When will public anger over the NHS reach a political tipping point? | Polly Toynbee

There is an ebb and flow in reporting on the NHS as Trump, Syria and Brexit dominate front pages. But the pressure-cooker state of the entire service still worsens. This morning’s latest figures are just a snapshot of deterioration – but every target is missed, for A&E, ambulance response times, for treating psychosis within a week, for cancer waiting times, blocked beds and diagnostic tests.

“Demand” is rising, the government says, as if serious illness were a choice, though the pressure comes from well-predicted rapidly increasing numbers of old, sick people: this February’s A&E figures are, as ever, better than deepest winter January, but worse than February last year, as this crisis ratchets up. Major A&E centres are treating 81.2% of patients within four hours, against a target of 95% that used to be hit before 2010. The government likes to blame frivolous users of A&E, but those are easily triaged to on-site GPs. Serious delays are due to very ill people needing to be admitted with no empty beds: bed occupancy is at dangerous levels, as Chris Hopson of NHS providers warns, where doctors often have to decide “one in one out”, discharging those who still need more care too early.

Take the temperature in virtually every part of the NHS and the wonder is how the heroically overstretched staff keep the wheels on the trolley. Take this week alone: the Royal College of Physicians says 84% of doctors have to cope with staff shortages and gaps in rotas. GPs? Two years after a government promise of 5,000 more GPs, numbers are still falling. They dropped by 400 just in the last three months of last year: as doctors find the workload unmanageable some escape abroad, take earlier retirement or become locums. Too few new doctors want the burden of running a GP partnership, so 92 practices closed last year, tipping hundreds of thousands more patients on to already overloaded neighbouring GP lists.

Today the Royal College of Nursing starts consulting its members on whether to hold a strike ballot, the traditionally most reluctant of unions to take action. But with public sector pay frozen yet again at 1%, when inflation will shortly hit 3%, nurses are departing, like doctors, for less stressful, better-paid work. Recruitment from the EU is plummeting, as predicted.

As everyone firefights, all the preventative services are being cut that might prevent patients needing a crisis bed

As everyone firefights, hand to mouth, all the preventative services are being cut that might help keep patients from needing a crisis bed. The government has lines to take but no answers, and some of those “lines” are fictions. No, the NHS has not had £10bn, as Theresa May keeps claiming: it’s more like £4.5bn over four years, says the Kings Fund.

No, the £2bn given to social care will not ease the beds crisis, for all the exhortations to councils to use every penny of it in releasing bed-blocking patients with new care packages at home. NHS Providers, representing NHS hospitals, mental and community trusts, says councils are using that money to stem the collapse of existing care services and care homes, as the higher minimum wage and rising costs cause multiple closures. Cuts leave at least half a million old people getting no care, who would have done, and that risks falls, neglect and extra hospital visits. The care crisis is seeing 900 care workers a day leaving underpaid and overworked jobs.

Money, you might think, comes last in hospital managers’ priorities. But they are being severely harried and punished by NHS England to rein in ballooning debt by plundering capital funds and selling bits of land to cover running costs, one-offs many say they can’t repeat this year. An NHS England-commissioned report says £10bn is needed to cover this depleted capital: that’s not for grand new projects, but for basics like outworn dialysis machines.

A chair of a leading teaching hospital tells me “heroic assumptions” are being made by most trusts agreeing their “control totals”, their spending limits for this year. Debts will swell again. This year the NHS gets just a 1% increase, next year an unprecedented zero.

One of the Labour’s NHS triumphs was to cut waiting times for operations from 18 months to 18 weeks – but now that totemic 18-week limit has been abandoned. However, that only adds to hospitals’ financial woes as they rely on income from elective surgery, while every extra emergency costs them money.

This is the dismal background to the reorganisation that NHS England head Simon Stevens is attempting, almost undercover. His state of play review of his five-year forward plan passed hardly noticed, announcing a first tranche of England’s 44 STPs, (sustainability and transformation plans) to reconnect local services fragmented by the Lansley 2012 act.

Most observers think it the right way to go, putting the NHS and social care under a united structure with one finance hub, ending destructive and expensive competition and tendering of services. But hardly anyone thinks this can be done with no new money: every STP calls for capital for new beds and units. Virtually all involve closures and mergers stirring a local political outcry.

Jeremy Hunt, who always presented himself as the patient’s ally, rooting out poor quality, wallowing in the Labour disaster at Mid-Staffs, has fallen uncharacteristically quiet. He has nothing much to say about patient safety in A&Es or elderly patients turned out of beds too soon. Not even deaths on trolleys in A&E corridors in Worcester roused his usual righteous ire.

