Google"s DeepMind plans bitcoin-style health record tracking for hospitals

Google’s AI-powered health tech subsidiary, DeepMind Health, is planning to use a new technology loosely based on bitcoin to let hospitals, the NHS and eventually even patients track what happens to personal data in real-time.

Dubbed “Verifiable Data Audit”, the plan is to create a special digital ledger that automatically records every interaction with patient data in a cryptographically verifiable manner. This means any changes to, or access of, the data would be visible.

DeepMind has been working in partnership with London’s Royal Free Hospital to develop kidney monitoring software called Streams and has faced criticism from patient groups for what they claim are overly broad data sharing agreements. Critics fear that the data sharing has the potential to give DeepMind, and thus Google, too much power over the NHS.

In a blogpost, DeepMind co-founder, Mustafa Suleyman, and head of security and transparency, Ben Laurie, use an example relating to the Royal Free Hospital partnership to explain how the system will work. “[An] entry will record the fact that a particular piece of data has been used, and also the reason why, for example, that blood test data was checked against the NHS national algorithm to detect possible acute kidney injury,” they write.

Suleyman says that development on the data audit proposal began long before the launch of Streams, when Laurie, the co-creator of the widely-used Apache server software, was hired by DeepMind. “This project has been brewing since before we started DeepMind Health,” he told the Guardian, “but it does add another layer of transparency.

“Our mission is absolutely central, and a core part of that is figuring out how we can do a better job of building trust. Transparency and better control of data is what will build trust in the long term.” Suleyman pointed to a number of efforts DeepMind has already undertaken in an attempt to build that trust, from its founding membership of the industry group Partnership on AI to its creation of a board of independent reviewers for DeepMind Health, but argued the technical methods being proposed by the firm provide the “other half” of the equation.

Nicola Perrin, the head of the Wellcome Trust’s “Understanding Patient Data” taskforce, welcomed the verifiable data audit concept. “There are a lot of calls for a robust audit trail to be able to track exactly what happens to personal data, and particularly to be able to check how data is used once it leaves a hospital or NHS Digital. DeepMind are suggesting using technology to help deliver that audit trail, in a way that should be much more secure than anything we have seen before.”

Perrin said the approach could help address DeepMind’s challenge of winning over the public. “One of the main criticisms about DeepMind’s collaboration with the Royal Free was the difficulty of distinguishing between uses of data for care and for research. This type of approach could help address that challenge, and suggests they are trying to respond to the concerns.

“Technological solutions won’t be the only answer, but I think will form an important part of developing trustworthy systems that give people more confidence about how data is used.”

The systems at work are loosely related to the cryptocurrency bitcoin, and the blockchain technology that underpins it. DeepMind says: “Like blockchain, the ledger will be append-only, so once a record of data use is added, it can’t later be erased. And like blockchain, the ledger will make it possible for third parties to verify that nobody has tampered with any of the entries.”

Laurie downplays the similarities. “I can’t stop people from calling it blockchain related,” he said, but he described blockchains in general as “incredibly wasteful” in the way they go about ensuring data integrity: the technology involves blockchain participants burning astronomical amounts of energy – by some estimates as much as the nation of Cyprus – in an effort to ensure that a decentralised ledger can’t be monopolised by any one group.

DeepMind argues that health data, unlike a cryptocurrency, doesn’t need to be decentralised – Laurie says at most it needs to be “federated” between a small group of healthcare providers and data processors – so the wasteful elements of blockchain technology need not be imported over. Instead, the data audit system uses a mathematical function called a Merkle tree, which allows the entire history of the data to be represented by a relatively small record, yet one which instantly shows any attempt to rewrite history.

Although not technologically complete yet, DeepMind already has high hopes for the proposal, which it would like to see form the basis of a new model for data storage and logging in the NHS overall, and potentially even outside healthcare altogether. Right now, says Suleyman, “It’s really difficult for people to know where data has moved, when, and under which authorised policy. Introducing a light of transparency under this process I think will be very useful to data controllers, so they can verify where their processes have used or moved or accessed data.

“That’s going to add technical proof to the governance transparency that’s already in place. The point is to turn that regulation into a technical proof.”

In the long-run, Suleyman says, the audit system could be expanded so that patients can have direct oversight over how and where their data has been used. But such a system would come a long time in the future, once concerns over how to secure access have been solved.

Google"s DeepMind plans bitcoin-style health record tracking for hospitals

Will NHS transformation plans kill or cure the health service?

“Secret plans to change our NHS”: This is the allegation levelled at sustainability and transformation plans (STPs) – the government’s latest NHS reform initiative – by campaigning group 38 Degrees. Some politicians seem to agree, with former shadow health secretary Diane Abbott calling them “a dagger pointed at the heart of the NHS”.

Simon Stevens, the chief executive of NHS England, sees it differently: “Now is quite obviously the time to confront … the big local choices needed to improve health and care across England.” For him, STPs are a way of delivering the reforms he set out in the NHS Five Year Forward View (pdf) and the £22bn of efficiency savings he promised to the government, while maintaining or improving the quality of care.

As details of the STPs have been made public and the extent of the winter crisis in the NHS has become apparent, the debate about their role in the health service has become dangerously polarised. The question is whether these controversial plans will prove to be kill or cure. Based on a detailed analysis of all 44 plans, we at IPPR think the reality is probably more nuanced and complex than either side let on.

The IPPR’s STP finder tool gives a breakdown of the scale of the financial challenge facing each area, and outlines the changes each plan is expected to bring about.

On the one hand, it’s clear that some elements of the argument made by campaigning groups – for example, that the government is knowingly underfunding the health and care service – stack up. Our analysis shows that every STP area is forecast to be in deficit by 2020-21, and these deficits total more than £24bn. For Theresa May and (somewhat more reluctantly) Simon Stevens to suggest that this financial gap can be closed through reform alone is disingenuous to say the least.

On the other hand, campaigners are wrong to argue that the reform agenda is simply about delivering dangerous cuts. The NHS cannot stand still as the world transforms around it. Instead, it must respond to growing demographic pressures; new evidence about what works and what doesn’t; and cutting edge technologies that can transform health and care.

Hospital reconfigurations are a perfect example of the need for a more balanced discussion. Campaigning groups have raced to uncover “secret” plans to close local hospitals, arguing that these changes are evidence of the government’s deceit. And, they are right to highlight that these changes are afoot: our research finds that up to 44% of STPs include hospital closures or reconfigurations.

However, the potential benefits of these changes have gone largely unnoticed. There is strong evidence for some services, in particular A&E and specialist surgery (pdf), concentrating care in fewer locations. This can save lives by ensuring people have access to the most highly trained doctors and the best equipment. Likewise, there are many examples where treatment could be moved out of hospital all together, saving money but also improving outcomes: for example, only 7% of people say they would prefer to die in hospital with the vast majority opting for home.

This doesn’t mean that all the planned changes are justified, some are likely to be driven by the need to cut costs but many are not and should end up improving health outcomes over the coming years.

Likewise, the wider health and care reform agenda is yet to get a fair hearing, with a number of initiatives likely to result in better care, for example new “community care hubs”, which will bring together GPs, mental health services and social care at a local level; “a truly seven-day health service” with GPs opening on evenings and weekdays; and the adoption of new technology that allows people to receive support remotely.

STPs are an opportunity to deliver these reforms – which will help to transform the quality of care delivered up and down the country – ensuring that the NHS is fit for the 21st century. However, there is no doubt that the NHS will struggle to seize these opportunities without three key changes.

First, the government must recognise that the health and care system needs more funding both to manage the immediate pressures of the winter crisis but also to properly fund the reform agenda. A good start would be a rise in national insurance. This could raise up to a further £16bn over the next five years, dramatically closing the funding gap.

Second, the government – in particular Theresa May and Jeremy Hunt – must start supporting NHS leaders in making the case for reform, in particular controversial and little understood hospital reconfigurations. This will give local NHS leaders the political leadership they need to argue for their proposals locally.

