Chief Inspector of Hospitals Speaks out on NHS Funding

England’s outgoing chief inspector of hospitals believes that more money should be spent on hospitals, but also concedes that funding is not the sole answer to the NHS crisis.

Prof Sir Mike Richards says that the health services in a particularly worrying condition, and that urgent investment must be a priority.

In particular, Richards suggested that a pay rise for nurses is essential, and asserted that the NHS will have problems returning nursing staff if this is not instigated.

But the chief inspector of hospitals also suggested that other improvements could be made without spending vast amounts of money.

“Even at times of austerity, when the money hasn’t been coming through fast, we have seen a number of hospitals actually getting better during that time [and] a number of mental health trusts getting better because they have focused on what really matters to patients, on patient safety, on the whole leadership agenda within these hospitals, in order to engage their staff and deliver better care,” Richards told BBC Radio 4’s Today programme.

The executive effectively repeated the message that had previously been promoted by Theresa May, namely that the NHS must spend money more effectively, as opposed to simply being given additional funding.

Experts have stated that the investment pledged to the health service by the Tories would be significantly less than is needed.

But Richards acknowledged that wise investment should be considered critical.

“Two things can be true at the same time. There’s no doubt the NHS needs more money because of increasing demand on it and the need to transform services. But [it’s] also true, as we have seen, that things can be done better without more money. And that is what we’re encouraging, alongside saying yes, we will need more money.”

Richards also believes that more must be done to retain staff following the recent EU referendum on Brexit, which is expected to impact on the NHS.

“The workforce of the NHS and, indeed, the care system generally is absolutely critical and we do need to have more staff – we do need to recruit those staff – and that’s true in virtually every sector that we look at. Of course, if we are leaving the EU, there is a threat to that, which we need to make sure is being dealt with so that we aren’t losing staff and we can then replace them and, if necessary, to grow our own, if you like.”

And Richards also called for “far greater integration between GPs, hospitals, care homes and community health services to make that work”.

Richards was an Imperial Cancer Research Fund research fellow in medical oncology at St Bartholomew’s Hospital in London (1982–86), and then an oncology consultant at Guy’s Hospital in London (1986–95), becoming a Reader in 1991.

He received his CBE in 2001 and his knighthood in 2010, and in 2014 he received a Cancer Research UK Lifetime Achievement Award.

 
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New French Technique Offers Insight into Blood Diseases

A new technique to study the flow of liquids developed by scientists from Université Paris-Saclay and the University of Amsterdam offers fresh hope for tackling blood diseases like thrombosis.

Previous microfluidic measurement tools have been based on particle tracking.

The new technique uses polarised optical signals from luminescent nanorods to measure flow shear – i.e. the strain produced by directional pressure – at an instant, microscopic level never achieved before.

This can be used in medical diagnostic devices, as well as in other channels, to replicate diverse flow systems such as blood vessels.

Jongwook Kim, assistant professor of physics at École Polytechnique, Université Paris-Saclay, explained how the new approach works.

“Like logs floating on a river, it is known that elongated objects orient along the direction of flow. This rule is even more strictly obeyed by tiny nanorods, into which we incorporate luminescent properties to signal their orientation. We suggest a novel way to analyse flows on a microscopic scale by detecting the group orientation of the nanorods dispersed in fluids.”

This new technique is perfectly suited to the study of thrombosis as the generation and breakdown of blood clots are directly influenced by shear stress that depends on the geometry of veins and capillaries.

As blood flow is dynamic, with beats and swirls, the new technique can provide an instant, precise measurement.

Furthermore, beyond microfluidics, the principle of rod-orientation determination developed by the team shows promise as bio-markers to monitor the complex dynamic motions of micro-biosystems such as cells, genes, and enzymes.

These findings, that have the potential to be applied to many fields, have been published in the journal Nature Nanotechnology.

 
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Number of NHS Staff Vacancies Jump 10% in Just 12 Months

Official figures indicate that the number of unfilled NHS post escalated by 10% in the last 12 months alone.

This means that tens of thousands of jobs are vacant across the NHS system.

Responding to the data, the Labour Party accused Theresa May and the Conservative government of taking the whole service for granted, effectively overseeing “an unprecedented workforce crisis in the NHS”.

In March this year, there were 30,613 vacant full-time NHS positions being advertised, compared to 26,424 in the same month in 2016, and 26,406 in 2015.