Concern about the NHS has risen high in recent polling: what no one knows is when public anger will reach a political tipping point. May and Hammond stay iron-clad adamant: all this is NHS shroud-waving and there will be no more money. Lack of any opposition helps, but can they really tough it out where Thatcher, Major and Blair all bent in the face of NHS crises?

When will public anger over the NHS reach a political tipping point? | Polly Toynbee

Tipping point: revealing the cities where exercise does more harm than good

Who says exercise is always good for you? Cycling to work in certain highly polluted cities could be more dangerous to your health than not doing it at all, according to researchers.

In cities such as Allahabad in India, or Zabol in Iran, the long-term damage from inhaling fine particulates could outweigh the usual health gains of cycling after just 30 minutes. In Riyadh, Saudi Arabia, this tipping point happens after just 45 minutes a day cycling along busy roads. In Delhi or the Chinese city of Xingtai, meanwhile, residents pass what the researchers call the “breakeven point” after an hour. Other exercise with the same intensity as cycling – such as slow jogging – would have the same effect.

“If you are beyond the breakeven point, you may be doing yourself more harm than good,” said Audrey de Nazelle, a lecturer in air pollution management at Imperial College’s Centre for Environmental Policy, and one of the authors of the report.

The study, originally published in the journal Preventive Medicine before the World Health Organization’s latest global estimates, modelled the health effects of active travel and of air pollution. They measured air quality through average annual levels of PM2.5s, the tiny pollutant particles that can embed themselves deep in the lungs. This type of air pollution can occur naturally – from dust storms or forest fires, for example – but is mainly created by motor vehicles and manufacturing.

People cycle in heavy smog in Beijing. Photograph: Imaginechina/Rex/Shutterstock

Breathing polluted air has been linked to infections including pneumonia, ischemic heart disease, stroke and some cancers. The Institute for Health Metrics and Evaluation’s Global Burden of Disease study ranks it among the top risk factors for loss of health.

The report in Preventive Medicine assumed cyclists moved at speeds of 12/14kph, with health benefits calculated in a similar way to the WHO’s Heat assessment tool. It also assumed cyclists used roads with double the background levels of air pollution, which may underestimate how poor air quality is in many developing world cities: for example, a study in Lagos found five out of eight sites exceeded Delhi’s annual PM2.5 concentration.

People commuting to work along busy roads in a city with average annual background PM2.5 levels of 160 micrograms per cubic metre (μg/m³) or above will pass the breakeven point at just 30 minutes a day, the study found. Using the WHO’s latest global estimates, published in May, those levels are only reached in Zabor, and in Allahabad and Gwalior in India – although many large cities in the developing world do not accurately measure air pollution so were not included in the WHO database.

Breakven point for different levels of cycling and air pollution

Fifteen cities (see map above and table below) have annual mean PM2.5 levels of 115μg/m³ or above, according to the WHO data, so the breakeven point is reached after an hour of active travel. Fine particulate levels above 80μg/m³ were found in 62 cities, making cycling more harmful than beneficial after two hours.

The study found people in western cities such as London, Paris or New York would never reach the point where PM2.5 air pollution’s negatives outweigh exercise’s positives in the long term.

“The benefits of active travel outweighed the harm from air pollution in all but the most extreme air pollution concentrations,” said Nazelle. “It is not currently an issue for healthy adults in Europe in general.”

London’s annual average PM2.5 pollution was estimated at 15μg/m³ by the WHO – above the WHO’s guideline of 10, but still at a level at which the study estimated active travel would always be beneficial. Paris had ambient PM2.5 levels of 18μg/m³, while New York had 9μg/m³.

However, the study did not consider the health impacts of short-term spikes in PM2.5 pollution, or take into account the effect of exercising in air containing larger PM10 particulates, ozone, or toxic nitrogen oxides (NOx) from diesel cars.

London mayor Sadiq Khan issued his first “very high” air pollution alert last month when air in the UK capital hit the maximum score of 10 on the Air Quality Index, equivalent to PM10 in excess of 101μg/m³. NOx pollution causes 5,900 early deaths a year in the city, and most air quality zones across Britain break legal limits.

“This is the highest level of alert and everyone – from the most vulnerable to the physically fit – may need to take precautions to protect themselves from the filthy air,” Khan warned.

