Monitor, the health regulator, has launched an investigation to find out how many NHS walk-in centres have been closed down since opening in 2008.

The ‘Darzi centres’, providing care to unregistered patients, have largely been closed down – apparently due to high levels of walk-in use making them too expensive.

The fact that Monitor has not been told how many NHS walk-in centres have been closed down, or why, is a sign of poor transparency.

Following Lord Darzi’s NHS ‘next stage review’ in 2008, each PCT was required to commission at least one walk-in centre to provide routine or urgent primary care to patients without an appointment.

The new centres were open from 8am to 8pm seven days a week. According to Monitor, they have proved “very popular with patients”. However, since 2009 many of them have been closed down.

The walk-in centres were commissioned by PCTs through competitive procurements, with five-year contracts typically awarded to providers including GP-led groups and the independent sector.

Catherine Davies, Executive Director of Cooperation and Competition at Monitor, said: “It is in the interests of patients to find out why walk-in centres are closing. Walk-in centres are very popular with patients, and the potential impact of such closures at a local and national level needs to be better understood.”

From 2009 onwards, she noted, many PCTs have renegotiated or terminated walk-in centre contracts. “We understand that the rationale... was often that there had been an unexpectedly high number of walk-in consultations (leading to higher payments than anticipated) and fewer than expected registered patients.”

NHS England has taken over responsibility for the existing walk-in centre contracts, but only in relation to registered patients. The CCGs are responsible for deciding whether to maintain walk-in centre services for non-registered patients.

The number of GPs in England will rise by 400 over the next two years, according to the Government’s mandate for Health Education England (HEE).

The 14% increase in the number of GP training posts seeks to address the growing need to reduce the pressure on secondary care by improving and extending primary care.

In addition, the ‘task force’ recently set up to increase the number of doctors in emergency care will be maintained until 2015.

The new mandate for HEE requires it to ensure that 50% of medical students are training to become GPs by 2015. This requires the number of GP training posts to increase from 2,850 to 3,250 by 2015.

The new body responsible for healthcare education and workforce planning will need to develop and implement a plan by this summer to draw more doctors into emergency care.

HEE will also need to:

• ensure and demonstrate that selection for training programmes is based on values and behaviours as well as technical and academic skills

• ensure that trainee doctors have enough time with patients

• ensure that at least 50% of student nurses have community placements as part of their training by March 2015

• develop a postgraduate training programme for nurses who care for older people with complex needs

• provide dementia awareness training – including early symptom recognition and effective interaction with patients – to 100,000 healthcare staff by March 2014.

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 Royal Pharmaceutical Society (RPS) has published a guide to medicines optimisation for primary care professionals.

Medicines Optimisation: helping patients make the most of medicines places emphasis on safe and evidence-based medicine use to reduce wastage and improve patient outcomes.

The guide, endorsed by the ABPI and the Royal College of General Practitioners, reflects the growing role of community pharmacists in medicines management and the care of people with long-term conditions.

Sir Bruce Keogh, Medical Director of NHS England, said the guide “could revolutionise medicines use and outcomes”. It outlines four basic principles:

• Aim to understand the patient’s experience.

• Make sure the choice of medicine is made on the best available evidence.

• Ensure that medicines use is as safe as possible.

• Make medicines optimisation part of routine practice.

“I would encourage everyone to adopt these principles whether prescribing, dispensing, administering or taking medicines,” Keogh concluded.

The RPS guide is partly a response to evidence that 30–50% of patients are not compliant with prescribed medication, and £300m worth of NHS medicines are wasted each year.

Shilpa Gohil, Chair of RPS England, commented: “As care shifts towards primary care prevention, unprecedented economic challenges combined with problems around medicines waste, adherence and safety mean that medicines optimisation is now essential to good patient care and the effective use of NHS resources.

“Medicines optimisation will require health professionals to work across boundaries to individualise care and work in partnership with each other and patients to secure better outcomes and drive improved adherence.”

Health Secretary Jeremy Hunt has pointed the finger of blame at GPs for rising A&E admissions and the added pressure placed on emergency services.

Speaking to MPs, Hunt said that “poor primary care provision” was behind some four million additional people unnecessarily visiting accident and emergency services.

But the General Practitioners Committee called Hunt’s claims “nonsense”.

A Department of Health spokesperson played down Hunt’s accusations insisting the Health Secretary was “clearly not blaming GPs” and that he was referring to procedures set by the former Labour government.

Hunt was responding to figures published by Labour that showed the NHS had missed its national A&E waiting times each week for the past six months.

