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The National Institute for Health and Care Excellence (NICE) has decided not to recommend Evusheld for adults who are unlikely to have an adequate immune response or cannot have the vaccine against Covid-19, citing a lack of evidence that it is effective against circulating variants. However, it is still reviewing whether the antibody drug could be used to prevent covid-19 infection in adults at the highest risk of severe illness, including people with immunodeficiency, people who have had a solid organ transplant, and people with cancer. NICE’s director of medicines evaluation, Helen Knight, acknowledged that the decision would be “disappointing for the many thousands” of vulnerable people who “continue to significantly modify their behaviour to avoid infection. Commenting on NICE’s decision, Lennard Lee, senior clinical research fellow at the University of Birmingham, said, “While it’s right for NICE to ensure that treatment options are based on the best possible evidence for their safety, efficacy, and cost effectiveness, it must be recognised that those who remain extremely vulnerable to covid need to be prioritised in trials akin to those early days of the pandemic to find treatments fit for them. “Otherwise, we run the risk of consigning half a million people to continue to live in 2020, stuck in their homes, not able to see their families and friends for fear of infection with no protection.” Read full story Source: The BMJ, 16 February 2023

Emergency patients are being left open to abuse when they are at their most vulnerable because of a lack of vetting of ambulance workers, watchdog officials have warned. One watchdog official warned that abusers would even seek out work as a paramedic because it provided an “attractive environment” for exploitation. Figures show that dozens of ambulance workers have faced action over sexual assault in the past two years, while paramedics account for one in three cases of tribunal action against care professionals. But one survivors’ group warned the figures were just the “tip of the iceberg”. Paramedics who have been struck off in the past two years include one who performed a sex act in front of a patient, while another was handed a suspended prison sentence for possessing thousands of images of child pornography. Helen Vine, special adviser to the Care Quality Commission, told a recent webinar: “There is a small proportion of the population who are seeking to abuse our patients and the ambulance can be an attractive environment for that type of individual. One of the reasons for this is the ambulance sector is predominantly lone working … and ambulance services offer privileged often unsupervised access to patients who can be very vulnerable". She said the lack of checks meant offenders were able to move between providers, adding: “They test the waters and their behaviours ... if they are challenged, they will move on, however, if they are not challenged then they can hide in plain sight, and they are wearing a trusted uniform and given responsible access to that patient group. Read full story Source: The Independent, 12 February 2023

CVS Health confirmed last year it was closing half its Coram home infusion branches and firing about 2,000 nurses, dietitians and pharmacists. Their patients with life-threatening digestive disorders depend on parenteral nutrition, or PN — in which amino acids, sugars, fats, vitamins and electrolytes typically are pumped through a catheter into a large vein near the heart. A day later Optum Rx, another big supplier, announced its own consolidation. Suddenly, thousands were scrambling for their complex essential drugs and nutrients. “With this kind of disruption, patients can’t get through on the phones. They panic,” said Cynthia Reddick, a senior nutritionist laid off last summer in the CVS restructuring. “It was very difficult. Many emails, many phone calls, acting as a liaison between my doctor and the company,” said Elizabeth Fisher Smith, a 32-year-old public health instructor in New York, whose Coram branch closed. A rare medical disorder has forced her to rely on PN for survival since 2017. “It added to my mental burden,” she said Home and outpatient infusions in the USA are a growing business, as new drugs for chronic illness expand treatment options and enable patients, providers and insurers to avoid hospitalisation. But while reimbursement for expensive new drugs has attracted corporations and private equity, the industry is constrained by a lack of nurses and pharmacists. The less profitable parts of the business — and the vulnerable patients they serve — are at risk. This includes the 30,000-plus Americans who rely on parenteral nutrition — including premature infants, post-surgery patients and those with damaged bowels because of genetic defects. Read full story (paywalled) Source: The Washington Post, 6 February 2023

Vulnerable female patients have been sexually “exposed” on a mixed gender ward deemed not “fit for purpose”, the NHS watchdog has warned. The Care Quality Commission found that sexual incidents had occured at Hill Crest, a 25-bed mixed gender mental health unit in Redditch, as male and female were being put at risk. It found male patients are able to walk into female bathrooms and bedrooms, leading to risks of sexual assault and relationships. It found that sexual incidents had taken on the unit because of the risks. The rate of assaults on mixed sex wards is significantly higher than on single-sex wards, data has shown. According to the CQC, the trust graded sexual incidents between patients as “low harm” but did not fully consider them or follow up actions to keep patients safe. Read full story Source: The Independent, 8 February 2023

