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INSIDE HEALTH

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Programme 2.

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TX:听 30.09.14听 2100-2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听听GERALDINE FITZGERALD听

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Porter

Coming up in today鈥檚 programme:听 Funding long term care and the NHS 鈥� I will be examining claims that tens of thousands of people are missing out on help with the costs of care.

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Clip

Continuing Healthcare affects a small number of people in a very, very big way.听 It can be incredibly stressful.听 It can be 鈥� it is incredibly emotive and it can be emotionally exhausting.

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Porter

Flu jabs 鈥� it鈥檚 that time of year again. Millions will be visiting their surgery for their annual jab over the next month or so, but what do we know about the likely benefits. Margaret McCartney鈥檚 been looking at the evidence.

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And if this sounds all too familiar:

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Clip 鈥� person snoring

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Don鈥檛 miss our item on what your smart phone can tell you about how well you sleep and whether your snoring is anything to worry about.

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But first antibiotics and new research looking at bacterial resistance in the community. 听A team from Cardiff University looked at over 10 million prescriptions for four common infections and found that the proportion that didn鈥檛 work due to bacterial resistance had risen from 13.9% in 1991, to 15.4% in 2012.

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Chris Butler is a GP and Professor of Primary Care at the Universities of Oxford and Cardiff.

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Chris given the recent apocalyptic predictions of a post antibiotic era where people could die from simple infections, were you surprised by your findings, which seem to suggest that resistance really isn鈥檛 growing that quickly?

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Butler

Yes so what we found was that treatment failure from a single course of antibiotics had increased by over 10% overall during this 20 year study period.听 But hidden within that were pretty dramatic increases in certain infections like lower respiratory tract infections, for example, that had increased by 35%.听 So it鈥檚 not a 鈥� it鈥檚 not a picture that we can relax about across the board.

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Porter

So the average looked okay or not too bad anyway, what you鈥檙e saying hidden within that was some particular 鈥� and chest infections are one of the common reasons that people are using antibiotics and potentially a very serious infection?

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Butler

It is and people are getting older and more frail in the community and therefore we鈥檙e using these antibiotics more often for those that consult and as I say treatment failure鈥檚 increased dramatically in this.

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Porter

We talk about treatment failure but what does that actually mean for the individual potentially?

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Butler

So people who have resistant infections, even in primary care, not just the sick ones in hospital, but even in primary care if they have a resistant infection they鈥檙e going to be sicker for a whole lot longer, they鈥檙e going to consult more often, there鈥檚 more work associated with the healthcare system and they inevitably end up getting more antibiotics which drives up resistance again.

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Porter

There have been calls for better use of antibiotics for years, I mean doctors like you and me have been told not to prescribe them so often, patients have been given the message that you shouldn鈥檛 be getting them for simple coughs and colds.听 Yet looking at the number of prescriptions issued the message doesn鈥檛 seem to be getting through?

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Butler

Mark, it is a problem because we do find that overall antibiotic prescriptions in the community is going up despite all the publicity and concern around the issue.听 But hidden within that are some good news stories.听 So in the study that we鈥檙e talking about now we鈥檝e found that fewer people are consulting with respiratory tract infections.听 So in a sense the public are getting the message that for most of these infections they don鈥檛 need to attend for healthcare.听 Secondly, we鈥檙e finding that when doctors do choose to prescribe an antibiotic more often they鈥檙e choosing narrow spectrum recommended antibiotics.听 So it鈥檚 not all doom and gloom in terms of practice, both on the side of the public and on the professional side.

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Porter

Professor Chris Butler, thank you very much. And there is a link to that new research on resistance on the Inside Health page of the Radio 4 website.

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A GP surgery caused traffic chaos in Colchester when 1800 of its patients converged on the building to get their flu jabs. We may not have had quite that response at my surgery in Wotton, but this year鈥檚 拢100 million programme is now well underway across the UK.

But what do we get for our money? Inside Health鈥檚 Dr Margaret McCartney has been looking at the evidence.

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Before we discuss that, Margaret, there have been some changes to the criteria for who is eligible in recent years haven鈥檛 there?

