NHS Current Challenges

Here I will attempt to stay up-to-date with key healthcare challenges, looking at questions including:

  • What is the country’s long term plan for the NHS?
  • Should vaccinations against infection be compulsory for children?
  • How should the provision of NHS resources be used to tackle ill mental health?
  • What is your opinion on robotics in healthcare?
  • How can we tackle the NHS bed shortage crisis?

The NHS is currently trying to revolutionize itself. The NHS Five Year Forward View, developed in 2014, is already making a positive impact on our society’s healthcare standards. More focus has been placed on prevention over cure, and greater access to services such as out of hours appointments with GPs and urgent care centres. CCGs (Clinical Commissioning Groups) were a main figure of the Five Year Plan. These groups are GP led and allow doctors to contribute their opinion as to how funds from the government are divided. With GPs at the centre of primary care, they perhaps have a better understanding more than any speciality of what facilities local communities most require. Success from the Five Year Forward View is enabling the vision of those creating the Long term plan to now appear more realistic; this is desirable if our country is to maintain our NHS. A few objectives, in short, of the plan, are:

  • Greater care based on individuals’ personal needs.
  • Improving the quality of community-based care prior to hospital admission.
  • Services closer to people’s home with quicker access to treatment.
  • Each patient will have the right to online GP consultations.
  • Greater investment in cancer treatment – specific aim to increase the proportion of cancers diagnosed early from half to three quarters.
  • Empowering people to self-manage diseases such as diabetes more effectively.
  • Moderate the demand on the NHS through the prevention of illness. This prevention will come about through NHS-funded programmes, group sessions and greater media coverage.
  • Increase the number of nursing and undergraduate places to ensure candidates who would service the NHS well are not turned away.

“Reducing lifestyle risks and treating high-risk conditions such as smoking, obesity, poor diet and physical inactivity are key to preventing serious ill health, and the NHS Long Term Plan will help people take positive action for their own wellbeing, while investing in life-changing services, close to home, when ill health hits.” 

Professor Stephen Powis, NHS National Medical Director

Part of the Five Year Forward View is early detection and prevention. Part of this is screening which will have benefits including:

  • Resulting in a reduction of disease progression and complications which may be harder to treat further down the line.
  • Treatment being more effective as it is used early.
  • Reducing wastage of NHS resources which can be directed into more specialised care.
  • Reducing mortality rates through early detection of disease.
  • Helping people make better-informed decisions about their health, early on.

Screening is currently used for Heart Disease, breast cancer, pregnancy and diabetes.

But, the NHS still faces many challenges, and now I am going to look at some:

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Are patients addicted to prescriptions?

Patients are becoming increasingly dependent on prescribed medication, namely antidepressants, sleeping tablets and strong analgesics (painkillers). Benzodiazepines – mostly prescribed for anxiety, and opioids for chronic non-cancer pain are also major groups of medication which have been called in for review. 17% of England’s adult population, 7.3 million people, are currently on antidepressant medication. Between 2015-2016 and 2017-2018, the prescription rate for antidepressants rose from 15.8% to 16.6%.

Why are prescriptions increasing? 

Firstly, patients say that they aren’t being offered alternative, non-medicinal treatment options, therefore drugs are dispensed too easily.

Secondly, some patients require long-term prescribing of antidepressants to maintain their benefit and prevent relapse. But really, drugs need to stop being the first option to treat mental health conditions in the first place. For mental health condition, medicine doesn’t wholly cure the condition, but it manages the symptoms, by balancing the chemical imbalances in the brain. But, this is best done alongside psychotherapy, and, between 1998 and 2007, there was an increase (from 44% to 57%) in people who are prescribed drugs for mental health conditions, without any psychotherapy. However, there are many good reasons why drugs alone should not be the reflexive treatment of choice for many mental health problems. Here are some reasons:

  1. Drug treatments are often associated with subsequent relapse.
  2. Treating some common mental health problems with drugs from the outset may effectively ‘medicalize’ them, turning what might have been short-term, acute bouts into a longer-term, chronic problem, and hence people occasionally require antidepressants for their whole life. Good business for the pharmaceutical industry!
  3. Prescribing drugs at the onset of a mental health problem perpetuates a medical model of mental health that may lead many sufferers to believe their recovery is now out of their hands and in the hands of medical experts. This is akin to labelling a mental health problem a ‘disease’, and this can have very significant negative effects on the sufferer’s ability to self-regulate and help themselves. For example, studies show that recent attempts to label obesity as a ‘disease’ actually has a significant negative effect on self-regulation of obesity symptoms.
  4. Unfortunately, most current diagnostic criteria for mental health problems are categorical rather than dimensional. That is, the criteria indicate that you will either be diagnosed with a mental illness or you will not (the categorical approach). In contrast, the dimensional approach suggests that mental health symptoms are on a dimension from mild to severe. The current categorical model is perfect for conceiving of mental health problems as ‘diseases’ that have a diagnostic ‘cut-off’ point, and this conception brings with it all the problems described in point 3. In addition, it is also a perfect scenario in which pharmacological companies can promote the use of drugs to treat mental health problems as ‘disease categories’.
  5. Drug companies need to sell drugs to survive, so will have an incentive to invent new disorders to generate a market for new drugs. Very often this may lead to the medicalization of perfectly normal emotional processes, such as bereavement. A good example of the way in which normal psychological processes can be surreptitiously medicalized and made to appear abnormal in order to create markets is in the example of the female menopause.
  6. They also significant and distressing side effects. These side effects can be physical and include fatigue, blurred vision, gastric disorders, headaches, dizziness, sexual dysfunction, risk of cardiac disorders, and weight gain. In many cases (such as antipsychotics) these side effects are significant enough to make up to 50% of those taking medication stop taking them. But apart from medical symptoms, some pharmacological treatments can also increase psychological symptoms such as anxiety, suicidal ideation, and even increase suicide attempts
  7. A number of studies have suggested that there may be a significant publication bias in randomized controlled trials (RCT) reported by drug companies. For example, RCTs assessing the effectiveness of drug treatments are significantly more likely to report a positive effect if the study was funded by the pharmaceutical industry than if funds came from non-industry sources. This tends to suggest that drug companies may not publish studies that show that their drugs are ineffective! And this bias is also likely to significantly over-estimate the effectiveness of drugs for mental health problems.
  8. While prescribing drugs for mental health problems may have a short-term palliative effect, drugs don’t obviously help people to change the way they think or change the socio-economic environments that might be the root cause of their psychological problems.
  9. Sadly, many of those health professionals (e.g. GPs) at the first point of contact with people suffering from mental health problems are poorly trained to identify psychological problems in their patients and have little time available to devote to dealing with these types of problems.
  10. At present, we don’t have any wealthy ‘multinational psychotherapy conglomerates’ to match the financial fame of the pharmaceutical industry, so when it comes to ‘selling’ treatments for mental health problems, drugs will always have the marketing advantage regardless of whether they are more or less effective than psychological therapies.

These are just some of the reasons why we should be wary of the increasing trend of treating psychological problems with medications, and medications without accompanying psychological help and support. Certainly, attempts are being made in many countries to increase access to psychological therapies for those who need them, but while mental health is still viewed primarily as a medical problem within health care systems promoting medical models, little is likely to change rapidly. But that is another issue and I don’t want to get sidetracked…

Despite some patients definitely requiring that long-term use of medication for clinical benefit and even their own safety, there are certain groups where use is inappropriate, similar to what we looked at with the mental health conditions above.

“The need for doctors to prescribe medication long-term indicates a severe lack of alternative options”

Professor Helen Stokes, Lampard, Royal College of General Practitioners.

The need therefore for these alternative options is imperative. Although services have been made available such as therapy, exercise classes and other recreational activities, communities require more education and awareness of these options for proper implementation.

Overprescribing of drugs has been a colossal problem in the United States. Despite sharp increases in the prescription of opioid painkillers, there do not seem to attempts to tackle their misuse. Public Health England reviews demonstrate that despite the UK not being on such a level, other countries within Europe certainly have lower opioid prescription rates. To read more about prescription drug issues, particularly with withdrawal, see this article.

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