And nursing has been particularly hard hit, with 40% of vacancies in March 2017 being for nursing and midwifery positions.

Janet Davies, head of the Royal College of Nursing (RCN), warned that “NHS staffing levels are reaching crisis point”.

“At the very moment the NHS needs to be recruiting more nursing staff, we learn the number is falling and the NHS finds itself advertising for more jobs we know it cannot fill. A lethal cocktail of factors is resulting in too few nurses and patient care is suffering. The Government desperately needs to keep the experienced staff still working in the NHS,” Davies commented.

The climate in nursing is underlined by the fact that the nursing profession has threatened to strike for the first time in NHS history over staff shortages and pay.

This has been strongly supported by the Royal College of Nursing, which has described the government’s decision to retain a 1% pay freeze for NHS staff as a “bitter disappointment”.

Meanwhile, Justin Madders, Labour’s shadow health minister, said a repeat of last winter’s chaotic scenes, with A&E patients lined up on trolleys in corridors to be seen, “is simply intolerable”.

“For years the Tories have taken NHS staff for granted and asked them to do more for less, resulting in a recruitment and retention crisis which threatens patient care on a daily basis. Frankly the Government’s solution of hiring expensive agency staff or asking hard-pressed existing staff to cover extra shifts is not in the best of interests of patients or medical professionals,” Madders asserted.

And Liberal Democrat shadow health secretary Norman Lamb largely concurred with this credit.

“The NHS is finding it harder and harder to recruit the staff it needs, yet still this government is refusing to end years of cuts to pay”.

Responding to this criticism, a Department of Health spokesperson outlined the effort is that the authorities have made to improve the situation in the NHS.

“Staffing is a priority – that’s why we have invested in the frontline and there are almost 32,400 more professionally qualified clinical staff including almost 11,800 more doctors, and over 12,500 more nurses on our wards since May 2010.”

But Dr Mark Holland, president of the Society for Acute Medicine, believes that’s the 1% pay cut must be removed if the situation is to significantly improve.

“Removing the pay cap on NHS staff, particularly the lowest paid, is long overdue, while the extra pressure on overworked frontline staff to meet targets must be eased. This data shows it is high time we saw steps taken to stop disincentivising staff – salaries must be fair, working conditions must be safe and sustainable and clear career pathways must be in place.”

 
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Lancet Study Suggests Many Dementia Cases are Preventable

A major study published in the Lancet journal suggests that around 35% of dementia cases could be prevented if people made more effort to look after their brain health throughout their lives.

The international study listed nine key risk factors for dementia including lack of education, hearing loss, smoking and physical inactivity.

And the study will be presented at the Alzheimer’s Association International Conference in London.

It is believed that 131 million people people could be living with dementia worldwide by 2050, while it is estimated that around 47 million people already live with the condition.

Nine factors contribute to the risk of dementia:

Mid-life hearing loss – responsible for 9% of the risk
Failing to complete secondary education – 8%
Smoking – 5%
Failing to seek early treatment for depression – 4%
Physical inactivity – 3%
Social isolation – 2%
High blood pressure – 2%
Obesity – 1%
Type 2 diabetes – 1%

With these factors totalling 35%, it is clear that more than one-in-three cases of the condition could be prevented.

“Although dementia is diagnosed in later life, the brain changes usually begin to develop years before,” said lead author Prof Gill Livingston, from University College London. “Acting now will vastly improve life for people with dementia and their families and, in doing so, will transform the future of society.”

Twenty-four international experts were involved in the authoring of the report, which emphasises the importance of lifestyle factors.

The text of the Lancet article speaks of building a cognitive reserve, which strengthens the brain’s neural networks, enabling it to function in later life even when damage is present.

Dr Doug Brown, director of research at Alzheimer’s Society, believes that the research is particularly illustrative.

“Though it’s not inevitable, dementia is currently set to be the 21st Century’s biggest killer. We all need to be aware of the risks and start making positive lifestyle changes.”

While Dr David Reynolds, chief scientific officer at Alzheimer’s Research UK, called on the government to invest more funding in research on dementia.

“Alongside prevention research, we must continue to invest in research to find a life-changing treatment for people with this devastating condition.”

