5 ways the UK’s health plan falls flat

Theresa May promised a £20.5 billion spending boost but there’s concern it won’t go far enough.

There’s life beyond Brexit, according to the U.K. government. Nobody else seems convinced.

Prime Minister Theresa May visited a hospital in Liverpool on Monday to lead a carefully choreographed announcement of the new 10-year plan for the National Health Service. Designed to show the government is capable of doing more than just leaving the EU, the plan aims to “save almost half a million more lives” in the next ten years by focusing on prevention and making better use of digital health services.

With most domestic policy initiatives on hold because of Brexit, the government has promised a £20.5 billion spending boost by 2023-24 to back up its health plans — money May said will come in part from the windfall to be enjoyed when the U.K. stops sending money to Brussels.

But the reactions from health care providers focused largely on the uncertainties facing the NHS ahead of Brexit, both in terms of finance and the departure of EU27 nationals that will worsen staffing issues. (Few believe a Brexit windfall is likely despite the Vote Leave’s red bus.) Lengthening wait times for services was another politically sensitive issue set aside in the government’s announcement.

“This is not about miracles — money will be tight and staffing will remain a headache for years to come,” Niall Dickson, chief executive of the NHS Confederation, which represents health service providers, said in reaction to the plan. Warning of the risks of “over-promising,” Dickson said: “Our plea is that politicians be honest about the trade-offs that will be required and that we are realistic about what can be achieved given the ever-increasing demands of an ageing population.”

Health groups say the £20.5 billion budget increase by 2023-24 unveiled in June is not enough to get the NHS back on track following years of austerity

The announcement also suffered from the government’s strategy of pre-announcements: major policy initiatives from new cancer screening to mental health service improvements had been widely previewed, leaving praise confined to celebrating the “vision” of tying those initiatives together.

Here’s five reasons why the plan failed to match expectations.

1. Not enough money

Health groups say the £20.5 billion budget increase by 2023-24 unveiled in June is not enough to get the NHS back on track following years of austerity. The figure amounts to a 3.4 percent increase in funding, but think tanks such as the Nuffield Trust say a 4 percent boost is needed at least to “put the NHS on a sustainable footing.”

“Ultimately, there is a need for honesty about how far the £20.5 billion over five years will stretch,” British Medical Association (BMA) council chair Chaand Nagpaul said Monday. “World class care requires world class funding and the investment in the long-term plan will still leave the U.K. falling behind comparative nations like France and Germany.”

Britain’s Health Secretary Matt Hancock | Ben Stansall/AFP via Getty Images

Plus there’s concern a no-deal Brexit would deplete the promised funding — “the extra costs and tasks required would eat up the first instalments, stopping progress dead in its tracks,” Nigel Edwards, chief executive of the Nuffield Trust, said in a statement.

Health Secretary Matt Hancock has promised the extra funds will be available “irrespective” of the outcome of Brexit talks with the EU, which doesn’t quite fit with May’s suggestion it will come in part from money London will no longer be sending to Brussels.

2. Ignoring staffing woes

Staffing shortages are top of the list for nearly 60 percent of U.K. voters when asked where the extra NHS cash should be spent, according to a poll by The Times, but the government’s plan kicks that can down the road.

The plan promises “NHS staff will get the backing they need” by balancing “supply and demand across all staff groups.” The funding for hiring, training and professional development of NHS staff “has yet to be set by government” and won’t be published until “later in 2019,” it said.

Staff “are routinely struggling to cope with rising demand and, as a result, are subject to low morale, stress and burnout” — Chaand Nagpaul, BMA council chair 

The BMA, which represents doctors, and NHS Providers, which represents various NHS staff, cautioned the NHS will be hard-pressed to make good on the plan’s promises if it doesn’t improve the staffing situation. One in 11 posts are estimated to be vacant and the situation is predicted to worsen after Brexit, with the King’s Fund, Health Foundation and Nuffield Trust predicting a shortfall of around 250,000 NHS staff by 2030.

Nagpaul of the BMA said doctors and staff “are routinely struggling to cope with rising demand and, as a result, are subject to low morale, stress and burnout.”

3. Hedging on waiting times

The government’s plan commits to reducing waiting times for mental health services across the board, ranging from children to adults and community-based care to crisis situations.

But as the NHS continues to come up short on waiting times for emergency care and routine surgery, the new plan offers no clear path forward other than to say “sufficient funds” will be allocated to local NHS services to cut long waits.

