Suncream, cold remedies and gluten-free food may no longer be available on the NHS in England under a crackdown on “low value” medicines.

NHS England announced a review after local health bosses identified £400m of spending they believe has little or no clinical value.

It also includes some types of pain relief and travel vaccines.

The proposals could see an outright ban or tighter restrictions on some products being prescribed by GPs.

An initial list of 10 products has been drawn up by NHS Clinical Commissioners, which represents local health managers who are in charge of budgets.

A number of them are available over-the-counter at a lower price than the cost to the NHS of prescribing them or include drugs for which there are more effective or cheaper alternatives.

Evidence submitted to NHS England – and seen by the BBC – argues that the prescribing of gluten-free products dates back to the 1960s when there was not the choice there is now in supermarkets and shops.

Cutting back on prescriptions for the 10 products could save the NHS over £100m a year.

While patients can be charged for prescriptions, the wide range of exemptions mean only one in 10 items handed out are paid for by individuals.
‘Low value’ medicines on the list and their annual cost to the NHS:

£30.93m on Liothyronine to treat underactive thyroid
£21.88m on gluten-free foods
£17.58m on Lidocaine plasters for treating nerve-related pain
£10.51m on Tadalafil, an alternative to Viagra
£10.13m on Fentanyl, a drug to treat pain in terminally ill patients
£8.32m on the painkiller Co-proxamol
£9.47m on travel vaccines
£7.12m on Doxazosin MR, a drug for high blood pressure
£6.43m on rubs and ointments
£5.65m on omega 3 and fish oils

Source: NHS Clinical Commissioners

NHS Clinical Commissioners has also highlighted other products which it wants reviewed once the initial batch of 10 have.

This includes suncream, cough and cold remedies and indigestion and heartburn medicines, which could bring the saving to £400m a year.

That is out of a total bill of over £16bn on medicines once those dispensed by both hospitals and GPs are taken into account.

NHS Clinical Commissioners chief executive Julie Wood said “difficult choices” had to be made given the unprecedented financial and demand challenges facing the NHS.

She said it was important to reduce spending on prescription items that have “little or no clinical value”.

NHS England confirmed the review would begin in April, but did not put any timescale on how quickly a decision would be made.

The news comes ahead of a major announcement by NHS England later this week on the future of the health service.

The number of people facing “long waits” for hospital treatment in England has more than doubled in the past four years, figures show.

Patients needing routine care such as knee and hip replacements are meant to be treated in 18 weeks under NHS rules.

But the numbers waiting longer than that now top 350,000 – a 163% rise since 2012. There are 3.7 million people in total on the waiting list.

The government promised the NHS would do “better in the future”.

Scotland, Wales and Northern Ireland have also seen pressures grow – meaning no part of the UK is now meeting its target to see patients.

Royal College of Surgeons president Clare Marx said the picture was “very disappointing” as these operations and treatments could make a huge difference to people’s lives.

“Someone waiting for a gall-stone removal will be in a lot of pain and discomfort. The longer you wait for a hip or knee replacement the less likely you are to have good outcomes. These waits really matter. The standards of care are being eroded and we don’t want it to get worse.”

But Richard Murray, from the King’s Fund think tank, predicts the numbers on the waiting list will keep rising.

The total of 3.7m is a 44% increase since 2012, but he expects to see the trend continue and break through the four million barrier by the spring.

The latest figures cover the month of November and mean the target for the NHS – that at least 92% of patients on waiting lists will not have been waiting over 18 weeks – has been missed since February last year.

A Department of Health spokesman said the NHS was having to treat more patients – 5,000 extra a day compared with 2010 – so the levels of performance were actually a “tribute” to the work of NHS staff.

He said the investment being made in the NHS this Parliament would help “transform services” and mean the NHS will do “better in the future”.

The targets for routine treatments are measured differently in Wales, Scotland and Northern Ireland, but all show a similar picture.