Not smoking, doing exercise, keeping a healthy weight, treating high blood pressure and diabetes can all reduce the risk of dementia, as well as cardiovascular disease, and cancer, researchers concluded.

However, the scientist also indicated that they did not have enough data to include dietary factors or alcohol in their calculations but believe both could be important.

 
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Cows Offer Hope on HIV Vaccine Research

US researchers believe that cattle can help develop a vaccine to tackle the HIV virus.

According to scientists, cows have “insane and mind-blowing” ability to help research in this area.

It has been found that the bovine animals rapidly produce a certain type of antibody which can neutralise the HIV virus.

While it is not understood why cows are particularly effective in this area, there is speculation that the animals have developed a particularly strong immune system due to their complex and bacteria-packed digestive system.

Infamously, cows benefit from four separate stomachs.

The US National Institutes of Health stated that the findings were of “great interest”.

Researchers at the International Aids Vaccine Initiative and the Scripps Research Institute, involved with the immunisation of cows, found that the response outstripped even the most optimistic projections.

And the required antibodies were produced by the cow’s immune system in a matter of weeks.

“It was just insane how good it looked, in humans it takes three-to-five years to develop the antibodies we’re talking about. This is really important because we hadn’t been able to do it period. Who would have thought cow biology was making a significant contribution to HIV,” one of the lead researchers commented.

The results, published in the journal Nature, showed the cow’s antibodies could neutralise 20% of HIV strains within 42 days.

And Dr Dennis Burton, a researcher involved in the study, commented that cows could have a much more profound influence on developing an HIV vaccine that anyone could have predicted.

“The potent responses in this study are remarkable. Unlike human antibodies, cattle antibodies are more likely to bear unique features and gain an edge over HIV.”

Dr Anthony Fauci, the director of the US National Institute of Allergy and Infectious Diseases, believes that the research represents a major breakthrough in teaching the debilitating and deadly condition.

“From the early days of the epidemic, we have recognized that HIV is very good at evading immunity, so exceptional immune systems that naturally produce broadly neutralizing antibodies to HIV are of great interest – whether they belong to humans or cattle.”

The research suggests that cattle could eventually become a source of drugs to make more effective vaginal microbicides to prevent HIV infection.

It is hoped that the cattle study will play a major role in developing a vaccine that encourages the human immune system to make the antibodies required to fight the HIV virus.

 
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New Help for parents to give Every Child in Wales the Best Possible Start

A new Public Health Wales programme, ‘Every Child Wales’, is being launched today in oder to improve the health and wellbeing of children, as new survey results reveal that parents do not always recognise when their child is overweight.

In the survey, just 4% of parents with children aged 4 to 5 described their child as being overweight for their age and height.

However, the 2015/16 Child Measurement Programme results show that just over a quarter (26%) of children aged 4 to 5 are overweight or obese in Wales.

Beaufort Research undertook a survey on behalf of Public Health Wales consisting of a total of 1,503 telephone interviews with parents and carers of children aged 0 to 5 in Wales, between 11 April and 6 June 2017, in order to gather data for this study.

Every Child Wales, which was launched at Gibbonsdown Children’s Centre in Barry, brings together lots of great information and advice to support parents in giving children a happy and healthy start in life.

A new Every Child Wales website will help parents from when they are planning their pregnancy to when their child is five.

The advice will help parents to ensure their children stay a healthy weight.

A child who is overweight at five is more likely to be obese by the time they are eight, and could grow up to develop long term health problems like type 2 diabetes or asthma.

Every Child Wales provides advice to parents on subjects like breastfeeding, how to cut down on sugary drinks, how to make sure children get enough sleep, and how to manage the amount of screen time their children have.

These are all factors that can increase the risk of a child becoming overweight or obese.

Dr Julie Bishop, Director of Health Improvement for Public Health Wales, suggested that the new initiative could have a positive impact on public health.

“Every child deserves the best possible start in life. If a child spends their early years healthy and happy, they are more likely to grow into healthy and happy adults. Many parents may not realise that their child is overweight, or they may not be aware that it’s something to take seriously. When children are a healthy weight, they feel better about themselves, and they find it easier to play and learn. Starting from birth, helping children stay a healthy weight is the best approach.”

The launch of Every Child Wales is the first stage of a long term programme of work to increase the proportion of children who start school a healthy weight.