Finally, once central government has helped local leaders win support for their reform plans, they must be given the tools to deliver these changes and allowed to get on with it. This may well mean giving NHS leaders real powers to intervene in their local area, as well as devolving functions currently undertaken by central government as has happened in Greater Manchester.

STPs are an opportunity rather than a risk for the NHS, but without these fundamental changes, it seems inevitable the NHS will remain a 20th century system in a 21st century world.

Harry Quilter-Pinner is a research fellow on public services at the IPPR thinktank. This is an edited version of an article on the IPPR blog and is part of a wider project on STPs.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

Will NHS transformation plans kill or cure the health service?

Royal College of Surgeons slam plans to cut back on hip and knee replacements

The Royal College of Surgeons has hit out at cost-cutting plans to ration who can receive hip and knee replacements.

Three clinical commissioning groups (CCGs) in the West Midlands have proposed slashing the number of people who qualify for hip replacements by 12% and introducing a 19% cut over who is eligible for knee replacements.

Under the new rules patients would now need to have such severe levels of pain that they cannot sleep or carry out daily tasks to qualify for an operation. Board papers reported by the Health Service Journal suggest an “opportunity to reduce expenditure on hip and knee replacement surgery” by £2m a year.

This would include only treating “severe to the upper end of moderate” cases, and people who are obese with a body mass index of 35 or over who need to lose 10% of their weight unless their problems were very severe.

Documents said a “patient’s pain and disability should be sufficiently severe that it interferes with the patient’s daily life and/or ability to sleep”.

Redditch and Bromsgrove, South Worcestershire, and Wyre Forest are the CCGs that intend to change their scoring system for eligibility, hoping to prevent about 350 operations needing to be carried out each year. But the Royal College of Surgeons has said there is “no clinical justification” for their plans.

The move is the latest in a round of cost-cutting by CCGs – with some slashing access to treatments, expensive drugs and IIVF despite guidelines from the National Institute for Health and Care Excellence (Nice).

Stephen Cannon, vice president of the Royal College of Surgeons, said: “We appreciate that the CCGs face significant financial challenges, which now mean they are looking at which groups of patients they can target to save money.

“While the CCGs have stated they hope this policy will save them £2m a year, it is unclear whether they have considered the costs of not treating a patient. This could include the cost of pain relief medication and a later operation when the patient does meet the required pain and weight thresholds.

“Delaying access to surgery also adversely affects a patient’s quality of life and surgical outcomes, meaning the operation may not be as beneficial as if it had been carried out earlier.”

He said the scoring system used by the CCGs – known as the Oxford scoring system – were designed to measure outcomes of care and “should not be used to create barriers to care”.

He added: “Such criteria are in explicit contravention of Nice and surgical commissioning guidance, and have no clinical justification in being applied to a general population to determine who gets NHS treatment. This policy is the latest demonstration of how NHS financial pressures are directly affecting patients.”

Paul Green, from Saga Group – which focuses on needs for over-50s, said: “To suggest that it is acceptable for people to have to wait until they are unable to sleep before they are eligible for an operation is an outrage, how would these people feel if that was their mother or father or grandparent?

“Remaining mobile is fundamental for people’s mental as well as their physical wellbeing, it appears an unkind cut and the bean counters should examine their conscience.”

A spokesman for NHS Redditch and Bromsgrove CCG said: “The Oxford scoring system is a guidance for clinicians and they recognise that many patients will benefit from physiotherapy and weight loss before considering surgery.

“If a patient feels that they require this surgery but do not meet these criteria, there is a clear appeals system via individual funding requests whereby the effects can be considered upon the patient and the decision made regarding eligibility for funding.”

Royal College of Surgeons slam plans to cut back on hip and knee replacements

Republicans push ahead with plans to hinder insurance coverage for abortions

Republicans in Congress are advancing a bill that imposes a far-reaching ban on private insurance coverage for abortion services for as long as the Affordable Care Act remains in effect and would make permanent a longtime ban on the use of Medicaid to cover abortions.

The bill, H R7, would allow Donald Trump to fulfill a promise that helped his volatile presidential campaign secure the support of major anti-abortion rights activists. In an open letter published in September, he vowed to sign the Hyde amendment, a perennial budget rider that Congress has approved every year for 40 years, into permanent law. Since 1976, the Hyde amendment has prevented millions of women who rely on Medicaid, the government-funded insurance for low-income individuals, from using it to cover their abortions.

But if the bill passes, the most immediate changes will be felt on the insurance exchanges where millions of women purchase healthcare coverage.

HR7 prohibits insurance carriers from offering policies that contain abortion coverage on the exchanges set up under Obamacare to sell insurance coverage to individuals. It prohibits low-income women who qualify for a healthcare subsidy from receiving it if they purchase a healthcare plan that covers abortion. And it would withhold the small business tax credit from employers who offer policies with abortion coverage.

Critics of HR7 fear it could impose a widespread ban on private insurance coverage of abortion by banning abortion coverage in the small subset of private insurance policies that are sold on the Affordable Care Act exchanges.

Because many insurance carriers offer policies to individuals on the exchanges that are similar to the group policies they sell to companies, covering abortion in one case but not the other requires an extra layer of administration.

Health experts said they could not be certain that would be the outcome.

“What that would do to other plans, we don’t really know,” said Laurie Sobel, the associate director for women’s health policy for the Kaiser Family Foundation, a healthcare thinktank. But she noted that after Obamacare began requiring contraceptive coverage in individual policies sold on the exchanges, group policies that did not face the same requirements began to offer identical coverage.

“With very limited exceptions, health insurance companies essentially did the same thing with everybody,” Sobel said. “That is worrisome in terms of, if abortion coverage was restricted in the marketplace, insurance companies might just adopt that policy across the board.”

The ban on using subsidies or tax credits toward policies with abortion coverage could also effect significant changes, because carriers could be reluctant to design plans that so many women or small business owners would be ineligible to purchase. In 2016, there were 871,000 uninsured women eligible to purchase policies containing abortion coverage using subsidies, according to the Kaiser Family Foundation.

Under the bill, tens of thousands more who have already used their subsidies to purchase insurance would lose abortion coverage.

The bill’s restrictions on the health insurance exchanges would cease to apply if and when legislation passed by Republicans in Congress repeals the Affordable Care Act. But the bill is almost certainly a preview of the lengths to which Republicans will go to restrict abortion when they come to replace Obamacare.

“It’s a pretty sweeping bill,” said Destiny Lopez, a director of All Above All, a coalition of abortion rights groups that opposes the Hyde amendment. “It’s an attempt to withhold abortion from nearly all women in the US through burdensome regulation intended to stop insurers from covering abortions. It could restrict abortion for nearly every woman in this country in some way, and do significant harm in particular to low-income women.”

Insurance coverage for abortion is already limited in a way that forces thousands of women to pay for abortions out of pocket. Twenty-five states restrict the sale of insurance policies covering abortion on their state exchanges. And exchanges in six other states don’t offer any plans that cover abortions, possibly because Congress imposed extra administrative hurdles under the ACA for providing abortion coverage.

A 2013 study found that only about a quarter of abortion patients who had insurance used it to cover their procedure. Those who didn’t use their insurance overwhelmingly said their insurance did not cover abortion or they weren’t sure.

The bill would also convert a slew of existing, provisional bans on abortion coverage into permanent law. These include bans on abortion coverage for women on federal insurance, such as many Native American women, women in the Peace Corps, in federal prisons, or those enrolled in Medicare or the Children’s Health Insurance Program, and prohibit the city of Washington DC fromusing its own local funds to subsidize abortion services.

The House of Representatives approved a version of the bill on Tuesday, and the Senate will consider similar legislation next week. But Republicans in that chamber will need to peel off eight Democratic or independent votes for the 60 needed to overcome a filibuster. Unless Republican leaders change the Senate’s rules to eliminate the filibuster, the fate of the bill may lie with Democrats facing re-election in 2018 in states that voted for Trump.

