England"s new metro mayors will have influential role in NHS | Richard Vize

While Labour will be desperate to push the NHS to the centre of the general election campaign, and the Liberal Democrats will be emphasising their commitment to mental health services, it is the six regional mayors being elected for the first time in May who could provide the biggest surprise when it comes to health policies.

The exact powers of the six – covering Tees Valley, Greater Manchester, Liverpool city region, West Midlands, West of England and Cambridgeshire & Peterborough – vary depending on the deal each region reached with the government, but none of them will control the NHS.

However, like any self-respecting local politician, the candidates are not allowing the limits of their formal powers to deter them from trying to influence such an important policy area.

The manifesto of Andy Burnham, Labour’s candidate for mayor of Greater Manchester, typifies the influence mayors intend to wield. Burnham wants to cut waiting times for child and adolescent mental health services, manage the transition from child to adult mental health services more effectively, have a plan to get local people into NHS jobs, provide more incentives for services to shift from treatment to prevention, and “introduce in Greater Manchester the country’s first fully-integrated National Health and Care Service, building on the work that is already ongoing”.

This tone of his promise on integration implies a clear leadership role for the mayor in health and care policy, well beyond their formal position as just one of many members of the region’s health board.

With these devolved health powers, the temptation for Manchester’s mayor to get involved in broader NHS policy will be irresistible – especially if the winning candidate used to be health secretary. The city region is likely to become the test of how much power regional mayors can exert over health.

Mayors could easily derail STP plans without any obligation to provide a coherent alternative

If the mayor emerges as a driving force for the region’s ambitious health devolution plans – perhaps acting as a broker in disputes and providing reassurance to the public over service changes – then the NHS may begin to see advantages in metro mayors having a more formal role in local health plans. But NHS England will be wary of anything that reduces its firm, if usually discreet, grip on the Manchester experiment.

In the other regions, amid inevitable controversies over sustainability and transformation partnership (STP) plans to move and close services, a metro mayor’s intervention could prove decisive in influencing public opinion. Free of the requirement to make the tough choices, mayors could become a rallying point for public dissatisfaction with local health services.

The implications of this could be far-reaching. Mayors could easily derail STP plans without any obligation to provide a coherent alternative. This could leave NHS leaders in the position of having to either rein in radical changes essential to long-term clinical and financial sustainability, or force through unpopular plans and stand accused of damaging services.

Exerting power without assuming responsibility would be the worst outcome for the NHS from the introduction of metro mayors. STP leaders need to make sure this does not happen. They need to recognise the importance of these new powerbrokers and engage with them quickly and openly. That means listening as well as telling.

It is an opportunity to involve them in key aspects of STP plans, such as tackling the root causes of health inequality and improving mental health with the help of major local employers.

NHS England and NHS Improvement will also have to make some accommodation with this new political reality. They have an important role in ensuring mayors understand the context in which STP plans have been put together, the guidance that local leaders are having to follow, and what clinical and financial sustainability looks like.

Whatever the devolution deals signed with the government say, the NHS will have six new leaders on 5 May.

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England"s new metro mayors will have influential role in NHS | Richard Vize

Simon Stevens" NHS gamble is probably the right choice - but price could be high | Richard Vize

The NHS plan for the next two years represents a perceptible contraction of the health service’s offer to the public.

The proposals in Next steps on the NHS Five Year Forward View, published on Friday, are shaped by shortages of money and staff.

Simon Stevens, the NHS England chief executive, has burned through much of his political capital in disputing government claims about whether the NHS has been given all the money it asked for, so this was not an opportunity to push for further cash.

So in the face of the unrelenting pressure of the government’s austerity programme and barely controlled hospital debt, he is gambling that politicians and the public will stomach longer waits for routine surgery if the health service can deliver better performance on cancer treatment, A&E waits, mental health services and GP appointments.

In the wake of slipping cancer treatment times and the recent outcry over the death of a child waiting for urgent surgery, this is probably the right choice. But the price could be high.

Allowing elective surgery times to slide over many years was what led to hundreds of thousands of patients waiting months for operations by the time New Labour came to power in 1997, elected partly on its pledge to slash waiting lists. It would be a serious blow if the NHS returned to the days of people dying while waiting months for heart surgery, and many more forced to endure avoidable pain and disability.

Access to some of the latest approved drugs is also to be delayed – in breach of a commitment in the last Conservative manifesto to speed up access.

Stevens is anxious to reassure the public that performance will not slide back to that of the 1990s, but it is difficult to see how growing waiting times will be arrested and reversed in the coming years.

