NHS international intelligence scanning service

Amid widespread political interest in the productivity of the NHS, the latest round of NHS England planning guidance, published in late March, has placed significant pressure on NHS leaders to deliver stretching targets that seek to improve access to output of services from the elective waiting list to improving the provision of mental health in the community, to children & young people, and the perinatal period. 

It begs the question, to what extent are other health systems struggling to provide timely access for their citizens to such a diverse range of services, what actions are being taken to address this, and how is their focus on short-term access being balanced with the ambition to address the long-term drivers of ill health?

Diagnostics

In the USA, where inequalities in access and uptake of diagnostics pervade across socioeconomic, ethnic and racial divides, policy-makers are thinking differently about how they provide diagnostics that are easier to access, and how to overcome the issue of how communities can be reached. 

In the latest episode of The Dose, The Commonwealth Fund spoke with UCLA Professor of Medicine and Director of the Gastroenterology Quality Improvement Programme, Dr Folasade May. With a dual focus on medical treatment and health equity policy, the podcast concentrates on Dr May’s efforts to improve the methods used for diagnosing colorectal cancers, design bespoke engagement initiatives for diverse communities, and effect national policy interest for a cancer that has become the number one killer of men, and number two killer of women in the USA.  

Access to primary care

NHSE planning guidance also places an emphasis on improving access to primary and community services and places a requirement on ICBs to report on how well trusts are improving the primary-secondary interface. Primary care, and the scale of services it delivers, is often taken for granted in the UK, but for many health systems in similarly wealth nations, an integrated approach to primary care has been lacking for a long time, with poor coordination for patients requiring ongoing care for multiple conditions and significant inequalities in service provision.

Back in the USA, where state spending on primary care is among the lowest in the OECD at 5-7% of total healthcare spending (based on OECD metrics the UK comes in at 16%), the Commonwealth Fund has formed the Primary Care Investment Network alongside The Primary Care Development Corporation and the Milbank Memorial Fund. Made up of representatives from 25 states, and amid a disparate and underdeveloped system, the Investment Network’s task is no mean feat. Their initial task has been to simply define what is and isn’t considered primary care in the American context, before it is possible to go onto address accountability, stakeholder engagement, and evaluation methods. 

Despite this challenging base, the Network has already been able to identify some good practice. In California, a Primary Care Investment Coordinating Group has had success in aligning the interests of  public and private healthcare providers, policy-makers, and patient representatives to agree investment in primary care. 

Germany’s health insurance-based health system, much admired for its comparatively high investment in health and the resulting degree of technical and professional capacity at its disposal, is often criticised for the lack of integration between services and providers. Several steps have been taken over the past decade to rectify this and one such initiative, introduced at a single site in 2017 and now being scaled across the country is Health Kiosks. 

Designed to support socially disadvantaged citizens to easily access comprehensive health services where there is limited access to physicians, Health Kiosks can be established in various settings and act as a source of providing health services, preventative care and general welfare. Since their introduction in 2017, there has been a commitment from central government to expand to over 1,000 kiosks across the country and invest in the expansion of electronic health records and wider digital infrastructure in the Kiosks.

And this is not the only effort being made in Germany to increase integration across primary care. Since 2017, the Robert Bosch Foundation have been investing in Patient-Oriented Centres for Primary and Long-Term Care programmes (PORTs). The intention of PORTs is to develop community health centres that are designed around an ageing, multimorbid population. Integrating prevention and health promotion, POSTs will coordinate treatments for patients and help them manage their own conditions, in acknowledgement of patients wanting to take greater agency in their care.  

Elective waiting lists

The government of New South Wales (NSW), Australia, has been making efforts to reduce their waiting lists for elective surgery. A ‘Surgical Care Taskforce’ was established in May 2023 and initial reporting from the Bureau of Health Informatics suggests that the Taskforce’s initiatives have so far reduced waiting times for elective surgeries by 35%.