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McCartney

Yes, so the two big changes are that pregnant women are now very much encouraged to have flu vaccine as soon as they know they鈥檙e pregnant and also for children, so there鈥檚 been a big programme rolled out for both pre-school and primary school children.听 There is actually quite good evidence that says that children have got a fair bit to benefit from getting the flu vaccination and what鈥檚 interesting is that it鈥檚 not just the children that benefit but it鈥檚 also the community benefits because it seems to be that children are the vectors of flu in the community, they鈥檙e very good at getting infections and then spreading them around.听 And you only need to vaccinate seven children in order to prevent one case of flu, which for a medical intervention is actually pretty good.听 And other studies have come out and said that you can actually half the amount of flu suffered by pre-school children.

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Porter

What about pregnant women?

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McCartney

Again for pregnant women there is a fair bit of evidence that would say that not only are pregnant women more likely to have significant complications for flu, not just for them but for the baby, but it does seem to be something that is more likely to help pregnant women than not but it certainly does seem to cut down flu in women and cuts down premature birth.

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Porter

What about people with asthma 鈥� they鈥檙e another group that are included?

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McCartney

Asthma is one of those uncertainties.听 So there was a Cochrane Review in 2013 that came back and said basically we鈥檙e not sure whether it helps or not.听 However, if you have chronic obstructive airways disease, COPD, bronchitis, then there is quite a good chance that having the flu vaccination will prevent you from having an exacerbation over the winter.

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Porter

What about the biggest group of all and that鈥檚 the over 65s, the elderly?

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McCartney

Yeah and here鈥檚 where there is the biggest contention.听 There was a big Cochrane Review that was done looking at all the evidence in 2010 that came out and said that we really do not have the evidence to say that flu vaccination is useful or provides benefits for people in the over 65 age group, this is otherwise healthy people who are not getting it because they鈥檝e got bronchitis or anything else, just normal 65 year olds and above looking for a bit of extra protection.听 We don鈥檛 have the evidence to say that it works.

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Porter

Well given the cost of the programme why do we offer it to that group, is it that most of them will or a large proportion of them anyway will have some other underlying criteria for having the jab?

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McCartney

Well I鈥檓 not sure and it really is a bit of a tragedy because there鈥檚 lots of things that we could be doing to find out whether it works or not and it would be a pretty easy thing to set up a trial, we鈥檙e giving out the flu vaccine an awful lot.

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Porter

Okay, here鈥檚 a controversial one 鈥� what about healthcare workers?

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McCartney

Well the rationale is that by vaccinating healthcare workers we keep the staff at work, we prevent them from passing on bugs and we prevent them from getting bugs that they鈥檒l get into contact with during the course of their day.听 Unfortunately we do not have the evidence to say that healthcare workers get a benefit to themselves or to their patients.听 Now there have been some studies that have been done looking at people who work in long term care homes and some studies have come back and said that it鈥檚 beneficial, others haven鈥檛 and the most recent Cochrane Review has said that they can鈥檛 support vaccination of healthcare workers.

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Porter

And it would seem that many healthcare workers are aware of that because the uptake鈥檚 not great is it amongst doctors and nurses and other clinical staff?

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McCartney

It鈥檚 not, it鈥檚 not, I would be delighted to have the vaccination as part of a randomised control trial, so we could really try and sort out is this beneficial or not.

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Porter

I think I know the answer to this Margaret but what you鈥檙e saying is that you haven鈥檛 had a flu jab?

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McCartney

That鈥檚 entirely correct but I would be delighted to have one as part of a randomised control trial so please set one up and invite me.

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Porter

Thank you very much Margaret. And that list of who is eligible this year is on the Inside Health page of bbc.co.uk/radio4

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Now have you ever wondered how you are going to fund you care in old age? Or what would happen if you were to fall ill and need ongoing care earlier? Perhaps it鈥檚 a dilemma that you - or your family - are already facing.