 
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Date Announced for Hypo Awareness Week 2017

Hospitals and GP surgeries are being urged to come together as a “national collective” to raise awareness of a short-term complication of diabetes.

They are being urged to take part in Hypo Awareness Week 2017, which runs from Monday, October 2, to Sunday, October 8.

Hypoglycaemia, also known as a hypo, happens when the blood glucose levels of people with diabetes drop too low and they can feel shaky, unwell and can even slip into a coma.

The campaign aims to raise awareness of hypoglycaemia in the UK by educating healthcare professionals about the short-term complication of diabetes.

Last year, a total of 136 sites, mainly hospitals, across the country took part in Hypo Awareness Week.

Organiser Oliver Jelley, of Orange Juice Communications, outlined the ethos behind this event.

“Hypo Awareness Week represents an ideal opportunity for diabetes inpatient teams and GP surgeries to be part of a national collective, all coming together for one week of the year to promote awareness of hypoglycaemia and share good practice. Now an established part of the diabetes calendar, the week is also a chance to embed new systems and processes to reduce episodes of hypoglycaemia. So, let’s join together and use Hypo Awareness Week to improve diabetes care.”

Around one in six hospitals beds are occupied by a person with diabetes (17 per cent), according to the 2016 results from the National Diabetes Inpatient Audit1.

Hypo Awareness Week has been taking place annually since 2012 and during this period the prevalence of all hypoglycaemic episodes in hospital has decreased by six per cent, according to the 2016 National Diabetes Inpatient Audit report (NaDIA)2.

Latest results from the bedside survey indicate that hypoglycaemic episodes in hospitals, both mild and severe, have decreased from 26 per cent in 2011 to 20 per cent in 20163.

Mild hypoglycaemia has fallen from 23 per cent in 2011 to 18 per cent in 20164, while severe hypoglycaemia has dropped from 11 per cent in 2011 to eight per cent in 20165.

Participating hospital and GP surgeries will stage training events to raise awareness of the condition. Resources, including leaflets, guidelines and educational slides, will be used to help spread the word.

This programme is organised by Orange Juice communications and has been made possible with the support of Sanofi, with the global life sciences company funding the campaign as part of its commitment to improve healthcare and help people living with diabetes enjoying a healthier life.

Sanofi has no editorial control over its contents.

 
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Future of NHS to be Debated at Royal Society of Medicine

A public meeting to debate the future of the NHS will take place at the Royal Society of Medicine on Saturday 19th August.

Professor Sir Simon Wessely, the newly inaugurated RSM President, will open the meeting.

Prominent panellists will examine the state of the NHS, the decisions and events that led us to the current situation, and discuss what is needed to sustain its founding principles.

Speakers will include Dr Sarah Wollaston, Conservative MP and Chair of the Health Select Committee; Nigel Edwards, Chief Executive of the Nuffield Trust; Professor Neena Modi, President of the Royal College of Paediatrics and Child Health; Dr Clare Gerada, former Chair of the Royal College of General Practitioners; and Liz McAnulty, Chair of Trustees, the Patients Association.

Chairing the sessions through the day will be GP and broadcaster Dr Ayan Panja and Guardian health policy editor Denis Campbell.

The name of the eminent keynote lecturer will be announced shortly before the meeting.

Speaking ahead of the debate, Wessely indicated the important nature of the debate on the future of the publicly-funded health service.

“We hear from the media, politicians and medical practitioners that the NHS is in trouble and that the morale of doctors and healthcare workers is at an all-time low. But a proper diagnosis needs to be made before we can start to cure the NHS. This debate offers the public the opportunity to get involved with the process of diagnosing just what is wrong with the NHS and how it can be put right.”

The meeting, which is co-hosted by Discourse, will take place from 09.30 on Saturday 19 August at the Royal Society of Medicine, 1 Wimpole Street, London, W1G 0AE.

Registrations can be made at www.rsm.ac.uk/talkNHS.

 
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GP Leaders Warn of ‘Airbrushing’ Over GP Numbers

GP leaders have warned that the government must not ‘airbrush’ its failure to deliver satisfactory increases in GP numbers.

This follows the Health Secretary’s annual review of performance in NHS England failing to evaluate progress on GP recruitment; a serious red flag indicating that all is not going according to plan.

Jeremy Hunt lauded the GP Forward View and good progress on implementing improved access to GP services in the report, also noting the requirement for a larger primary-care workforce.

