A state of decay? The importance of good oral health in older people

Posted by Centre For Health Solutions on 15/04/2014 at 5:29 PM in Current affairs NHS, Frail and elderly, Social care Permalink Comments (0)

Ind_tmt_glb_ve_593_hiIn our recent report ‘Better care for frail older people’ we acknowledged that improving the experience and outcomes for frail older people requires action on three fronts: physical and mental healthcare, social care and place of care. One area that we didn’t cover, however, was the challenge of maintaining the oral health of older people. Research into this challenge has identified that timely access to good dental care is critically important for frail older people but that increasing dependency, reduced mobility and failing health means access is particularly difficult and the costs and consequences of poor oral and dental health are very high. 

A clean, healthy mouth is fundamental to everybody’s quality of life. Although many older adults have good oral health and access to services, a significant percentage of dependent older people struggle to access services. Poor access to routine preventive and expert dental care can lead to poor oral health, with a devastating impact on overall health ranging from pain and ulcers caused by ill-fitting dentures, to dehydration, malnutrition and mortality. Poor oral health can also have a negative impact on older peoples’ ability to interact with their peers and carers and, by affecting their self-esteem, can exacerbate problems of isolation and loneliness.

Achieving and maintaining good oral health for older people is challenging, especially for older people in care homes or in receipt of domiciliary care who rely on care staff to help maintain their oral health. Research also shows that older people rarely complain unless their symptoms are particularly severe. Care staff therefore need to understand the importance of good oral hygiene and know how to deliver this aspect of personal care.

As the number and proportion of frail older people increases, the number of older people retaining at least some of their natural teeth is rising at levels not seen before. The Adult Dental Health survey shows rapid improvement in the number of adults that have 21 or more natural teeth; which rose from 74 per cent in 1978 to 86 per cent in 2009. Fifty-three per cent of those in the 85 or over age group had some of their natural teeth, while just over a quarter retained 21 or more natural teeth. While the increase in older people retaining their own teeth is to be welcomed, the current generation of older people will typically have many large fillings - the ‘heavy metal generation’ – who require large amounts of maintenance as well as the additional care required for their unrestored teeth.

There is limited information available about the uptake of professional dental care by care home residents in the UK. The information that is available suggests high levels of unmet need. One study of care homes in the Avon area found that 71 per cent of the residents had not seen a dentist in the last five years. Similarly, less than half (48 per cent) of the care homes in a Welsh survey had mechanisms in place to ensure that residents attend regular dental check-ups. A survey of residential and nursing home residents in Glasgow reported that dental treatment was needed by approximately half of residents, with 6 per cent needing urgent treatment. Other research points to under-use of services by frail older people and that the rate of domiciliary care provided by Primary Care Dentistry has been reducing year on year.

A report by the British Dental Association (BDA) in 2013, based on interviews with 13 care homes, its annual survey of Clinical Directors of Salaried Primary Dental Care Services and a literature review, identified high levels of unmet dental need in care home residents and that the provision of dental care was less than ideal. Levels of oral health training among care home staff were patchy and formal input from a dental professional was rare. High staff turnover and staff attitude towards performing oral health functions, often regarded as the least desirable aspects of providing care, exacerbated the problem. Furthermore, while knowledge and care appeared to be improving, there was still a lot to do to develop standardised care and integrate oral hygiene into the daily routine of residents.

The negative impact of poor oral on the quality of life of older adults is an important and costly public health issue, needing urgent attention. Oral healthcare needs to be less marginalised and dental care commissioning for older adults needs to be improved. While dental care may appear to be only one aspect of health, it plays an important role in safeguarding personal wellbeing. Indeed, regular oral health assessments and check-ups with a dental professional should be seen as an essential part of maintaining older people’s health and wellbeing. While aspects of oral health may continue to improve, thanks to access to fluoride toothpaste, the financial constraints on the NHS and associated system reforms, provide an opportunity to re-evaluate priorities and assess how dental and oral health can be delivered as part of an integrated health and wellbeing strategy for older adults.


Karen TaylorKaren Taylor
Research Director, Deloitte UK Centre for Health Solutions




Social media in healthcare – too risky to adopt yet too risky to avoid

Posted by Centre For Health Solutions on 9/04/2014 at 4:36 PM in Current affairs NHS Permalink Comments (0)

The Internet has not only changed the way people communicate, it has become a powerful and important resource for health information. Today, 82 per cent of U.S. adults use the Internet, and among those 80 per cent have looked online for health related information. Indeed, social media (including online communities, blogs, and social networking websites such as Facebook and Twitter) is rapidly becoming an increasingly popular source of health information, helping to decrease health-related communication gaps and inequalities - Facebook is reported to be the 4th most popular source of health information in the UK.