In Wales, 95% of patients are supposed to start treatment within 26 weeks. This target has not been met since August 2010 and the number of long waiters has risen by 74% to 60,643 in November 2016.

Scotland’s target is for 90% of patients to start treatment within 18 weeks. This has been missed since June 2014. The number waiting longer than 18 weeks was up 82% over that period at 16,635.

Northern Ireland has a target of 55% per cent of patients waiting no more than 13 weeks for an operation. The number waiting longer than that was up 95% in the four years to September 2016.

There are calls for more to be done to stop people smoking at hospitals and promote healthy living.

Health boards say they are powerless to enforce smoking bans on their grounds as they are not yet backed up by law.

BMA Cymru said a decision had to be made on whether hospitals were “places of health or not” as smoking areas could still be allowed in future.

The Welsh Government said the Public Health Wales Bill would help make the Welsh NHS an “exemplar” to follow.

The National Obesity Forum has also called for a blanket ban on the selling of junk food to patients, visitors and staff, saying hospitals should be “role models” for healthy living.

If introduced, the bill currently under consideration by the assembly for the second time, would make it illegal to smoke on hospital grounds in Wales.

But a clause in the draft legislation – which has faced some criticism for containing no specific measures to tackle obesity – would give hospital managers the power to create designated smoking areas if they chose.

But Dr Phil Banfield said there should be no exceptions to the rule anywhere on hospital grounds, as the sites needed to promote healthy lifestyles.

“There is a conception that hospitals are places of healing,” he said. “Having an activity that is the leading cause of death and hospital admissions on the doorstep seems a contradiction.”

Mr Banfield said most people smoked while they are waiting in hospitals or visiting ill relatives “because they are bored” and more had to be offered as an alternative distraction at all times of the day and night.

He added that people should be offered help to quit smoking while they are in the hospital grounds – with access to support at any time, on the same footing as drug addicts.

“Hospitals need to be more inventive about how we promote the wider issues for the community,” he said.

“We are very rigid in the way we run our hospitals, really we have to think about them as community assets – our hospitals belong to the people.”
Image caption Public Health Wales Bill measures on the table

Since 2008 health boards have been barred from stocking vending machines with unhealthy snacks – such as crisps and fizzy drinks – following Welsh Government guidance.

Despite the rules stressing only food with “positive nutritional benefit” should be sold, some health boards appear to be ignoring the advice.

Cwm Taf health board said all six of its hospitals had vending machines containing canned drinks and sweets, while Abertawe Bro Morgannwg hospitals have 34 machines selling fizzy drinks, according to a Freedom of Information (FOI) request by the Welsh Conservatives.

The BMA has previously called for hospital food standards to be made law rather than guidance as part of the Public Health Wales Bill, but has warned some areas to tackling the problem are outside the assembly’s control.

Tam Fry, of the National Obesity Forum, said: “A hospital is a place people go to be cured, if we therefore do not have healthy food and behaviours in the hospital for the patients, visitors and staff, then we are selling short of what is required.

“You have barely walked through the door and there are places selling and promoting sugary food and drink, it is soul destroying for the people that work there, who are trying to free people from disease. The people that are buying this stuff are probably going to be treated by them, if not now, then in the future.”

A spokeswoman said that the new health bill would build on voluntary smoking bans and new hospitals were being focused on the “patient environment and journey” with courtyards and breakout spaces.

“We want people to be able to access health services in a modern, fit for purpose environment. “Many of our hospital buildings have access to coffee shops and other facilities run by a range of organisations which provide access for visitors and patients.”

Delays in discharging people from hospital are rising more rapidly in mental health trusts than other parts of the NHS in England, a study shows.

NHS England data found a 56% rise in the number of bed days lost to delayed discharge in psychiatric trusts in October 2016 compared to November 2015.

There was a comparable rise in acute trusts of 30%.

A spokeswoman said the Department of Health was investing £400m over four years to support people in their homes.

