The NHS needs to integrate its urgent care services and simplify access to them, according to a review led by the NHS Medical Director.

Patients uncertain which service to access are “defaulting” to A&E, increasing the pressure on emergency services, the Urgent and Emergency Care Review said.

The report identified “fragmentation and diverse nomenclature” as factors reducing ease of access, and called for a more unified 24/7 system.

Sir Bruce Keogh, who led the review on behalf of NHS England, said there was an “excellent opportunity” to improve the system by simplifying access.

Demand for urgent care is growing due to the ageing population, the prevalence of long-term conditions and the proliferation of new treatments, the report noted.

The “fragmentation and variation” of acute care services in this environment is leading to over-reliance on A&E because it is easy to find at all times.

Health professionals are also unsure about the availability of urgent care services, helping to create a pattern of “patients presenting at services that may not best suit their needs”.

The report warned that many patients receiving telephone advice “lack confidence” in it and seek a second opinion, potentially duplicating services.

It recommended better patient education about the services available from community pharmacists, and called for senior clinical staff to be more available to patients (especially at weekends).

Professor Keith Willett, chair of the review’s steering group, commented: “We know that A&E is the pinch point of the health and care system and that staff are working very hard to provide the care they know the public need.

“To relieve the pressure and design a system that is sustainable and fit to meet future challenges, we need as many patients, doctors, nurses and NHS colleagues as possible to get involved.”

A new report from an industry working group calls on NHS England to appoint a National Clinical Director (NCD) for Eye Health.

Better Vision for All, produced by the ABPI Pharmaceutical Ophthalmology Initiative (POPI), warns that NHS eye care is too fragmented and inconsistent to meet the growing clinical need.

The report’s recommendations span commissioning, access to treatment and prevention, with a National Eye Health Network supporting the NCD.

Other recommendations include:

• An eye health awareness campaign for public health and healthcare professionals.

• A question on eye health to be added to the NHS Health Check.

• A care plan for every eye care patient, owned by one practitioner, to promote a well-integrated service.

• Minimum standards to guide patients on what they should expect from primary, secondary and social care.

The POPI group is made up of companies with a special interest in eye health, including Bausch & Lomb, Bayer, MSD and Novartis.

Better Vision for All notes that the number of people registered as blind or partially sighted is rising rapidly. However, eye care delivery is split between primary, secondary and social care, and between private and NHS providers.

Sir Bruce Keogh, NHS Medical Director, has admitted that eye care is being rationed – for example, cataract surgery is often delayed until the patient is blind.

The ageing population and the increasing prevalence of diabetes and obesity mean that sight loss is likely to increase.

Lord Low, chair of the All Party Parliamentary Group on Eye Health and Visual Impairment, said: “With a service as fragmented as eye health, a National Clinical Director, supported by an advisory National Eye Health Network, is essential.

“Without a leader to drive the implementation of change, as has proven successful in services for cancer and cardiovascular disease, more patients will needlessly lose their sight.”

“What comes out clearly in Better Vision for All is the strength of opinion about fragmented services in eye care,” said Joe Brice, Chair of the POPI group.

“We hope that this consensus will help bring about change, with the potential for stronger national leadership to put services on a more sustainable footing across the country to meet rapidly growing demand to the benefit of patients.”

Sir David Nicholson has used his last speech to the NHS Confederation to challenge the coalition Government’s health record.

As well as saying he was “incensed” by the Government’s recent attempt to blame A&E problems on GPs, Nicholson pointed out that the worsening economic picture since 2010 has prevented the QIPP agenda from making any difference.

Implicitly criticising the NHS reform policy, which was driven by the Department of Health, he said: “NHS England needs to involve the public in setting out a long-term strategy for the NHS.”

Other criticisms of the Government were implied in his praise for the NHS tribute in the Olympic Games opening ceremony (which Jeremy Hunt had tried to veto) and his statement that the two years following the 2010 election were “wasted” for the NHS.