He claimed this was down to poor alternatives to primary care which was the result of changes introduced by Labour to the GP contract.

“The reason that there is so much pressure on A&E is because of the disastrous GP contract that was negotiated,” he told the House of Commons. “That is what is causing the huge pressure. That is what we are determined to put right.”

The Health Secretary said the solution to the rising number of A&E admissions was to analyse the GP contract, introduce alternatives to secondary care and integrate health and social care services.

Novo Nordisk (NN) has celebrated 90 years of manufacturing and selling insulin for the treatment of diabetes.

The Danish company was the first to develop human insulin and the insulin pen for fixed dose injection.

It now produces half of the world’s insulin – a drug vital to all people with type 1 diabetes and many with type 2.

NN was founded by medical researchers August and Marie Krogh. August was a Nobel Prize winning zoologist and Marie was a doctor and diabetes patient.

In 1922, the couple went to Canada to meet Professor Macleod, the leader of the team who had discovered insulin. They gained permission to commercialise the drug in Scandinavia, and launched the company in early 1923.

Treatment innovations developed by NN include ‘modern’ insulins (genetically engineered insulin analogues with enhanced properties) and GLP-1, a type 2 diabetes drug than enhances the production and absorption of the body’s insulin.

In 2002, NN started the World Diabetes Foundation, an international funding agency supporting diabetes prevention and treatment in the developing world.

The company also manufactures biopharmaceuticals to treat haemophilia and growth disorders, and established the Novo Nordisk Haemophilia Foundation in 2005 to support patient care and treatment.

“Our 90 year anniversary is a significant milestone for Novo Nordisk. Our commitment to changing the lives of people with diabetes is unparalleled both globally and here in the UK, where we have been operating for over 25 years,” said Peter Meeus, NN’s UK Managing Director.

“Our researchers have discovered many breakthroughs in diabetes treatments for patients and our dedication to the training and support of NHS doctors and nurses has helped thousands to share expertise between primary and specialist care.”

Based in West Sussex, Novo Nordisk UK employs about 400 people.

NHS chemotherapy services are being stretched to the limit by the combination of increased demand and reduced funding, a new report from Roche warns.

The drug company has published The Cancer Capacity Challenge, which argues that new systems to deliver chemotherapy more rapidly and cheaply are needed.

Over 70% of oncology specialist nurses, responding to questions from their colleagues, said lack of capacity to deliver the service was harming care.

The report says that improvements in diagnosis and treatment have increased the life expectancy of patients with cancer – but this in turn has increased the level of demand for services.

According to oncology specialist nurses surveying the views of their colleagues:

• 71% believe patient care is suffering from lack of NHS capacity in chemotherapy

• 76% believe waiting times for chemotherapy are set to increase

• 67% said their day units are fully stretched or over-full.

The incidence of cancer in the UK has increased by 20% in men and 40% in women over the last 30 years, due primarily to the ageing population.

The CCC report recommends that the capacity of chemotherapy services could be increased by treating more patients at home or in primary care.

To facilitate this, Roche argued, there is a need for chemotherapy drugs that can be administered more quickly and easily in a range of settings. The report suggests that Roche may be planning new products in this important area.

Kate Denby, Haematology Advanced Nurse Practitioner, Royal Exeter and Devon NHS Foundation Trust, said: “The steps involved in each patient visit can take as long as seven hours. Patients usually prefer shorter visits to hospital for their chemotherapy treatment, so it’s essential that we are able to find solutions that help improve the patient experience.”

The Labour Party has outlined plans to integrate health, mental health and social care in a single system, ultimately run by local government.

Shadow Health Secretary Andy Burnham has argued that such a ‘whole person care’ approach is the only way to meet the challenges of chronic illness and the ageing population.

The current system, he argued, merely sees patients slipping in great numbers from primary care to hospital and hence to nursing homes.

Speaking to the King’s Fund health think tank, Burnham said a Labour government would legislate for “a one budget, one service approach”.

Health and social care would merge, he said, with the NHS providing social care and local authorities commissioning healthcare.

Echoing recent statements by NHS Confederation leader Mike Farrar, Burnham said that integrated care was the only way to meet the clinical and economic needs of the NHS.

To shift the balance of healthcare towards prevention, he argued, the Payment by Results tariff needed to be replaced by a ‘year of care’ payment system for patients with complex needs or chronic diseases.

The providers of integrated care might be either acute NHS trusts or primary care services, he said, but in either case both services would be combined – with mental health services brought under the same control.

