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We're running the NHS well into the red zone

The CEO of NHS Providers, the association of NHS foundation trusts, says realistic funding is desperately needed. 

 

It’s like a scene from an old war movie. The National Health Service is a Royal Navy ship crashing through a stormy sea being buffeted by wave after wave of surging demand. Fuel is running low. The captain calls for more power. The needle on the engine room pressure dial goes above 100 per cent, and becomes stuck deep in the red zone. After ten minutes of running at absolute maximum power the engines falter and the ship shudders. Nervous glances cross the bridge. How much longer can the ship stay in the red zone? Can it stay afloat? When will it founder?

Excuse the dramatic license, but that’s how it feels in the health service at the moment – we’re trying to run the NHS permanently above its sustainable limits, well into the red zone.

Take NHS funding. We are in the middle of the longest and deepest financial squeeze in NHS history. Costs and demand are growing by five per cent a year, but we are in the midst of a twelve year stretch where funding, on current plans, will rise by less than one per cent a year on average.

Although NHS trust finances have started to stabilise, there is still an underlying deficit of at least £3.5bn. We are only balancing the books by robbing capital budgets, selling off land and making one-off, nonrecurrent accounting adjustments or savings. The consequences are increasingly obvious; for example, the safety-critical NHS maintenance backlog has more than doubled in just two years from £458m to a whopping £947m.  As the National Audit Office has pointed out, the health service at a local level remains under considerable financial pressure and the NHS still has a long way to go before we can regard it as being once again on a sustainable footing.

The workforce pressure dial is firmly in the red too. We have widespread staff shortages. There are growing recruitment and retention problems due to Brexit and ongoing NHS pay restraint. Many staff argue they can’t provide the safe, high-quality care that patients deserve, despite routinely working longer than recommended or paid hours.

I was particularly struck by a conversation I recently had with a nurse who, after building her experience and expertise for 12 years, had decided to leave the profession because she had woken up too many times at three in the morning worrying about whether she had been able to do her job safely. That is what trying to run the NHS permanently in the red zone looks like from a staff point of view.

It is the same situation with NHS performance. We have now reached a point where the health service is no longer able to deliver all that is being asked of it. Mental health bed occupancy rates regularly reach 100 per cent. District nurses are run ragged, trying to cover an impossibly large number of patients. Despite best efforts, for the first time ever last year, all four key NHS hospital performance targets were missed. Waiting lists for routine surgery are the longest for a decade. And only a handful of trusts are consistently meeting the four hour target in A&E.

Last winter provided graphic evidence of what running in the red zone looks like for patients. Far too many mental health and community services stretched to capacity. Far too many patients stranded in ambulances queueing outside overcrowded A&E departments. Far too many twelve-hour trolley waits in busy corridors. Too often, patient safety is being put at risk. 

The trust leaders we represent – the people who are responsible for providing frontline care to a million people every 36 hours – are clear what they need to offer the safe, high-quality care we all want the NHS to provide.

Firstly, honesty and realism about what can be delivered with the funding available. Trusts want to deliver the performance standards set out in the NHS Constitution, but they can only do this if they are properly funded to meet those targets. Their leaders are not magicians; they cannot deliver the impossible. So the November Budget needs to set a clear plan for the rest of this Parliament which matches NHS delivery expectations to the money available.

We must also, as a matter of urgency, come up with a clear strategy to address the workforce challenges that trust leaders now say are their biggest problem. That includes a plan to end pay restraint, and much-needed reassurance and clarity for the current and potential future NHS workforce on what happens after Brexit. Above all we need urgent steps to fill gaps in the current workforce and an affordable long-term strategy that sustainably matches workforce supply to likely future demand.

Finally, we should support the NHS to deliver the transformation in care that is required to meet the growing and changing needs of our society. That means putting greater emphasis on preventing ill health and ensuring wellbeing. It also means delivering much more care closer to home so hospitals are used only for those who require acute care. We need a better integrated health and care system where different elements – community, mental health, ambulance and hospital services, GPs and social care – come together to serve the needs of the population. 