“No-one should face unnecessary delays in being discharged,” she said. “The Five Year Forward View for Mental Health will transform services by 2020/21 to make sure urgent improvements are made.”

A delayed discharge occurs when a patient is declared medically well enough to leave hospital but something else hinders their departure.

NHS England says 17,509 bed days were lost in October 2016 in the 24 trusts which particularly specialise in mental health and learning disability care, an increase of nearly 56% on the previous November.

A broader analysis – including trusts that provide community as well as mental health services – shows a 43% increase between the two months.

Many of the problems are caused by a lack of social care packages available to support people once they leave hospital because of cuts to local authority budgets and rising demand.

But experts say mental health patients are further disadvantaged by poor community psychiatric provision and reduction to other support services such as detox, which has had a disproportionate impact on mental health.

In 2015, an inquiry ordered by the Royal College of Psychiatrists found that the main reason that some mental health patients were having to travel long distances to get a hospital bed was because of delayed discharges and a lack of community psychiatric provision.

A report last May from the National Audit Office estimated that delayed discharges across England were costing the NHS £820m a year.

Paul Farmer, chief executive of the mental health charity Mind, said: “When you are hospitalised in a mental health crisis, you are at your most unwell and desperately need the right care at the right time.

“The time after leaving hospital is critical as that is when people are at the greatest risk of taking their own lives. People need the right support to recover and manage their mental health properly and trusts should be planning properly for discharge from the point at which someone goes into hospital.

“These types of problems are symptomatic of mental health historically not being given the attention and funding it deserves – mental health services have been underfunded for decades, at a time of rising demand.”

Senior doctors say they are concerned about the number of cancer patients having their operations cancelled amid “tremendous pressure” facing the NHS in England this winter.

Ian Eardley, from the Royal College of Surgeons, said a shortage of beds was one of the causes. Such surgery is usually protected under treatment time guidelines, he added.

The NHS said it was “pulling out all the stops” to ensure patients receive surgery “as quickly as possible”.

A spokesman for NHS England said there had been a steady increase in the number of operations over the last 15 years and more people were surviving cancer than ever before.

Guidelines for hospitals in England stipulate that cancer patients should be seen within 31 days and receive primary treatment within 62.

In November 2016, the latest period which NHS figures are available for, the 62-day target for treatment to start was missed – with 83.5% of patients being treated in that timeframe instead of 85%.

Mr Eardley, vice president of the RCS, said most hospitals were able to see more than 90% of patients within that time period, but in the past year “it’s been more difficult to achieve that”.

He said that while cancer operations were cancelled “from time to time”, especially during the winter, the RCS had heard from its members in England about an increasing number of cancellations within the last week.

“There are current pressures – since Christmas particularly – and the number of cancelled operations has been going up,” he told the BBC.

“The NHS is under tremendous pressure – more and more patients are going to A&E and there is more difficulty in getting patients home, and it’s not something we are comfortable with at all.

“If we could get patients home more quickly and effectively, we could carry on with doing surgery more quickly and more effectively.”

He added that solving the shortage of beds caused by problems with arranging care in the community would be “the easiest thing to do most quickly, although there are other longer-term problems and there also needs to be a broader review of the NHS.”

People who live near major roads have higher rates of dementia, research published in the Lancet suggests.

As many as 11% of dementia cases in people living within 50m of a major road could be down to traffic, the study suggests.

The researchers, who followed nearly 2m people in Canada over 11 years, say air pollution or noisy traffic could be contributing to the brain’s decline.

UK dementia experts said the findings needed probing but were “plausible”.

Nearly 50 million people around the world have dementia.

However, the causes of the disease, that robs people of their memories and brain power, are not understood.

The study in the Lancet followed nearly two million people in the Canadian province of Ontario, between 2001 and 2012.

There were 243,611 cases of dementia diagnosed during that time, but the risk was greatest in those living closest to major roads.