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Most people are aware that social services will provide means tested support for care. But only if your savings or assets 鈥� and that includes your house - amount to less than around 拢25,000, depending on where you live in the UK. Which means most people end up paying themselves, at least to start with.听

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But there is a third way. The NHS will sometimes pick up the bill for your care 鈥� in a home or in your own home - if you have ongoing complex medical needs.

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It鈥檚 called NHS Continuing Health Care but most people have never heard of it. And applying for the funding is fraught with difficulty, as I鈥檝e discovered here at the Oxford offices of Beacon, a social enterprise organisation that spun off from Age UK to help people understand their rights and get what they are entitled too.

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People like Ivan Lax who struggled to get the financial help he thought his mother-in-law Betty deserved.

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Lax

She was diagnosed with Alzheimer鈥檚 in 1992 and from there until 2001 we pretty well managed that.听 Her husband, Jack, was also in need of medical care and support so between them they were described as 鈥渂ook ends鈥�.听 Jack needed physical support, Betty needed mental support.听 Unfortunately in 2001 Betty needed to go into hospital for some surgery and the week before that Jack died.听 And we鈥檇 already arranged some respite care.听 It was very obvious once she went into nursing home that it wasn鈥檛 going to be possible for her return home alone and we decided to 鈥� discussions with everyone 鈥� that it would be best that she stayed there.听 And everything was fine for the first few months but later that year it became clear she couldn鈥檛 stay in the nursing home.听 She was being disruptive, she was trying to escape 鈥� as they put it 鈥� and we were told we needed to find a secure environment for her.

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Porter

Who was paying the bills?

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Lax

Well we sold the house, the family house, to pay the bills, that鈥檚 the conversation with social services at the time 鈥� we would need to sell the family home.听 Social services paying the bills initially until the house was sold then they were repaid from the sale and then we just was self-funding.

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Harbour

My name is Dan Harbour, I鈥檓 the managing director of a social enterprise business called Beacon and what Beacon does is to help people at any stage of the Continuing Health Care assessment or appeal process.听 NHS Continuing Health Care is a package of care which is arranged and funded by the NHS.听 It鈥檚 for people who have a certain level of ongoing healthcare needs which result from an accident or a disability or indeed an illness such as Alzheimer鈥檚 disease.听 And this is significant because people who are eligible have the full cost of their care and accommodation paid for by the NHS.听 And what Continuing Care attempts to do is to clarify the boundary between health 鈥� what is a health need and what is a social care need 鈥� and that鈥檚 important because of course in this country health 鈥� healthcare is provided free at the point of need whereas social care is means tested.听 Beacon helps families and individuals at any stage of the NHS Continuing Health Care process, so we can help people for example who have gone into hospital for the first time and are thinking well who pays for my long term care, how does this whole system work.听 And we can help people all the way through to the appeal process, right the way to the ombudsman and beyond.

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Press

My name is Martin Press and my mother, who will be 100 in six weeks鈥� time, has been in long term care since 2002 following my father鈥檚 death.听 She had become increasingly confused and she became also progressively immobile to the point where she is now completely paralysed from the neck downwards.听 She鈥檚 virtually mute 鈥� she will occasionally get a word out but there is no way of communicating with her which makes it very hard to assess whether she鈥檚 distressed and the extent to which she understands what鈥檚 going on.

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My parents sold their house when my father had a stroke in the 鈥�90s and that money, together with the family savings, paid for nursing home fees of something like 拢40,000 a year from 2002 when she went into the home till in 2008 we got a message that she might be eligible for NHS Continuing Care for funding.听

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Porter

Now you were a hospital doctor, had you heard of this before?

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Press

No really not, I don鈥檛 think I had any more information than if I鈥檇 been an accountant or a grave digger.

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Porter

So you didn鈥檛 know about it, it was news to you but obviously it must have seemed attractive at the time to apply for it?

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Press

Well clearly and we were faced with coming to the end of our money and the ghastly thought that we might have to move her to somewhere else.

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Harbour

People come to us for two reasons 鈥� firstly, there has either been a significant event such as a loved one has had a stroke or a fall, been diagnosed with dementia and they just don鈥檛 know how the long term care system works.听 Or they come to us following completion of a Continuing Care Assessment where the care is already in place, they feel that they have significant health needs and the NHS have deemed that they don鈥檛 have a primary health need, that i.e. they鈥檙e not going to pay for the full cost of their care.