Nicholson’s speech was reminiscent of his warning in late 2012 that the Government policy of “carpet bombing” the NHS with private providers would lead to “misery and failure”.

Noting the way in which the media (led by Hunt) had run with the idea that GPs were to blame for the overloading of A&E departments, he observed: “There is a sort of wheel that gets spun every so often, and on that wheel this week it is nurses. Let’s have a go at the nursing profession... But I was particularly, I think, incensed about some of the coverage in relation to general practice.”

Nicholson also acknowledged the futility of the ‘Nicholson challenge’, saying: “We talked about QIPP a few years ago thinking there will be no growth for a few years. There was an assumption that things were going to turn around in a few years – well they haven’t, so we need to make a long-term plan. NHS England needs to involve the public in setting out a long-term strategy for the NHS.”

The NHS reforms had wasted time and resources that should have been invested in transforming services, he said: “During the 2010 general election period, political parties went around the country making promises of no change. What happened when we got a new government was we wasted those two years where you can really make change happen. We didn’t talk about the really important changes that are required for the NHS.”

A legal review of the ‘whistleblower’ situation has concluded that NHS England has no legal power to direct Foundation Trusts (FTs).

The review followed NHS Chief Executive Sir David Nicholson’s promise that he would intervene if NHS organisations failed to protect whistleblowers.

Like Health Secretary Jeremy Hunt’s promise to sack FT leaders who neglect patient safety, the promise overstated his powers under the Health and Social Care Act.

In February, Nicholson was asked by the Commons Health Committee what he would do about trusts that did not support whistleblowers.

He replied: “Wherever I see it or if I have a whiff of it, I immediately intervene in the organisations themselves to tell them what their responsibilities are.”

However, Nicholson later warned a doctor who had been forced to sign a gagging agreement regarding the treatment of dementia patients in a hospital that he could not intervene.

Lawyers had determined that the Department of Health has no legal authority over FTs, he said.

All NHS trusts have to become FTs by April 2014, and they will then not be subject to any control by NHS England or the Department of Health.

A spokesperson for NHS England commented that Nicholson was able to raise relevant issues with the Care Quality Commission, which can take steps to protect patient safety.

Sir David Nicholson will retire from his role as Chief Executive of NHS England, and from the NHS altogether, in March 2014.

The announcement of his retirement will relieve the pressure on him to resign following the Francis report, which implicated him in the Mid Staffordshire tragedy.

It also means that he will not have to deal with growing anger over revelations that the ‘Nicholson challenge’ of cutting £5bn from the NHS budget each year means an absolute cut in the NHS budget.

A former Communist Party member, Nicholson has been a strong supporter of current Conservative health policy: he began implementing the Health and Social Care Act prior to its approval by Parliament.

However, last autumn he warned that “carpet bombing” the NHS with private sector providers would lead to “misery and failure”. NHS reform needed to support clinical decision-making, he argued.

The Francis report into the unnecessary deaths at Stafford Hospital between 2005 and 2009 found that Nicholson, as head of the region’s SHA, had not acted on warnings about the hospital’s high death rate.

While the Francis report blamed inadequate staffing levels and bad management for the tragedy, Nicholson pinned the blame on the Labour Government’s infection control and waiting time targets.

Nicholson has worked in the NHS for 35 years, and was NHS Chief Executive for almost seven years. In April this year he became Chief Executive of NHS England, a role effectively continuous with his previous one.

In a letter to Professor Malcolm Grant, Chair of NHS England, Nicholson declared his continued support for the NHS reform process: “I still passionately believe in what NHS England intends to do. My hope is that by being clear about my intentions now [I] will give the organisation the opportunity to attract candidates of the very highest calibre so they can appoint someone who will be able to see this essential work through to its completion.”

Nicholson’s retirement will quieten the controversy over his role in the NHS reforms of this and the last government, and allow recognition of his lifelong commitment to the NHS.

A new ABPI Vaccine Group has replaced the UK Vaccine Industry Group (UVIG), which represented UK vaccine companies for more than a decade.