Manchester city council is setting up two special children’s homes to house the increasing number of vulnerable young people who end up stuck in hospital because no residential providers will take them. The homes, believed to be the first of their kind, aim to undercut private operators which sometimes demand tens of thousands of pounds each week to look after children with the most complex needs. Five Manchester children with complex emotional needs spent many weeks in hospital in 2022 because no children’s homes would take them because of their challenging behaviour, according to the city council’s director of children’s services. Manchester council has developed what it calls the Take a Breath model. Two houses are being renovated to house up to four children in total, with the first hopefully moving in by March. The idea is that when children first turn up at hospital – often at accident and emergency after a suicide attempt or self-harming incidents – once their injuries have been treated they can be discharged straight into the new homes rather than occupying a paediatric bed they do not need. Jointly commissioned by the council and the NHS, the two homes will cost £1.4m a year. Of that, MCC expects to spend £5,500 a week for each child. It represents a huge cost saving compared with some external placements. Last year the council was charged £16,550 a week by one private provider to look after a young profoundly autistic person with learning difficulties deemed a danger to themselves and to others. Read full story Source: The Guardian, 22 January 2023

An NHS trust declined to provide care for a vulnerable Black man days before he died in police custody while having a psychotic episode, The Independent has learnt. Godrick Osei, 35, died after being restrained by up to seven Devon and Cornwall Police officers in the early hours of 3 July 2022, after fleeing his flat and hiding in the cupboard of a care home in Truro. His family said he had been expressing “paranoid thoughts” and had called the police himself for help. He was arrested and died within an hour. Mr Osei had been diagnosed with anxiety and depression, had suspected post-traumatic stress disorder (PTSD) and was prescribed various medications to treat these conditions. He also intermittently used illicit drugs and had suffered alleged sexual assault in prison around 2013, according to a medical report from North East London NHS Foundation Trust (NELFT). In the days before his death, Mr Osei was in the care of NELFT’s community mental health team, whose caseworkers were concerned that he was exhibiting signs of a further severe illness – emotionally unstable personality disorder (EUPD) – and was a high risk to himself. However, Mr Osei was based outside the team’s catchment area, and NELFT asked the neighbouring Cornwall Partnership NHS Foundation Trust (CPT) to assess him instead. CPT refused without explaining why, according to a medical report seen by The Independent. Following Mr Osei’s death, an investigating officer from NELFT made multiple attempts to contact CPT to explore the possibility of a joint investigation into the matter, but didn’t receive a response. Read full story Source: The Independent, 16 January 2023

Patients discharged from hospital without social care packages could die at home, doctors have warned. They said Welsh government advice to do this showed a system at breaking point. The British Medical Association (BMA) said it rejects the guidance to "change the risk threshold" for releasing people from hospital. The Welsh government said discharging patients could help them get better "by reducing the risk of infection and muscle wastage". Royal College of General Practitioners Wales chairwoman, Rowena Christmas, said the NHS was "unbelievably stretched". "A frail, elderly person coming home, who can't really safely get from their bed or their chair to the bathroom without risk of falling over, they're not going to be able to survive at home," Dr Christmas said. "I completely understand we need more beds, but that feels like a bad move." Read full story Source: BBC News, 6 January 2023

The antiviral, molnupiravir, does not reduce coronavirus hospital admissions or deaths in vaccinated people at high risk, new research suggests. But the treatment was associated with a shorter recovery time, by four days, and reduced viral load. People who received molnupiravir reported feeling better compared to those who received usual care, the study found. Researchers suggest that while the drug could have some benefits in terms of symptom reduction, the cost of the drug may mean it is not the best choice for the general population, given the study findings. But it may be useful in reducing the pressure on UK health systems, they added. Chris Butler, professor of primary care in the Nuffield Department of Primary Care Health Sciences and co-chief investigator of Panoramic, said: “Finding effective, safe and scalable early treatments for Covid-19 in the community is the next major frontier in our research response to the ongoing worldwide pandemic. “It is in the community where treatments could have a massive reach and impact. “But decisions about who to treat should always be based on evidence from rigorous clinical trials that involve people who would most likely be prescribed the drugs.” Read full story Source: The Independent, 23 December 2022

Some of the most vulnerable patients could risk missing out on covid treatment because new rules will place the onus on them to access antiviral medication themselves instead of the NHS contacting them directly, senior figures have warned. The warnings follow NHS England’s national medical director Sir Stephen Powis writing to local leaders last week advising them the national commissioner will no longer identify patients who are eligible for covid treatment. This means eligible patients will need to contact local services themselves, rather than being approached proactively by a covid medicines delivery unit. Patients Association chief executive Rachel Power said: “Expecting patients ill with covid to know they’re eligible for these treatments and ask for them is unreasonable. How will they know they’re eligible or who to contact?” Read full story (paywalled) Source: HSJ, 6 April 2023