The NSW government is now attempting to replicate the success with the establishment of an emergency department taskforce. This comes as new national statistics show that NSW has the highest number of ED presentations in the country (3 million). Official statistics and patient experience reporting show that it should be possible for the taskforce to significantly reduce ED presentations. Almost half of presentations to ED were for the two most minor categories of injury, while 45% of patients reported that they felt they could be treated by a GP. As such, the taskforce will focus much of its efforts on initiatives to reduce unnecessary presentations and efficiently moving patients across the system, so they can be treated in the most appropriate setting. 

NSW is matched in its ambition to reduce elective waiting times by Sweden, where waiting times are increasing, and disparities are emerging between the regions. To combat this, the national government has commissioned the eHealth Agency to develop a new ‘care intermediation system’. The system allows providers of care across the country's regions to identify alternative providers that can deliver elective care to patients in a timelier manner. 

Delivering a balanced financial position

These efforts all come with a significant financial cost attached to them, and NHS leaders may feel some comfort knowing that it is not just they who are facing down the prospect of needing to make significant cost savings. 

Finland, another publicly-funded health system where healthcare is devolved to regional level, has asked its health regions to make significant savings to their healthcare budgets amid a national budget that will see spending fall and taxes rise. Spending across the nation’s public services will fall by £6bn euros and this cut in public spending, alongside the proposed changes to healthcare provision have caused anger among the public and discontent among healthcare and political leaders across the Finnish regions. The resignation of the Managing Director of Wellbeing services in one region and the subsequent loss of confidence in the Chair of the Regional government, by their party, serve as an indication of the degree of fallout. 

Amid the austerity programme is permission from central government to increase debt for investment that will see small health centres and central hospitals close and be replaced by larger social and health care units. Larger than the existing local health centres and smaller than Finland’s central hospitals, social and health care units are expected to provide greater economies of scale, be more attractive places of work for a range of healthcare professionals and remain easily accessible to all patients. 

These plans follow the recommendations of a working group convened by the Ministry of Health that has suggested that the number of central hospitals in Finland be reduced from 15 to between 5-8, with the sites purpose shifted away from the provision of accident & emergency care and elective surgeries, to the ongoing care of an ageing and multimorbid population. It is expected that from 2027 these reforms will save the health service €100 million per annum. 

Conclusion

The latest round of planning guidance has placed NHS leaders in the challenging position of delivering greater access to a wide range of services, with little additional financial support to do so. As the NHS Confederation acknowledged in its response, the ambition is welcome, but successfully meeting this ambition will remain unclear. In the face of such demands, it is hopefully reassuring to NHS leaders that they are not alone in these endeavours and there are international counterparts outside the NHS whose experience and best practice they can share. 

Speaking at this month’s Nuffield Trust Summit, Professor Chris Whitty, the Chief Medical Officer, drew upon his annual report to discuss the challenges posed by an ageing society and how we need to collectively think about ageing differently.  

Whilst praising the advances that have been made in life expectancy, the CMO sought to position ageing from the perspective of increased quality of life, and not just the quantity of years. Currently, the average healthy life expectancy for men in England is 62.4 years and 62.7 years for women, with significant geographical variation across the UK and subject to socioeconomic factors. This is well understood to have profound impacts on the overall wellbeing of individuals, their families, carers, and wider communities who depend on a healthy older population. Additionally, as communities age in poor health, there is an increasingly negative impact on the broader economy and a heavily resource-constrained NHS.  

In his foreword to the report, the CMO chose to highlight that improving healthy ageing is not the responsibility of any one individual or group and that the general public, policy-makers and medical profession all have a role to play. Our focus should be on our ability to influence how well we age, how healthcare planning can reflect the geographies and built environments in which older individuals age, and the increasing incidence of multi-morbidity, not single disease, associated with ageing in the 21st century which must be reflected in service design, and medical provision and research.  

As other nations contend with similar challenges arising from an ageing population, it makes sense to consider how our peers are approaching this demographic shift, what interventions are being made, and what impact, if any, they are having on the quality of life of older adults and the demands faced by the health and social services supporting them?