In part this trend seems to be driven by consumer facing industries pioneering the use of digital channels to engage, educate, and build relationships with customers and in doing so, changing the public’s preference for information, creating an expectation that information should be easily accessible. There is also a genuine unmet need for information and support for patients and their carers/ family members who desire to feel empowered and take control of their own and their loved-ones’ health.

The pharmaceutical industry is well placed to deliver on this unmet need and, if they are successful, reap the rewards for their effort. A recent survey found that “mastering multichannel marketing and improving digital effectiveness” was a top strategic priority for pharmaceutical marketing executives. Digital communication channels can be used by pharma to:

  • build more effective relationships with customers 
  • improve clinical trial efficiency (by speeding up trial recruitment and reducing dropouts through closer engagement) 
  • collect qualitative real world data to enhance other sources of information regarding products and practices.

While investment in social media is increasing, the focus is on lower risk and less innovative avenues than those adopted by other industries and indeed, the pharmaceutical industry is often described as a laggard in terms of its speed in adoption of digital technologies. An IMS survey of 50 of the top pharmaceutical companies recorded that almost half did not use social media to engage with consumers or patients on healthcare-related topics. For those that did, Twitter was the most popular (22/50) – a low risk option when used to simply link or broadcast information already out there (on company websites). This reluctance or slowness to adopt channels used by other consumer industries is mainly due to fear of regulation and risk as well as lack of content control and privacy concerns. For example:

  • a key challenge remains a lack of guidance from leading regulatory agencies – although as of January, in the US, the FDA has published draft guidance on interactive promotional media as a first step towards a definitive regulatory framework, but there remain many grey areas which have led to a host of fines and punishments issued by regulators
  • adverse event reporting is a big concern as companies will need to monitor their own social media channels in real time to remain compliant. While the estimated level of adverse events reported is expected to be quite low (around 0.2 per cent for general posts; up to 7 per cent on dedicated patient forums) this can quickly add up to a significant number of events, a large amount of work to investigate and significant risk to the reputation of the company
  • justifying investment in digital channels like social media is another hurdle - how do you calculate the value of a mouse click or a ‘like’? 

Social media’s ability to challenge geographical and linguistic boundaries, bring people closer together and share information across differently regulated regions is unique and patients will increasingly use these channels as a source of support and information related to their health. Without pharma’s engagement, or some form of regulation, there is an increased risk for rapid dissemination of non-credible and potentially erroneous health information which can lead to confusion and misdiagnosis. Therefore, the pharma industry have no option but to find a way to work more in this space to help patients exchange ideas, experiences and form opinions. If Facebook is the 4th most popular source of health information in the UK then pharma companies have little choice but to create their own Facebook profile.


Karen TaylorKaren Taylor
Research Director, Deloitte UK Centre for Health Solutions




The growing GP crisis: more for less but at what cost?

Posted by Centre For Health Solutions on 2/04/2014 at 6:18 PM in Current affairs NHS, Primary care Permalink Comments (0)

In May 2012, our report Primary care today and tomorrow: Improving general practice by working differently highlighted the fact that the capacity and capability of the primary care workforce was coming under increasing pressure and that the expectations under the NHS reforms would add to this pressure. We identified the need for general practice to move to a more strategic approach to improve the health of their practice population, based on more collaborative working and the development of a more multi-professional practice team. We suggested that increasing the actual numbers of GPs and practice nurses was only part of the solution and suggested GPs needed to work differently, including adopting new business models and incentives and embracing technology to improve access, information and support for patients.

Reading last week’s newspaper coverage, you could be forgiven for thinking that the threat to general practice is such that we are watching the death throes of a much beloved institution. We are told GP morale is at an all-time low and that many of our more experienced GPs are planning to retire. We know that recruiting full time GPs is becoming increasingly difficult and that most practices are relying increasingly on locums or part time female GPs. Indeed, female family doctors now outnumber their male counterparts for first time.

Paradoxically, we also know that the proportion of NHS funding spent on general practice has actually slumped across the UK. In 2004-2005, 10.33 per cent of the British NHS budget was spent on general practice but by 2011-2012 this figure had declined to only 8.39 per cent. This decline comes despite the fact that that demands for primary care are at an all-time high and the political mantra is for more care closer to home. Importantly, GP feedback suggests that the slump in funding is compromising the standard of care they can offer patients, leading to longer waiting times, and increasing pressure on hospitals.

These concerns have substance as shown by the new report from the over-50s group Saga. This found that 500,000 people had experienced delays of up to four weeks the last time they attempted to book a GP appointment with only one in three managing to secure a same-day appointment. Perhaps if the patient population was getting healthier and needing less intervention then funding reductions might be justified. However, as our recent report on Better services for frail older people shows, demand for primary care is increasing substantially as growing numbers of older people present with more complex health conditions and more people develop life limiting conditions.

