge is a well-documented pinch point for the NHS.
According to The King’s Fund, delayed discharges from hospital are ‘a widespread and longstanding problem that can have a significant impact on both patients’ recovery and the efficiency and effectiveness of health and care services’.
And the Nuffield Trust says a huge challenge facing the NHS is that more patients are experiencing delayed discharges. ‘Reversing this trend is a major system priority given rising waiting lists, overstretched A&E services, and the risks that unnecessary long stays in hospital pose to patients,’ it says.
Analysis by the think tank found that the total number of patients in acute hospitals who were ready to leave but were delayed has increased by 43% from an average of 8,545 patients per day in June 2021 to 12,223 patients per day in June 2024. At its peak, in January 2024, there were 14,096 patients delayed in hospital.
The fall and rise of delayed discharges observed this year may be indicative of winter pressures. ‘Every winter sees an increase in A&E admissions and a reduction of staff due to sickness absence that can hinder effective discharge processes within hospitals,’ it says.
Changes in the total number of delayed patients are mainly attributed to increases in delayed patients who have been in hospital for up to 21 days or longer, this analysis shows. These patients are more likely to experience delays in discharge because often their needs are more complex and their care needs outside of hospital are greater, and organising that care takes more time and resources, says Emma Dodsworth, a researcher at the Nuffield Trust.
Prolonged stays in hospital are ‘bad for patients, especially for those who are frail or elderly’, NHS England says. ‘Spending a long time in hospital can lead to an increased risk of falling, sleep deprivation, catching infections and sometimes mental and physical deconditioning.’
Delays to patient discharge impact the wider health system. ‘We know that hospitals are struggling to manage the flow of patients because of the high volume of beds being occupied by people who might be better cared for elsewhere,’ says Ms Dodsworth. ‘When people are struggling to get out of the system it is more difficult to get people into the system – so we tend to see pressures on entry points to health services such as on ambulance services and A&E departments,’ she says.
Delays to patient discharge are also having an increasing impact on community health services and social care, says Ms Dodsworth. She says often, there is a desire to get people out of acute settings and quickly into community settings in the form of a step-down intermediary care package. ‘But you risk putting them into an additional setting that also faces delays with discharge and risk pushing the bottleneck further down the patient pathway,’ she says.
A lack of capacity in social care settings is often cited as a reason for delayed discharge, says Ms Dodsworth. The most common reason for discharge delays experienced by patients who have been in hospital between seven and twenty days is that they are waiting for some form of home care – and this could be due to staff shortages within the sector, says Ms Dodsworth.
And the most common reason for delayed discharges for patients who have been in hospital 21 days or more is waiting for a bed in a nursing or care home – and there is ‘a shortage of places in council-run care homes’, says Ms Dodsworth.
However, the reasons for delayed discharge are also ‘complex and varied’, she says. These can include hospital processes delaying discharge, for example, a discharge summary that needs to be written up or a final assessment or agreement on what further care the patient might need. Delays to these processes could be due to a shortage of healthcare staff, says Ms Dodsworth.
Funding given to help tackle discharge delays can also bring problems.
To reduce delays every winter, in England, it has become normal practice for the Government to provide additional one-off funding.
Last year, researchers at The King’s Fund interviewed commissioners and service providers in six local areas who said that while they welcomed extra funding, it came with ‘insufficient advance notice for effective planning, sometimes having to be spent on residential care that was available at short notice rather than developing more services to support people at home’.
Commissioners and service providers also wanted to be able to use the funds to prevent avoidable hospital admissions and ‘strongly criticised burdensome monitoring requirements’, researchers found.
Some areas did manage to use the funding to put services in place and support the social care workforce but were ‘not confident they were spending funding as effectively as possible’.
Researchers found varying depths of partnership working and that not all have a shared understanding of local causes of delayed discharges and priorities for action. ‘This, together with fragmented and inconsistent data, could hinder their ability to use additional funding effectively,’ the report found.
Key partners – including ICBs and the local authorities – ‘are all trying to work together, but because of different accountabilities don’t always have a depth of partnership’, says Alex Baylis, acting director of policy, events and partnerships at The King’s Fund, and one of the report’s authors.
Affecting these partnerships is a culture of ‘who is to blame for discharge delays’, with some hospitals blaming social care and vice versa, says Mr Baylis.
This year, the money to reduce discharge delays in winter was rolled into the Better Care Fund ‘so we’ll need to see whether there is a better sense of partnership’, says Mr Baylis.
Some £1.6bn has been allocated to social care services for 2023-25 as part of the Better Care Fund, which will include a focus on reducing delayed discharges, says Ms Dodsworth.
And ICSs have put in place initiatives to better handle winter pressures and the delayed discharges that come about during this time, she says.
Initiatives include virtual wards, allowing people to receive hospital care in their own homes, and transfer of care hubs which bring together system partners to better coordinate services to support timely discharge, says Ms Dodsworth.
Mr Baylis says there are examples of good practice around the country, rooted in local organisations – particularly across the NHS and local authorities – having a shared understanding of their specific local issues and the same shared data and plan.
There are also widespread examples of initiatives using the voluntary and community sectors to support people at home after discharge, he says.
In some areas, work is being done around discharge lounges, ‘which are staffed a bit like wards, may have beds, and can help get people off the wards into a lower intensity environment and free up a bed for someone who is acutely unwell’, he says.
Asked how the primary/secondary or social care/secondary care interface are working to better manage the flow of patients, Mr Baylis says: ‘Each general practice is unique, and each care home is independent, so it’s difficult to generalise how they work with hospitals.’
‘We found the involvement of general practice in local planning around winter discharge was quite variable, partly because it’s difficult to engage all of the GPs because they are independent. But GPs need to know if they are going to have patients discharged with higher levels of acuity and complexity,’ he says.
