2020 has been a big year for the NHS. COVID-19, Brexit, the junior doctor contract; currently, there are a whole swathe of issues facing our public health service. This blog post aims to examine some of these issues and to consider possible solutions. Much of the information in it is credited to https://www.themedicportal.com/application-guide/medical-school-interview/nhs-hot-topics/
COVID-19 pandemic
How did coronavirus reach the UK?
The coronavirus originated in Wuhan, China, with the earliest known person with symptoms being discovered to have fallen ill on 1 December 2019. Following that, the virus spread globally. Scientists have combined large-scale data and genomic sequencing to map the lineage of different strains of COVID-19, to get an understanding of which countries the virus came from. They found that a third (34%) of transmission lineages came from Spain, 29% from France, and 14% from Italy. It’s important to note that the results are preliminary and the research hasn’t been peer-reviewed.
How does the coronavirus effect the human body?
Some symptoms of COVID-19 can be relatively non-specific; the two most common symptoms are fever (88%) and dry cough (6%), according to data collected by the WHO.
Some early studies suggest between 10 - 20% people with COVID-19 will experience symptoms lasting longer than a month (long Covid). The UK case fatality rate is around 4%.
The coronavirus enters the body through inhalation, or through the eyes, nose or mouth. Once the virus enters the body, it enters our cells through a two-step process. In the first stage, the spike proteins on the virus bind to ACE2 receptors located on host cells. During the second stage of the process, the virus hijacks a special enzyme called a protease that speeds up the breakdown of protein. There are lots of different proteases, but the one that SARS-CoV-2 targets is called TMPRRS2. Once this happens, the protease cleaves the spike protein on the virus in two places, allowing the virus to fuse with the host cell and deposit its RNA into the cells. This allows for the mechanisms inside of the cell to replicate the virus’ RNA and make copies of it.
Once inside, the virus produces an immune response. Cytokines are produced in a cytokine storm and these can attack healthy cells, especially in the lungs - due to the presence of the AEC2 receptor.
Why are there more cases of COVID-19 in countries such as Brazil and India as compared to Europe?
Countries such as Brazil and India have greater economic disparities between their populations. This can lead to less access to healthcare from poorer demographics and mean that there are a greater number of fatalities.
Do lockdowns work?
Yes, it drove infection numbers down, so if that was the goal then it could be said to have worked. It also stopped the NHS from being overwhelmed – but at what cost in the long-term? A YouGov poll showed that three million adults had gone hungry in the first three weeks of lockdown, with 1.5 million going an entire day without eating. Lockdowns can be said to delay transmissions of the virus. However, Sweden didn’t have a lockdown and they didn’t see their national rates of transmission spiking uncontrollably, or their healthcare system becoming overwhelmed. Herd immunity has been largely unattainable; five months into Europe's pandemic and only 6% of the population is known to have antibodies, according to Swedish Public Health Agency research.
Did the UK government respond well to the pandemic?
The UK government offered good economic support, with the furlough scheme (which The Telegraph notes could end up costing <£100 billion). The NHS wasn’t overwhelmed, and the government did put in good precautionary measures, such as the Nightingale Hospitals. However, UK death rate remains high - 3rd highest globally (50,000). The government has been blamed for inconsistencies and u-turns - including the exams fiasco in August. Additionally, many experts argue the government took action ‘too little, too late. These included rejecting lockdown measures, abandoning contact tracing, and downgrading the covid-19 threat level, so that a lower level of PPE was required to treat patients. Earlier lockdown in March could have saved 20,000 lives, according to Dr Neil Ferguson.
BAME and the NHS
95% of NHS Doctors who died of COVID-19 were from BAME backgrounds. The disproportionate death rate in BAME staff is only partially explained by health conditions, age and socio-demographic factors. 20% of the NHS workforce are from BAME backgrounds, but they make up only 10% of board members. The interim NHS People Plan has action points to increase BAME representation across the workforce.
Brexit and the NHS
The UK officially left the EU in January 2020. The NHS may receive more funding as a result. In 2018, the UK government stated that an extra £20 billion per year would be invested in the NHS budget, partly as a result of the Brexit dividend. However, there is a major issue of staffing. Figures from the Nursing and Midwifery Council (NMC) show almost 5,000 nurses and midwives from EU countries have left the NHS in the last two years, with many identifying Brexit as the reason. NHS England still faces a shortage of over 40,000 nurses, putting a large strain on the existing workforce. There is also concerns that Britons living in the EU may return to the UK, putting an extra pressure on the Healthcare service. Secondly, there is the issues of medical stockpiling. Brexit may disrupt medical supply chains from Europe, leading to threats to patient safety. Finally, medical research may be jeopardised. One in three scientific papers are co-authored with EU authors. After December 31st, the UK is at risk of joining other non-EU nations that have a six- to twelve-month delay phase before they can access the same drugs as EU members.
Issues facing A&E
There are three main types of A&E departments in England:
Type 1 departments are what most people may think of as an A&E service: major emergency consultant-led departments providing a 24-hour service. These departments account for most attendances (63% in 2018/19).
Type 2 departments are dedicated for specific specialities (e.g. treating only eye conditions or dental issues)
Type 3 departments treat minor injuries and illnesses and include walk-in centres or minor injury units.
The most prominent measure of A&E performance in England is the four-hour standard. This standard could be scrapped, as many hospitals are unable to meet it (not at a national level since 2013). In 2018, a NHS England review was undertaken into the standard, which recommended that the current four-hour A&E target should be replaced with several new measures instead. This is currently being trialled in 14 different hospitals.
Why have waiting times increased?
Waiting times in A&E have increased due to staffing shortages, increased attendances (20% increase from 2010), and fewer beds (beds have halved over the past 30 years).