Burnham said: “In the century of the ageing society the gaps are becoming dangerous. People are falling into the ever-expanding cracks between our three systems. We are paying for failure, allowing people to fail at home and drift into expensive hospital beds and from there into expensive care homes.”

However, critics will argue that local authorities lack healthcare expertise and are often the least responsible and reliable kind of politicians.

As the incidence of diabetes in the UK soars, the austerity NHS is increasingly unable to meet the needs of patients with this complex and lethal disease. How can the pharmaceutical industry help the situation?

Blindness. Foot and leg amputation. Kidney failure. These are among the complications of diabetes, a complex metabolic disorder that is now the leading health challenge facing western society.
In diabetes the absorption of glucose (sugar) from the blood fails, causing it to accumulate in the circulatory system. This occurs either because the pancreas stops producing the hormone insulin (type 1 diabetes) or because insulin production is inadequate or the body’s response to it is poor (type 2 diabetes).
Both types of diabetes have genetic risk factors, but type 2 or ‘mature onset’ diabetes has other risk factors such as age, obesity and lack of exercise. Type 1 or ‘juvenile onset’ diabetes is fatal unless the missing insulin is replaced by injection. In type 2 diabetes, a range of medications such as metformin can be used to improve glucose uptake.

The number of people diagnosed with diabetes in the UK has increased from 1.4 million in 1996 to 2.9 million in 2012, and continues to rise, with type 1 diabetes now accounting for only 10% of the total. The prevalence of type 2 diabetes has risen sharply, due to the ageing population and the trend towards obesity.

There is no cure for diabetes. A range of medications exist to treat it, but establishing the correct dosage levels is not easy: only an estimated 6% of diabetes patients get the balance right. Since no medication can make diabetes go away, the condition demands constant monitoring and medication adjustment, as well as checks for complications.

And at a time of deepening austerity in NHS funding, that level of attention to patient needs is getting harder to afford. All the signs are that people with diabetes (especially the more high-maintenance type 1) in the UK are at increasing risk of disabling or fatal complications. Sugar is killing more of us all the time.

High and dry
In November 2012, the Public Accounts Committee observed that diabetes care in England was “depressingly poor”, with 24,000 preventable deaths from the disease happening each year. The report pointed to a lack of clinical leadership and a ‘postcode lottery’ in diabetes care.

Barabara Young, Chief Executive of charity Diabetes UK, commented: “Given all the increasingly strong evidence of inadequate care, we simply cannot understand why the NHS has sleepwalked into this situation.”

During 2012, Diabetes UK drew attention to the need for better access to diagnostics, more referrals to specialist care, and wider awareness of the role of healthy lifestyle in preventing and controlling diabetes.
In April 2012, Young noted that 80% of NHS spending on diabetes care went on treating preventable complications. In May 2012, Diabetes UK stated that diabetes care in England was in a “state of crisis” with fewer than half of patients receiving adequate care.

Yet the medicines and diagnostics exist to reduce the incidence of diabetes, manage the condition and avoid complications. It’s not rocket science. What has gone wrong – and what is the solution?

A preventable crisis
Tracy Kelly, Head of Care at Diabetes UK, spoke to Pf about the problems of diabetes care. For the patient, she said, “Optimal diabetes control requires dedication and motivation from the individual to test, inject or take medication, adjust their dietary intake, potentially make lifestyle changes, monitor their condition and ensure they are receiving their health checks.”

This puts the patient under intense pressure, especially if they have other chronic conditions. How can the pharmaceutical industry help? In three ways, Kelly said: “Better provision of information and education for people with diabetes and for the healthcare professionals; commitment to research into new and improved treatments and monitoring approaches; and bridging the gap in healthcare services by supporting specialist nurses and dieticians in hospitals, for example with pump training and starting on insulin.”
Importantly, Kelly noted, the agendas of drug treatment and lifestyle change are not opposed: “There should always be a dual approach.” In treating both types of diabetes, clinicians need to look for the optimum blend of medication and lifestyle factors for each patient. The NHS needs to deliver programmes of risk assessment and early diagnosis; offer effective education in self-care for all patients; and ensure that they receive the nine regular checks recommended by NICE.

Working together
Successful diabetes care depends on integrating primary and specialist care, Kelly emphasised. “Effective diabetes care can only be achieved through integration. There must be clear referral plans in place and transparency about who does what and where specialist diabetes care is required. Specialist teams also have a key role to play in educating and supporting primary care.”