Changes in the composition of the group include the addition of AstraZeneca and the loss of Sanofi Pasteur MSD.

The ABPI Vaccine Group will work in partnership with the new Public Health England and NHS England bodies to support UK immunisation programmes.

The new industry group has six members: Abbott Healthcare Products, AstraZeneca, GSK, Janssen, Novartis and Pfizer.

The disbanded UVIG also had six members: Baxter Healthcare, GSK, Novartis, Solvay, Sanofi Pasteur MSD and Wyeth (a subsidiary of Pfizer).

Sanofi Pasteur MSD, the manufacturer of Gardasil – recommended by NICE for immunisation against cervical cancer – plays a major role in the UK’s public health vaccination programmes.

Vaccination is an increasingly important strategy in global health protection, as ease of travel has made infectious diseases harder to control. According to the World Health Organisation, vaccines save 2.5 million lives each year.

Stephen Whitehead, Chief Executive of the ABPI said: “This addition to the ABPI strengthens the unity of the biopharmaceutical industry and further underlines the ABPI’s position as the leading life sciences trade association in the UK.”

“Vaccinations against disease play a vital role in improving public health and help protect us from preventable illnesses.”

The NHS has launched a plan to support its overloaded A&E services, with the formation of ‘urgent care boards’ able to invest in emergency care.

NHS England will work with the NHS Trust Development Authority and Monitor to address the problem of increasing A&E waiting times.

One priority is for hospitals to bring forward their planning for next winter to ensure that seasonal urgent care needs are under control.

The growing pressure on A&E services is due to increasing demand – four million more people in England are using these services than in 2004 – combined with the budget cuts of the ‘Nicholson challenge’.

Health Secretary Jeremy Hunt angered the BMA by blaming the increased A&E attendance figures on lack of GP access, but it is beyond doubt that many people use A&E to bypass primary care and referral barriers.

The NHS support plan therefore aims not only to help maintain A&E capacity, but to relieve the pressure on emergency care through GP and outpatient care.

At the same time, the increasing number of people attending A&E who require urgent hospital care points to a need to improve not just access to care, but the quality of care outside hospital.

While 90% of patients in A&E are seen within four hours, the average waiting time is increasing. The support plan notes: “Long waiting times in A&E not only deliver poor quality in terms of patient experience, they also compromise patient safety and reduce clinical effectiveness.”

The urgent care boards will bring together healthcare leaders from across the local NHS. By the end of May, these boards will ensure that local recovery and improvement plans are in place for each A&E department.

NHS England will ensure that extra money is made available: the urgent care boards will oversee the use of the fees paid for emergency admissions, and ensure that expenditure achieves specific improvements.

Professor Keith Willett, NHS England’s National Director for Acute Episodes of Care, commented: “When pressure builds across the health and social care system, the symptoms are usually found in the A&E department.”

The Government’s controversial shake up of the NHS resulted in more than 10,000 workers being made redundant, new official figures show.

Information in the DH’s people tracker report showed that 2,394 redundancies were made in 2012-13, 2,100 in the year before that and an estimated 5,600 throughout 2010-2011. An additional 3,841 left the NHS on their own accord.

Initial estimations by the DH in January 2011 expected around 16,000 redundancies and a further 3,600 staff to leave the health service during the reforms.

These figures have since been acknowledged by the DH as uncertain but the report hailed a “successful people transition process while minimising redundancies and maximising the retention of essential skills.”

The report adds there may be more redundancies to come from commissioning groups as a result of reorganisation.

However, further job losses were avoided as 34,204 jobs from organisations such as strategic health authorities and primary care trusts were moved to new bodies, such as NHS England.

The Government has launched a ‘catch-up’ programme to give the MMR vaccine to a million children in England who lack full protection against measles.

The campaign, in which Public Health England and NHS England will work together, was provoked by the recent outbreak of measles in Swansea.