Air pollution – cities where harm from exercise outweighs benefits – table

Guardian Cities is dedicating a week to investigating one of the worst preventable causes of death around the world: air pollution. Explore our coverage at The Air We Breathe and follow Guardian Cities on Twitter and Facebook to join the discussion

Tipping point: revealing the cities where exercise does more harm than good

Social care cuts take English service to tipping point, regulator warns

A&E units are struggling to cope because social care services that help elderly people have been cut so much that they are reaching a “tipping point”, England’s care regulator is to warn.

Hospitals are ending up dangerously full and have seen “bedblocking” hit record levels because of a widespread failure to give elderly people enough support to keep them healthy at home, says the Care Quality Commission.

A worsening lack of at-home care services and beds in care homes are forcing hospitals to admit more patients as emergencies, which deepens their already serious financial problems. “What’s happening, we think, is that where people aren’t getting access to [social] care, and we are not preventing people’s needs developing through adult social care, is that they are presenting at A&E,” said David Behan, the CQC’s chief executive.

Figures contained in the commission’s annual report show that the number of hospital bed days lost through patients being unable to leave because social care was not available to allow them to be discharged safely soared from 108,482 in April 2012 to 184,199 in July this year – a 70% rise.

The fact that growing numbers of mainly frail, elderly people are being left without the help they need with basic chores such as washing, dressing and cooking “creates problems in other parts of the health and care system, such as overstretched A&E departments or delays in people leaving hospital,” he added. GP surgeries are also having to treat patients who became unwell or suffered an injury because they did not receive help they needed.

Behan urged ministers to give social care a higher priority and urgently find extra money for it to prevent its ongoing deterioration causing even worse problems. “We are becoming concerned about the fragility of the adult social care market, with evidence suggesting that it might be approaching a tipping point,” he said.

The CQC’s assessment of health and social care, called State of Care, adds that: “The difficulties in adult social care are already affecting hospitals. Bed occupancy rates exceeded 91% in January to March 2016, the highest quarterly rate for at least six years, and in 2015-16 we saw an increase in the number of people having to wait to be discharged from hospital, in part due to a lack of suitable care options,” the CQC’s annual report says.

The number of people in England receiving local council-funded social care services fell by 26% from 1.1m in 2009 to about 850,000 in 2013-14, at a time of Whitehall-driven cuts to town hall budgets. The number of people with unmet needs has risen from 800,000 in 2010 to more than 1 million last year, according to Age UK.

Growing unavailability of social care was a key driver of the 3% rise in emergency admissions to hospital last year and 11% rise in bed days lost to bedblocking. That was mainly due to patients having to wait for a package of care to be put in place to let them return home or for a place in a nursing home to become available. “The effect of these delays on the NHS is significant, costing hospitals £820m a year,” the National Audit Office says.

NHS bodies, health thinktanks and charities urged government to use next month’s autumn statement to inject extra funding into social care.

Simon Stevens, the chief executive of NHS England, has already called for any extra funding for the health service to instead be used to prop up social care. Jeremy Hunt, the health secretary, is understood to privately agree. On Monday Stephen Dorrell, the ex-Conservative health secretary, said that the government’s policy of giving social care less and less money was “insane economics and bad social policy” and undermined its claim to be backing the NHS.

Cuts to social care and also mental health and public health mean “the NHS is being stretched to the limit,” said Stephen Dalton, chief executive of the NHS Confederation, which represents hospitals. “Relying on political rhetoric that promises to protect the NHS but fails to acknowledge that a cut in social care results in a cost to the NHS, is an economic deception.”

The CQC also disclosed that about 800,000 patients are registered with a GP practice that its inspectors have judged to be inadequate on safety grounds. It is concerned that some surgeries deliver “unacceptable standards of care”. Safety failings include poor management of medicines, inappropriately trained staff and premises that are unsuitable.

The Department of Health welcomed the CQC’s findings that “the majority of the NHS, 72% of adult social care services and 87% of GP practices inspected are good or better – and that improvement is taking place all over the country”.

A spokeswoman said: “The NHS is performing well at a time of increasing demand. The government is investing £10bn to fund its own plan for the future, and crucially is ensuring that the amount of money available to local authorities for social care is rising in future years of the parliament, reaching up to £3.5bn extra by 2020.”

Social care cuts take English service to tipping point, regulator warns

Tipping The Scales In The Global Battle Of The Bulge

Not lengthy in the past, healthful living was the domain of fitness fanatics. Today, it is a mainstream subject, in every day conversation as effectively as in the media. What might be a lot more surprising is the similarity of individuals conversations in several parts of the globe.