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Press

Well it was a long process, we said yes we would like her assessed.听 Three months later I phoned them because we鈥檇 heard nothing, three months after that I phoned again because we鈥檇 still heard nothing and she was finally assessed and the assessment done by the nurse who visited my mother in the home went before a panel of the primary care team who downgraded her on some of the assessments, even though they鈥檇 never met her, and so she didn鈥檛 qualify.听 It was odd to me because the purpose of the assessment was to determine whether her primary needs were health or social and there was no arguing with the fact that she required long term hospital care for her immobility and confusion.听 So on the one hand you had a questionnaire which she hadn鈥檛 scored highly enough to pass and on the other hand nobody argued with the fact that she had to be kept in the nursing home for medical reasons.听 So we appealed.

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Porter

So that appeal you were refused at that appeal?

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Press

Yes.

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Porter

What happened next?

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Press

Well she then got reassessed and this time she passed, although in all conscience she wasn鈥檛 really very different from the way she had been previously.听 So in 2012, 10 years after she went into the nursing home, she was approved and it was backdated to 2011.听 And she remains funded though she has to be reassessed every year.

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Harbour

The decision rests with the Clinical Commissioning Groups, which are GP led.听 The CCGs have to make the final decision as to whether somebody is eligible or not.听 However, there is a whole assessment process, a very, very important assessment process, which feeds into that final decision making process and this is a really important point because this is one of the areas that we feel is breaking down in the assessment process.

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Porter

So let鈥檚 say that we鈥檙e aware of NHS Continuing Health Care and we start this process off what are our likely chances of success, even if we鈥檙e entitled to it 鈥� is it an uphill struggle?

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Harbour

Many people do find it an uphill struggle.听 Unfortunately it does partly depend on where you live in the country, some Clinical Commissioning Groups are assessing people according to the processes laid down in the national guidance, others are not, and that makes for a degree of postcode lottery.听

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Porter

I mean looking at the figures there鈥檚 a threefold variation in the odds of getting this which suggests that some people are giving it much more freely than others.

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Harbour

Yes.

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Press

When we moved mum to the EMI registered residential home鈥�

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Porter

So this is a home that鈥檚 capable of looking after people with dementia for instance?

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Lax

Yes it provides them with a safe secure environment where they鈥檙e properly cared for - we were advised to go and talk to the charity who advised us that actually there was a thing called NHS Continuing Care and in reality they felt that mum should have been assessed for that when she was discharged from the hospital.

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Porter

From the moment that you were told for the first time that there might be a source of NHS funding how long did it take you to get that funding?

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Lax

Well actually I wouldn鈥檛 say we ever did get that funding, we never got NHS Continuing Care and that took a 10 year battle, right up until when Betty died in September 2012.

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Porter

So you battled for a decade for something that you felt your mother-in-law was entitled to but she actually died and you still didn鈥檛 get it?

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Lax

The people that were supporting mum鈥檚 application were her GP who saw her probably two or three times a week and the psychiatrist who was looking after her.听 They both supported her application along with the home manager.听 And yet their opinions were ignored and even questioned by people who either neither met mum or the assessor who completed the paperwork who met her once for less than an hour.

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Press

And I appreciate you鈥檙e dealing with a very expensive situation because there are an awful lot of people in the same situation but this is not just normal ageing, one end of the spectrum we have the Mary Berry鈥檚 of this world and at the other end you have people like my mother.听 The fact that she can鈥檛 stand up, it鈥檚 not because she doesn鈥檛 want to stand up, the fact that she can鈥檛 talk is not because she doesn鈥檛 want to talk, the fact that she doesn鈥檛 understand or know who I am, it鈥檚 not because she doesn鈥檛 want to 鈥� this is a disease process.

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Porter

But your feeling is in your particular case that the patient isn鈥檛 being put first and that may be finances are?

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Press

It鈥檚 hard to see why somebody as handicapped as my mother is would not qualify as having primary health needs.听 I mean it鈥檚 just obvious.