Italy

Health system design is one such intervention that needs to be considered, with the CMO noting that health service planning currently doesn’t sufficiently reflect the geographical spread of older adults and how the built environment in these geographies impacts access to care. There is general recognition in England of a need for a ‘left shift’ of resources into community settings, and this is one area where the English NHS could learn from the Italian healthcare system, especially from the northern region of Emilia-Romagna. Counter to the common Italian approach of heavily centralised, specialist hospitals and single doctor primary care clinics, in 2013 Emilia-Romagna (healthcare in Italy is devolved to the regional level) embarked on the development of a series of ‘health homes’ that provide services for all patients who don’t require hospitalisation for complex treatment, with services including psychiatry, dietetics, adult social care, and even beds for those requiring monitoring. This approach came to prominence during the covid-19 pandemic as it proved to be much more adaptable and stress resistant than centralised institutions and has proven far more accessible to Italy’s older adults who, not dissimilar to their English counterparts, are distributed across small towns and villages, and require ongoing and frequent, but non-urgent care for multiple conditions.  

United States

Similar approaches have been taken in the United States to improve services for the rural older population, with providers of health and long-term care services working to improve access to services, overcoming workforce shortages and making facilities ‘age-friendly’. In 2023, the New York based Commonwealth Fund published a report with various case study examples of these interventions. One such example, on a smaller scale than its Italian comparator, comes from Cochise County, Arizona, where one geriatrician has attempted to overcome limitations in Medicare’s funding for primary care provision for rural populations, by initially establishing a solo home-based independent living service. When reviewed by the University of Arizona, the programme was found to have resulted in reduced costs of participants attending specialist clinics, A&E and requiring hospitalisation. In 2017 the programme was expanded, via state grants, to collaborate with paramedics and the employees of local primary care clinics. This extension of the programme resulted in the reduction of 30-day re-hospitalisation rates among participants from 19 percent to 8 percent, with a subsequent push to establish the long-term sustainability of the programme through Medicaid reimbursement.  

Australia

In 2018 the Australian government introduced a $150 million grant programme – The Move It AUS - targeting inactive older Australians, with the ambition to increase participation in sport and activity. Since its launch, the initiatives funded by the programme have resulted in participants almost doubling their weekly physical activity, with the most disadvantaged communities increasing their activity from once a week to almost three times per week.  

Taking control

The CMO's report also highlights the importance of the state supporting individuals to take control of their health and take the necessary action to improve their chances of ageing healthily – such as healthy diet, physical activity and reducing nicotine and alcohol consumption. Examples of national and local initiatives can be found in almost all countries with an ageing society, including Italy and Japan, with the WHO’s Global Database of Age Friendly Practices a key repository of such initiatives.  

STAGE research programme

The CMO’s final call was to the medical and health science professions, highlighting that as adults live longer, but with increasing incidence of multi-morbidity, it will be crucial that general medical skills are retained alongside the development of deep specialisms, and that the medical research community increasingly reflects the incidence of multi-morbidity in their research, in a shift from researching single diseases in a siloed fashion.  

At present, this siloed, single disease approach is creating gaps in our knowledge of how to age healthily and in January this year the STAGE research programme was launched to overcome the resulting dearth of evidence on a European level. A partnership of 22 European organisations which includes universities, SMEs and NGOs (including Imperial College London and the University of Bristol) and funded to the tune of €20 million by Horizon Europe and UKRI funding, STAGE will take a life course approach to understand how the built environment, social conditions and the fundamental biology of ageing allow us to grow old healthily. Ultimately, the project will use increased levels of scientific evidence to co-develop resources with citizens, healthcare providers and policymakers that can inform policymaking on ageing and the creation of age-friendly urban developments.  

With an election for UK Parliament required by 25 January 2025, and heavily expected to come in 2024, the UK’s political parties have well and truly (although unofficially) entered onto an election footing. For those of us in the health service, we know that means that the NHS will have to as well. In response, the health policy community has begun preparing their ‘asks’ of any future government. Last week the NHS Confederation launched its manifesto. This week has seen the Health Foundation reveal its priorities for the next general election and Healthwatch England publish their Vision for the NHS in 2030.  