The plan makes some brave assumptions about the ability of the NHS to expand its workforce, including 4,000 more nurses through improving staff retention – turning round a recent trend – and up to 2,000 more nurses returning to practice.

There is yet another pledge to increase the number of GPs substantially, despite little discernible progress. However, concerns are growing that staff shortages will be exacerbated by EU staff heading back to the continent in the wake of the Brexit vote.

More promisingly, the plan may well mark the beginning of the end of the internal market. It names nine areas being considered as pioneering “accountable care systems”, with NHS organisations and local authorities working together as an integrated health system.

These areas will have considerably more control over how they deliver their healthcare, and will be effectively freed from the endless focus on contracts rather than patients imposed by the purchaser/provider split.

However, doing so will require ever greater legal contortions to simultaneously stay within the law while circumventing it. This is a necessary bodge, as it will be years before anyone attempts another NHS reform bill, but these workarounds cannot be sustained indefinitely.

Everyone will now be working in Sustainability and Transformation Partnerships, and NHS England makes clear that anyone who fails in their duty to collaborate can expect to be handled roughly.

In the absence of more money, the alternative to Stevens’ plan would be a steady atrophying of performance across the entire health service. Instead, NHS England is pushing forward on the key priorities of emergency care, cancer treatment, mental health and primary care, and allowing routine surgery to pay the price.

But many of its promises look optimistic, and there is a danger that the slide in surgical performance will eventually reverse years of progress.

For the time being this can be portrayed as a tactical move, but with austerity set to last well into the next decade, there is a risk that the NHS will cease to be a comprehensive service.

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Simon Stevens" NHS gamble is probably the right choice - but price could be high | Richard Vize

Technology could redefine doctor-patient relationship | Richard Vize

Advances in clinical uses of artificial intelligence (AI) could have two profound effects on the global medical workforce.

AI, which mimics cognitive functions such as learning and problem-solving, is already making inroads into the NHS. In north London it is piloting use of an app aimed at users of the non-emergency 111 service, while the Royal Free London NHS foundation trust has teamed up with Google’s DeepMind AI arm to develop an app aimed at patients with signs of acute kidney injury. The hospital claims the project, which uses information from more than 1.6 million patients a year, could free up more than half a million hours annually spent on paperwork.

AI raises the prospect of making affordable healthcare accessible to all. According to the World Health Organisation, 400 million people do not have access to even the most basic medical services. Hundreds of millions more, including many in the world’s most advanced countries, cannot afford it. A key factor driving this is the worldwide shortage of clinical staff, which is getting worse as populations grow.

At last month’s DigitalHealth.London summit, Ali Parsa, founder of digital healthcare company Babylon, argued that mobile technology coupled with AI makes universal access a realistic goal, while replacing doctors with intelligent systems will slash costs.

“There is no solution which can fundamentally cut the costs of healthcare as long as we are reliant on humans,” he said.

So the second impact of artificial intelligence could be not merely augmenting the pool of medical talent but beginning to replace it. Big claims are being made for the clinical power of AI. Last year IBM’s Watson supercomputer was credited with diagnosing in minutes the precise condition affecting a leukaemia patient in Japan that had been baffling doctors for months, after cross-referencing her information with 20m oncology records.

However, the same system has just consumed five years and $ 62m (£51m) in an unsuccessful attempt to transform care at the University of Texas MD Anderson Cancer Center, showing how difficult it is to connect these digital behemoths to everyday hospital work. With the NHS still struggling to introduce electronic patient records, the idea of plugging the UK healthcare system into an all-knowing digital brain any time soon is fantasy.

While there is no doubt that AI will enable faster and more accurate diagnoses, a more realistic prospect than replacing doctors is to redefine their role.

That will be to put machine-generated information into the context of the unique life and needs of the individual patient, which cannot yet be reduced to an algorithm. As Dr Ameet Bakhai, consultant cardiologist at the Royal Free trust, told the summit, machines making clinical decisions on their own without that human context could fail to meet Isaac Asimov’s first law for robots of “do no harm”.

Digital evangelists argue that intelligent machines will be able to incorporate the latest data and research immediately, but that is both questionable and a potential weakness. Clinical trials vary in scale and quality, and indiscriminate inclusion would inevitably lead to mistakes. Digital hardliners would argue that machines should judge the quality of the research, but for the foreseeable future the expertise of doctors will be essential to deciding the validity of new approaches.