Most independent research continues to point to general practice as the core reason why the UK is still able to provide a comprehensive health service that is "free" at the point of delivery. Yet for the most part, the model of care has evolved exceedingly slowly and remains a patchwork of small, independently minded units and, as a result, is unable to operate at the scale needed to meet the changing and challenging population needs. While one size certainly won’t fit all its hard to see how small practices can continue to meet the needs of an increasingly medically complex population.

But just how big is the financial challenge? A Deloitte Economic Consulting report, prepared for and published today by the Royal College of General Practitioners, estimates that between 2008-09 and 2012-13 a 12 per cent funding gap has opened up in general practice funding across the UK. The biggest contributor to this gap is the continued growth of consultations in general practice which are estimated to have increased from 303,900 in 2008-09 to 360,838 in 2013-14. The report also estimates that by 2017-18, the funding gap will widen to 24 per cent if the share of the NHS budget spent on general practice remains at 8.39 per cent. However, should the share of NHS funding decline at the same rate as in the last few years, the share of the NHS budget could fall to 7.29 per cent by 2017-18 (creating a funding gap of 36 per cent).

The argument for increasing investment in general practice is compelling but, in return, general practice can no longer continue to rely on face to face, one to one consultations, nor can it remain such a data free zone. For example there is no robust data on the exact scale and complexity of consultations and limited information on the comparative effectiveness of interventions. Now, more than ever, we need general practice to scale up the adoption of new models of care, we also need general practice to collect robust performance data and information on activity and outcomes to justify investing more of the constrained NHS resources in what can and should be a truly cost-effective NHS services. In this way we can ensure more people can receive good quality, continuity of care where they say they want it - in the community.


Karen TaylorKaren Taylor
Research Director, Deloitte UK Centre for Health Solutions




The right to die well - Dying well should be a human right

Posted by Centre For Health Solutions on 26/03/2014 at 5:23 PM in Current affairs NHS, Frail and elderly, Social care Permalink Comments (0)

Parliament is once again poised to debate the need for a law to allow assisted suicide. Based on legislation drawn up by Lord Falconer of Thoroton, politicians will be given a free vote on this sensitive and emotive issue. This week Norman Lamb, the Liberal Democrat Care Minister, is one of several high profile politicians to state his support for the change, while David Cameron and other members of his cabinet have confirmed they will vote against the move. Having recently co- authored a global report on end of life care (Dying Healed: Transforming End of Life Care through Innovation) for the World Innovation Summit for Health (WISH) held in Qatar in December 2013, I thought it would be timely to explore this issue.

The current situation in the UK is that euthanasia (in which one party takes action to end the life of a second party, at the request of the second party) is regarded as either manslaughter or murder and is punishable by law with a maximum penalty of up to life imprisonment; and assisted suicide (where physicians, or others, provide the means for patients to end their own lives) is illegal under the terms of the Suicide Act (1961), punishable by up to 14 years' imprisonment. However, grey areas have emerged, and the Director of Public Prosecutions in 2010 indicated that anyone acting with compassion on the will of a dying person was unlikely to face charges.   

Euthanasia is an issue that divides most cultures. Surveys in the UK and US show that public support for euthanasia has hovered between 60 and 80 per cent since the mid- 1970s. With similar levels of support emerging for physician assisted suicide. A report on the 2005 British Social Attitude Survey shows that people make clear distinctions between the acceptability of assisted dying in different circumstances - 80 per cent of respondents agreed that the law should allow voluntary euthanasia to be carried out by a doctor for someone with a painful, incurable, and terminal condition - but less than 50 per cent agreed for cases where the illness is painful, but not terminal. 

Yet, over 90 per cent of palliative care doctors are opposed to assisted suicide in the UK. This is largely because hospice and palliative care professionals see what they do as quite distinct from assisted suicide or euthanasia. The danger is that unless the public gains a full understanding of palliative care, and have confidence that they will have access to good quality, pain free care, euthanasia and/or assisted could become the default position.

Most people’s greatest fear about dying is that they will die in severe, untreated pain. Examples where this appears to have been the case is often the trigger for a media campaign and often result in calls for euthanasia and assisted suicide to be permitted. Failure to provide adequate pain relief is often likened to torture and suggests that a more important debate should be about the need to provide equitable access to adequate pain relief as a human right – which is a key recommendation in the above WISH report.

Euthanasia is currently permitted in three European countries. In 2002, the Netherlands passed a law allowing patients suffering unbearably to request euthanasia while protecting the doctors carrying out those requests from prosecution, provided they have followed a set of strict guidelines. Belgium followed suit the same year and Luxembourg did so in 2009. In Switzerland assisted suicide—but not euthanasia—has been legal since 1941, provided assistance is given for altruistic motives. Stricter legislation is currently under discussion. The Netherlands and Luxembourg also permit assisted suicide, although Belgium does not. The numbers of people who have availed themselves of this option are a very small percentage of the people who have died during this period. 