“We’re confident that the Senate will continue to be a firewall on this issue,” said Lopez.

Also on Tuesday, Republicans introduced a federal “heartbeat” bill that they say would effectively “eliminate” abortion, but is less likely to pass even the House.

Despite Hyde’s longevity, progressive lawmakers in recent years have adopted efforts to see it overturned. Even Hillary Clinton, in her 2016 bid for the presidency, promised to attempt to remove Hyde from future budget bills. HR7, although it does not change the fact that women on Medicaid have long been forced to pay for any abortion services out of pocket, would make it harder for a future Democratic Congress or president to do so.

HR7 is titled the No Taxpayer Funding for Abortion and Abortion Insurance Full Disclosure Act of 2017. Republican congressman Chris Smith of New Jersey introduced the bill in early January, as he has for several years running.

At an event to announce the bill, Smith said he supports repealing and replacing the Affordable Care Act, but that it is necessary to restrict the ways in which the law facilitates abortion coverage until that time.

“No one knows how quickly the replace part will actually occur,” Smith said. “In the meantime, the unborn child is about to be killed with public funding. We need to enact a statute that takes abortion out of [Obamacare].”

Republicans push ahead with plans to hinder insurance coverage for abortions

NHS transformation plans are beset by infighting

Behind the vision documents and targets, what is really going on inside the sustainability and transformation plan (STP) process?

A clinical commissioner outside one meeting was overheard asking: “How are we going to shaft the acute?” But elsewhere there is a growing recognition that old-style NHS infighting is a big part of the problem. For there to be any chance of ensuring services have a viable future, local leaders are increasingly trying to understand what skills they need to run health and care as a system.

To fathom how the people immersed in these tough negotiations are behaving, and what they need to do to think and act as leaders of the whole system, I interviewed 10 senior health and local government managers for the Institute of Healthcare Management.

The resulting report, Swimming Together or Sinking Alone, reveals frank assessments of the difficulties they are encountering, alongside their insights about what needs to happen.

The impulse to work together is strongest in areas where they know they face a crisis, while some of the most fraught discussions are where everyone is just about managing – inspection results are acceptable and financial targets are largely being hit. Like a drunk struggling to stay upright, there are worried that the slightest move will tip them over.

As leaders from different organisations edge closer, the thought processes can resemble the “prisoner’s dilemma” – the optimum outcome requires everyone to work together, but an individual might benefit from breaking ranks. As one manager put it:

They are thinking, ‘What if we behave as doves and they behave as hawks?’ They are worried they might … be taken advantage of

The big message is that systems leadership depends on trust. Without it there is no system, just individual institutions manoeuvring and negotiating. Trust means shared ownership of problems and solutions, an appreciation of the value of all the players involved, and authentic leaders behaving the same in public and private – a lesson our “shafting” clinical commissioner would do well to appreciate.

A few STP groups have recognised that they need to invest time and effort in their own organisational development, because simply sitting in a room together and expecting understanding and trust to develop won’t work: “Those who learn together, work together.”

Health managers often find working with local government baffling and frustrating. Difficulties included rivalries between councils and nervousness around this May’s local elections.

But NHS leaders are coming to understand that building political support can be critical in shaping and driving through change. In the current financial climate, local government politicians and managers are constantly making tough calls on local services, so they know what it takes to win public acceptance or ride out controversy.

Building a relationship with local government means listening, not asking them to rubber-stamp your plan. Good local politicians see the wider picture – what really is driving demand, why people really turn up to A&E – because they spend their lives talking to local people and have insights into how those issues might be tackled.

Worryingly, STPs have given little thought to engaging with staff and patients. Since the whole process is ultimately about getting clinicians to work differently, STPs are risking serious resistance to their plans unless clinicians shape and lead it.

Perhaps the biggest threat to STPs is management overstretch. Virtually every part of the country has serious concerns about whether they have the skills and capacity to deliver these plans. As well as doing their day jobs, managers and senior clinicians will have to spend many hours winning support and working through the details of delivery. Project management skills are in short supply.

Difficulties will inevitably be exacerbated by pressure from the central bodies to deliver change more quickly the local teams can manage.

STPs are exposing the shortcomings of decades of silo working. If local managers can work as system leaders focused on the needs of communities rather than organisations, they have a chance of escaping the relentless cycle of crisis management and short-term fixes that fails patients and demoralises staff.

Join the Healthcare Professionals Network to read more about issues like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

NHS transformation plans are beset by infighting

Plans for seven-day GPs not thought out, says spending watchdog

Whitehall’s spending watchdog has criticised government plans to let patients see GPs every day of the week as poorly planned and likely to cost much more than weekday family doctor services.

In a new report, the National Audit Office said that Jeremy Hunt has set targets for rolling out the scheme – a key Conservative pledge – without evaluating the cost or working out where the money for it would come from.

Giving patients access to GPs from 8am to 8pm across the entire week by 2020 was championed by David Cameron while he was prime minister. Ministers also pledged to increase the number of GPs in England by 5,000 by 2020 – promises that have been backed by Hunt and Theresa May .

However, auditors who analysed the pledges found that the minimum additional capacity required by the new commitment equates to £230 per appointment hour at weekends and in the evening for every 1,000 registered patients. In GPs’ core contracted hours, from 8am to 6.30pm, the cost is just £154.

Hunt and the prime minister are under increasing pressure regarding serious problems within frontline services this winter. Ministers have been forced to deny claims by the Red Cross that the service is facing a “humanitarian disaster”.

Dr Chaand Nagpaul, BMA GP committee chair, said the government had been “irresponsible” in making uncosted pledges and must deliver extra investment to ensure patients could receive timely, safe care.

“Given that funding in general practice has failed to meet patient demand, NHS England and commissioners need to fully consider the consequences of their plans to extend access,” he said.

“To proceed without any sort of evaluation into the cost-effectiveness or the consequences of its objectives is irresponsible and could lead to much needed investment being spent on measures which don’t adequately meet patient needs,” he said.

The report, entitled Improving Patient Access, set out to evaluate how the Department of Health (DoH) and the NHS are tackling concerns around access to England’s 42,000 GPs in 7,600 GP practices.

The report found an apparent lack of knowledge within the DoH about the cost of extending GP surgery hours.

“We have not seen evidence that the department and NHS England fully understand the effect of this commitment to extend hours on continuity of care or other arrangements for providing general medical services outside of core hours,” it said.

Auditors, keen to establish the reality of extending opening hours, found that nearly half of all GP practices – 46% – close during core working hours, while 18% closed before 3pm one day a week.

Efforts to increase the workforce are at risk because GPs are leaving the service at a greater rate than they are entering it, thanks to shortfalls in recruitment, the report said.

Health Education England only filled 3,019 (93%) out of a target of 3,250 GP training places in 2016/17, according to auditors.

“The latest available data on part-time working in new GPs suggest there may be 1,900 fewer full-time equivalent GPs by 2020 than Health Education England had estimated there would be,” the report said.

The report sheds light on how patients registered with GP services open for fewer hours than average are more likely to attend accident and emergency departments. It found there were 22 more A&E attendances per 1,000 registered patients [8%] at practices open for 45 hours or less per week, after adjusting for differences in patients’ age and sex.

Meg Hillier MP, the chair of the public accounts committee, claimed that ministers were “trying to shoehorn in seven day access to general practice without a clear idea of the additional costs or benefits it will bring patients or taxpayers”.

Prof Helen Stokes-Lampard, chair of the Royal College of GPs, said the report “hits the nail on the head” by questioning the cost-effectiveness of forcing GP surgeries to deliver routine services seven days a week.

However, she went on to question why auditors failed to acknowledge the stresses that GPs are under or why surgeries may have to close temporarily during core hours for staff training, patient consultations or home visits.

“If general practice fails, the rest of the NHS collapses behind it. That’s why we urgently need NHS England to deliver in full on the pledges it has promised … swiftly and effectively, and for all governments in the UK to invest properly in the family doctor service, including more GPs,” she said.