So perhaps one of the most powerful effects of artificial intelligence will be, perversely, to make healthcare more human and personal. It will remove the dependency on doctors’ fallible memory and incomplete knowledge, and free them to use machine-generated information to work with patients to shape their specific treatment.

This has profound implications for medical training and what defines a leading clinician. It will be those who can harness AI to their own medical knowledge and their human skills of context and empathy who will be the leaders of their profession. In the new world there will still be a great deal for highly-trained humans to do.

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Technology could redefine doctor-patient relationship | Richard Vize

How can health services keep pace with the rapid growth of cities? | Richard Vize

The relentless growth of urban populations is driving city and national governments to increase access to healthcare while tackling the root causes of poor health.

According to Oxford Economics [pdf], the world’s largest 750 cities will be home to 2.8 billion people by 2030 – more than a third of the global population. They will account for almost a third of the world’s jobs and more than half its consumer spending. More than a dozen cities will have populations greater than 20 million.

Rapid, uncontrolled urbanisation strains many aspects of city life that determine health. Traffic, factories, generators and construction poison the air, meanwhile water supplies can become contaminated, poor housing harms the health of children, and food supply and quality can be compromised.

Unplanned urban growth drives poverty. About 900 million people worldwide live in urban slums, where overcrowding encourages the spread of infectious diseases such as tuberculosis, dengue fever and cholera. The United Nations estimates that by 2030, roughly 60% of city inhabitants will be under the age of 18, which puts huge numbers of children at risk from illnesses such as diarrhoea and pneumonia, the leading causes of global childhood death.

Health services, particularly in developing countries, are concentrated in cities. As Mark Britnell notes in his study of global healthcare, many developing countries such as China, Indonesia and India suffer from a chronic shortage of health workers. This creates big disparities in care between cities and the countryside; doctors are reluctant to work in rural areas because pay is poor, career choices are limited, hospital facilities are often inadequate and primary care tends to be underdeveloped.

Meanwhile, in the cities, hospitals become overcrowded because patients know that is where the best doctors, research and technology are found. The dominance of hospital care in cities often means primary care is neglected, which according to the World Health Organisation (WHO) [pdf] can lead to unregulated, unsafe and ineffective private services. In some African cities, public primary healthcare has almost disappeared.

Britnell highlights some of the efforts being made to bridge the shortfalls. Brazil has announced new medical schools to train thousands of additional doctors, and training is being extended to include two years working in public service posts. This could add up to 36,000 working students to the system by 2021. Compulsory training in public hospitals was inspired by the NHS.

In addition, Brazil has recruited at least 10,000 doctors from Cuba to work in the poverty-plagued favelas on the peripheries of cities, as well as in remote areas.

The chronic shortage of clinicians is encouraging countries to make better use of volunteers and community workers. India is trying to boost its services in slums through the National Urban Health Mission, which emphasises reproductive health and works with women’s health committees.

Toronto [pdf]has been trying to bring together its primary and hospital services to provide joined-up care for patients with several health conditions. This includes individual care plans, one point of contact, and multidisciplinary teams supporting high-risk patients after they have been discharged from hospital. The city’s Ageing at Home programme aims to make it easier for older people to continue to live at home after illness.

Toronto also provides impressive support for people living on the streets with mental illness. Its Streets to Homes programme includes incentives for private landlords to offer accommodation. Several thousand people have moved into their own home since 2005, and about 80% of them remain there for at least a year.

Yet for many people, access to healthcare depends on the ability to pay, which excludes swathes of the population. Increasingly, countries such as China, Thailand and Indonesia are addressing this problem by pursuing universal healthcare. At present around two in five countries have some form of universal healthcare.

Britnell argues that its expansion is being driven by two opposing forces: capitalism and globalisation have grown a middle-class demanding more from governments, while about 1 billion people lack access to basic healthcare and 100 million are impoverished every year through catastrophic healthcare costs. Providing more equal access to health services strengthens social cohesion and promotes economic growth.

But while developing countries are increasing the proportion of their wealth spent on healthcare, urban populations are expanding so quickly that it is all but impossible to provide the health infrastructure and staff to keep pace.

Faster progress can be made, however, in improving the environment, such as providing cleaner air and water. For this reason, the WHO believes local government – and particularly executive mayors – are central to improving city health.

Beijing and Shanghai, for example, have introduced tough anti-smoking laws. In 2013 Mexico City became the first in the world to levy a tax on sugary drinks, which had been a factor in Mexico having among the world’s highest obesity and diabetes rates. Kuwait City has reduced salt content in bread to tackle high blood pressure. London and Paris were among the first cities to attempt to cut traffic pollution and increase exercise by offering free bicycle use.