Most of the children targeted are aged 11–16, a group made vulnerable by a steep decline in uptake of the MMR vaccine following the publication of a medical paper in 1998 claiming it was linked to autism.

The paper has since been exposed as fraudulent, though its claims are still supported by some anti-NHS tabloids.

In the mid-1990s, measles had almost been eradicated in the UK. But by the year 2000, uptake of the MMR vaccine had dropped to 80%, allowing the virus to circulate widely.

In 2012, there were nearly 2,000 cases of measles in England – the highest level in two decades. This year, an outbreak in Wales has infected over 900 people.

The million children in England targeted by the new NHS campaign form three similar-sized groups: children aged 11–16 who have received no vaccine; children aged 11–16 who have received one vaccine dose without the ‘booster’ jab; and children in other age groups who lack protection.

Local area teams will use general practice case registers to identify children at risk and ensure their vaccination in schools and GP surgeries.

Mary Ramsay, Head of Immunisation at Public Health England, said that although take-up of the MMR vaccine had returned to a high level, there was a “legacy of under-vaccinated children” who needed protection.

MMR vaccines, which protect against measles, mumps and rubella, are available from GSK and Sanofi Pasteur MSD.

This month Brigadier Pinching shares a surprisingly palatable civil service coffee with the Department of Health’s NHS/big pharma relationship expert, Naima Khondkar.

I love Elephant and Castle. If you are in any doubt about where you are, just outside the station, there is large sculpture of... an elephant and a castle. Oxford Circus, King’s Cross and Cockfosters have clearly missed out on a neat trick. Anyway, I digress, for I was in central London on important business – to chat with Naima about how the private and public sector could make their marriage work. Having spent six years in curious governmental buildings, this was my territory. Bring on the future!

Hi Naima, what’s your story?

At the Department of Health I work in the Medicines, Pharmacy and Industry Group. The head is Giles Denham and he has a number of teams which sit under him. One looks after the pricing environment – which is very topical right now because of the negotiations – while the pharmacy team takes care of community and pharmacy issues. Another concentrates on prescription policy, and I’m in the industry sponsorship team.

How do you guys roll?

We’re almost account managers for the pharmaceutical industry, within government, and also the first port of call on health policy issues concerning research-based pharma companies, including global outfits that have locations in the UK. There’s a very high-level of strategic engagement, driven by the Ministerial Industry Strategy Group, which combines global heads of pharma, from as far afield as Japan and America, and ministers from health, business, the treasury and UKTI (UK Trade and Investment). The discussions are a great way to highlight how government policy can help partnerships. Our minister, Earl Howe, is a particularly engaging contributor, while ‘No 10’ frequently sends along a representative, indicating how serious the Government is about forming cohesive inter-sector partnerships.

How has the concept of joint working progressed?

Over the last few years we have carefully considered how to fundamentally improve the relationship between industry and the NHS, and a lot of this consideration has been carried out in conjunction with colleagues at the ABPI. There is still a lot of mistrust on both sides, however, and that is one of the greatest challenges reform needs to overcome. The NHS has the perception of pharma as being a big bad wolf, just above the arms and tobacco industries in terms of popularity! For some reason people have a big problem with the pharmaceutical industry making any kind of money. Sometimes I think the level of suspicion is unjustified, but then again, I don’t think pharma do themselves many favours sometimes. It’s important to be open and honest about these things! Equally, the NHS can sometimes be over-sensitive – they don’t like to be told by other people how to do their job.

What needs to change?

There needs to be a shift in how people on both sides view one another and they must learn to wipe the slate clean. Bad relationships can date back to minor incidents that happened 25 years ago, when a young, naive rep went into a meeting with a box of doughnuts to help flog a new product. Something as trivial as this may have resulted in a door being shut. Whereas now NHS representatives need to re-engage, open doors and think about the broader benefits of working together with the pharmaceutical industry towards joint goals. It’s really important that both sides build allegiances and forget past animosities. Ultimately this will benefit everyone.

Do the ‘different’ motivations of the public and private sector make gelling difficult?