When Bain &amp Business lately surveyed one,200 grownups in New York City, Munich and New Delhi, we discovered some striking consistencies in both the value individuals area on residing more healthy lifestyles and the challenges they encounter in creating that come about. When asked to decide on between straightforward, affordable entry to planet-class health care care or effortless, reasonably priced access to healthier living options, for instance, a lot more than half of people we surveyed in all three cities opted for wholesome residing. Eight out of ten respondents said they recognize what healthful living implies, and three-quarters indicated that they would like to stick to a healthier life-style. No matter which city they live in, more than half of respondents explained they have comparable priorities of engaging in much more bodily exercise, following a healthier diet plan, getting a lot more sleep and managing tension greater.

All good intentions, of program, but what prevents people from following via? Here again, some powerful similarities emerged, irrespective of demographics or culture. About 80% of respondents indicated that they encounter at least one major constraint to residing a healthier existence. Whilst about half of respondents readily admit they do not meet the Planet Well being Organization’s suggested minimum physical activity degree for their age group, the motives they gave reflect the constraints of a active workforce—stress, lack of time and the vexing problems of shifting previous habits. Financial constraints are a aspect as effectively. Younger respondents in all 3 cities cited higher pressure levels and time constraints two or 3 times as often as older respondents.

Connected: The Long term Of Healthcare—There’s An App For That

Some of the variations in worldwide attitudes about wholesome living are equally striking. For instance, our investigation suggests that emerging markets may current options to leapfrog standard approaches and put into action new designs of prevention and care, utilizing new technologies. The younger and more educated New Delhi cohort reported that they frequently read through about health troubles and search for details on the web. Almost two-thirds mentioned they read through posts about healthier residing at least as soon as a week, compared with 29% in Munich and 42% in New York. The New Delhi respondents expected companies to advertise healthy lifestyles via video games, the Net and social media. New Delhi respondents had been also much more probably to say they are concerned about individuals with unhealthy lifestyles in their city and admit that their personal lifestyles put them at chance for creating a chronic ailment. Offered this self-awareness and commitment to healthier living, what would support the New Delhi respondents accomplish their goals? A lot more than twice as many in New Delhi mentioned that governments need to pass a lot more laws to assistance healthy residing, even if it means restricting person freedom.

Whilst governments and policy makers about the globe are commencing to act, probably the most strong insight to emerge from our research is the require for firms to anticipate industry modifications and discover to operate in a new environment. Basically put: Healthier residing presents massive possibilities for businesses, inside and outside of the healthcare sector. Consumers are searching for revolutionary, customized remedies to help them alter their habits. It’s hard to predict how significantly money consumers would really put on the table, but the signs level to an chance for businesses in many sectors to check out this hypothesis as they develop new wholesome products and providers.

Personal sector possibilities to encourage healthier residing are evolving at a quick tempo, demanding a total break from previous roles and a new “cross-sector” language of integration that can capture the imagination of buyers. Pharmaceutical and medtech organizations, for example, have exclusive access to hospitals and physicians—among the most trusted providers of details on wholesome residing, according to 68% of the men and women we surveyed. That produces possibilities to develop new, progressive approaches to retaining sufferers healthier, with unique target on secondary prevention as properly as new goods and services this kind of as dietary dietary supplements and consumer-friendly diagnostics.

Technologies that simplify healthy options and assist consumers overcome barriers to conduct modify will see rapid growth. Hundreds of businesses are working on smartphone applications and monitoring or wearable products linked to wholesome living. As that ecosystem grows, search for the emerging leaders to stand out by linking players with each other and focusing on evidence-based mostly, customized and time-saving tools.

In client products, a single emerging opportunity is to strengthen the feedback loop in between brief-phrase pleasure and prolonged-phrase wellness at the stage of purchase. Customers say they are hunting for more healthy meals and new types of exercising tools and programs, specifically for customized products and companies that are priced affordably and offer you quick and easy techniques to stay healthy.

Now far more than ever, we need industries that assistance and increase wellness in an innovative way. As much as we know about habits alter, it stays difficult for people to apply that knowledge to encourage their personal well being or keep their commitment to these actions. Outcomes from the survey present that consumers under­stand what they need to have to do, but they want a great deal a lot more assist doing it. Companies that can perform across sectors, personalize their goods creatively or develop a sus­tainable marketplace for a item however to be invented will create enormous value—for their shareholders and for the world.