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Porter

Dan, there is a framework for people to follow, providing guidance in situations like this, do you think it鈥檚 being followed in all cases?

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Harbour

No I absolutely think it鈥檚 not being followed in all cases.听 The overwhelming majority of the cases that come to us at Beacon have problems not only with the application of the criteria but in the way in which the assessment procedures have been carried out the effect on the outcome as to whether somebody is determined as eligible for continuing care or not.

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Porter

Well it can mean the difference, can鈥檛 it, between you getting it and you not?

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Harbour

Exactly which is the difference between selling your house and spending your children鈥檚 inheritance or the health service paying for the full cost of your care.听 And what we鈥檙e particularly concerned about is that people who are eventually eligible for continuing care will have had to fund that care in the interim period, possibly by selling their house.听 They might get the money back from the NHS if they鈥檙e eligible in the long run but they鈥檒l never get their homes back.听 To be fair to the professionals who are on the ground trying to apply this to real people in real life it鈥檚 incredibly difficult, they have an enormous set of guidance but there is no clear distinction as to what this primary health, this golden nugget of the primary health need actually is.

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Lax

I wonder how much it鈥檚 really being driven by the funding constraints of the NHS rather than the real criteria around healthcare needs.听 I just believe that鈥檚 dishonest.

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Press

Well the situation now is that she鈥檚 got funding so no it鈥檚 been well worth it, it鈥檚 been essential actually because I don鈥檛 know where we would have been if we hadn鈥檛 got it but why wouldn鈥檛 we get it?

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Porter

I suppose the point is that if a retired consultant with a mother who鈥檚 approaching a hundred who鈥檚 paralysed from the neck down and mute and very dependent on the extreme nursing needs decides halfway through the process that actually he might not finish this because it鈥檚 too difficult then that鈥檚 a sad reflection on the process is it not?

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Press

Well I think the process does need to be brought up to date with a hefty dose of common sense.听 You don鈥檛 need to score somebody in 11 domains to know that they require full time nursing care.

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Porter

And it needs to be easier for people to navigate?

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Press

Yes, yes absolutely.

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Porter

Martin Press talking to me at the offices of Beacon in Oxford.

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We asked NHS England to comment and it sent us this:

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Statement from NHS England

There are currently around 59,000 people in receipt of NHS Continuing Health Care in England and the NHS undertakes around 133,000 assessment of eligibility annually.听 There is a clear process for patients to request a review of a decision with regard to eligibility.听 They can request this from their CCG and if they鈥檙e still not satisfied they can ask for an independent review.

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And you鈥檒l find more information on NHS Continuing Care, and how to apply for it, on our website.

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Clip 鈥� Person snoring

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Not the sort of sound you want to hear during the day, let alone at night, but for around half a million people in the UK heavy snoring may be the first clue of a more sinister underlying issue - obstructive sleep apnoea syndrome.

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The classic story is someone who snores loudly and then appears to hold their breath before spluttering and resuming their snoring. During these prolonged breath holdings - or apnoeas - which can last a minute or more - oxygen levels plummet and trigger a survival reflex that briefly wakens the individual.

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The resulting cycle of snoring and waking leads to disturbed nights with multiple, but typically forgotten, awakenings (hundreds in some cases) that leave sufferers feeling sleepy throughout the day. Making them irritable and impairing their ability to perform complex tasks such as driving.

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But how do you tell if there is more to your snoring than an annoyed partner?

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Welcome to the world of burgeoning health apps which now includes a number that claim to analyse how well you sleep. So could sleeping with your smartphone provide the answer? Gari Clifford is Honorary Professor in Biomedical Engineering at the University of Oxford and he鈥檚 been casting a critical eye over the market and is on the line from Beijing.

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Clifford

There鈥檚 a wide variety, ranging from just checking to see how long you鈥檝e slept to analysing different depths of sleep to trying to diagnose you for different illnesses such as restlessness during the night, insomnia or sleep apnoea.

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Porter

Gari, what are the sort of clues that somebody might have that they鈥檝e got a snoring related sleep because lots of people snore, so how do we differentiate between simple snoring and more worrying sleep apnoea?