NHS chief Simon Stevens | Tolga Akmen/AFP via Getty Images

“We also need immediate, practical solutions and the necessary investment for hospitals to deliver both in the long and short-term,” said Nagpaul of the BMA.

NHS chief Simon Stevens said there should be “tougher, faster” standards when it comes to emergency room waiting times in an interview with BBC Radio 4 on Monday, and suggested the existing four-hour guideline by which NHS progress is judged needed to be updated. “The problem with that is it doesn’t distinguish between turning up at A&E with a sprained finger and turning up with a heart attack,” he said. He declined to commit to specific targets.

4. Mixed messages on prevention

One of the main pillars of the government’s plan is prevention — stopping health problems before they start by trying to reduce smoking and drinking or increase exercise, for instance.

While many groups supported this move, they couldn’t help but note the hypocrisy of the fact that government funding for local public health services has been cut in recent years. The latest projections are a cut of £85 million for 2019-20, to £3.1 billion.

“The reforms we all know are needed to the way we pay for care have been kicked into the long grass again and again” — Nigel Edwards, chief executive of the Nuffield Trust

Nagpaul of the BMA urged the government to take bolder stances on issues such as a minimum unit price for alcohol and restricting sugar in food.

“The reforms we all know are needed to the way we pay for care have been kicked into the long grass again and again,” said the Nuffield Trust’s Edwards.

5. Raised expectations

U.K. Chancellor Philip Hammond hit the nail on the head when he wrote in the Daily Mail on Monday: “The leaders of the NHS must now ensure they get the basics right. Alongside greater quality of care and ending waste, the public will demand that progress is made on the back of their investment.”

The widely-touted funding rise will leave people expecting a better and more efficient NHS, which requires delivery on the basics such as wait times that the plan doesn’t address.

The government’s major targets are focused around specific diseases: the plan aims to prevent 150,000 heart attacks, strokes and dementia cases, and 55,000 cancer-related deaths, and help 380,000 more people get treatment for anxiety and depression. As Conservative Party MP and health select committee chair Sarah Wollaston noted, some of the priorities mirror those set out in the previous five-year plan, “many of which remain unfinished business.”

“The last plan was undermined by the cuts to social care, public health, capital and training budgets and it is important not to see this repeated,” Wollaston wrote in a blog post.


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EU citizens still welcome after Brexit

UK minister lays out the government’s post-Brexit migration policy.

The United Kingdom’s departure from the EU means an end to freedom of movement between the two, but the British government still wants EU citizens to know they are very welcome to come to Britain to visit, work and study.

On Wednesday we set out what the new skills-based immigration system will mean for Europeans coming to the U.K.

The U.K. may be leaving the EU, but we are determined that our shared values and enduring friendships with Europe will continue long into the future.

Our shared history and commitment to democracy, prosperity and security will mean we continue to influence each other after Brexit.

EU citizens have made magnificent contributions to our economy and society, just as British people have done in countries across Europe.

We are not just reassessing the shape of our immigration system, we are also taking steps to modernize the processes that support it.

One of the top priorities for the government has been securing their rights, regardless of the outcome of the Brexit negotiations, and we have been clear that we will protect their rights, deal or no deal.

The EU Settlement Scheme, which opens next year, will be simple to use and allow more than 3 million people who have made Britain their home to stay here.

We have successfully processed thousands of applications through the pilot of the scheme, it is already working well and the feedback from those using it is positive.

We welcome the Commission’s announcement this week that member states should ensure that U.K. citizens legally residing in the EU on the date of withdrawal continue to be considered legal residents.

Daniel Berehulak/Getty Images

However, once we leave the EU our relationship will change.

Our new single skills-based immigration system will enable EU workers to come to the U.K. when they are sponsored by companies operating here.

There will be no limit on the number of skilled people, such as engineers, doctors and IT professionals, who can come to live and work here through a new route open to people who meet a salary threshold that the government is consulting on. That route will be open to people with a wide range of qualifications.

The U.K. is home to some of the very best universities in the world and already over 440,000 students from across the world are currently studying in the U.K. We recognize the positive contribution that these students make to our culture and society.

After Brexit we will continue to welcome students from across Europe and we will not limit their numbers. Under the student visa route, every EU student studying at university will have generous work rights whilst studying, and the opportunity to secure permanent, skilled work post-study.

This new immigration system allows us to deliver on the views that the British people expressed in the EU referendum, but it will still enable Europeans with the skills and experience that will benefit the U.K. economy and our society to come.