In the UK, very few studies or debates have examined public perceptions of end of life, palliative and hospice care whereas public debates about euthanasia and physician-assisted suicide, are often played out in the media, and often supported by high profile media figures, such as Terry Pratchet.  This is despite the fact that many more people would benefit from better end of life care and by adopting the principles of good palliative care.   

Ultimately, pain control is the point from which all palliative care stems, and the availability of opioids (morphine and its equivalents) is fundamental to quality of end-of-life care. But across the world an estimated 5 billion people lack access to opioids. A lack of training is a problem, with many doctors and nurses ignorant or fearful of how to administer them. Here in the UK the furore over Dr Shipman and now the Liverpool Care Pathway has again raised questions as to what constitutes adequate or appropriate pain relief, the risk is that over the coming weeks and months with a spotlight on this issue, clinicians will run shy of providing sufficient relief for fear of being accused of hastening the person’s death.

On balance, I believe we do need a debate but rather than being about an issue that affects a small minority of people we need a public debate on equitable access to palliative care, and in particular, to appropriate pain relief.  We also need to adopt a consistent, compassionate and evidence-based approach to tackle what is often a very distressing and difficult time, which few of us want to openly confront.  If we had better care of the dying for all, with appropriate pain control, we might not need to have a debate about euthanasia or assisted suicide as everyone could be assured of dying well and that they have a human right to a good death.


Karen TaylorKaren Taylor
Research Director, Deloitte UK Centre for Health Solutions




Accessing pharma innovation – an increasing challenge for patients?

Posted by Centre For Health Solutions on 20/03/2014 at 10:07 AM Permalink Comments (0)

Pressures to increase productivity and maintain investment returns has led to Pharmaceutical companies filling their early stage research and development (R&D) pipelines with more targeted niche products that address high unmet need. It is because of this more targeted approach with smaller patient populations that a new challenge is emerging: how to ensure all patients who can substantially benefit from these new treatments have access.

In an ideal world effective and innovative medicines would displace established less effective medicines as they slot seamlessly into health systems offering a significant and easily measurable clinical and financial benefit. Goals of industry and Health Technology Assessment (HTA) agencies would be in perfect alignment as appropriate access is granted, providing companies with sufficient returns to feed future R&D, and health systems with cost savings and improved outcomes to help manage spend on an ageing population with complex needs.

The reality is far from this ideal and the common goal of improving patient outcomes is currently overshadowed by short term financial pressures on both sides. Today’s health system is facing well documented challenge, expenditure is increasing faster than GDP - indeed across Europe it’s projected to reach between 12 and 15 per cent of GDP by 2030. Innovative new drugs are increasing expenditure and adding tension to the already challenged health system as they:

  • are often additive rather than replacing existing drugs. The increasing use of combination therapies for cancer is a good example
  • launch with a higher price tag. With a decreasing patient population, a higher price tag may be necessary to generate the required revenues to cover R&D expenditure (Alexion’s Soliris is priced at $490,000 per year per patient in the US!)
  • more frequently offer improvement in outcomes than provide a demonstrable cost saving

The net result when governments and HTA agencies are considering approval of new treatments is a requirement for pharmaceutical companies to:

        1.  ‘prove that it works’


        2.  ‘prove that it’s worth it’ (i.e. deliver a cost saving)

This mentality has led to slower uptake of innovation as industry struggles with the ‘prove that it’s worth it’ in more targeted patient populations at higher price points. With the increasing financial pressure, gaining access for orphan and ultra-orphan drugs across Europe is becoming increasingly difficult. For example it is estimated that up to 30 per cent of rare disease patients in Europe are unable to access regulatory approved therapies. So the key question is whose responsibility is it to ensure access? It could be argued that industries priority is to invest in good science with the greatest potential to address unmet need and to build a strong enough evidence base for HTA agency approval. However, the interdependency of challenges facing industry and health systems suggests shared ownership of this challenge and an amended approach to the new R&D pipeline is needed.

One example of shared ownership is the UK’s new Pharmaceutical Price Regulation Scheme in which the Department of Health and industry have committed to control spending while improving access to and uptake of effective innovation. However, industry is looking for an environment that encourages shared ownership before the HTA takes place, an environment that may be created by early access schemes currently in development. These schemes have the potential to enable early and controlled adoption of drugs to small identifiable groups of patients to increase the patent period, facilitate evidence development and improve outcomes for patients.