But the Health Secretary bizarrely stopped short of assessing the progress of NHS England in this area; a decision that has been strongly criticised by GP leaders.

Hunt has previously pledged to deliver 5,000 extra doctors by the end of the decade, with NHS England and Health Education England responsible for this procedure.

And the government has reiterated this commitment in recent weeks, with primary care minister Steve Brine MP noting this aim in a statement to the House of Commons.

The target is now a major pillar of the GP Forward View, yet figures back in May indicated that the GP workforce had diminished by 445 during Q4 of 2016.

GPC chair Dr Richard Vautrey stated that increasing numbers in general practice should be a major focus for the healthcare system.

“It’s a concern if the DH is airbrushing out the failure so far to increase GP numbers and genuinely expand the primary care workforce in a sustainable way. They must not ignore these crucial areas, no matter how difficult the task is, and they would be far better spending scarce NHS resources on these areas rather than more extended access to an already overstretched general practice service.”

In its annual report, also published earlier this week, the Department of Health conceded that there had been “particular difficulty in building on the number of GPs in practice”.

It also commented that “despite ongoing work there was a drop in the effective GP workforce, from 34,914 full-time equivalent GPs recorded in March 2016 to 34,372 full-time equivalents”.

Hunt, elsewhere in his report on NHS England’s performance, praised the roll out of extended access to GP services.

“I am pleased to see the continued improvement in in 2016/17, with 17m patients (30% of the registered population) benefiting from extended access to general practice.”

The report nonetheless concludes that “there remains a great deal more to do to meet this vision, particularly to improve quality and safety whilst maintaining financial sustainability. The scale of the challenge the NHS faces is significant”.

 
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GPs Urge Government to Reconsider HIV Vaccination Stance

There has been strong criticism of the government by GPs concerned about the policy of failing to extend HPV vaccination to boys.

The Joint Committee for Vaccinations and Immunisations (JCVI) has announced that research commissioned by the organisation found that extending the HPV vaccination to males is “highly unlikely to be cost-effective”.

But HPV Action, a campaign group composed of 47 patient and professional organisations, believes that escalation of the vaccination should be considered essential.

It has also been suggested that the decision is contrary to existing equality law, and companies are considering legal action in order to challenge the policy.

Research indicates that the doctors almost unanimously support extending the vaccine to boys, and there has been a strong response to the verdict of the JCVI.

GP groups have warned that the decision potentially means boys, and particularly men who have sex with men, are open to aggressive cancers caused by the virus.

HPV Action has already announced that legal proceedings are being considered on the basis that the decision is contrary to existing equality law.

Dr George Kassianos, the RCGP’s national immunisation lead, stated that the Royal College is strongly opposed to the policy.

“We are disappointed at today’s announcement as the RCGP has always supported equality in gender with respect to HPV disease prevention in order to protect all our patients. HPV infection is associated with aggressive cancers and other conditions in all patients, regardless of gender. We would, therefore, urge the DH to extend HPV immunisation to boys as a matter of urgency.”

Dr Andrew Green, the GPC’s clinical and prescribing policy lead, noted that the decision could have a particularly detrimental impact on practising homosexual men.

“I am very disappointed that the opportunity to protect boys had not been taken. There is a significant population of men who have sex with men, and the burden of HPV related disease affects them every bit as much as women. The only way to offer them effective protection is a universal vaccination programme for boys.”

And Peter Baker, HPV Action campaign director, also spoke very strongly on the decision.

“It is astonishing that the government’s vaccination advisory committee has ignored advice from patient organisations, doctors treating men with HPV-related cancers, public health experts and those whose lives have been devastated by HPV.”

Baker suggested that it was fiscally motivated rather than emanating from a commitment to protecting public health.

“The decision not to vaccinate boys is about saving money not public health. HPV Action will continue to make the case for a national vaccination programme that protects men and women equally. There may also be grounds for a legal challenge on the grounds that the decision breaches equality law.”

 
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GMC Releases Six-Point Action Plan

In an attempt to ensure that medical revalidation is more positive and meaningful for doctors, the General Medical Council has released an action plan of six major commitments.

These milestones are to be delivered by March 2018, in the ongoing effort to improve general practice in particular.