Women at risk of dying in pregnancy or childbirth will be treated at a network of specialist NHS centres under a national drive to halve maternal deaths. For the first time, women in England with conditions such as heart disease, epilepsy or cancer will have access to specialist care from doctors trained to treat medical problems in pregnancy. Two thirds of maternal deaths in the UK are due to medical conditions that pre-date or develop during pregnancy, rather than direct complications of birth. Previously there was no dedicated national service for these women. The 17 NHS centres, covering every region of the country, aim to prevent these deaths by bringing together specialist doctors, obstetricians, midwives and nurses under one roof. GPs and A&E staff will also be trained to identify “red flag” symptoms of illnesses in pregnant women and refer patients directly to the centres, where they can be assessed and receive medication or procedures. Read full story (paywalled) Source: The Times, 20 March 2023

Time is running out for hundreds of thousands of vulnerable people who are facing another winter shielding from Covid, campaigners have said. They are calling on the government to buy a drug called Evusheld to provide some protection against the virus. The government says it is not clear how long that protection will last when up against the Omicron variant. But patients, charities and health experts argue the protection offered is better than nothing. There are around 500,000 people in the UK with suppressed immune systems. That means their bodies struggle to produce antibodies, so the existing vaccines offer them little or no protection, leaving them very vulnerable to Covid. Blanche Hampton has lupus, a condition where her immune system has turned against her. The drugs she takes to control the lupus also suppress her immune system, meaning her body has no defences against Covid. Blanche has been shielding for two and a half years, but she believes Evusheld offers a chance for at least some kind of existence outside of her small flat in Inverkip, west of Glasgow. "Evusheld would give me a layer of protection, that is better than nothing. Because that's what I have currently - nothing." And Blanche, like many people who find themselves in the same situation, says she feels abandoned. Read full story Source: BBC News, 17 October 2022

Lung cancer screening should be offered to over-55s who have smoked, government advisers have said. New guidance from the UK National Screening Committee has called for a mass introduction of checks for all present and former smokers between the ages of 55 and 74. While the NHS offers routine screening for other types of cancer, including breast, bowel and cervical, there is no lung cancer screening programme. Lung cancer is the UK’s deadliest form and every year 48,000 people are diagnosed, with 35,000 deaths. The death rate is so high because it is often spotted when symptoms develop and it is too late for treatment. Only 5% of those diagnosed with lung cancer at the latest stage survive for five years, but when picked up early more than half survive. Officials have recommended targeted screening to cut death rates. It involves a CT scan which takes a detailed picture of the lungs to look for abnormalities. The National Screening Committee said that targeting all of those who have smoked would reduce deaths because 70% of lung cancer cases are caused by smoking. Read full story (paywalled) Source: The Times, 30 September 2022

A leading academic is calling on new Health Secretary Therese Coffey to reconsider rolling out a Covid drug for people with weakened immune systems. Last month the government decided it would not supply Evusheld in the UK. But Dr Lennard Lee, an academic medical oncologist from Oxford University who is backed by more than 120 leading scientists and clinicians, said a rethink was needed. The government said more data was required on the treatment. Evusheld was approved for use in March, but was reviewed after the Omicron variant emerged. The drug's manufacturer AstraZeneca said there was "ample real-world data" that it worked. It is currently available in 32 countries. Dr Lee told the BBC: "It's time for a re-review of the data, and to think about transparency in terms of why they decided not to do this, and also the pros and cons of doing this. "We do know that coronavirus cases are likely to go up in winter, and we do know there are people who face increased risks... "Therefore if there is anything we can do to protect... anyone immunosuppressed I think this is something that does need to be reconsidered." Research from the US and Israel suggests Evusheld reduces the risk of infection by about 50%, and cuts the risk of serious illness by 90%. Read full story Source: BBC News, 21 September 2022