Success relies on a number of complex factors. Firstly, better tools e.g. electronic health records and companion diagnostics are required to identify target patients which HTA agencies are willing to grant early access to. Secondly, once in the real world of early launch, there is a need to establish fair and transparent evidence requirements for assessment and better tools to collect and interpret data, for example through patient reported outcomes (PROMs) so that a richer understanding of value (clinical and economic) can be achieved.

Successful implementation of early access schemes and the required analytical capabilities (on both sides) could create a more collaborate access model and help to ensure the maximum appropriate use of innovate medicines to improve patient outcomes.


Karen TaylorKaren Taylor
Research Director, Deloitte UK Centre for Health Solutions




The magic bullet that is increasingly being misfired

Posted by Centre For Health Solutions on 11/03/2014 at 7:06 PM in Current affairs NHS, International Permalink Comments (0)

Antibiotics, discovered in the late 1930s, were seen as a magic bullet to treat all infections. For around 50 years they were used successfully to treat and control bacterial infections. However, inadequate control of their use and lack of understanding or monitoring of resistance has led to the emergence of highly resistant strains of bacteria - a problem that has been acknowledged for more than 30 years.

Just recently under the week long initiative - Protecting Health: Nursing and Midwifery Successes and Challenges - a key theme yet again was the growing problem of antimicrobial resistance and its link to healthcare associated infections. This follows hot on the heels of the report from the Chief Medical Officer for England, Dame Sally Davies, who suggested that the risk to public health of the rise in drug-resistant bacteria is equal to the risk posed by terrorism. A risk she believes needs to be on the Department of Health’s Risk Register. Many key commentators, including the major Pharma companies, have welcomed her report but noted that antimicrobial resistance is actually a major global public health problem.

The debate is once again focussed on the need for more effective control over the use of antibiotics and more importantly, the need to find novel ways of funding the development of new antibiotics - a widely acknowledged and intensifying problem. Over the last 30 years very few new antibiotics have been brought to market mainly due to the “challenging environment for antibiotic discovery, development and commercialisation". The paradox of course is that should a new antibiotic be developed, recovering R&D costs would be severely hampered by the need to minimise prescribing to reduce the risk of further resistance. 

The 1998 report by the House of Lords Select Committee on Science and Technology – Resistance to Antibiotics and other antimicrobial agents was a key initiative in the war against resistance and made a similar, well researched case for action. Actions included: the media campaign stating that “Antibiotics don’t work on colds or most coughs and sore throats”; and an information prescription. Since then there have been numerous reports, guidelines and recommendations from, among others, the UK’s Antimicrobial Resistance Steering Group, all aimed at raising the profile of this important issue. While they have had a positive impact on antibiotic prescribing in primary care, there hasn’t been the same success in hospitals or in agriculture and farming. Clearly, simply presenting the evidence and producing guidelines are not enough.

There have been similar initiatives across the developed world to encourage the development of new antibiotics and reduce antibiotic usage – but again with limited success. In November 2011, the European Commission set out “concrete actions” to beat the growing threat of antibiotic resistance and in May 2012 the European Commission/ Innovative Medicines Initiative (IMI) launched a €223.7 million programme aimed at tackling antibiotic resistance and speeding up the delivery of new antibiotics to patients based on “co-funding clinical trials”.

A key concern is in under-resourced countries where antimicrobial drug resistance is usually not monitored because of a lack of surveillance networks, laboratory capacity, and appropriate diagnostics. In these countries this accelerating problem accounts for a substantial number of deaths, with infants often paying the highest price. Drug resistance in hospital-born babies is estimated to cause an additional 96,000 deaths each year in southern Asia.

Globally there is a need for: accurate mapping of antimicrobial drug resistance, a new international research agenda; a map of existing networks and recommendations to unite them; and a communication plan for national, regional, and international organisations. There is an important role for health care professionals in ensuring their understanding of the challenges and the importance of conserving the antibiotics we have left by using them optimally. The process of developing new antimicrobials and new technologies to allow quicker diagnosis and facilitate targeted treatment must be accelerated. Given the enormity of the challenge this necessitates local, national and global action.

We know what to do, but what are the odds that this time the actions really will work? We have to hope for all our sakes that they will, as it’s not just a problem for the under-resourced countries with 25,000 people across Europe dying each year as a result of drug resistant infections, at a cost of £1.5billion. Numbers that are likely to increase exponentially. More importantly, successful surgical interventions that we take for granted today, may well end up being just as high risk a procedure as before the discovery of antibiotics!