As we brace ourselves for what analysts predict may be a particularly unpleasant political campaign, it could be easy to forget that globally 2024 is expected to be the busiest election year on record, with up to 4 billion people casting their votes in national elections (of varying degrees of democratic freedom). Whilst other health and care systems might not be as politicised as the NHS, that doesn’t mean that health isn’t prominently positioned on the election agendas of our international partners. 

Whilst it is not possible to delve into the detail of each and every country heading to the polls this year, this blog picks up some of the most interesting campaign debates, and in some instances the direct ramifications for the NHS.  

EU

Britian’s closest neighbour, the European Union, will head to the polls this year to elect members of the European Parliament, alongside several EU member states' national elections including Belgium, Czech Republic, Portugal, Austria, Slovakia, Finland, Croatia, and non-EU nations Iceland and San Marino.  

Health inequality remains a hot topic in the EU, and EuroHealthNet Director, Caroline Costongs, has called for the EU to establish a Commission Vice-President for the Wellbeing Economy in response. The Vice-President will be instructed to secure and maintain high-level attention for the wellbeing of people and to plan and ensure coordination of wellbeing policy across the EU.  

Elsewhere in the the EU, Commission President, Ursula von der Leyen, began her formal bid for a second term earlier this month. Such is the perilous path to a second term, von der Leyen is reported to have “watered down, held back, or shelved” policies on food, alcohol and tobacco, amid accusations of nanny state-ism.  

It should not be forgotten either that 2024 is the year that will see the UK-EU data adequacy agreement - the acknowledgement by the European Commission that data protection in the UK is of equal standing to that of the EU and therefore data can flow more seamlessly across our borders - formally reviewed. While experts expect the agreement to be renewed, the passage of the Data Protection and Digital Information Bill through the UK Parliament has raised questions about the possibility of issues arising. 

Finland

At the front and centre of the UK health policy community's mind is how we can improve health and care without investing any additional resources due to demands on government budgets. This has led to discussion in some quarters about the rationing of services and we have certainly seen rises in inequality of access increase across England.  

Whilst insurance-based systems sometimes have an explicit or implicit mechanism for deciding what is and isn’t funded, the same cannot always be said for publicly-funded health systems, where there is an often unspoken understanding that the health service is there to provide as much as it can. In time of hardship, this can lead to geographical variation in provision of services which have become more prominent in England.  

This is part of a broad debate in Finland, another EU member state with a national election this year. An Amnesty International report published in 2023 highlighted that successive governments' under-funding of the public health service had taken trust in public provision to breaking point, particularly affecting access to dental, gynaecological and mental health services. This is part of a broad debate in Finland that has consumed professional bodies such as the Finnish Ministry for Health and the Finnish Council for Choices in Health Care (Finland’s equivalent of NICE), most recently over whether access to vasectomy procedures, where waits can extend up to three years in length, should be afforded the same access protections as life-threatening conditions requiring treatment. 

Portugal

Elsewhere in Europe, Portugal, a health system similar in basic design to our NHS, is a country where a national election will come soonest, with the two-week lead into the general election having already started on Sunday 25 February.  

Triggered amid corruption scandals that have seen President Marcelo Nuno Duarte Rebelo de Sousa’s Chief of Staff arrested and former president Antonio Costa (2005-11) required to stand trial for corruption, Portugal also faces a persistent housing crisis, and poor-quality public health. 

Politico polling has both major parties' neck and neck, sharing roughly 60 per cent of the vote. The PDS, Portugal’s Centre Right party, is guaranteeing annual health check-ups which they have stated will be based on international best practice and is aiming to personalise the delivery of healthcare through a combination of public, private and social providers. Meanwhile, Portugal’s current governing party, the centre-left Socialist Party, has proposed extending prescribing rights in General Practice and establishing networks of dentists. It may be the smaller parties at the further extremes of Portugal’s political system that have more sway over which policies are prioritised, if a power-sharing agreement is required again.  