A coroner has written to the health secretary warning a lack of guidance around a bacteria that could contaminate new hospitals' water supply may lead to future deaths. It follows inquests into the deaths of Anne Martinez, 65, and Karen Starling, 54, who died a year after undergoing double lung transplants at the Royal Papworth Hospital in Cambridge in 2019. Both were exposed to Mycobacterium abscessus, likely to have come from the site's water supply. The coroner said there was evidence the risks of similar contamination was "especially acute for new hospitals". In a prevention of future deaths report, external, Keith Morton KC, assistant coroner for Cambridgeshire and Peterborough, said 34 people had contracted the bacteria at the hospital since it opened at its new site in 2019. He said the bacteria "poses a risk of death to those who are immuno-suppressed" and there was a "lack of understanding" about how it entered the water system. There was "no guidance on the identification and control" of mycobacterium abscesses, the coroner said. Mr Morton said documentation on safe water in hospitals needed "urgent review and amendment". "Consideration needs to be given to whether special or additional measures are required in respect of the design, installation, commissioning and operation of hospital water systems in new hospitals," he said. Read full story Source: BBC News, 22 November 2022

The antibody drug Evusheld is effective for protecting clinically extremely vulnerable people from Covid-19, including its omicron variants, a preprint study has reported. The prophylactic treatment, manufactured by AstraZeneca, is a combination of two long acting antibodies (tixagevimab and cilgavimab). It is given as two separate, sequential intramuscular injections in the same session and can be administered in the community. A research team, led by the University of Birmingham alongside academics from King’s College London and the UK Health Security Agency, carried out a systematic review and meta-analysis to examine its effectiveness in immunocompromised patients. The paper examined the outcomes among 24 773 immunocompromised participants across 17 international studies, 10 775 of whom received Evusheld. Overall, it reported that the treatment was 86% effective for preventing covid specific death, 88% effective in preventing intensive care admission, effective in preventing hospital admission, and 40% effective in preventing Covid-19 infection. The study’s senior investigator, Lennard Lee, senior research fellow at the University of Birmingham and academic medical oncologist at the University of Oxford, said, “There is strong evidence emerging across the world that this approach of using prophylactic antibody therapies in combination with vaccination is a revolutionary approach to safeguard the most vulnerable patients this winter. The science and data suggest that it would be a successful approach for many cancer and immunocompromised patients at the highest level of risk.” Evusheld is already being given to immunocompromised patients in countries including the United States, France, and Israel, but the UK government is waiting for more data on the duration of protection it provides against omicron and its subvariants before deciding whether it should be used. Read full story Source: BMJ, 8 November 2022

Dr Rebecca Fisher gives the lowdown on why maintaining general practice as a ‘front door’ to the NHS that is safe for both GPs and patients is not easy. It’s fair to say that Matt Hancock’s pronouncement that henceforth all consultations should be “teleconsultations unless there’s a compelling reason not to”, has not been universally welcomed in general practice. In my surgery, practicing in a pandemic has seen us change our ways of working beyond imagination. In March, like many other practices, we shifted overnight to a “telephone first” approach. And whilst at peak-pandemic we kept face-to-face consultations to a minimum, we’re now seeing more and more patients in person again. Although many consultations can be safely done over the phone, we’re very clear that there are some patients – and some conditions and circumstances – where a patient needs a face-to-face appointment with a GP. NHS England have also been clear that all practices must offer face-to-face consultations if clinically appropriate. But maintaining general practice as a “front door” to the NHS that is safe for both GPs and patients is not easy. Options to quarantine and pre-test patients set out in national guidance and intended to help protect secondary care cannot be deployed in primary care. Other national guidance – for example regarding wearing masks in clinical sites – often seems to be issued with secondary care in mind, with little or delayed clarity for primary care. Measures like maintaining social distancing are also likely to be harder in general practice, where the ability of a surgery to physically distance staff from each other, and patients from each other and staff, is in part dependent on physical factors. Options to quarantine and pre-test patients set out in national guidance and intended to help protect secondary care cannot be deployed in primary care Things like the size and layout of a practice, or the availability of a car park for patients to wait in are hard to change quickly. Stemming from those challenges are ones related to staffing; how to keep practice staff safe from covid-19? NHS England and the British Medical Association have stated that staff should have rigorous, culturally sensitive risk assessment and consider ceasing direct patient contact where risks from covid-19 are high. The risk of catching COVID-19 – or dying from it – is not equally distributed amongst GPs. Age, sex, ethnicity, and underlying health conditions are all important risk factors. New Health Foundation research finds that not only are a significant proportion of GPs at high or very high risk of death from covid-19 (7.9 per cent), but one in three single-handed practices is likely to be run by a GP at high risk. If those GPs step back from face-to-face consultations we estimate that at least 700,000 patients could be left without access to in-person appointments. Even more concerningly, there’s a marked deprivation gradient. If GPs at high risk from COVID-19 step back from direct face-to-face appointments, and gaps in provision aren’t plugged, the patients likely to be most affected are those in deprived areas – the same people who have already been hardest hit by the pandemic GPs at high risk of death from covid are much more likely to be working in areas of greater socioeconomic deprivation. And single-handed practices run by GPs classed as being at very high risk from covid are more than four times as likely to be located in the most deprived clinical commissioning groups than the most affluent. If GPs at high risk from COVID-19 step back from direct face-to-face appointments, and gaps in provision aren’t plugged, the patients likely to be most affected are those in deprived areas – the same people who have already been hardest hit by the pandemic. Where do solutions lie? Ultimate responsibility for providing core general practice services to populations lies with CCGs. In some areas, collaborations between practices (such as GP federations and primary care networks), may be able to organise cross-cover to surgeries where face-to-face provision is not adequate to meet need. But these collaborations have not developed at equal pace across the country, have many demands on their capacity and may not be sufficiently mature to take on this challenge. These local factors – including the availability of locums – will need to be considered by commissioners. It’s vital that CCGs act quickly to understand the extent to which the concerns around GP supply highlighted by our research apply in their localities. In some cases, additional funding will be needed to enable practices to ‘buy in’ locum support for face-to-face consultations. This should be considered a core part of the NHS covid response. Face-to-face GP appointments remain a crucial NHS service, and must be available to the population in proportion with need. Just as in secondary care, protecting staff, and protecting patients in primary care will require additional investment. Failure to adequately assess the extent of the problem, and to provide sufficient resource to engineer solutions is likely to further exacerbate existing health inequalities. Original Source: The HSJ

