The upcoming Major Conditions Strategy – aimed at improving outcomes arising from the six most common major health conditions over the next five years – has gathered opinion from users and stakeholders across the NHS. Their learnings continue to inform the strategy and have produced a number of both positive and negative findings. In positive news for our industry, the paper acknowledges the huge potential of technology and research to aid secondary prevention and early diagnosis. The strategy is expected to be published in 2024.
In this piece, we will examine what the Government has learnt and what it intends to do through the prism of our industry. The six major conditions covered are: cancers, cardiovascular disease (CVD) (including stroke and diabetes), musculoskeletal disorders (MSK), mental ill health, dementia, and chronic respiratory disease (CRD). Alarmingly, these conditions account for over 60% of mortality and morbidity in England, with many having two or more of these conditions together.
The report acknowledges that early diagnosis is key to improving outcomes and reducing the condition’s impact on a patient’s life but admits that the NHS has not performed well historically in providing timely diagnoses. Exploring and introducing the plethora of exciting, innovative technologies which can alleviate these problems remains an important target going forward.
By altering existing structures through enabling better leadership, promoting research and technology, limiting Government intrusion, and working on better regulatory and funding alignment, the landscape for fostering the flourishing of innovation can be improved. This more integrated model mirrors a wider change in NHS operations, namely the establishment of ICSs.
The report states that the health service is making the right steps forward, through expanding screening services, establishing CDCs and funding local prevention programmes—however, this is merely the start.
Health inequalities remain a pressing issue for the NHS, with socio-economic differences affecting population health and lifespan significantly. Moreover, health disparities between men and women – with different sets of issues affecting each gender – as well as disparities between different ethnicities continue to present a challenge. For instance, while ethnic minority groups have higher life expectancy, prevalence of diabetes is three to five times higher than in the white British population. High rates of long-term sickness, resulting in the inability to work, is both a national catastrophe as well as an economic drag.
The NHS continues to spend colossal sums on the treatment of preventable diseases, hence why prevention and early diagnosis are keystones of this plan. The health service spends 10% of its budget per year (£10 billion) on diabetes, which represents an enormous 1% of UK GDP each year. Controlling numbers of diabetes cases, for example, through early diagnosis and prevention will unlock some of the £10 billion spend and allow them to be used elsewhere on other services – creating a progressive cycle of incrementally improved healthcare.
The NHS seeks to encourage behaviour change to embed healthier lifestyles among the population, including cash incentives via apps for healthy living and expanding smoking services. It is also important to note that those who possess unhealthy habits, such as excessive drinking, are also more likely to indulge in other risky lifestyle behaviours, such as smoking or poor diet. This is where ICSs will prove pivotal. Their emphasis on local-driven healthcare allows them to identify the problems affecting their populations and taking appropriate action to stop the exacerbation of these issues. ‘Secondary prevention’ of this kind has proven to be highly effective.
The NHS is committed to bringing services closer to the community and believes this is the correct strategy to address health challenges. Expanding community pharmacy services and blood pressure services, for example, will save 10 million appointments a year and significantly reduce pressure on GP services. To further tackle this issue, the NHS is evaluating self-sample cervical screening tests for women who have not attended previous screening appointments and are increasing the number of people who self-monitor at home; making this as convenient as possible for them and their general practice.
There is also a drive to make prevention services more personalised and smarter. For instance, the NHS Health Check allows for patients to test their risk scores for major conditions conveniently and then suggests actions or pathways for them to follow to access treatment or tests.
Early diagnosis will be at the heart of the future strategy. Benefits have already been shown through cancer screening, having adopted considerations from the UK National Screening Committee. AI will play an increasingly important role in early diagnosis and make programmes more efficient. The £26 million innovative cancer programme led by Genomics England in partnership with the NHS to evaluate cutting-edge genomic sequencing technology to improve the accuracy and speed of diagnosis for cancer patients and use AI to analyse a person’s DNA, alongside other information, is also proving greatly beneficial.
Targeted diagnoses will also be prioritised to ensure that those in deprived communities, who are traditionally diagnosed with cancer at a later stage, are not left behind.
Data and digital provide endless opportunities to revolutionise healthcare across the NHS, particularly the improvement of care, the better use of data and increased ability for self-management of conditions. Moreover, the ready flow of data will allow the NHS to better understand people and what works best for them, intervene earlier to prevent ill health, and better plan services and allocate resources. Work is currently ongoing to streamline patient records across different divisions and safely share anonymised data to aid researchers and for population health planning purposes.