Poor road safety takes many urban lives. Fatal traffic accidents [pdf]cost about 21 lives per 100,000 population annually in Brasilia and 18 in Nairobi, compared with 1.3 in Tokyo. Cutting road deaths depends on many factors – higher population density actually reduces deaths compared with sprawling areas. São Paulo (Brazil), Bogotá (Colombia) and Accra (Ghana) are among cities pursuing safer road design.

The health of city populations is becoming a central concern of local and national governments and international institutions. Affordable access to health services is just part of the story. Local government in particular recognises that improving the health of city populations depends on everything from ensuring water quality to designing safe roads and controlling air pollution.

But there is a chasm between cities where growth is controlled and those where the relentless quest to find work is creating polluted, overcrowded slums.

• Richard Vize provided editorial support to Mark Britnell for his book In Search of the Perfect Health System, which won the health and social care prize at the BMA Medical Book Awards 2016.

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How can health services keep pace with the rapid growth of cities? | Richard Vize

Do plans for transforming principal care stand up to scrutiny? | Richard Vize

Ed Miliband is promising an appointment at a GP surgical treatment inside 48 hrs of in search of a consultation. Photograph: Lynne Cameron/PA Wire

The emphasis of the NHS and politicians is lastly shifting to where the transformation in healthcare demands to consider location – primary care companies. Who should commission them, how considerably income they must get and what they need to do are all being debated.

It is striking that 1 of Simon Stevens’ 1st actions as NHS England chief executive has been to tackle the paralysis in primary care improvement, by acceding to clinical commissioning group calls for a significantly greater function in establishing primary care. His invitation to CCGs to demonstrate how they would use additional powers to improve good quality and place their local NHS on a “sustainable path” is a major phase forward in turning the speak about shifting resources from hospitals to communities into action.

The shadow overall health minister, Andy Burnham, attacked the strategies simply because they open up the chance of GPs possessing a conflict of curiosity – the reason the 35,000 primary care contracts had been given to NHS England in the first place. But transparency and powerful oversight will be a key component of the exams NHS England will apply to the bids, and the contracts themselves may possibly nicely remain with its area teams, leaving the CCGs to concentrate on creating solutions and strengthening high quality. Wellness and wellbeing boards – for whom Burnham desires a a lot larger function – are the apparent selection for supplying regional oversight of CCG ideas.

This all generates a lot more governance spaghetti, but the time for organisational elegance is long past all that matters now is what performs. Offering CCGs more influence above principal care improvement is the appropriate issue to do. It speedily grew to become clear to every person – like NHS England – that location teams lack the capability, regional knowledge and major care expertise to develop and put into action ideas which would shift care from hospitals to communities.

With CCGs now in a position to range across major, community and secondary care – and signals from Stevens that they will soon have a larger part in commissioning professional providers as properly – they will now be capable to develop joined-up plans for most local services which ultimately commence to move sources.

Labour’s own massive thought for main care – unveiled on Monday – is firmly centred on electoral appeal and unburdened by information such as credible costings. Leader Ed Miliband stated that underneath Labour there would be a “same day consultation” for individuals with urgent difficulties, with all individuals entitled to a GP appointment within 48 hrs.

The party claimed it would expense £100m, to be paid for by cutting the bureaucracy developed by competitors. The outdated line that culling bureaucrats and lawyers is all which is needed to fund new providers may possibly pass muster for a press release, but it does not stand up to scrutiny.

Even if it did, the income is not adequate to increase the amount of GPs and practice nurses and adjust the way they operate – notably with greater use of technology – to safe the rapid entry for patients the get together is promising.

As the Royal University of Standard Practitioners factors out, it only amounts to about £10,000 per practice, which is going to make little inroad into the price of using additional clinicians. The RCGP claims the further value of delivering the kind of principal care services that everyone talks about is nearer £3bn, which would indicate rising the major care share of the NHS budget from 8% to eleven%. For as soon as, the college might not be exaggerating this averages at about £14m per CCG.

In the rush to broaden out-of-hospital care, basic practice should not be the unique focus for new investing. Hospital services need to be part of the out-of-hospital resolution, with their clinicians increasingly working in the community and the previous demarcations in between major, community and acute companies being taken down. It would be an terrible mistake if main care took the perspective that “it really is our turn now”. If we have discovered anything from the extreme investing on acute care, it must be that joined-up answers operate greatest.

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Do plans for transforming principal care stand up to scrutiny? | Richard Vize