The government claims that 17 million patients are already benefiting from evening and weekend appointments.

In response to the report, the health minister David Mowat said evidence shows that extended GP access is helping to relieve pressure on other parts of the health service such as A&E.

“We’re also relieving pressure on GPs by cutting red tape and investing an extra 2.4 bn to recruit 5,000 more doctors – in fact, fill rates for GP training this year were at a record level,” he said.

An NHS England spokesman criticised the NAO report for raising “the rather obvious fact” that it costs more to provide evening and weekend urgent primary care services than it does during Monday to Friday, nine to five.

“The alternative would be that patients simply head to A&E, with all the consequences that brings for more major cases.

“No one is suggesting each individual GP practice should offer this extended access, but there’s quite wide agreement that, as GP numbers expand, practices do need to club together to offer this service, a bit like the out-of-hours duty chemist rota.

“Across much of London, Manchester and a fifth of the country, GPs are already doing this, and more areas will follow next year,” he said.

Plans for seven-day GPs not thought out, says spending watchdog

How Britain plans to lead the global science race to treat dementia

Early next year, Professor Bart De Strooper will sit down in an empty office in University College London and start to plan a project that aims to revolutionise our understanding and treatment of dementia. Dozens of leading researchers will be appointed to his £250m project which has been set up to create a national network of dementia research centres – with UCL at its hub.

The establishment of the UK Dementia Research Institute – which was announced last week – follows the pledge, made in 2012 by former prime minister David Cameron, to tackle the disease at a national level and comes as evidence points to its increasing impact on the nation. Earlier this year, it was disclosed that dementia is now the leading cause of death in England and Wales. At the same time, pharmaceutical companies have reported poor results from trials of drugs designed to slow down the progress of Alzheimer’s disease, the most common form of dementia.

“Humans have truly wonderful brains that can cope with terrible diseases like Alzheimer’s for decades and can find all sorts of ways to get around defects that are growing inside,” said De Strooper, who is currently based at the University of Leuven in Belgium. “Eventually individuals succumb to the condition and start to display memory loss and other symptoms – but usually only after decades have passed and their brains have gone through considerable changes. This makes it very difficult to treat the disease. That is the challenge that we need to tackle.”

Current understanding of Alzheimer’s suggests the disease is triggered when beta amyloid, a protein in nerve cell membranes, starts to clump together. Slowly the brain undergoes metabolic changes as amyloid clumping continues. In particular, a protein known as tau, which is involved in memory storage, is affected. It starts to form tangles inside the brain’s neurons and these die off. Eventually, symptoms – such as severe memory loss – manifest themselves.

To date, most attempts at drug interventions have focused on medicines that could prevent beta amyloid from forming clumps, the most recent being Solanezumab, developed by the pharmaceutical company Eli Lilly. However, results of clinical trials of the drug – revealed last month – indicated that it had no significant effect on the thinking abilities of people with mild Alzheimer’s. Solanezumab had also failed in people with more advanced versions of the disease in earlier trials.

This double failure has led some scientists to argue that amyloid clumping is not a cause of the disease but is merely a symptom. By targeting it, scientists are wasting time, it is argued. Professor John Hardy, a geneticist based at UCL – who has played a key role in setting up the college’s Dementia Research Institute – does not agree. “All the evidence we have from families affected by early onset dementia indicates that the disease begins with the deposition of amyloid plaques in the brain,” he said. “The trouble is that this buildup starts 15 to 20 years before dementia’s symptoms appear. The drugs we have developed so far offer treatments that are, in effect, too little and too late.”

Hardy drew a parallel between cholesterol buildup in blood vessels that eventually leads to cardiac disease and the buildup of amyloid plaques in the brain and the onset of Alzheimer’s. “Unfortunately, we have no equivalent of a cholesterol test to assess how much amyloid is clumping in a person’s brain,” he added. “However, that could change in the near future.”

Research suggests between 20 and 30 genes are involved in predisposing people to Alzheimer’s. Photograph: Getty

Recent research has pinpointed a group of around 20 to 30 genes that are involved in predisposing individuals to Alzheimer’s. These genes come in different variants. Some variants of a gene predispose individuals to dementia more than other variants of that gene. If a person inherits a package of genes made up of variants that particularly predispose to dementia, they are very likely to develop Alzheimer’s.

“We are now within five years of developing a chip that will be able to tell – from a blood test – whether a person is likely to have amyloid plaques forming inside their brains in middle age,” added Hardy. “This would then be followed up by a brain scan to confirm if this is true or not.”

This would be dementia’s equivalent of a cholesterol test. The problem is that there is, as yet, no equivalent of drugs which would halt this amyloid buildup in a way that parallels the use of statins to block buildups of cholesterol, once detected, and so head off cardiac illness. For their part, researchers argue that the use of drugs like Solanezumab – although seemingly ineffective on patients in whom amyloid plaques have become established – could be far more effective in the early stage of the condition.

Many other issues complicate our understanding of dementia, however. “A good example is provided by the immune system,” said David Reynolds, chief scientific officer of Alzheimer’s Research UK. “There is a lot of evidence now that the immune system is involved in the development of Alzheimer’s after beta amyloid clumps appear.”

However, the nature of that immune response is still not fully understood. “We do not know whether the immune system tends to overreact – as with conditions like rheumatoid arthritis in which the body’s own tissue is attacked by its own immune defences – or react weakly and allow amyloid clumps to develop when they could be stopped,” added Reynolds. “Certainly it would be unwise to wade in with drugs until we know exactly what it is we want to achieve.”

And this is where the distributed nature of the Dementia Research Institute network could prove important. Based in different university cities (Edinburgh, Oxford and Cambridge are all candidates for units), these outlying centres will focus on different aspects of the disease: environmental factors, care of dementia patients – and immunology. “The creation and direction of these centres will depend on existing expertise at that university,” added Reynolds. “A centre that focuses on immunology and dementia would be particularly useful in finding new ways to tackle the condition.”

The Dementia Research Institute network is to be supported, over the next 10 years, by £150m funding from the Medical Research Council – with further inputs of £50m each being made by Alzheimer’s Research UK and by the Alzheimer’s Society. This commitment marks a significant increase in dementia research in the UK, which had already raised its annual funding from £50m in 2008 to £90m in 2012 and is now a world leader in the field.

“It is good news but we need to put it in perspective,” said James Pickett, of the Alzheimer’s Society. “In 2012 we spent more than £500m on cancer research; there are five times more researchers working on cancer in the UK; while the number of clinical trials of dementia drugs is less than 1% of those of cancer drugs.”

At the same time, the need for some form of treatment to tackle dementia is becoming increasingly urgent. More and more people are living to their 80s and 90s when their chances of getting dementia increase markedly. There are currently 850,000 people with dementia in the UK, a figure that will rise to one million by 2025 and two million by 2051.

“We are going to have to be very nuanced in understanding all the risk factors involved in dementia – and in appreciating why factors like education and general health provide some protection against its onset,” said Professor Carol Brayne, of Cambridge. “That is going to be the strength of the institute. It offers us the opportunity, for the first time, to follow so many different avenues and approaches to dealing with and understanding the dementia.”

GROWING THREAT

• ■ Dementia overtook heart disease as the leading cause of death in England and Wales last year. More than 61,000 people died of the condition in 2015, 11.6% of all recorded deaths.

• ■ The Office for National Statistics said the increase had occurred because people were living for longer while deaths from other causes, including heart disease, had gone down. In addition, doctors are now better at diagnosing dementia, and it is appearing more often on death certificates.

• ■ The bulk of dementia deaths last year were among women: 41,283, compared to 20,403 in men.

• ■ According to the Alzheimer’s Society, dementia is the only one of the top 10 causes of death that we cannot prevent or even slow down.

• ■ The leading cause of dementia is Alzheimer’s disease, which accounts for 62% of all cases in the UK: 520,000 of the 850,000 people living with dementia in the UK today. Other forms of the disease include vascular dementia and Lewy Body dementia.