We are not just reassessing the shape of our immigration system, we are also taking steps to modernize the processes that support it. As part of that, we will introduce a new Electronic Travel Authorisation scheme — similar to the ETIAS system announced by the EU last week.

It will be a simple online service with a low fee and will allow EU citizens to come for short visits and people with biometric passports will be able to go through our efficient e-gates as smoothly as before.

These proposals show that while we have honored the EU referendum, we will still be open to Europe and look forward to forging the next chapter in our history.

Caroline Nokes is the U.K.’s minister of state for immigration.


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Growing pains: Europe’s push for medical cannabis

Big companies are making inroads into a potentially lucrative market, but legislators aren’t moving at the same speed.

Europe is coming around to medical cannabis — but many patients fear financial benefit will trump pain relief.

In November alone, the U.K. allowed doctors to write prescriptions for medicines containing cannabis; Greece granted its first two licenses to cultivate and process cannabis; and Luxembourg legalized cannabis for recreational purposes. Most EU countries currently allow some form of medical cannabis.

As patients push for access to these treatments, pharmaceutical companies and cannabis producers are hoping to claim a piece of a market that could be worth €55 billion by 2028, according to an industry report. The concern for many patients, however, is that legislators can’t (or won’t) keep up with demand, leaving medical cannabis to inch its way onto the market, product by product, country by country.

The European market is fragmented. Each country sets its own standards and regulations for cannabis products, meaning Germans can get a prescription for medical cannabis from a doctor, while the French have no legal medical cannabis options at all.

“Right now it’s like a jungle to navigate the European market,” said Thomas Skovlund Schnegelsberg, co-founder and CEO of Danish medical cannabis company StenoCare.

“They’re produced for people who want to get high on a Friday night” — Thomas Skovlund Schnegelsberg, co-founder and CEO of StenoCare

The European Union isn’t helping clear up the confusion. “We have a competence only to support the member states [on medical cannabis rules],” Peter Mihok from the European Commission’s migration and home affairs department told a European Parliament committee in June. “They are the ones that have to act first.”

But many countries aren’t acting, at least in part because legalizing medical cannabis is often confused with legalizing recreational marijuana. So when countries do allow medical cannabis, they often bring in strict rules. After the U.K. legalized medical cannabis last month, for example, it can only be given by prescription, from a specialist doctor and after other treatments have failed.

Such tight rules might work for those who want pills from a pharmacy, or cannabinoid (CBD) oil sold in shops, but it doesn’t help patients who want to grow cannabis at home, either for cost reasons or to give them more treatment options.

Patients’ push

Cannabis has become an increasingly popular treatment for patients with all kinds of diseases and conditions, including multiple sclerosis, epilepsy, anorexia, insomnia and cancer.

The cannabis sativa plant has more than 100 unique compounds known as cannabinoids, according to the European Monitoring Centre for Drugs and Drug Addiction. The most well-known of these is tetrahydrocannabinol (THC), which causes a euphoric high, although many people who use cannabis for medical purposes select cannabinoids with different effects, such as the invigorating sativa and relaxing indica.

Aerial view taken on September 19, 2018 shows farmers with their specially developed harvesting machines cropping a cannabis field in Naundorf, eastern Germany | Jan Woitas/AFP via Getty Images

Carola Pérez was taking 19 pills a day before she discovered medical cannabis. Pérez has suffered from chronic pain since she broke her tailbone at the age of 11. The childhood accident led to 13 surgeries and an addiction to the opiates she took for relief.

Pérez first tried THC-infused milk 10 years ago, before CBD oils were available. She felt relief almost instantly, and over time was able to reduce the 19 daily opiates she was taking to just two. “Cannabis saved my life,” she said.

The problem was how to get it.

Pérez is from Spain, where cannabis is permitted for personal use but there is no national regulation for how much one person can grow. The hazy law led to the creation of so-called cannabis social clubs — registered groups that grow cannabis largely for recreational use.

At first, Pérez asked a friend to get her the drugs she needed, then she used a street dealer. She tried the cannabis social clubs, but they didn’t have enough. That’s when she took things into her own hands.

Pérez now grows 16 strains of cannabis in her home. Depending on the day, she can create a cannabis cocktail with whatever levels of CBD, THC, sativa and indica she needs.

That gives her a freedom that isn’t available in the pharmacy. Sativex, a cannabis-based mouth spray costing over €400 a bottle and made by GW Pharmaceuticals, was approved for Spanish patients in 2010. But it can only be used by people with multiple sclerosis.