Doctors and surgeons’ leaders have issued a warning that the NHS must not shut down normal care again if a second wave of Covid-19 hits as that would risk patients dying from lack of treatment. Here, one patient tells her story. Marie Temple (not her real name) was distraught when her MRI was cancelled in March, shortly after the UK went into lockdown and Boris Johnson ordered the NHS to cancel all non-urgent treatment. Temple, who lives in the north of England, was diagnosed with a benign brain tumour last year after suffering seizures and shortly afterwards had surgery to remove it. She had been promised a follow-up MRI scan in late March to see if the surgery had been a success, but she received a letter saying her hospital was dealing only with emergency cases and she didn’t qualify. Read the full article here.

New analysis by the Health Foundation reveals the devastating impact the pandemic has had on social care in England. The independent charity says the findings provide further evidence that the government acted too slowly and did not do enough to support social care users and staff, and that protecting social care has been given far lower priority than the NHS. The Health Foundation finds that policy action on social care has focused primarily on care homes and that this has risked leaving out other vulnerable groups of users and services, including those receiving care in their own homes (domiciliary care). It also notes that the shortcomings of the government’s response have been made worse by longstanding political neglect and chronic underfunding of the social care system. Since March there have been more than 30,500 excess deaths* among care home residents in England and 4,500 excess deaths among people receiving domiciliary care. While high numbers of excess deaths of people living in care homes have been well reported, the analysis shows there has been a greater proportional increase in deaths among domiciliary care users than in care homes (225% compared to 208%). And while deaths in care homes have now returned to average levels for this time of year, the latest data (up until 19 June) shows that there have continued to be excess deaths reported among domiciliary care users. The Health Foundation says that decades of inaction by successive governments have meant that the social care system entered the pandemic underfunded, understaffed, and at risk of collapse. Read full article here.

More than a quarter of black, Asian and minority ethnic NHS staff had not yet had a risk assessment in relation to their exposure to coronavirus, according to the latest data collection by national NHS leaders. Full article here on the HSJ website (paywalled)

The government removed a key section from Public Health England’s review (published Tuesday) of the relative risk of COVID-19 to specific groups, HSJ has discovered. The review reveals the virus poses a greater risk to those who are older, male and overweight. The risk is also described as “disproportionate” for those with Asian, Caribbean and black ethnicities. It makes no attempt to explain why the risk to BAME groups should be higher. An earlier draft of the review which was circulated within government last week contained a section which included responses from the 1,000-plus organisations and individuals who supplied evidence to the review. Many of these suggested that discrimination and poorer life chances were playing a part in the increased risk of COVID-19 to those with BAME backgrounds. HSJ understands this section was an annex to the report but could also stand alone. Typical was the following recommendation from the response by the Muslim Council of Britain, which stated: “With high levels of deaths of BAME healthcare workers, and extensive research showing evidence and feelings of structural racism and discrimination in the NHS, PHE should consider exploring this in more detail, and looking into specific measures to tackle the culture of discrimination and racism. It may also be of value to issue a clear statement from the NHS that this is not acceptable, committing to introducing change.” One source with knowledge of the review said the section “did not survive contact with Matt Hancock’s office” over the weekend. Read full story Source: HSJ, 2 June 2020