Compared with those living 300m away from a major road the risk was:

7% higher within 50m
4% higher between 50-100m
2% higher between 101-200m

The analysis suggests 7-11% of dementia cases within 50m of a major road could be caused by traffic.

The researchers adjusted the data to account for other risk factors like poverty, obesity, education levels and smoking so these are unlikely to explain the link.

Dr Hong Chen, from Public Health Ontario and one of the report authors, said: “Increasing population growth and urbanisation have placed many people close to heavy traffic, and with widespread exposure to traffic and growing rates of dementia, even a modest effect from near-road exposure could pose a large public health burden.

“More research to understand this link is needed, particularly into the effects of different aspects of traffic, such as air pollutants and noise.”
Should I flee to the country?

There are already plenty of reasons to avoid the polluted air in our cities.

The World Health Organization says three million people die every year due to outdoor air pollution.

It increases the risk of stroke, heart disease, lung cancer and respiratory diseases.

However, it is not clear whether dementia should be added to the list. This study “hints” there may be something going on, but does not definitively prove it.

So if you’ve not already been persuaded to up-sticks and move somewhere greener, then this study shouldn’t change your mind.

Risk factors for dementia

Ageing
Genetics
Being female
Type 2 diabetes
Smoking
Physical inactivity
Unhealthy diet

Source: Alzheimer’s Society

The government wants surgeries to open between 08:00 and 20:00, seven days a week, unless they can prove the demand is not there.

Some GPs in England have been warned they could lose extra funding if they fail to meet their commitments to keeping surgeries open for longer.

It said many patients were going to under-pressure A&E departments because they could not get GP appointments.

The British Medical Association accused ministers of “scapegoating” doctors.

Surgeries are currently expected to open between the core hours of 08:00 and 18:30, Monday to Friday.

Extra funding is available to those offering appointments outside those hours.

Downing Street said surgeries should do more to ensure they offered appointments in the evening and at weekends. It said: “Most GPs do a fantastic job, and have their patients’ interests firmly at heart.

“However, it is increasingly clear that a large number of surgeries are not providing the access that patients need – and that patients are suffering as a result because they are then forced to go to A&E to seek care. It’s also bad for hospitals, who then face additional pressure on their services.”

Why bother with seven-day GP opening?

The government highlighted October 2015 figures from the National Audit Office (NAO), which showed that 46% of GP surgeries closed at some point during core hours, and 18% closed at or before 15:00 on at least one weekday.

Three-quarters of those that closed early were receiving extra funding in 2015-16 to provide access outside of core hours, the NAO said.

Number 10 also said ministers had been shown evidence that some GP surgeries were failing to tell patients about extending hours for appointments or ensuring they were at convenient times.

It said patients not seen outside working hours were “left with little option” but to go to A&E.

It comes as figures show more than four in 10 hospitals in England declared a major alert in the first week of the new year as they faced unprecedented pressures.

The director of acute care for NHS England, Professor Keith Willett, has estimated that 30% of patients attending A&E would be better cared for elsewhere in the system, the government said.

Downing Street said the prime minister wanted to help reduce pressures on hospitals in a number of ways:

Ministers may ask GP surgeries to use a new appointments tool to submit appointments data
GPs would receive extra funding for offering extended hours only if they could demonstrate they were offering appointments which patients wanted and were advertising them properly
Surgeries receiving extra cash for longer opening times would be asked to expand their online services for patients to free up time for consultations and treatment

The British Medical Association (BMA) accused ministers of trying to “deflect blame” on to doctors rather than address the NHS funding crisis.

GP committee chairman Dr Chaand Nagpaul said pressure on A&E services was down to seriously ill patients for whom seeing a GP would not prevent a hospital admission.

The government must “take responsibility” and outline an emergency plan to tackle NHS under-resourcing, he said.

Health think tank the Nuffield Trust’s chief executive Nigel Edwards said the problem was capacity, not timing.