“No pharmaceutical company is going to be able to offer us that,” said Jacqueline Poitras, a medical cannabis activist in Greece whose 18-year-old daughter takes CBD oil for often-daily epileptic attacks. “Only nature can offer us that.”

Here comes big business 

Big companies — both pharma giants and cannabis producers — are lobbying lawmakers across Europe to put their products on the market now.

They argue that untested cannabis may contain harmful pesticides and that products sold on the black market are often created for recreational use and merely re-labeled as being for medical purposes. Patients using such products report psychosis and other unpleasant side-effects because “they are not made to be used for sick people,” said Schnegelsberg of StenoCare. “They’re produced for people who want to get high on a Friday night.”

Plants growing in a cannabis field in Naundorf, eastern Germany, on September 19, 2018 | Jan Woitas/AFP via Getty Images

But smaller cannabis producers are wary of the pharmaceutical companies’ push. The European Industrial Hemp Association said it “strongly opposed” attempts by big pharma to make CBD a prescription drug.

“This only serves the interests of a few companies while damaging the young CBD industry,” the association wrote in October.

Stephen Murphy, managing director of the international cannabis consulting company Prohibition Partners, said he saw a similar situation in the U.K. Once GW Pharmaceuticals was “in the driving seat” there was almost no national debate on the issue, he said.

“It took quite a big PR campaign this year to legalize cannabis for patients in the U.K. despite the fact that cannabis has been grown in the U.K.,” Murphy said. “There was never any pressure to challenge that.”

Patients also have concerns about how the big companies are attempting to enter the market. “These companies only call us … to say, ‘Oh poor patients,’ but then they don’t take care of us, don’t help us with our projects,” said Pérez. “They just call us to [be able to use us] to tell our stories and then continue with their business.”

The debate has reached the EU. In the summer, the European Parliament’s Environment, Public Health and Food Safety Committee called on the European Commission to create an EU-wide policy for medical cannabis. Not long after, big companies came calling to make their voices heard.

One was Canadian company Canopy Growth, one of the largest cannabis firms in the world and which recently invested €100 million to create more production facilities in Europe. Another was GW Pharmaceuticals.

Canopy Growth did not respond to a request for comment. GW Pharmaceuticals said it would not comment on individual meetings with MEPs, but it “has ongoing engagement with relevant stakeholders focused on education.” It said it has no stance on legalizing medical cannabis, but that with cannabis-derived medicines, “clinicians and patients can be sure of their quality, safety and efficacy — the same as for any other medicine.”

Debate in the parliamentary committee focused on whether the resolution should contain the term “medical cannabis” or “cannabis-based medicines.” That matters because the former would advocate for citizens to grow their own cannabis while the latter would be limited to over-the-counter medicines.

Some want the EU to create a set of guidelines for member countries to consult when they begin the process of legalizing medical cannabis | Leon Neal/AFP/Getty Images

The committee’s resolution passed last month with amendments, using the more narrow “cannabis-based medicines” language, much to the frustration of some Parliament officials.

“Of course, it’s understandable that companies that have undergone decades of research want some preference for their products, but a lot of research shows that herbal cannabis is important,” one parliamentary official said. “That experience should not be taken away from patients.”

The next step is a debate of all MEPs in Strasbourg.

Michael Barnes, a U.K.-based professor of neurology who worked with the U.K. government on changing its medical cannabis laws, said he’d “love to see some kind of standardization” across Europe.

So would many patients. Some want the EU to create a set of guidelines for member countries to consult when they begin the process of legalizing medical cannabis. Others want cannabis covered by the directive on medicinal herbal products. But mainly, they just want the EU to do something.

I think they could, but I don’t think they will,” said Sébastien Béguerie, a cannabis activist and founder of AlphaCAT labs, which tests the quality of cannabis. “It would open the gates too much … and legislators are afraid.”

For now, patients are fighting on the national level. Poitras is working with Greek officials to create a law that stops big, foreign cannabis companies buying up land to grow cannabis and export it.

“We’re pushing,” Poitras said, adding that in the meantime she’s encouraging patients who need medical cannabis to grow their own.

Superbug risks fail to dent attitudes to antibiotics

Antimicrobial-resistant infections could be killing more than 33,000 people a year in Europe.

Warnings about drug-resistant superbugs aren’t enough to change most people’s behavior on using antibiotics, according to a Europe-wide poll out Thursday.

The Eurobarometer survey reported seven in 10 people who received information telling them not to take antibiotics unnecessarily said it didn’t change their views on using them.