Better usage of data will also improve staff decision making, including improving the ways in which conditions are screened, diagnosed, treated and managed, thereby supporting clinicians to make the best use of their expertise, save time and improve outcomes for patients. The AI diagnostic fund has already been established to increase the rollout of AI diagnostic technologies in the NHS. The development of an end-to-end innovation pipeline to ensure novel and high impact products that address national priorities are adopted at speed and scale is ongoing following the MedTech Strategy. Moreover, the Innovative Devices Access Pathway (IDAP), which is to launch later this year, will also help to accelerate access to innovative technologies.
Critical to the strategy is understanding that research is fundamental to prevention of disease and the identification of health challenges. In recent years this has been chiefly led by UKRI and NIHR, with their heavy investment yielding beneficial results. For instance, a troponin blood test to identify heart attacks quickly and accurately, which was validated via NIHR research, has now been rolled out in most NHS trusts and saves over £100 million each year. Further work will be done to align the eventual strategy with the UK’s research agenda, including collaboration with the NHS’s newly established policy health units. Increasing clinical trial uptake and public engagement in research will also be explored.
The NHS will work with government to better comprehend how they can collaborate to enable systems to improve the health of local populations and support the delivery of local approaches and innovation. This will likely involve a reduction in the imposition of central targets on systems. The report will build upon the Hewitt Review and move beyond the central strategy setting and local implementation of old, to an approach that seeks to address local needs through experimentation and improvement. ICSs will be supported in this endeavour.
To summarise, following extensive consultations the strategy will focus upon five key priority areas, which the NHS believe has the greatest potential to transform health. They are:
- rebalancing the health and care system, over time, towards a personalised approach to prevention through the management of risk factors
- embedding early diagnosis and treatment delivery in the community
- managing multiple conditions effectively – including embedding generalist and specialist skills within teams, organisations and individual clinicians
- seeking much closer alignment and integration between physical and mental health services
- shaping services and support around the lives of people, giving them greater choice and control where they need and want it and real clarity about their choices and next steps in their care
In the next phase, NHSE will continue to engage closely with people with lived experience, academic and other experts and representative organisations to further hone the strategy before publication.
More on cancer
In order to better tackle high rates of cancer, NHSE is implementing a comprehensive early diagnosis strategy by:
- lowering the age for bowel screening and extending lung health checks
- giving primary care teams direct access to certain diagnostic tests and clinical decision support tools to help identify cancers earlier, and trialling a new route of referral from community pharmacies
- using genomic testing to identify people with Lynch syndrome or the BRCA mutation who are at greater risk of developing cancer, so that we can check them regularly
NHSE are also piloting a number of tests which identify genetic risks of certain cancers. Diagnostic checks remain are a key part of many elective care pathways, including cancer. In 2021 the UK government awarded £2.3 billion to transform diagnostic services over 3 years.
The NHS Genomics Unit is funding a national transformation project, to provide evidence on ctDNA testing in the NHS to support diagnosis of cancer for patients who currently cannot have a tumour biopsy or do not yet have a confirmed diagnosis.
The NHS is streamlining cancer pathways to support diagnosis within 28 days – for example, through the implementation of non-specific symptom pathways and best practice timed pathways. By June 2023, 108 non-specific symptom pathways were already live.
More on CVD, including stroke, and diabetes
The framework sets out some of our key CVD activities to intervene at an early stage and deliver quality care for CVD.
NHS operational planning guidance sets objectives for improving detection and management of people with hypertension and high cholesterol, to drive delivery of NHS LTP commitments. In addition, the guidance sets ambition for ICBs to consider how they can best implement new technologies, including home testing.
More on CRD
NHSE are working to ensure early and accurate diagnosis in the community via high-quality objective testing – quality assured spirometry and fractional exhaled nitric oxide (FeNO). This can be performed in both primary care, community settings and in secondary care.
CDCs are being established to deliver additional, digitally connected, diagnostic capacity in England, providing patients with a co-ordinated set of diagnostic tests in the community, in as few visits as possible, enabling an accurate and fast diagnosis on a range of clinical pathways including pulmonary fibrosis.
As part of this, a pathway for the diagnosis of undifferentiated breathlessness is being piloted in a small number of CDCs with a view to wider rollout.