“If you haven’t got more GPs and more practice nurses to do it, you haven’t increased the number of appointments, you’ve just put additional pressure on a service that’s already under a very severe level of pressure,” he said.

The government said ministers believed GP surgeries had a “vital role” to play in alleviating pressure on A&E.

A 14% increase in funding to general practice will ensure there will be about 5,000 more doctors by 2020, it added.

Hospitals in England collected more than £120 million in car parking fees in the last year.

NHS hospitals appear to be making more money than ever from parking fees.

A report from the Press Association says hospitals in England collected more than £120m last year – up by 5%.

Many trusts defended the charges, saying the money was put back into patient care or maintaining car parks.

However the chief executive of the Patients Association said it was unfair that hospital parking in Wales and Scotland was largely free, while patients in England had to pay.

Of the 120 trusts asked by PA, 89 responded to the Freedom of Information request on the charges.

The responses showed £120,662,650 had been collected in car park fees over 2015/16, up from £114,873,867 the year before.

Only 27 trusts responded to a question about parking fines, but they showed over £2m had been collected in a four year period, with over £635,000 collected this year alone.

The figure which each trust accrued varied, partly as a consequence of their size. But more than half were making over £1m in car park fees in a year.

The investigation also found that almost half of all NHS trusts charged disabled people for parking in some or all of their disabled spaces.

Hospital car parking fees were abolished in Scotland and Wales in 2008, although a small number of hospitals still charge as they are signed up to private contracts to manage their parking facilities.

However, fees are allowed to be charged in Northern Ireland.

Katherine Murphy, chief executive of the Patients Association, said the investigation showed the “shocking reality” faced by patients, saying hospitals were “taking money from the sick and vulnerable to top up NHS coffers”.

She added: “This is not what car parking charges should be used for. The NHS is clearly underfunded, but the onus on meeting the funding crisis should most certainly not be shouldered by the sick, injured and vulnerable.”

Ms Murphy said it was important that drivers parked sensibly, but said fines were a burden on the sick. We take a very clear line that car parking fees need to be scrapped or strictly capped,” she said.

The deputy mayor of Leicester Rory Palmer said the charges created two levels of “profound unfairness”.

“First, people find themselves paying different amounts, at different hospitals, in different parts of the country,” he said. “That incoherency is unfair and, in effect, creates a postcode lottery.”

“But the real question is whether its actually fair to charge people who might be very ill, having to make lots of visits to hospital for treatment of to charge people visiting their sick relatives?”

“I’m not sure that’s in the true spirit of the National Health Service, which is about providing a service free at point of access.”

The Heart of England NHS Foundation Trust made the most out of parking, with £4,841,108 collected across the year.

The majority – £3,465,357 – came from patients and visitors, whilst staff paid £1,375,751. Almost £40,000 was also collected by the trust in car park fines.

The London North West Healthcare NHS Trust made £968,170 in car park charges. A further £1,262,194 went to the private firm Apcoa under a private finance initiative (PFI) contract to manage the multi-storey car park at Northwick Park hospital.

The trust made £28,449 from car parking fines and the private firm kept a further £25,990 in fines in 2015/16. Over four years, Apcoa has kept £167,357 in fines under the terms of the PFI contract.
In 2014/15 the trusts made £3,728,000 and £1,421,172 respectively, meaning the total figure for all trusts across England could be much higher.

The NHS has disputed claims from the Red Cross that there is a “humanitarian crisis” in its hospitals in England.

One of NHS England’s specialist directors said he thought the service was not “at that point” of crisis, but admitted demand was higher than ever.

The Red Cross helps some hospitals with patient transport and provides care for patients who have returned home.

Labour’s Jeremy Corbyn urged Theresa May to tell MPs how she would fix the “national scandal” of the NHS.

Mr Corbyn said: “The fact is, this government have repeatedly failed to put the necessary resources into our health service, while they have cut social care and wasted billions on a top-down reorganisation to accelerate privatisation.”