■ • Dementia costs the UK economy approximately £26bn per year, according to the Alzheimer’s Society.

• ■ If a drug could be found to slow cognitive decline in dementia, that would delay the need for paid care and reduce the financial burden on families, the NHS and social care.

How Britain plans to lead the global science race to treat dementia

Shock figures show Tory plans are ‘making social care worse’

The full extent of the crisis facing social care is revealed by an Observer investigation which demonstrates the government’s flagship policy to keep elderly people out of hospital is failing in most parts of the country.

The findings – amid claims from senior NHS figures that “we are going backwards in many places” – come as ministers face calls to provide an urgent injection of extra cash to local councils to avoid services buckling under increasing financial pressure.

The Tory chair of the Commons select committee on health, Sarah Wollaston, said ministers should act immediately to prevent more suffering for elderly people, their families and other patients.

She also demanded all-party talks on the future of the NHS and social care. “We are at a tipping point,” she said. “We are seeing indications of the great stresses in the system and these need addressing now.”

The Observer’s investigation reveals that the landmark government scheme designed to relieve the strain on overcrowded hospitals – the Better Care Fund – is failing to deliver its aims of keeping older people healthy at home and so cutting “bedblocking”, despite £4bn a year being poured into it.

Theresa May and the health secretary, Jeremy Hunt, have repeatedly claimed that the fund, and a separate policy of allowing councils to raise more money for social care by increasing council tax, are jointly addressing the spiralling problems in social care.

Responses to freedom of information requests submitted to 151 local councils reveal that in England 58% of targets for improving care in people’s homes and local communities were missed.

In another blow to ministers, new figures from the King’s Fund thinktank show English councils will raise just a fraction of the sums required to plug gaps in their budgets by increasing council tax bills.

Better care at home is universally accepted as the way to keep people out of hospital and free pressure on beds. With so many elderly people and others having no alternative but hospital, services suffer a chain reaction of lengthening waiting lists and cancelled operations for other patients.

May and Corbyn clash over NHS and social care funding at PMQs

Data from 98 of the 151 local authorities in England with statutory responsibility for social care show that they met only 218 (42%) of 515 targets to improve social care in their area and missed the other 297 (58%).

Under the Better Care Fund councils receive money, mainly from the NHS budget, in return for introducing schemes to reduce demand for hospital care. This is done, for example, by providing better care for people in their own home or in care homes. But the FoI responses reveal that councils met barely a quarter of their targets in 2015-16 for reducing non-elective (emergency) admissions to hospital.

One senior NHS boss, speaking on condition of anonymity, said the disclosures raised the possibility that the fund was turning out to be “a waste of money”.

Chris Hopson, chief executive of NHS Providers, which represents hospitals, said efforts to improve out-of-hospital care were “going backwards in many places”. He added: “These findings show that the Better Care Fund – a key government scheme to increase out-of-hospital care – is not delivering as intended.

The findings are echoed in the fact that more than 50% of NHS trusts told us in a survey conducted last week that reductions in care facilities beyond hospitals have made it more difficult for the NHS to meet the demand it faces.

“Just at the point when the NHS desperately needs more out of hospital care, we seem to be going backwards in many places. That can’t be right,” Hopson said.

Stephen Dalton, chief executive of the NHS Confederation, said: “These figures are very worrying as we head into what could be a very tough winter for the NHS. We only need a significant dip in the weather, which has been mild so far, and people would become more vulnerable and we would see a big spike in demand. We have a perfect storm going on at the moment of unprecedented demand for care, the fact that we have reached a tipping point in terms of the demographics, and cuts to local councils that are among the biggest in their history.”

Oxfordshire council performed worse than in 2014-15 against all six targets, while Bracknell Forest, Wolverhampton and North Yorkshire each did worse against five of the targets.

The new data from the King’s Fund shows councils across England will raise £382m a year as a result of their ability to increase council tax to pay for social care in 2016-17, a fraction of the funding gap they face this year.

The social care “precept” allows councils to charge up to an extra 2% on council tax bills from this year in order to fund social care services. But King’s Fund analysis shows it will raise less than 3% of what councils will spend on social care, which does not even cover the extra £612m cost they face as a result of the “national living wage”.

The King’s Fund figures also show the social care precept will widen inequalities in access to care services, contributing further to fears of a developing two-tier system.

The 10 most affluent areas will raise more than two and a half times (£41m) the amount of the 10 areas with the greatest level of pensioner need (£17m). Tower Hamlets, the council with the highest level of pensioner need as measured by pensioner income deprivation, will raise just £7 per head of its adult population, compared with the £13 per head that will be raised by Wokingham, with the lowest level of pensioner need in England.

This week ministers are rumoured to be preparing to increase further the amount that councils can raise to pay for social care. But the Tory chairman of the Local Government Association’s community wellbeing board, Izzi Seccombe, said this would not be an adequate response, as she warned that the country was facing the “worst ever funding crisis” in social care.

“Extra council tax-raising powers will not bring in enough money to alleviate the pressure on social care and councils will not receive the vast majority of new funding in the Better Care Fund at the end of the decade,” she said. “Even with this extra money, we have estimated the funding gap amounts to at least £2.6bn. This includes £1.3bn needed right now to stabilise the provider market and a further £1.3bn by 2019-20.”

A Department of Health spokesperson said: “We are giving local areas access to up to £3.5bn extra for social care by 2020. While many areas are already providing high quality services within existing budgets, the Better Care Fund, which brings together health and social care provision locally for the first time ever, will get additional funding in the next few months to raise standards further. This government is committed to ensuring those in old age throughout the country can get affordable and dignified care.

Chancellor wrong on social care funding, says former health secretary

Shock figures show Tory plans are ‘making social care worse’

Citizens must get a say in NHS sustainability and transformation plans

A recent report on sustainability and transformation plans (STPs) has sparked quite a debate about the importance of citizen engagement in redesigning health and care services.

The report, commissioned by the campaign group 38 Degrees and produced by health policy consultancy Incisive Health, found that the “extent of ‘co-production’ with patients and the public appears to have been limited” in the plans. The Nuffield Trust, in its review of STPs, arrived at a similar conclusion.

NHS England has since published a guide on community engagement, which is welcome news. But guidance, as we know, is never enough on its own. We need concerted action at all levels to ensure STPs aren’t a wasted opportunity for meaningful involvement.

We have been here before. Earlier in the decade, in an attempt to shift costs out of hospitals and into communities, the NHS ran what were called “acute service reconfigurations”. This involved reshaping services at a sub-regional level.

Not only were these met with public protests, but the lack of citizen engagement led to ill-considered plans that didn’t reflect people’s aspirations or needs. We must avoid the same thing happening with STPs. Engaging people should not merely be a step in the process, but part of everything we do. We must think all the time about how we can involve citizens in the design, commissioning and delivery of services.

While STPs will soon be signed off, it is crucial that as we move into implementation, citizen engagement is at the heart of decision making. Thankfully there is a powerful set of principles that can guide our thinking and behaviour. As part of the NHS’s Five Year Forward View, the People and Communities Board, with support from the National Voices coalition, developed six principles for engaging people and communities.

Those principles require those undertaking STP planning to work with the knowledge, skills and experience of people in their communities. This should also apply to the implementation of plans.

One of the principles is about ensuring that the “voluntary, community and social enterprise, and housing sectors are involved as key partners and enablers”. This is vitally important, as the reach of a health or care service will be limited by various parameters. However, the combined reach of the voluntary and community sector, alongside services, is far greater.

Another of the principles is that “carers are identified, supported and involved”. Carers have vast experience and knowledge of the strengths and weaknesses of existing services, and great ideas on how they can be improved. They also have needs that are not always sufficiently supported. Involving carers in decision-making is vitally important.

All of these principles are underpinned by the notion of co-production – that is, a way of developing services that has service users and communities as equal partners in shaping how services are delivered.