Excess use of the drugs is contributing to a growing threat of antimicrobial resistance and related infections. As germs multiple they can develop the ability to defeat the medicines designed to kill them — and those infections could be killing more than 33,000 people a year in Europe, according to recent estimates.

“It is ridiculous,” European Health Commissioner Vytenis Andriukaitis said in response to the fact that people aren’t responding to warnings, at an event in Brussels Thursday. “We have science on one hand and lack of trust on the other.”

“Unless we act decisively, immediately and together, we could face a public health and financial disaster,” he added.

The EU is failing to gain traction with its effort to get member countries to combat the rise of resistance.

The Eurobarometer survey showed the number of people who had taken antibiotics in the last 12 months fell from 40 percent in 2009 to 32 percent in 2017. But less than half of people said they were aware that antibiotics don’t work to treat viruses, and 20 percent said they take antibiotics to treat flu or colds.

Seven percent of people said they took antibiotics without having seen a doctor or getting a prescription.

Andriukaitis said the survey, which polled around 27,400 people in 28 countries, shows Europeans “are still not sufficiently aware of the dangers of AMR.”

A report from the European Centre for Disease Prevention and Control (ECDC) on Thursday raised particular concern about the rise of superbugs in hospitals and care centers — estimating there are around 8.9 million cases of health care-associated infections in European facilities each year, many of them caused by multidrug-resistant bacteria.

Brussels is largely forced to take a backseat to national capitals | George Frey/Getty Images

The ECDC said these infections are being fueled in part by overprescribing of so-called broad-spectrum antibiotics, which wipe out multiple forms of bacteria and are stronger than traditional, more targeted antibiotics such as penicillin. Prophylactic antibiotics, meaning those prescribed before a surgery in anticipation of potential infection, are also being prescribed for too many days, it said.

Meanwhile the EU is failing to gain traction with its effort to get member countries to combat the rise of resistance.

The Commission released a One Health Action Plan in 2017 that included guidelines on how to ensure prudent use of antimicrobials in people, and promised to promote global standards in areas such as trade. It also set aside funding for research to monitor and control potentially fatal infections, and develop new antibiotics or vaccines to combat transmission.

But the EU’s limited competence in health means Brussels is largely forced to take a backseat to national capitals. While governments such as the U.K., Sweden and Finland have made fighting antimicrobial resistance a priority, Andriukaitis said Thursday he’s frustrated the EU can’t be more effective.

“Our main goal is to show that the EU is a best practice region fighting against AMR. But it will be empty words if you do not have concrete instruments at member states level,” he said.

Last line of defense

One area the Commission has been able to push new rules in on the use of antimicrobials in farm animals.

Andriukaitis said he is expecting a “major breakthrough in a few days” when the Council of the European Union will greenlight new rules on veterinary medicines and medicated feeds. These are designed to phase out the prophylactic use of antimicrobials as well as preventing their use to promote growth in cattle.

The EU will also under the new rules ringfence a protected list of antibiotics for human-use only — part of an attempt to keep drugs that still work in humans from becoming obsolete.

Malta and Croatia were named for their poor performances | Joe Raedle/Getty Images

The proposed list, a joint effort between the ECDC, the European Medicines Agency and the European Food Safety Authority, is expected to be put out for consultation next month, according to the ECDC.

ECDC Director Andrea Ammon said at the event Thursday that getting patients, health care providers and national governments to cut down on unnecessary prescribing will take time but there is still a chance to limit the threat from AMR.

The ECDC’s efforts to monitor antimicrobial resistance country-by-country in Europe have been “quite powerful because no one wants to be at the bottom” of the list, Ammon said. The agency also visits European countries at their request to assess their national antimicrobial resistance plans and recommend improvements.

Eight European countries saw a statistically significant drop in public consumption of antibiotics between 2013 and 2017, according to ECDC data released Thursday: Finland, Germany, Italy, Luxembourg, the Netherlands, Norway, Sweden and the U.K.

One area the Commission has been able to push new rules in on the use of antimicrobials in farm animals | AFP via Getty Images

Malta and Croatia were named for their poor performances, recording increases in antimicrobial consumption in hospitals.

A report on antibiotic use in humans by the World Health Organization published Monday concluded Greeks consume the most antibiotics on average in Europe, with Italy, France and Belgium also named as having high use.

Improvements are “not something that will happen very quickly because this epidemic has built up over years and it will take some years until it goes down. It needs sustained efforts,” Ammon said.


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