The Labour leader said he was “demanding” that Theresa May appeared at the Commons on Monday to explain “how she plans to fix her failure on the NHS”.

It comes as a third of hospital trusts in England warned they needed action to cope with patient numbers last month.

Figures show that 42 A&E departments ordered ambulances to divert to other hospitals last week – double the number during the same period in 2015.

Diversions can only happen when a department is under significant pressure, such as lacking the capacity to take more patients or having queues of ambulances outside for significantly prolonged periods, and when all existing plans to deal with a surge in patients have been unsuccessful.
Image caption The British Red Cross provided support to staff at the East Midlands Ambulance Service

The Royal College of Emergency Medicine said staff were under intense pressure, while the Society for Acute Medicine warned this month could be the worst January the NHS had ever faced.

Its president, Dr Mark Holland, said that the term “humanitarian crisis” was strong, but “not a million miles away from the truth”.

He said: “We have been predicting that we would face a winter from hell. I think that time has arrived.”

Professor Keith Willett, medical director for acute care at NHS England, said he did not think the service was at the level of a humanitarian crisis, but admitted demand was at its highest level ever and staff were under “a level of pressure we haven’t seen before”.

Speaking to BBC News, he would not answer whether the government was taking reforms to social care of patients returned from hospital seriously, but said that was where future investment needed to go.

“We have to transform and modernise the way the NHS works and we do have to move much more care into the community where it is much more appropriate, particularly for the elders in our society,” he said.
Chief executive Mike Adamson said: “The British Red Cross is on the front line, responding to the humanitarian crisis in our hospital and ambulance services across the country.

“We have been called in to support the NHS and help get people home from hospital and free up much needed beds.

“We’ve seen people sent home without clothes; some suffer falls and are not found for days, while others are not washed because there is no carer there to help them.”

He said that if people did not get the care they needed “they will simply end up returning to A&E, and the cycle begins again”.

After the festive season- when people often over indulge there is a new warning on the damage that alcohol does.

Women who regularly drink more than three-and-a-half bottles of wine a week should get their livers checked, says new draft advice for England.

For men, the threshold is five bottles of wine a week or 50 units of alcohol, says the National Institute for Health and Care Excellence.

The organisation says GPs should refer “harmful” drinkers for liver scans.

Cirrhosis can be silent until the damage becomes so extensive it stops the liver working. It usually takes years for the condition to reach this stage of organ failure.

Anyone who has been drinking harmful amounts for months should get scanned, say the draft recommendations.

Early treatment and support can prevent serious liver damage.

According to Public Health England, nearly 2 million people in England are drinking harmful amounts of alcohol – more than 50 units a week for men and 35 units a week for women.

The NHS recommends adults should not regularly drink more than 14 units of alcohol a week.

If you drink as much as 14 units a week, it is best to spread this evenly over three or more days.

A unit of alcohol is about half a pint of normal-strength lager or a single measure of spirits. A small (125ml) glass of 11% strength wine is about 1.4 units, while the same size glass of 14% strength wine is 1.8 units.

Prof Gillian Leng, deputy chief executive of NICE, said: “Many people with liver disease do not show symptoms until it is too late.

“If it is tackled at an early stage, simple lifestyle changes or treatments can be enough for the liver to recover. Early diagnosis is vital, as is action to both prevent and halt the damage that drinking too much alcohol can do.”

Dr Andrew Fowell, liver expert at the Portsmouth Hospitals NHS Trust, said: “Identifying people who are at risk of liver disease and offering them non-invasive testing to diagnose cirrhosis is key to ensuring they are given the treatment and support they need early enough to prevent serious complications.

“Ten years ago diagnosis of cirrhosis would often require a liver biopsy, but now with advances in non-invasive testing it is much easier for patients and health professionals to make a diagnosis.”

The draft quality standard from NICE recommends a non-invasive scan called transient elastography which uses ultrasound and low-frequency elastic waves to check the liver. A consultation on the draft document is open until February 2017.