Karen TaylorKaren Taylor
Research Director, Deloitte UK Centre for Health Solutions




Better care for frail older people: A right that needs to become a reality

Posted by Centre For Health Solutions on 6/03/2014 at 1:01 PM in Current affairs NHS, Frail and elderly, New research pieces, Primary care, Social care Permalink Comments (0)

Advances in science and technology and year on year increases in funding have made a significant contribution to our ability to treat, manage and prevent disease. This success has led to increased longevity and a relatively active and prosperous older generation who provide an invaluable economic and social contribution to society. It has also contributed to what is arguably the most daunting challenge facing the UK health and social care system today - the need to care for and support growing numbers of medically complex, frailer older people with increasingly limited resources. As a result the current model of care for our most vulnerable members of society is at a tipping point and no longer fit for purpose.

Deloitte’s report titled ‘Better care for frail older people’ outlines the need to change the current health and social care delivery model to improve care for frail older people and explores how providers and commissioners can work differently to drive quality and efficiency and improve people’s experience in each place of care that they encounter.

The scale of the problem
Since 2010-11, real-term funding for healthcare in England has been almost flat against a background of increasing demand for services of around four per cent per annum, driven largely by an ageing population, whose number and prevalence of chronic disease is growing. At the same time social care support is reducing, restricted to those with substantial or critical needs. We estimate that current NHS and social care spend on the over 65s living with at least one long term condition is at least £30 billion a year. However this is spent largely on expensive acute intervention and residential care rather than on prevention, self-management, early intervention, and helping people live well and independently for longer. The number of people failed by the current system stands to increase considerably unless we act fast and adopt, as a matter of urgency, new models of care which address the current physical, mental and social care needs of our valuable, yet increasingly vulnerable, older generation.

Barriers to better services for frail elderly
Delivering the much needed change is challenging due to a number of entrenched barriers to better care, including:

  • separate funding models for health and social care despite the fact that older people's needs are increasingly interdependent, with significant cultural and behavioural tensions undermining efforts to integrate and improve care
  • fragmented care delivery with multiple groups of health and social care staff treating individual aspects of need in an un- coordinated manner when what is required is a shift towards treating the ‘whole patient’, facilitated by shared access to information at each place of care
  • Limited supply of adequately trained and remunerated home care and care home staff who have the most contact hours but the least education and training – with almost 40 per cent of the 1.56 million social care staff having no relevant qualification
  • capacity constraints in primary care with increasing demand for GP and practice nurse consultations and a workload in caring for the over 75s three times that of caring for the 45-64 age group
  • health conditions exacerbated by unsuitable living conditions, with a third of people over 75 living in housing that has failed the decent homes standard, and low availability and affordability of extra care housing and care home places. This is compounded by the fact that half of all people over 75 live alone and are often socially isolated leading to chronic loneliness which is as bad for health as smoking 15 cigarettes a day. 

The need to act to improve quality of care in all care settings is well publicised thanks to the many high profile national reviews and reports published over the last couple of years. However, exactly how the wheels of change will be set in motion is not yet clear especially given the difficulties prioritising, funding and implementing the long list of recommendations in these reports.

Improving the experience and outcomes for frail older people requires improvements on three fronts, physical and mental healthcare, social care and place of care. It also requires the redesign of services around the individual to enable them to live independently for as long as possible. This includes support in the community to allow prompt return home should admission to hospital or residential care be necessary. Our report outlines ways in which to achieve this goal, including new funding models which shift resources to primary, community and home care; supported by the wider adoption of technology; and access to better information, including patients medical records, for all those providing care. It also requires staff to work differently to forge sustainable partnerships and provide consistent coordinated services, 24/7.

None of this is rocket science, and indeed we are already seeing new models of care implemented in pockets of the UK which are revolutionising care for frail older people. However, the sheer scale of the challenge requires more immediate and widespread action to address the needs of increasing numbers of frail older people who aren’t in a position to wait for policy makers to take 5-10 years to develop the more integrated health and social care system that successive governments have agreed is the desired model of care.


Karen TaylorKaren Taylor
Research Director, Deloitte UK Centre for Health Solutions




Care.data – balancing the rights of individuals versus the state

Posted by Centre For Health Solutions on 27/02/2014 at 9:15 AM in Current affairs NHS Permalink Comments (0)

Last week saw a dramatic development in the Government’s handling of the NHS’s care.data project aimed at linking GP records to hospital records. Less than a month before starting to extract copies of everyone’s primary care records into a central database, NHS England has “paused” the project for six months so that they “can allow more time to build understanding of the benefits of using the information, what safeguards are in place, and how people can opt out”. This follows increasingly vocal opposition from the medical community (including the Royal College of GPs, the General Pharmaceutical Council and the British Medical Association), patient groups, the Information Commissioner’s Office (ICO), and an increasingly vociferous media campaign. Further fuel has been added to the flames by a number of GPs who have publicly declared their intentions to opt out and to advise their patients to opt out themselves.