In parts of the country, efforts are being made to ensure citizens are more closely involved shaping STPs. In both Leeds and Nottinghamshire, officials have gone to great lengths to involve local people in developing their STPs. In York, we have established an integration and transformation board that will co-produce a vision for person-centred and integrated care with local people. But, of course, much more could be done.

As Simon Stevens, the chief executive of the NHS, said recently, STPs are just the start of a process of massive change; the implementation that follows will be the much longer and harder part. We could have started sooner in engaging citizens in STPs, but getting engagement right from now on is still vital to the work.

Martin Farran is director of adult social care, housing and public health at York council and Ewan King is director of business development and delivery at the Social Care Institute for Excellence.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

Citizens must get a say in NHS sustainability and transformation plans

NHS transformation plans may be used as cover for cuts, says BMA

Controversial plans put forward as a way of improving the health service in England and ensuring its sustainability risk being used as a cover for cuts and running down the NHS, the head of the British Medical Association (BMA) has said.

The doctors’ union says the 44 regional sustainability and transformation plans (STPs) amount to £22bn in cuts by 2020-21 to balance the books, which will have a severe impact on patient care.

Guardian analysis of the plans that have been published has found that thousands of hospital beds are set to disappear, pregnant women will face long trips to give birth and a string of A&E units will be downgraded or closed.

Dr Mark Porter, the BMA council chair, said: “Improving patient care must be the number one priority for these plans. Given the scale of the savings required in each area, there is a real risk that these transformation plans will be used as a cover for delivering cuts, starving services of resource and patients of vital care.”

NHS England is expected to find £22bn in efficiency savings by 2020-21 but its finance directors and independent experts have suggested the target is unattainable, as the health service struggles with unprecedented demand and understaffing.

NHS England describes the STPs as intended to “drive genuine and sustainable transformation in patient experience and health outcomes of the longer term”.

The BMA says the plans have a potentially positive role to play if they help develop health policies more suited to local needs and integrate services across health and social care. It fears, however, that they are being driven by other priorities and claims there has been a lack of consultation.

A survey of 310 BMA members found around two-thirds said they had not been consulted and a third had never heard of the STPs. Only 14% firmly supported their introduction with 64% undecided and the rest against.

Porter said: “STPs have the potential to generate more collaboration and the longer-term planning of services based on local need, but it is crucial that any plans about the future of the NHS must be drawn up in an open and transparent way, and have the support and involvement of clinicians, patients and the public from the outset.

“At this stage nobody can be confident that this has happened.”

Among the acute service beds at general hospitals set to be cut are 535 in Derbyshire, 400 each in Devon and West Yorkshire and 30% of all beds in hospitals in Bristol, North Somerset and South Gloucestershire.

The BMA says the STPs should be funded appropriately so that they can deliver what has been promised, rather than being used to cut back services.

The shadow health secretary, Jonathan Ashworth, said: “These warnings that the proposed changes to local services in STPs are overwhelmingly driven by cuts – £22bn of them – will set alarm bells ringing and rightly so. It’s amazing that the government can claim that these plans are clinically driven when two-thirds of doctors say they haven’t even been consulted.

“What’s been revealed so far are drastic proposals to cut beds and services. It’s simply not acceptable for these decisions to made behind closed doors.”

The NHS medical director, Prof Sir Bruce Keogh, said the NHS was constantly adapting to improve services, “making commonsense changes in areas that really matter to patients”.

“We are talking about steady incremental improvement, not a big bang, tackling things doctors and nurses have been telling us for years,” he said. “By continuing to adapt to a changing world, the NHS will be able to secure a better service for future generations.”

NHS transformation plans may be used as cover for cuts, says BMA

Patients and staff shut out of NHS transformation plans, says thinktank

NHS plans that could lead to hospital and A&E closures have been kept secret from the public and barely involved frontline staff, a thinktank has said.

NHS England has told local health leaders not to reveal the plans to the public or the media until they are finalised and have been approved by their own officials first, according to published documents and a new analysis by the King’s Fund.

The national body even told local managers to refuse applications from the media or the public to see the proposals under the Freedom of Information Act.

Local managers accused NHS England of being intent on “managing the narrative” about the plans.

Health managers in 44 areas of England have been ordered to draw up strategies to reduce costs, change services and improve care in the wake of a record £2.45bn deficit.

The sustainability and transformation plans (STPs), some of which have been published or leaked, could see some hospitals, A&E units or maternity units close, and other services merged.

The proposal for Cheshire and Mersey includes the downgrading of at least one A&E department, while in south-west London the number of acute hospitals could be cut from five to four.

In north-west London there are plans to reduce the number of sites offering a full range of services, while Birmingham and Solihull’s STP proposes a single “lead provider” for maternity care.

NHS England and some health experts say the changes will improve patient care and are necessary to fulfil the plan of the health secretary, Jeremy Hunt, for full seven-day services. Opponents argue they are just a way of cutting services.

Some councils have objected so strongly to the lack of public involvement that they have ignored NHS England’s demand to keep the documents private until a later stage and have published them on their websites.

The report from the King’s Fund, based on a review of plans and interviews with local managers, says NHS England set very tight timescales, which is partly to blame for patients and doctors being shut out.

Expensive management consultants have been brought in but clinical teams and GPs have often been only “weakly engaged in the process”, it says.

The report says: “It is clear from our research that STPs have been developed at significant speed and without the meaningful involvement of frontline staff or the patients they serve … Patients and the public have been largely absent from the STP process so far.”

One local manager said of the lack of public involvement: “I’ve been in meetings where I’ve felt a little bit like, you know, where are the real people in this?” Another described the secrecy demanded by NHS England as “ludicrous”.

The report says: “As well as the timeline creating a barrier to meaningful public engagement, national NHS bodies had also asked STP leaders to keep details of draft STPs out of the public domain. This included instructions to actively reject Freedom of Information Act requests (FoIs) to see draft plans.”

On management consultants, the report says some leaders “felt that STPs had ‘created an industry’ for management consultants – and questions were raised about why money is being invested in advice from private companies instead of in frontline services”.

However, the King’s Fund said STPs still offered the “best hope” of improving health and care services.

Chris Ham, chief executive of the thinktank, said: “The introduction of STPs has been beset by problems and has been frustrating for many of those involved, but it is vital that we stick with them.

“For all the difficulties over the last few months, their focus on organisations in each area working together is the right approach for improving care and meeting the needs of an ageing population.

“It is also clear that our health and care system is under unprecedented pressure and if STPs do not work then there is no plan B.”

Ham said it was a “heroic assumption” to say out-of-hospital services and GPs could take on more of the work currently done by hospitals, given how under pressure they were.

He said there was “mixed evidence at best” that moving services closer to home improved care.

The NHS medical director, Prof Sir Bruce Keogh, defended the plans. “Advances in medicine mean it is now possible to treat people at home who would previously have needed a trip to hospital. It also means those with the most serious illness need to be treated in centres where specialist help is available around the clock,” he said.

“So this is not a moment to sit on our hands. There are straightforward and frankly overdue things we can do to improve care. We are talking about steady incremental improvement, not a big bang. If we don’t, the problems will only get worse.”

Patients and staff shut out of NHS transformation plans, says thinktank

Will the cultural chasm between NHS and local government threaten plans?

Serious tensions are emerging between the health service and local government.

There are three sources of conflict – centrally-imposed secrecy over the sustainability and transformation plan (STP) process, whether the aim of STPs is to fix the NHS or develop an integrated health and care system, and disputes over whether the financial plans being sent to NHS England are fact or fantasy.

At least five councils have now published the STP, despite NHS England asking local areas to keep them hidden until the central bodies have given their verdict.

This pointless subterfuge has put local politicians in an invidious position; if they do as they are told they run the risk of being accused of conniving in a cover-up of plans to shut services. Faced with incurring the wrath of either NHS England chief executive Simon Stevens or local voters, it is not a difficult choice. The surprise is that more councils have not taken the same step.