Issues facing GPs and primary care
GPs and primary care services are coming under increasing pressure due to vacant GP posts (<15%), increasing demand, closing practices (100 last year), long waits for appointments (1/3 eating >a week). Medical schools are encouraging more students to go into GP practice as a result. The NHS has a £10m scheme to incentivise Foundation Year doctors to become GPs by giving them additional financial support through Flexible Pay Premia (FPP). In 2017, a new scheme was announced in which newly qualified GPs can receive a ‘golden hello’ one-off payment of £20,000 if they start their careers in certain areas that need more GPs, in particular rural and coastal areas. Since the introduction of this, the number of trainee GPs taking up posts in these hard-to-recruit areas has doubled. A new five-year contract for general practice was announced by NHS England, which included an extra £4.5 billion investment by 2023/4.
Vaccinations
This month, the government has suggested that a vaccine may be rolled out throughout December. But in August, one in six people said they wouldn’t get the vaccine (study done by King’s).
One example of vaccine controversy is the Andrew Wakefield MMR scandal of 1998, which falsely suggested a link between the MMR vaccine and autism. As a result, childhood vaccinations began to fall in 1998. The fall continued until 2003/4, reaching a low of 80%. The UK saw a spike in measles cases last year due to the presence of unvaccinated students at university (as a result of Wakefield’s paper).
The NHS Long Term Plan includes various measures that will be used to increase the uptake of both MMR doses. This includes improving local coordination and support to improve immunisation conversation in low uptake areas. They’re also adding an MMR check for children aged 10 and 11 with GPs, and trying to ‘catch up’ young adults who missed the MMR vaccinations as children.
See my blog post on mandatory vaccination for further details on this issue.
Medicinal cannabis
Medicinal cannabis is very sparsely prescribed in the UK. In 2019 the NHS provided only 18 prescriptions for cannabis-related medications. Billy Calwell is one example. In 2017 Billy was prescribed cannabis oil by his GP. This was the first prescription of cannabis oil in the UK. The Home Office stated the doctor should not renew the prescription as it contained low amounts of THC, which is illegal in the UK. His mother travelled to Toronto to pick up medicinal cannabis and this was confiscated. Following public outcry, the Home Office decided that Billy would be allowed the cannabis oil as a special measure.
The junior doctor contract
The junior doctor contact, accepted by BMA in January increased basic salary but drastically reduced the supplements for on-call shifts outside of sociable hours. As a result, junior doctors are being paid less. In 2015, when the proposals were first put forward 98% of junior doctors voted against them, leading to four different 24-48hr strikes. 80% of junior doctors didn’t turn up for work. The new Junior Doctor Contract will bring a £90 million investment over the next four years.
Mental health
Studies show that almost one in three people experience mental health issues at some stage in their life. 1 in 5 women experiences perinatal mental health problems – most commonly depression and anxiety. It’s estimated that an extra £30 million goes into funding eating disorder services a year. NHS England and NHS Improvement will invest a further £15million towards efforts to strengthen mental health services for nurses, therapists, paramedics, pharmacists and support staff. Support will include:
Local mental health specialists will be available to assess and treat those who are referred by colleagues or refer themselves.
For more severe cases, a specialist centre of excellence will be able to assist NHS staff with the tools needed to cope with stress and anxiety caused due to work and family life pressures.
Charlie Gard
In 2016, Charlie developed MDDS (high parents were both carriers of the recessive gene). He couldn’t open his arms or legs or breathe properly. A High Court ruling recommended that Charlie’s life support be stopped. After the ruling, neurologist Dr Hirano offered to continue treatment in the US. Dr Hirano claimed there was a 10% chance that treatment could improve the baby’s condition – despite never meeting Charlie in-person. Experts at Great Ormond Street Hospital feared the treatment wouldn’t help and would prolong his suffering. Charlie’s parents accepted Dr Hirano’s offer of experimental treatment and raised the £1.3M travel and treatment costs through crowd-funding campaigns. The parent’s appeal was denied when it was taken to the Supreme Court and at the European Court of Human Rights. Sadly, Charlie passed away in 2017. Similar type of case for another patient, Alfie Evans.
Impact on the NHS
The Royal College of Paediatrics and Child Health (RCPCH) believe that such cases are “traumatic and distressing”, and this could lead to difficulties in recruitment and retention of vital NHS staff. Charlie Gard’s parents are advocating for a change in the law in order to prevent other parents from going through a similar court case. They want judges to ask whether the parents’ choice of treatment would cause significant harm and if not, they should be allowed to test their options.
Ethical dilemmas
Autonomy: A competent patient refuses it. In Charlie’s case, his parents acted on his behalf due to his age and mental state.
The National Institute for Health and Care Excellence (NICE) recommends treatment at £30,000 or less per Quality-Adjusted Life Year (QALY). Nucleoside bypass therapy was fairly inexpensive, but the cost of ongoing intensive care was estimated at £150,000. Furthermore, Dr Hirano’s best possible outcome was 10%, giving Charlie a shortened lifespan with a severe disability. Statistically, Charlie’s treatment was over 3x the advisory limit. Funds were raised privately, however.
The High Court concluded that the success was too low to justify the trauma Charlie would experience.
Medical licensing assessment
This is a new pass/fail exam that replaces the final medical exams. The test will have two parts: an applied knowledge test that will be computer-based, and a clinical and professional skills assessment. Changes to the Medical Licensing Assessment don’t have any impact on Foundation Training selection. When you apply for Foundation Training, you are assessed on your Education Performance Measure and your Situational Judgement Test. You can score up to 50 points on each. You also need to have passed the Prescribing Safety Assessment by the completion of your FY1 induction programme.
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