It is painfully clear that the NHS is now running in the red zone. We need national NHS leaders to acknowledge this is simply unsustainable. As the health service nears its 70th birthday, now is an opportune moment to make the big decisions which are urgently required to reach calmer waters, and bring that pressure dial round to “safe”. 

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The answer to the antibiotics crisis might be inside your nose

The medical weapons we have equipped ourselves with are losing their power. But scientists scent an answer. 

They say there’s a hero in everyone. It turns out that actually, it resides within only about ten percent of us. Staphylococcus lugdunensis may be the species of bacteria that we arguably don’t deserve, but it is the one that we need.

Recently, experts have cautioned that we may be on the cusp of a post-antibiotic era. In fact, less than a month ago, the US Centres for Disease Control and Prevention released a report on a woman who died from a "pan-resistant" disease – one that survived the use of all available antibiotics. Back in 1945, the discoverer of penicillin, Alexander Fleming, warned during his Nobel Prize acceptance speech against the misuse of antibiotics. More recently, Britain's Chief Medical Officer Professor Dame Sally Davies has referred to anti-microbial resistance as “the greatest future threat to our civilisation”.

However, hope has appeared in the form of "lugdunin", a compound secreted by a species of bacteria found in a rather unlikely location – the human nose.

Governments and health campaigners alike may be assisted by a discovery by researchers at the University of Tubingen in Germany. According to a study published in Nature, the researchers had been studying Staphylococcus aureus. This is the bacteria which is responsible for so-called "superbug": MRSA. A strain of MRSA bacteria is not particularly virulent, but crucially, it is not susceptible to common antibiotics. This means that MRSA spreads quickly from crowded locations where residents have weaker immune systems, such as hospitals, before becoming endemic in the wider local community. In the UK, MRSA is a factor in hundreds of deaths a year. 

The researchers in question were investigating why S. aureus is not present in the noses of some people. They discovered that another bacteria, S. lugdunensis, was especially effective at wiping out its opposition, even MRSA. The researchers named the compound created and released by the S. lugdunensis "lugdunin".

In the animal testing stage, the researchers observed that the presence of lugdunin was successful in radically reducing and sometimes purging the infection. The researchers subsequently collected nasal swabs from 187 hospital patients, and found S. aureus on roughly a third of the swabs, and S. lugdunensis on up to 10 per cent of them. In accordance with previous results, samples that contained both species saw an 80 per cent decrease of the S. aureus population, in comparison to those without lugdunin.

Most notably, the in vitro (laboratory) testing phase provided evidence that the new discovery is also useful in eliminating other kinds of superbugs, none of which seemed to develop resistance to the new compound. The authors of the study hypothesised that lugdunin had evolved  “for the purpose of bacterial elimination in the human organism, implying that it is optimised for efficacy and tolerance at its physiological site of action". How it works, though, is not fully understood. 

The discovery of lugdunin as a potential new treatment is a breakthrough on its own. But that is not the end of the story. It holds implications for “a new concept of finding antibiotics”, according to Andreas Peschel, one of the bacteriologists behind the discovery.

The development of antibiotics has drastically slowed in recent years. In the last 50 years, only two new classes of this category of medication have been released to the market. This is due to the fact almost all antibiotics in use are derived from soil bacteria. By contrast, the new findings record the first occurrence of a strain of bacteria that exists within human bodies. Some researchers now suggest that the more hostile the environment to bacterial growth, the more likely it may be for novel antibiotics to be found. This could open up a new list of potential areas in which antibiotic research may be carried out.

When it comes to beating MRSA, there is hope that lugdunin will be our next great weapon. Peschel and his fellow collaborators are in talks with various companies about developing a medical treatment that uses lugdunin.

Meanwhile, in September 2016, the United Nations committed itself to opposing the spread of antibiotic resistance. Of the many points to which the UN signatories have agreed, possibly the most significant is their commitment to “encourage innovative ways to develop new antibiotics”. 

The initiative has the scope to achieve a lot, or dissolve into box ticking exercise. The discovery of lugdunin may well be the spark that drives it forward. Nothing to sniff about that. 

Anjuli R. K. Shere writes about science. She was a 2016/17 Wellcome Scholar and science intern at the New Statesman.