The first local authority to reveal one of the plans was Birmingham city council. Its chief executive, Mark Rogers, articulated publicly the frustrations many in local government express privately. He complained in the Health Service Journal that Stevens and NHS Improvement chief executive Jim Mackey were pressurising NHS organisations to sort out the health service debt crisis rather than make the entire health and care system sustainable.

At the Ncas social care conference on Friday, NHS England operations director, Matthew Swindells, was forced to apologise after he said that councillors needed to be “managed” in the STP process.

“When I said ‘managed’ I meant brought into the whole of the conversation,” he responded to angry lead members for adult social care, who protested that they had been shut out of local STP discussions. “That was not our intention. If that has happened, that is not satisfactory and I apologise for that.”

Swindells admitted that NHSE’s handling of the STP process had been “not our finest hour”, explaining that while “most” of the 44 plans were good work, “a lot” needed rewriting before they were understandable by a wider audience. They would all be published before Christmas.

The Five Year Forward View held out the prospect of moving the centre of gravity of the health and care system at least a few inches towards primary and community services. But the STP process is now in danger of reinforcing the domination of the hospital sector rather than reforming it. The implications of that are far more serious than simply maintaining a system that is failing to cope; it will require even more money to be pumped into hospitals to expand the number of beds.

Arguably the biggest weakness of the STP process is that the pressure on hospitals to get their finances under control is so intense that some are offering up plans for savings that have virtually no chance of being achieved. One council chief executive said a local deeply-indebted hospital was claiming that it would save millions but did not have a credible plan for making it happen.

On Tuesday, Rogers took to the Today programme’s airwaves to ram the point home, pointing out that the funding gap will not be closed by “simply using the transformation word endlessly”.

Another local government chief I spoke to was visibly angry at the failure of his local hospital to take even the most basic steps to improve their estatesmanagement, back-office systems and procurement, while his authority was being eviscerated by another round of cuts – with public health taking a big hit.

There is a cultural chasm between the NHS and local government when it comes to handling public money. It is illegal for local authorities to run a deficit on their services spending, so they are compelled to make tough decisions to live within their means. Chief financial officers have extensive powers to intervene if they believe unlawful expenditure is going to be incurred.

In contrast, in some trusts there appears little connection between the financial decisions of the board and what actually happens. It is that disconnect which lies behind scandals such as the financial collapse of St George’s in Tooting in 2015.

Local government is no nirvana, of course. Several authorities – including Birmingham and Manchester – are still struggling to deliver effective child protection services, and although councils face severe increases in demand, these are not on the scale confronting the NHS. But local government’s financial management is far more effective.

Despite the inevitable tensions, the good news is that local government and the NHS are learning to work together, marrying up clinical services with a stronger sense of place and beginning to develop a clearer vision for integrating health and care.

The challenge now is to drive hospital efficiencies such as those proposed by Lord Carter before hospital debt derails the chance of building one system.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

Will the cultural chasm between NHS and local government threaten plans?

High court rules UK government plans to tackle air pollution are illegal

The government’s plan for tackling the UK’s air pollution crisis has been judged illegally poor at the high court, marking the second time in 18 months that ministers have lost in court on the issue.

The defeat is a humiliation for ministers who by law must cut the illegal levels of nitrogen dioxide suffered by dozens of towns and cities in the “shortest possible time”.

Legal NGO ClientEarth, which brought the case, argued that current plans ignore many measures that could help achieve this, placing too much weight on costs. On Wednesday Mr Justice Garnham agreed. He also said ministers knew that over-optimistic pollution modelling was being used, based on flawed lab tests of diesel vehicles rather than actual emissions on the road.

The government said it would not appeal against the decision and agreed in court to discuss with ClientEarth a new timetable for more realistic pollution modelling and the steps needed to bring pollution levels down to legal levels. The parties will return to court in a week but if agreement cannot be reached, the judge could impose a timetable upon the government.

Air pollution causes 50,000 early deaths and £27.5bn in costs every year, according to the government’s own estimates, and was called a “public health emergency” by MPs in April.

James Thornton, CEO of ClientEarth, said: “The time for legal action is over. I challenge Theresa May to take immediate action now to deal with illegal levels of pollution and prevent tens of thousands of additional early deaths in the UK. The high court has ruled that more urgent action must be taken. Britain is watching and waiting, prime minister.”

He said the increased action required would very likely include bigger and tougher clean air zones in more cities and other measure such as scrappage schemes for the dirtiest vehicles: “The government will have to be tougher on diesel.”

The mayor of London, Sadiq Khan, who took part in the case against the government, said: “Today’s ruling lays the blame at the door of the government for its complacency in failing to tackle the problem quickly and credibly. In so doing they have let down millions of people the length and breadth of the country.”

A spokeswoman for the Department of Environment, Food and Rural Affairs said: “Improving air quality is a priority for this government and we are determined to cut harmful emissions. Our plans have always followed the best available evidence – we have always been clear that we are ready to update them if necessary. Whilst our huge investment in green transport initiatives and plans to introduce clean air zones [in six cities] around the country will help tackle this problem, we accept the court’s judgment. We will now carefully consider this ruling, and our next steps, in detail.”

ClientEarth defeated the government on the same issue at the supreme court in April 2015. Ministers were then ordered to draw up a new action plan, but now that new plan has also been found to be illegal.

Documents revealed during the latest case showed the Treasury had blocked plans to charge diesel cars to enter towns and cities blighted by air pollution, concerned about the political impact of angering motorists. Both the environment and transport departments recommended changes to vehicle excise duty rates to encourage the purchase of low-pollution vehicles, but the Treasury also rejected that idea.

Documents further showed that the government’s plan to bring air pollution down to legal levels by 2020 for some cities and 2025 for London had been chosen because that was the date ministers thought they would face European commission fines, not which they considered “as soon as possible”.

There had been a draft government plan for 16 low emission zones, which polluting vehicles are charged to enter, in cities outside London but the number was cut to just five on cost grounds.

All these proposals will now be revisited. Thornton said a national network of clean air zones needed to be in place by 2018. “If you put in clean air zones, it works overnight.”

Dr Penny Woods, chief executive of the British Lung Foundation, said: “We urgently need a new clean air act that restricts the most polluting vehicles from our urban areas and protects everyone’s lung health – air pollution affects all of us.”

Sam Hall, at conservative thinktank Bright Blue, said there should be more power and funding devolved to local authorities to enable all English cities to set up clean air zones and more support for electric cars.

Keith Taylor, Green party MEP, said: “The failure highlighted by the judge today is as much moral as it is legal: ministers have displayed an extremely concerning attitude of indifference towards their duty to safeguard the health of British citizens.”

Air pollution table

High court rules UK government plans to tackle air pollution are illegal

Childhood obesity: May government diluted plans, claims Dispatches

Theresa May’s government has been accused of diluting plans drawn up under David Cameron that were designed to cut Britain’s childhood obesity levels.

Restrictions on junk-food advertising and on unhealthy product placement in supermarkets were among measures cut from a draft of the government’s childhood obesity strategy when it was published in August, Channel 4’s Dispatches programme will say on Monday.

The programme says the draft, a copy of which it has seen, also contained a pledge to halve childhood obesity by 2026 to 800,000 cases. But when the full strategy was released that had been changed to a pledge to “significantly reduce” the number of chronically overweight children.

Criticising the watering down of the strategy, Jamie Oliver, the celebrity chef and healthy food campaigner, tells the programme: “Obesity is killing huge amounts of people, well before their time. This is a war. If you are worried about the thing that hurts British people the most, it ain’t Isis, right?”

He said of the published strategy: “This should go to the Trade Descriptions Act because that says an ‘action plan’ and there’s hardly any action in there. When you look at how the plan came out at midnight, next to the A-level results, while the whole of government’s on holiday, it absolutely screams out, ‘we don’t care’. I’d say it’s never too late to say I’m sorry. And, just sort of, you know, start again.”

The leaked draft, thought to date from June, numbers 37 pages, while the strategy published in August ran to just 13 pages, according to the programme.