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Clifford

There are standardised scoring systems which basically ask simple questions such as what is your neck circumference, what is your age, has anybody noticed you stop breathing during the night 鈥� simple questions like that.听 And if you score highly on one of those standardised questionnaires then that鈥檚 something that you could then use to say okay I should actually screen myself at this point.

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Porter

You could look at these apps and say well a lot of them might be fun but you鈥檝e looked at them with a hard scientific eye, do they actually tell us anything useful?

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Clifford

In terms of actual scientific validity there鈥檚 not a single app out on the market that you could actually say this is useful and I could do something with this to change my lifestyle and improve my health and have any confidence that it might work.听

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Porter

There鈥檚 lots of people out there 鈥� you see people wearing these wristbands and I鈥檝e been to a dinner party, someone sat next to me, produced their phone and showed me how 鈥� what their sleep patterns were like.听 I mean presumably if you鈥檝e got something on your wrist they鈥檙e detecting whether you鈥檙e moving or not during the night, what does that tell you about your sleep quality?

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Clifford

It鈥檚 rather limited, it鈥檚 very hard to differentiate between somebody who鈥檚 an insomniac and somebody who鈥檚 in deep sleep.听 So if I have trouble going to sleep at night because of my insomnia I鈥檒l just lie there very, very still and my wrist worn device will tell me that I鈥檝e gone into either light or deep sleep.听 And unless I make some kind of gross movement it鈥檚 not actually going to say that I鈥檝e woken up in general.听 So the problem comes when you actually have some serious sleep problems and the confusion that can become between the two.听 So when we start augmenting these fitness devices with extra sensors then we鈥檙e going to be able to have much more accurate assessment of sleep quality.听 So things like the microphone in the room is useful and that helps significantly and then other sensors such as a little light based device that can clip on the end of your finger or on your earlobe and passes a light through your skin and tells you how much light is getting absorbed by the blood and that tells you how much oxygen is in the blood.

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Porter

But at the moment if you鈥檙e using one of these fitness devices to monitor your sleep and it鈥檚 telling you鈥檝e got good sleep or bad sleep it鈥檚 a pretty crude indicator is what you鈥檙e saying?

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Clifford

It can be crude but it can also be informative to the extent that 鈥� I mean I wear one and I use it mainly for just judging how long I slept for.听 My wife and I had a child a couple of years ago and I鈥檝e seen the number of hours of sleep that I get every night diminish significantly over time and it鈥檚 made me start going to bed earlier in the evening because I鈥檝e realised that no matter what I do I can鈥檛 get that early morning back.

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Porter

Too true.听 One of the problems we have in general practice 鈥� I mean looking at people with snoring related issues like sleep apnoea where they stop breathing is that we don鈥檛 really have a simple test that we can use in the community to spot this, we get a good story 鈥� someone鈥檚 got daytime drowsiness, the partner reports that they snore 鈥� but we have to send them into hospital, into a sleep laboratory, to clinch diagnosis, I mean are we at the stage where we might be able to use an app to help us do that in the community?

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Clifford

As a result of looking at all these different apps on the market we鈥檝e been working on an app that we could have some scientific basis for doing exactly this.听 We record the continuous ambient noise that you hear while you鈥檙e sleeping and this could be anything from your deep breathing to somebody snoring to a sudden loud choke.

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Porter

What results did you get 鈥� I mean how accurate is the app?

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Clifford

We found that our app was 85% accurate.听 So that converts into a score that tells you how likely you are to have sleep apnoea.听 So all it鈥檚 going to do is provide you with a certain first level confidence that you should go and do another screening.

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Porter

Professor Gari Clifford. And that next level for most people would be a chat with your GP.听 There鈥檚 a link to his free app on our website, but it only works on android phones and tablets and is still work in progress.

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Just time to tell you about next week鈥檚 programme when I will be discovering how to look after your thyroid during pregnancy and why it matters. And meeting a woman who is thrilled that she鈥檚 finally got to the bottom of why she was getting so many coughs and colds.

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ENDS