USA

At the end of the year, the eyes of the world will turn to America as the US elects to return either Joe Biden or - the all but confirmed Republican nominee - Donald Trump to the Whitehouse for a second term. For those of us with only a passing interest in US politics, the election may seem to hinge on the personality of the two Presidents, but analysts of the US health system tell us that healthcare, and each nominee’s position, will play a far larger part in voters' decision-making than we may give credit.

It will come as no surprise to anyone who has read about the Alabama Supreme Court’s ruling on IVF that reproduction rights are front and centre of the healthcare debate. This is an issue worthy of more thought and expertise than a paragraph in this blog, but ongoing developments at the state level, and polling showing up to 30 per cent of US citizens viewing the issue of abortion as an issue they must be aligned on with any candidate, show just how impactful a clear stance can be for the Presidential hopefuls.  

Unsurprisingly for the healthcare system with the honour of being one of the most expensive in the world, with high levels of inequality and poor outcomes, the cost of care will become a key dividing line between the Democratic and Republican Parties, but one both will try to tread through carefully. Polling is showing that up to 70 per cent of Americans support a policy of Medicare for all, a step that would establish a single payer insurance system in the country.  

Canada

In the spirit of devolution, talk of elections shouldn’t just focus on the national elections that will shape the health agenda, but across the world, regional elections will also be taking place.  

In Canada, where a federal election may signal the end of PM Justin Trudeau’s nine-year premiership remains possible, just three of the 13 Provinces and Territories will have elections in 2024 (British Columbia, New Brunswick, Saskatchewan) and primary Care is high on the agenda.

Primary Care is high on the agenda in British Columbia where the province’s 270 doctors per 100,000 citizens isn’t translating into access to primary care, where nearly 1 million citizens, or 20 per cent of the province’s population, don’t have access to a primary care doctor. This shines a light on the limitations of what simply greater levels of capacity can deliver as the complexity of patient need grows. In response the B.C. government has introduced a new framework that better compensates family doctors for the number, complexity and time necessary for onward referral, management and administration. The next step promised by the Minister for Health is to implement more multi-disciplinary team working in primary care, that reflects the roles for advanced nurse practitioners, pharmacists and social workers we increasingly see in the UK primary care sector.  

Conclusion

Whoever emerges from an election victorious and holding the keys to the NHS budget, they will be faced by the reality that more needs to be done with limited to no money, and a depleted workforce tired of reform. They will need to look for tried and tested approaches that won't cost vast sums to implement. And they may just find them among their fellow election winners around the globe.

Accessing healthcare for rural Australians is a perennial challenge for the nation’s health system. Rural communities in the state of Queensland live on average 7 years fewer than those in Metropolitain areas, and have a 25% increased rate of morbidity and mortality due to reduced access to specialist care. 

In an attempt to overcome this, the Royal Brisbane and Women’s Hospital have developed a remote-controlled robot for conducting echocardiograms for the state's cardiovascular patients. Partnering with two hospitals in rural Queensland, sonographers based in Brisbane are able to conduct echocardiograms almost 1000km away. 

Data from Queensland Health shows patients travelled more than 70 million kilometres annually by car alone to reach treatment, which they hope will be reduced with the further roll out of the echo robot – saving time for patients and costs for the state.  

There is also the hope that the 12-month evaluation of the programme can demonstrate that remote echocardiography can reduce the state's health inequalities by diagnosing disease earlier, treating patients faster and supporting and monitoring more robustly. 

A ten-year (2012-2021) Canada-wide study conducted by the University of Toronto into reform of primary care services across the country and their resulting impacts has concluded that despite significant time and investment, positive transformation is slow and limited and in some instances completely lacking. Despite this, advances in information technology, quality improvement and the development of multi-disciplinary teams were all noted by researchers as improvements in the past decade. Read the study.