Proposals removed included forcing restaurants, cafes and takeaways to put calorie information on menus, Dispatches says. Other plans dropped include making supermarkets remove junk food from checkouts and ends of aisles, and limiting buy-one-get-one-free and other multi-buy discounts on unhealthy foods.

The published strategy is also missing proposals for restrictions to junk-food advertising, including commercial breaks in and around popular Saturday night television programmes such as The X Factor, which were included in the draft.

Instead, May’s version emphasised the role of exercise, despite the Cameron-era draft which stated exercise “will not in itself solve childhood obesity”.

Doctors, health campaigners and politicians criticised the strategy when it was published, for not going far enough. Key elements include cutting sugar by 20% in food eaten by children and a tax on sugary drinks to raise money for school sports.

The health secretary, Jeremy Hunt, had previously said the strategy needed to be a “gamechanging” moment to tackle a “national emergency”.

James Cracknell, double Olympic gold rowing medallist and healthy eating campaigner, said of the published strategy: “The terminology – it’s about hope, would, should. A lot of it is voluntary codes, and we know that doesn’t work.”

Graham MacGregor, professor of cardiovascular medicine at the Wolfson Institute of Preventive Medicine, and chairman of Action on Sugar, told the programme: “I was gutted. I mean it was a pathetic plan. It didn’t include any restrictions on marketing or promotion or advertising to children, which is scandalous. We’ve missed a huge opportunity. We would have been the first country in the world to have a comprehensive plan for preventing obesity. We could have done it, and very sadly and very disappointingly Theresa May – for reasons best known to herself – decided not to go ahead with it.”

Writing in the Sunday Times, Oliver said: “Cameron’s strategy is 37 pages long and bravely commits to halving England’s childhood obesity levels within 10 years. May’s plan is only 13 pages long, and her voice and personal commitment do not ring true on a single one of those pages.”

He added: “After two years in the making, it took just 36 days for May to dismantle Cameron’s plan, and she has not replaced it with something better, bigger, bolder, braver or something that is even fit for purpose. What happened? Was it too big for her? Did parts of the food industry start to bite back? Nothing has changed to warrant milder action. Things have not got better, they have only got worse, especially in our most disadvantaged communities.”

A Department of Health spokesman said the government’s published strategy was groundbreaking. He said: “No other developed country has done anything as ambitious. The government has intentionally taken a careful and measured approach which will reduce obesity. We are taking bold action through the soft drinks industry levy to cut the amount of sugar consumed by young people.

“Alongside this, our restrictions on advertising and promotion are among the toughest in the world. These steps will make a real difference to help reverse a problem that has been decades in the making, but we have not ruled out further action if the right results are not seen.”

• Dispatches: The Secret Plan To Save Fat Britain, is on Channel 4 at 8pm on Monday

Childhood obesity: May government diluted plans, claims Dispatches

Sustainability and transformation plans are "least bad option" for NHS

Two years after NHS England unveiled the Five Year Forward View (pdf) – its blueprint for community-based, integrated healthcare able to cope with the pressures of a growing and ageing population – the central bodies are still not doing enough to make it happen.

The King’s Fund is about to publish analysis of progress in reforming the way the NHS works to allow the new care models outlined in the Forward View to flourish. Speaking to the Guardian’s Healthcare Professionals Network, chief executive Chris Ham identified four ways in which the system is hampering local reforms – a shortage of cash to kickstart change, too little progress on a payment system which encourages collaboration, the need to sort out the debacle of the contracting rules which emerged from the Lansley reforms, and rushing change.

“The big concern we’ve got is the importance of a transformation fund to prime new care models. Virtually all the money in the Sustainability and Transformation Fund is going into sustainability and deficit reduction. It leaves precious little left over to support transformation,” he says.

“It is difficult to see how you stem rising demand unless there is the resource to invest in the out of hospital services. More money has to be found to prime those services, which are creaking at the seams. The NHS and its leadership need to explore other avenues [to raise cash], such as the work going on in relation to the NHS estate to generate income.”

Ham wants the central bodies to move faster in shifting from the old payment by results system to population-based funding, which encourages organisations to collaborate around prevention, helping patients manage long-term conditions at home, and avoiding unnecessary hospital admissions.

So far local areas have largely been left to design population-based funding systems on their own. Ham warns that the collapse of the £800m UnitingCare Partnership scheme in Cambridgeshire and Peterborough shows “there are opportunities but massive risks in some of these innovative contracting and funding arrangements, so the centre needs to provide more hands-on support to local leaders in working through the detail”.

The contracting rules imposed by the 2012 reforms create the ludicrous situation whereby, with some of the new approaches to running services, commissioners and hospital managers are tied up in a long and expensive tendering process when it is obvious that the contract will go to the local hospital. “But it’s not clear to commissioners whether they can go ahead in that way or whether they have to test the market before they decide,” says Ham. Guidance would clear away some of the legal thicket which is holding back change.

Finally, Ham is adamant that rushing change could wreck it: “There is a real impatience among the national bodies to accelerate what’s happening, but we know that if you are going to build these new care models on a sustainable basis you have got to allow time in terms of building the relationships between clinicians and between leaders so they are built on strong foundations. The worst of all worlds would be to go too quickly and for them to fall over.”

But despite all these difficulties, Ham believes local teams have made considerable progress in developing new ways of working, and recognises the efforts NHS England and NHS Improvement are making to ensure they are giving the system clear and consistent messages about what is expected.

Ham believes that on balance the Sustainability and Transformation Plan (STP) process is helping deliver the Forward View: “STPs are not perfect; they are the least bad option for trying to plan in a more coherent way in an NHS that is more complex than at any time in my 40-year career. STPs are a workaround of the Lansley legacy. Nobody wants another top-down reorganisation, nobody thinks the current system works well, so the answer is STPs.”

The King’s Fund’s analysis shows that, even with hospitals soaking up virtually all the money set aside for transformation, there has still been considerable progress in delivering the vision of the Forward View. But the central bodies need to clear away some major obstacles, and someone, somewhere has to come up with the cash to invest in community-based services.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

Sustainability and transformation plans are "least bad option" for NHS

This undue rush could be fatal for NHS plans | Letters

Moves to create 44 sustainability and transformation plans to deliver NHS services across England could mean better coordination of health and care for patients. But the pace at which they are being pushed through risks undoing much of the good the plans could bring.

As unions and professional bodies representing the majority of the NHS’s million-strong workforce in England, we know only too well the pressures of trying to provide decent care with dwindling resources. While staff would much rather the government came up with the cash to give the health service and social care the investment they need, the plans could be a sensible step to make the best use of existing, yet limited, resources.

The plans could lead to closer working between the health and social care sectors, and between the various parts of the NHS in particular areas. That makes sound sense and is in the best interests of both patients and staff.

But the breakneck speed at which organisations are being asked to submit their plans and consult with local groups – to meet this week’s arbitrary deadline – makes no sense at all, and could well be storing up problems for later. Some already suspect the plans might be cover for further cuts, closures and mergers. This must not be the case. Both the public and health staff need reassurance now.

Jeremy Hunt, the health secretary, and Simon Stevens, the chief executive of NHS, must slow down the pace, extend the submission deadline, and ensure there is full consultation on future plans. Crucially, they must do more to convince staff and the public that change is happening for the right reasons – to make healthcare better and not simply to disguise cuts and save money.
Julia Scott British Association of Occupational Therapists
Annette Mansell-Green British Dietetic Association
Lesley Anne Baxter British Orthoptic Society Trade Union
Andrew Taylor Federation of Clinical Scientists
Jon Restell Managers in Partnership
Jon Skewes Royal College of Midwives
Janet Davies Royal College of Nursing
Brian Harris The Society of Chiropodists and Podiatrists
Richard Pembridge Society of Radiographers
Christina McAnea Unison

• Join the debate – email guardian.letters@theguardian.com

This undue rush could be fatal for NHS plans | Letters