Learn much more: Increasing Company Options For Healthful Residing

Norbert Hueltenschmidt leads Bain &amp Company’s Healthcare practice in Europe, the Middle East and Africa, and is a companion primarily based in Zurich. Tamara Olsen is a Bain companion based in Boston and a member of the firm’s Healthcare practice. Bain is a information spouse for the Planet Financial Forum’s healthful residing initiative. 

Adhere to @BainInsights on Twitter. 

Tipping The Scales In The Global Battle Of The Bulge

Disease resistance to antibiotics at tipping level, professional warns

Antibiotic capsules. Photograph: Helen Sessions/Alamy

The director of the Wellcome Trust has warned that resistance of illness to antibiotics has reached a tipping point at which it could creep into the Uk practically without recognize.

Prof Jeremy Farrar explained the results would be gradual and would be seen not just in resistant new infections but in daily health care practice and the therapy of every thing from diabetes to small wounds at threat of turning septic.

Having worked in Vietnam for the previous 18 many years Farrar explained he had currently witnessed firsthand resistance to medication in the shape of tuberculosis that had spread from patients’ lungs to their brain.

“This is occurring now,” Farrar told BBC Radio 4′s Right now programme. “It really is been taking place for the last decade or so or more and it will proceed to occur. What we will see is individuals really paying longer in hospital, sufferers receiving sicker and having issues and dying and it will creep up on us nearly with no us noticing.

“This will not be the sort of contagion-like event of someone landing from Hong Kong in London with a pneumonia that is emerging that we’ve all feared. This will creep up on us insidiously, and of course that is in numerous techniques far more tough to cope with.”

He explained there had been a “golden age” of antibiotics but complacency had set in in the 1970s and 1980s when there could have been a lot more investment and antibiotics could have been utilised much better, for instance in combinations, to avert the improvement of resistance to them.

“We’re viewing evolution happening,” he stated. “The viruses, the parasites have a pressure place on them from the medication. They want to reply to that by surviving and not currently being killed by these antibiotics so consequently they evolve in methods that make them resistant.”

Farrar explained that twenty many years ago there had been 18 companies in the commercial sector functioning in the field of antibiotics but now there had been just four, and consequently only 5 new classes of antibiotics had emerged in the previous ten many years.

He known as for far more imaginative methods to incentivise the pharmaceutical business, for instance through alterations to patents, and for regulation about clinical trials to be eased. He said accessibility to antibiotics needed to be regulated as they have been obtainable more than the counter at lower price in numerous countries.

“No government can do this on its own because this is a actually global problem,” he explained. “This is receiving to the tipping point where you will start off to see this in you and your families and we will start to see this not in infections many, a lot of miles away but right here in London.”

Last yr the chief healthcare officer, Dame Sally Davies, described what she referred to as an “apocalyptic scenario” exactly where men and women going for simple operations in 20 years’ time would die of routine infections “because we have run out of antibiotics”.

Farrar stated he was not presenting the crisis in apocalyptic terms but recalled the impact of HIV as an illustration of when a disease emerges that has no antibiotic for it.

“It really is etched on my thoughts thirty many years later,” he explained. “Young people, predominately male at that time, coming in and dying withing days, weeks and months of their infections simply because we had no way of treating it, and that is a threat that is actually really worth getting concerned about coming back. Even in HIV we run the chance of returning at some point in the long term to resistant HIV and that would be genuinely devastating.”

Disease resistance to antibiotics at tipping level, professional warns

Britain is reaching "a tipping level in its use of antibiotics", says Wellcome Trust director

“This will not be the contagion like occasion of someone landing from Hong Kong in London with a pneumonia that we’ve all feared. This will creep on us insidiously and that is in many approaches much more tough to deal with.”

In a lot of components of the world, this kind of as India and China, low-cost antibiotics are offered over the counter.

Not only does this lead to overuse but many men and women get medicines incorrectly or fail to full their course of treatment method, allowing infections to develop resistance.

Prof Farrar urged the Government to incentivise drug firms to come up with new antibiotics by means of patents or sophisticated buying and to loosen up regulations surrounding clinical trials.

It comes months following the Government’s Chief Healthcare Officer Professor Dame Sally Davies said the threat posed by antibiotic resistance was a “ticking time-bomb”, which ought to be place on the Nationwide Danger Register- which also includes “catastrophic terrorist attacks” and other civil emergencies.

Program operations this kind of as hip replacements could grow to be fatal in just 20 many years time if we get rid of the capacity to battle infection, she explained.

Britain is reaching "a tipping level in its use of antibiotics", says Wellcome Trust director