Most of the worry is about how potentially sensitive patient information will be used, who will have access to it (and for what reasons), as well as its security. Such fears are not just hypothetical, given that examples of lost patient notes and what appear to be the misuse of sensitive patient information (even for the best of intentions) already exist. This has led many commentators to speculate whether the initiative might be permanently holed below the waterline by people opting out and, indeed, whether care.data might end up in the same political graveyard as the poll tax and the ID Cards scheme? With opt outs currently running at 5 per cent and rising, perhaps these concerns are well founded.

Understandably, confusion abounds and it’s hard for people to know how to opt out because the leaflet telling everyone was sent as unaddressed (junk) mail to every household (except for those who have opted out of receiving junk mail, who got nothing) and in any case the leaflet wasn’t clear on how to opt out. Confused? So is everyone else.

The ICO has consistently said that citizens should be asked for their informed consent before their personal records are used for purposes other than those for which they primarily exist. In other words they think the law requires an opt-in mechanism. There is quite a gap between this regulator’s position and the approach taken by NHS England the next six months will therefore be particularly challenging but also critical to the future delivery of healthcare.

It’s also easy to see why the general public is becoming increasingly concerned. Conversations with GPs are amongst the most private and personal of all conversations outside your family and friends, indeed sometimes more private even than those with close family. Pseudonymisation, in which all personal identifiers are replaced with meaningless codes, can be done to an existing NHS standard but there is an unresolved debate over whether it is feasible to do it at source before the information leaves the GP system. In addition, the more that the “open” data concept publishes and links large data sets, as is happening at an increasing rate across society generally, the greater the likelihood that a person can be re-identified by multiple other means. This suggests that any expectations that privacy can be maintained in the future may become unachievable and NHS England could find itself offering privacy just at the point where such privacy can no longer realistically be achieved. Things may well look very different in five years’ time, as no government can irrevocably commit all future governments to a particular course of action.

And yet this data is massively valuable clinically. As a nation we have very little idea of clinical cause and effect in primary care, whereas hospital episode statistics (HES) have been telling us for decades what works and what doesn’t in secondary care. Indeed, HES has provided significant benefits in terms of improving patient outcomes through analysis of hospital activities and performance. Moreover, there have been no recorded examples of data loss leading to patient or public harm, or the actual (as opposed to theoretical) identification of individual patients. There is game-changing potential in the use of this linked data, possibly more than enough to move the needle on NHS affordability. So (not for the first time) the interests of the population and the interests of the individual are tugging in opposite directions.


Karen TaylorKaren Taylor
Research Director, Deloitte UK Centre for Health Solutions




Private sector health - prescribed an injection of competition

Posted by Centre For Health Solutions on 19/02/2014 at 8:07 PM in Current affairs NHS Permalink Comments (0)

Currently, at the national level, both private hospital ownership and the provision of private medical insurance (PMI) are highly concentrated with the five main hospital groups accounting for approximately 70 per cent of privately funded healthcare revenues in the UK. Last year, a complaint by Circle Partnership – an employee owned private hospital group – prompted an extensive review by the Competition Commission into the state of the UK private healthcare market and the value offered to its patients.

The initial investigation, published in August 2013, concluded that patients were losing out on competitive pricing due to lack of competition and high barriers to entry. This judgement didn’t go down well with private providers and since publication, the situation for these companies has improved slightly as the Competition Commission revised its stance and removed some rather unpopular recommendations such as a cap on charges and increased transparency. But divestment remains on the table.

So has private sector health become a victim of its own success? Chief executive and president of the world’s largest private healthcare company - Hospital Corporation of America (HCA) - Mike Neeb clearly thinks so as the Competition Commission insists he divests two London based hospitals, representing 30 per cent of UK revenues. While HCA stand to lose the most, should this forced divestment go ahead, they are not the only company to receive this news. BMI healthcare, the owner of 70 hospitals across the UK and employer of over 10,000 staff are also under pressure to divest 7 hospitals in various local markets.

Those under pressure to divest vow to resist until the bitter end using, if necessary, the Appeals Tribunal – where a number of Competition Commission decisions have been overturned. The majority of private healthcare providers, however, welcomed the measures to increase competition. Perhaps unsurprisingly, Insurers and smaller private health providers are strongly in favour of all measures and imply that more can be done to break the monopoly of the private heath market which they argue is costing patients as much as £200 million extra per year. They believe patient value for money can be improved through increased transparency measures and the reduction in negotiating power that large private healthcare providers have with medical insurers.

The prevailing view is that companies (UK and foreign) are queuing up take on attractive investments like private hospitals, but the question remains: will a change in ownership lead to a better deal for patients? BMI and HCA argue ‘No’. They consider that the original analysis is flawed as it underestimates the level of investment needed to install, operate and maintain world class health facilities. They also go a step further implying forced divestment sends a message to investors that the UK punishes success.