The action plan is intended to correlate with the recommendations outlined in Sir Keith Pearson’s ‘Taking Revalidation Forward’ report.

This document was released back in January.

Responding to the text, the GMC agreed to the proposed scheme with the newly-established Revalidation Oversight Group.

Particular priorities will be reducing the burden of revalidation on doctors, tracking the impact of revalidation, supporting improved local governance, making revalidation more accessible to patients, strengthening assurance where doctors work in multiple locations and tackling the impact of revalidation.

This is intended to address a situation that has sometimes been described as a ‘postcode lottery’.

Indeed, the British Medical Association had previously urged the General Medical Council to address the current climate, and crack down on local organisations utilising revalidation in order to set extra objectives to healthcare professionals.

The BMA instead asserted that national requirements should be the foundation for daily operations.

And the GMC also indicated a willingness to collaborate with the Care Quality Commission, in an attempt to cut down the amount of duplication in GP workloads.

BMA council chair Dr Chaand Nagpaul was broadly supportive of the new initiative, calling on the General Medical Council to draw on existing documentation.

“The BMA supports the principle of revalidation. We see this action plan as an opportunity to reduce the burden that revalidation imposes on doctors. In particular, we want to see implementation of the recommendation from Sir Keith Pearson’s review that local organisations should not use revalidation as a lever to achieve objectives beyond the GMC’s revalidation requirements. We also agree with Sir Keith that doctors should be able to challenge decisions they feel are unfair.”

Nagpaul also indicated that the BMA “will continue to press the GMC and other bodies about the actions needed to relieve the unnecessary burden that revalidation can sometimes place on doctors, in order to ensure the process delivers for patients, doctors and the NHS.”

GMC chief executive Charlie Massey acknowledged that a lot of work had been done, but also stated that significant progress must be made in order to enact the recommendations of Pearson.

“This is just the beginning, and it’s vital now that we maintain the momentum. We need the continued commitment from a wide range of organisations to make revalidation a better experience for doctors, especially at a time when they are under ever-increasing pressure. Revalidation is integral to assuring patients that we regularly confirm that a doctor remains fit to practise. Our focus now is continuing to work with other organisations, getting their feedback and input, as we act on commitments set out in this plan.”

 
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National Survey Indicates NHS Patients Positive About Cancer Care

An annual national survey indicates that key patient experiences of NHS cancer care improved over the past year.

The National Cancer Patient Experience Survey 2016 asked people with cancer across England for their views on their care, with 72,788 responding.

Asked to rate their care on a scale of zero (very poor) to 10 (very good), respondents gave an average rating of 8.74 (ie 87.4% favourable) a statistically significant increase on last year’s score.

Patients also reported statistically significant improvements over the past year on being seen as soon as they thought necessary for hospital cancer appointments, cancer tests, and cancer treatment.

The survey also shows people reported more positively on areas including involvement in decisions about care and treatment, feeling they were given enough information and being treated with dignity and respect.

The survey also points to areas for further improvement including follow up community and social care after treatment. Work is underway to improve in these areas, and the new Cancer Alliances will support organisations to ensure patients have a good experience of care.

Professor Chris Harrison, National Clinical Director for Cancer at NHS England, suggested that the data gathered is indicative of the progress being made.

“The latest data shows cancer survival is now at a record high and this survey confirms the vast majority of people with cancer are really positive about the NHS care they receive, reporting further improvements over the past year.”

Harrison also spoke on plans for the future in this area.

“One of our key ambitions is to put cancer patient experience front and centre at a time when the NHS is successfully treating more patients for cancer than ever before, so this positive feedback from patients is an encouraging testament to the hard work of NHS staff.”

Key findings of the national cancer patient experience survey 2016 include:

  • 87.5% of patients said they got their cancer tests at the right time, up from 86.6% last year;
  • 78% of respondents said that they were definitely involved as much as they wanted to be in decisions about their care;
  • 90% of respondents said they were given the name of a Clinical Nurse Specialist who would support them through their treatment. When asked how easy or difficult it had been to contact their Clinical Nurse Specialist, 86% of respondents said that it had been “quite easy” or “very easy”;
  • 88% of respondents said that, overall, they were always treated with dignity and respect while they were in hospital;
  • 94% of respondents said that hospital staff told them who to contact if they were worried about their condition or treatment after they left hospital;

The full results are available on the Quality Health website.

 
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