Cutting down on GP referrals is a growing NHS trend, praised by David Nicholson in his 2012 NHS review and promised in many CCG commissioning plans. Does this pose a threat to diabetes care? Kelly’s response was clear: “Cutting down referrals to specialist care may increase the risk of complications and could result in increasing costs to the health system. Diabetes is complex and any blanket rules to cut referrals could put lives at risk over the long term.”

For patients with type 1 diabetes, in particular, referral management is a recipe for trouble: “We know it is important for people with type 1 to have access to a team of specialists such as a dietician, podiatrist and counsellor. But often their access to this kind of support only comes once complications have developed.”
In short, drug manufacturers and healthcare providers can work together to support patients in avoiding complications – but clumsy cost-driven applications of QIPP are tending to disable care.

The hidden disease
As Louis MacNeice said, the North begins inside. Danish pharmaceutical company Novo Nordisk has specialised in diabetes care since its launch in 1923. Its insulin products (used by many type 2 as well as type 1 patients) are the standard of care in the UK. The company’s CEO, Lars Sorensen, recently observed: “What we are good at, all of a sudden becomes the biggest public health problem we have ever seen.”
Peter Meeus, Vice President, Novo Nordisk UK and Ireland, spoke to Pf about the company’s role in meeting the diabetes challenge. He noted that according to the National Diabetes Audit, only half of diagnosed patients in the UK are achieving treatment targets, while fewer than half of all people with diabetes receive all nine recommended healthcare checks.

Too often, Meeus noted, diabetes is only detected when secondary complications arise such as retinopathy and foot ulcers. Insulin can be the most effective treatment, but fear of injecting is sometimes a barrier to its adoption. As a result, “many patients start on insulin too late and are therefore at risk for developing serious late complications”. This is unfortunate, as the needles used today are much thinner and less painful.

Shot in the dark
According to Meeus, the pharmaceutical industry can help the NHS meet the challenge of diabetes by helping to identify the high proportion of diabetes patients who are poorly controlled, and to ensure these patients achieve control within the national guidelines.

He added: “Novo Nordisk is working with the DH and local health economies, together with physicians, to deliver agreed diabetes health outcomes at both national and local level, using appropriate innovative medicinal interventions as well as service design and support.” Specifically, the company provides Diabetes Education Nurse Facilitators to primary and secondary care organisations where needed, and its local Diabetes Outcomes Directors work to assist the redesign of diabetes services.

The company may owe its current growth in part to the growing incidence of diabetes, Meeus said, but its depth of experience in this therapy area has enabled it to take advantage of the opportunities: “Innovation and science have always been at the core of Novo Nordisk’s business, and as a result we today have the broadest portfolio of R&D diabetes projects. At a time when others in the pharmaceutical industry are cutting R&D budgets, we’re increasing our investment.”

“The challenge going forward,” he concluded, “is the fact that diabetes today is the biggest problem for healthcare systems, but at the same time the healthcare budgets are under increased pressure.” Diabetes UK and millions of patients would agree. But where there’s a will, there’s (sometimes) a way.

A limited ‘experimental’ version of the Government’s Innovation Scorecard points to variation and low overall levels in patients’ access to new NICE-approved medicines across England.

The spreadsheet and report published by the Health and Social Care Information Centre summarise the existing data on the availability of 76 medicines and 6 medical technologies recommended by NICE through NHS organisations.

While the initial ‘scorecard’ cannot be used to assess the performance of individual organisations, it will stimulate discussion on how to develop a fuller and more accurate version.

The goal of the Innovation Scorecard is to support the uptake of innovative therapies by the NHS, in line with the Government’s ‘Innovation, Health and Wealth’ strategy.

More information is needed to address the causes of the variation in availability of these treatments, since patient demographics and local purchasing arrangements may influence the data.

The report includes: estimates of actual and expected use of medicines; volumes of medicines used in primary care (daily dose per 100,000 of CCG population); and volumes of medicines used in secondary care (mg of drug purchased by hospital trust per 100,000 bed days).

The ABPI has expressed concern that the initial ‘scorecard’ not only reveals widespread variation but also shows the uptake of new medicines to be generally well below the expected level.

Stephen Whitehead, ABPI Chief Executive, commented: “This first Scorecard is less detailed than ABPI hoped for and we envisage future scorecards offering more details on how the NHS is complying with NICE guidance. But we welcome its publication as a first step on a transparency journey in the new NHS.

“I believe the Government understands the challenges, but it must act quickly and decisively to drive the adoption and diffusion of the newest and most innovative medicines across England.”