There is an incorrect perception that, because pharma makes money, someone else has lost. We must remember that if people have their lives extended due to better treatment then NHS, industry and wider society has won. Recently Helen Bevan, NHS Director for Transformation, said both industries have been very target driven in the last 15 years and, consequently, the humanity factor has eroded. Healthcare professionals on the frontline have been too busy with waiting lists and reductions, while sales reps have been under enormous pressure to shift products and been too focussed on sales. Patient cases have become about performance measurement rather than health outcome, or quality of experience. Clearly there needs to be a radical change in priorities.

What can big pharma do to engender trust?

Their approach can be ill-informed sometimes. Often they think they know the NHS, but actually they need to fully appreciate the complexities of what is an ever-evolving beast. Companies need to consider who they make responsible to forge vital connections and forming sustainable relationships. They regularly send an under-qualified person, who might have the enthusiasm, but not the authority. With joint working one of the big issues has been compliance and, often, the pharma representative at the table can’t actually make a decision about whether a company can work in a certain way. This is one of the areas we are really trying to help with.

How should they alter their approach?

If pharma goes in simply looking for a market share increase, they’ll get figured out straight away. Representatives of the big companies need to prove that they genuinely want to improve a health economy or health outcome, before profits. These are the aspects that make the whole system better, and ultimately everyone wins. The CCGs want more people appropriately treated and that means less hospital admissions and, in turn, more financial resources will be available for commissioning. In this respect pharma needs to look at the bigger picture. Remember, every service that the NHS uses is a business – from nurses to bed sheets – but because of the fractious history, the NHS is suspicious about pharma making money. When they do engage the NHS needs to feel like pharma is an integrated and credible part of the solution, as opposed to a procured service. It’s a fine balancing act.

What are the priorities when it comes to galvanising joint working?

Since joint working was outlined as part of NHS reform we have been keen to establish how it can be improved. A policy working group in 2007 carried out some market research and they came up with some recommendations. The two major areas of focus, on our side, were the issuing of guidance – clear definitions of how the NHS works - and the language that should be used. This is a refreshingly concise 11 page document. We also addressed the practical side by combining with the ABPI to launch the, ‘Joint Working tool kit’. It’s an interactive quick-start guide, which includes exactly what the NHS’s definition of joint working is, essential templates and a versatile project management tool. Above all, it avoids jargon and allows people to understand what is required straight away. This has been endorsed by NICE, the NHS Alliance and Confederation among others. We will be looking again at how we can update these documents and make them more practical in the ‘new world’ and also partnering with industry [through the ABPI] and the NHS to review and revitalise both these tools.

Are you optimistic about fruitful partnerships?

Joint working will continue to be an important focus and a part of my day job. QiPP came and went, so we had to hold fire for a while, but now Innovation Health and Wealth (IHW) has provided a restructure, we are pretty sure of what is happening; six months ago we sat down and established that the shift of power is moving to CCGs. Now individual CCGs. Director of Partnerships, Ivan Ellul is particularly keen on localised, dynamic relationships and Mike Farrar is also a champion. Ian Carruthers is the NHS England lead for IHW and is also keen to encourage this type of engagement.

Do you feel that the tide is turning already?

I’m resolutely positive about changes within the NHS. I’ve had heated discussions with clinicians and pharma about joint working, because a lot of them see it as more rhetoric. Some companies, however, are hugely proactive and want to be pioneers of change. GSK are a good example. They’ve shifted their entire salesforce to encourage new ways of working with NHS counterparts. Their leader, Andrew Witty, is passionate about successfully transforming approaches and he’s someone you can believe in, because GSK have freed up patents, conformed to the ‘alltrials’ ideology and shared data. This has filtered down to the way they engage with the NHS and the company have been very smart, as they realise it’s about increasing the whole market. If a healthcare pathway improves it will produce better diagnosis, and better diagnosis means more appropriate and timely use of medicines.

Well said, thanks Naima!