‘And in social care, the same happens – they are all independent businesses and charities, so different local authorities have different levels of ability to really engage across the whole social care market.
‘They all want the best thing for the individual patient, but they are not always organised to make it easy to deliver that,’ says Mr Baylis.
As for the role ICBs play in supporting the system in terms of patient discharge, he says they are ‘possibly the most interesting part of the entire health and care system at the moment, because they face in two directions’. ‘They support the local providers and services, but at the same time, they answer back up to NHS England,’ he says.
‘If NHS England puts pressure on ICBs to just get people out of hospital, that can undermine their role in supporting the development of the system as a whole because they are skewed towards those priorities.
‘So ICBs have a really important role to keep the focus on facilitating whole system approaches, and not to withdraw into the priorities that NHS England has specifically for hospital performance. It’s a balancing act,’ he says.
‘ICBs are in a tricky position because the short-term priority is to get people out of hospital. But the long-term solutions will only come from the whole system having a shared understanding, plan and way of working,’ he says.
To help address issues with patient discharge, the Nuffield Trust is calling for the government to ‘stop allocating funding to support discharge via short-term emergency pots that make planning impossible’, says Ms Dodsworth.
‘It means that ICS leaders and local authorities are reluctant to commit to commissioning new services because they don’t necessarily have long-term funding to support their ambitions,’ she says.
‘Needs are becoming increasingly more complex, and so we need system leaders to think about how to ensure the right care is available,’ she says. ‘Sometimes when we’re focused so much on getting people out of hospital, we’re not always thinking about whether we’re getting the patients into the best place that meets their care needs.’
Long-term sustainable approaches need to be rooted in prevention, she says. ‘Often, unpaid carers will feel that emergency admission of their loved ones could have been prevented in the first place if there was better access to support in the community. It’s about reframing prevention as a precursor to good care for people,’ says Ms Dodsworth.
Mr Baylis says there is ‘a good potential to reduce admissions to hospital in the first place’. He highlights NHS England’s Enhanced Health and Care Homes framework, ‘where GPs regularly visit care homes and check up on what can be done to keep people well’. He says this has been shown to reduce hospital admissions, particularly emergency admissions.
There’s also a role for ICB leaders to ‘get under the skin of how to make whole system working effective for reducing discharge’, he says. ‘ICB leaders have great potential to really work as system facilitators and support that partnership approach, which is driven by shared understanding and close working approaches that are fundamental to long-term solutions to discharge problems.
‘And when they do that, the benefits for individuals, staff pressures, and budgets are big. It is skilful work that is all about leadership across systems. And it’s not easy,’ he says.
‘Every area has unique challenges with patient discharge, and there is no “one size fits all” solution,’ says Mr Baylis. ‘That’s why it’s so important to have a shared understanding of the specific local issues, a shared plan, shared data, really close working and a shared view of what good looks like.’
Read more about the inspirational work being done across England to support the smooth and timely discharge of patients from hospital in these case studies:
This feature was originally published by our sister publication Healthcare Leader.
3rd October 2024
The rapidly developing area of technology and artificial intelligence (AI) within respiratory medicine and science was under the spotlight at this year’s European Respiratory Society (ERS) Congress, including the use of large language models (LLMs) such as ChatGPT to assess complex respiratory disease in children.
The LLM ChatGPT performed better than trainee doctors in assessing complex paediatric cases of respiratory disease, a study found, suggesting LLMs could be used to support patient triage.
UK researchers compared the performance of three LLMs (ChatGPT, Microsoft Bing and Google’s Bard) against early-career trainee doctors in providing responses to six paediatric respiratory clinical scenarios. Each scenario had obvious diagnosis and no published evidence, guidelines or expert consensus that pointed to a specific diagnosis or plan.
The 10 trainee doctors were given an hour with internet access, excluding access to LLMs, to solve each scenario with a 200- to 400-word answer.
Responses were randomised and scored by six experts overall and on specific criteria: correctness, comprehensiveness, utility, plausibility, coherence and humanness.
ChatGPT (median overall score 7) outperformed Bard (median 6), Bing (median 4) and the trainee doctors (median 4) in all domains.
Bard scored better than the trainee doctors in coherence, with Bing and the trainee doctors scoring similarly.
The six experts were able to identify Bing and Bard’s responses as non-human, but not ChatGPT’s responses.
Dr Manjith Narayanan, lead author and consultant in paediatric pulmonology at the Royal Hospital for Children and Young People, Edinburgh, and honorary senior clinical lecturer at the University of Edinburgh, UK, said they did not find any obvious instances of ‘hallucinations’ – the term for false information provided by LLMs – in the responses.
‘Even though… we did not see any instance of hallucination… we need to be aware of this possibility and build mitigations against this,’ he said.
The research team plan to test LLMs against more senior doctors and investigate newer and more advanced versions of the technology.
Commenting on the findings, Professor Hilary Pinnock, ERS Education Council chair and professor of primary care respiratory medicine at the University of Edinburgh, said the study pointed to a ‘brave new world of AI-supported care’.
She added: ‘As the researchers have demonstrated, AI holds out the promise of a new way of working, but we need extensive testing of clinical accuracy and safety, pragmatic assessment of organisational efficiency, and exploration of the societal implications before we embed this technology in routine care.’
ERS Congress co-chair Professor Judith Löffler-Ragg said the research presented at this year’s event under the theme of ‘Humans and machines: getting the balance right’ was pioneering and should guide future developments.
‘It is extremely important that we view developments in technology, and specifically AI, with an open mind but also a critical eye,’ she said.
‘Our vision is to advance personalised medicine through the responsible use of AI, continuously improving respiratory medicine.’
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