A new paper from the International Journal of Integrated Care (IJIC) examines the plans for the integration of services in Scotland and makes recommendations for how further reforms could strengthen the application of integration policies in Scotland. 

Established in 2016, the Scottish government set up 32 geographically defined Integration Joint Boards (IJBs) to manage two thirds of the NHS and social care budget and provide a space for local planning and service provision that provides greater involvement for stakeholders. Additionally, the IJBs were designed to break down the financial barriers between system partners. 

The performance of IJBs since their inception in 2016 was assessed by publicly available data that align to the intentions of integration, including, but not limited to, delayed discharges, avoidable admissions, A&E performance. 

Data leading up to the Covid-19 pandemic showed that delayed discharges, unplanned admissions and A&E performance were all deteriorating. Similarly, no improvement was seen in performance measures for mental health, and drug deaths had doubled in that time. This though is not the fault of IJBs themselves, but reflective of the complicated ecosystem they exist in, straddling the NHS and elected councils. Coupled with the non-voting advisory role that most IJB members have, their influence over service provision has been limited. This prevented IJBs from reallocating resources as much as they wished. 

IJIC proposes that a one positive step to strengthen the IJBs would be to provide full voting rights to members from health, social care, and third sector organisations.

As the gap between demand and financial resources becomes a growing and endemic problem in the UK and comparator health systems, it is increasingly recognised that suitable services cannot be achieved through increasing amounts of public funding and must instead be realised through strategic investment in the most effective areas of service provision. 

A new paper from the European Observatory on Health Systems and Policies seeks to summarise what might constitute efficient and effective investment. As policy-makers and NHS leaders will recognise, investment in primary care and a multidisciplinary workforce should be prioritised, as should carefully developed and integrated digital services. Mental health investment is also earmarked as a key area of priority for funding to address population health and service demand. 

The report stresses that while limited resources can be more effectively invested, the reality of demands on services and systems' structures means that funding will still need to be increased.

The need for greater cross-government policy development is not limited to the UK health system. Governments across the world are contending with demographic challenges that are not neatly rooted in a single department or agency's remit. This requires finding new ways of working for public servants and developing and articulating the intended benefits of a policy differently. 

One such example of this comes from the development of the European Health Investment Hub. Writing in EuroHealth, Johannes Rauch, Minister for Social Affairs, Health, Care and Customer Protection in the Austrian Government explains how developing a ‘Resources Hub for Sustainable Investing in Health’, an EU Commission funded project led by Austria, Belgium and Slovenia, is working towards strengthening the capacity for officials at national and EU level to make the economic case for investing in health. 

A new online suicide prevention training programme for pharmacists in Australia which supports them in identifying and supporting customers who may be at risk of suicide has been evaluated, with the results published in the International Journal of Clinical Pharmacy.

The results demonstrate that the training programme has improved attitudes, knowledge and confidence among pharmacists in helping their patients, immediately after and six-months on from the programme.

The effectiveness of the training could be further supported if community pharmacists had more dedicated time, privacy and resources to promote ongoing training and collaboration with other healthcare professionals. 

Health systems are under intense pressure to adapt to evolving needs and trends driven by population ageing, digitalisation, and climate change. They also need to be better prepared to withstand sudden, large-scale shocks such as pandemics, financial crises, natural disasters, or cyberattacks. 

This shifting policy context and emerging challenges called for a revision in how OECD countries assess health system performance, to help ensure that health systems meet people’s health needs and preferences, while providing quality healthcare for all. 

This document presents the OECD’s renewed health system performance assessment framework. It incorporates new performance dimensions, notably people-centredness, resilience, and environmental sustainability, and places increased emphasis on addressing inequalities, including those related to gender. 

The framework expands on existing OECD efforts in these domains and integrates the most recent advancements in health system performance assessment. By offering common definitions and fostering a shared understanding among policy-makers, stakeholders and organisations, the updated framework seeks to enhance international collaboration. Furthermore, it lays the foundation for developing future indicators, facilitating data collection, policy analysis, and the integration of knowledge.