The assumption is that changing hospital ownership will lead to increased competition. In some areas, however there is no guarantee that this will be the case and indeed may simply result in a change in who owns the monopoly. Furthermore, there is an assumption that increased competition will result in price adjustments for end users – the patients. Whilst ownership may change the specific challenges faced by the hospital will not, so guaranteeing patient benefit is difficult. Even more so when you factor in insurers willingness to adjust premiums in line with cost of care.

So is the prescribed injection of competition justified? There are merits to both sides of the argument, but obtaining conclusive evidence either way is a difficult and time consuming process. What is clear is those involved are in it for the long haul – factoring in the inevitable appeals process – and a willingness to dedicate significant time and money to fight their corner. Ultimately, whatever the outcome of the Commission’s final report in April, the prospect of increased competition in the short term appears unlikely.


Karen TaylorKaren Taylor
Research Director, Deloitte UK Centre for Health Solutions




Mobile-Health - transforming and enabling care

Posted by Centre For Health Solutions on 11/02/2014 at 4:16 PM in Current affairs NHS Permalink Comments (0)

First we had the internet, connecting people to information through emails and websites; then the development of social media and networks, connecting people to each other and encouraging us to reveal more about ourselves than we might previously have considered advisable. And now we are on the verge of the age of connectivity, connecting data analytics to the growing number of smart phones and other sensors that are increasingly second nature in our everyday lives. But with this connectivity comes an increase in personal data about us, both as individuals and as groups, on a scale never experienced before and which we are only just waking up to – both the good and the bad – as seen in  the current controversy over the English care.data proposals.

Whether we like it or not, one thing is certain, over the next few years scientists, doctors, and the public will have access to more data about the human body than they ever imagined possible. Much of this has been driven by the development of the mobile health (mHealth) market. The proliferation in mHealth is partly a response to policy makers searching for innovative ways to reduce healthcare spending while improving the quality and quantity of care, and partly driven by patients’ desire for empowerment and convenience to manage their own health.

Indeed, the adoption of mHealth is growing exponentially in developing countries; where the lack of an expensive infrastructure creates freedom to innovate and allows providers to leapfrog obstacles in the use of technology that more developed countries struggle to overcome. These obstacles include cultural, financial and regulatory constraints, and are well documented; yet despite these constraints mHealth technology is slowly but surely changing the way physicians, patients, and other stakeholders interact. Examples include:

  • GP e-Visits: Deloitte TMT predictions state in 2014, there will be 100 million GP eVisits globally (an increase of 400 percent from 2012 levels), saving over $5 billion annually compared to  the cost of in-person visits. eVisit usage however is likely to be largest in North America where around half of the 600 million annual visits to general practitioners are generally for reasons that could also be solved by an eVisit.
  • Remote rehabilitation – or telehabilitation - a relatively novel application that uses a computer game linked to a motion tracking computer mouse allowing patients the freedom to control their physical therapy from home. Use is currently being tested in patients with arthritis and balance and gait disorders and the approach is claimed to increase compliance and, improve recovery and, as a result, reduce costs.
  • Using m-health applications to modify interactions between physicians and patients. Our TMT predictions report suggests that the highest year-on-year increases in smartphone penetration in developed countries will be among the over-55s, bringing a population with arguably the most to gain from m-health well in reach of its applications. Uses, in addition to monitoring vital signs, include sending photographs of skin conditions or injuries via smart phones to clinicians.  
  • Wearable technology, which can provide  feedback on patient flow through the system, as well as improving reliability in delivering medication, assessments and diagnostics. It can also be used to support remote analysis of biomedical data for whole segments of the population, particularly the frail elderly, to enable more anticipatory care and patient monitoring to be done at a much larger and more efficient scale.

Whilst m-health can create convenience and possibly cost savings there are inevitably concerns at the impact it will have on quality of care. For example, e-visits have been shown to lead to an increase in antibiotic prescribing, at a time when control over such prescribing is key to reducing antibiotic resistance. But the evidence that better information improves quality is also important.

The case for m-health applications seems clear especially given the need to transform outdated models of working. Most healthcare policy makers and providers are waking up to this, however, confusion as to how to implement such initiatives and a lack of capital or willingness to invest continues to slow the adoption of mHealth. There is also the very real concern around data security and unauthorised access; an unintended consequence of health care’s digitisation and increased networked connectivity.

The question that remains therefore, is just how quickly will the potential of mHealth be realised in an industry that has traditionally struggled to embrace technology in its interface with service users? To realise this potential requires champions and leaders who fully understand the potential of  connected technology and be willing to apply this to healthcare and, by taking away the burden of routine and functional aspects of healthcare,  truly support staff to work differently.


Karen TaylorKaren Taylor
Research Director, Deloitte UK Centre for Health Solutions