“Much avoidable ill health can be prevented” – Labour Manifesto, 2024
1. Summary
There is a general recognition that the approach to sickness and health needs to adapt to reflect the change in the nature of disease, with a greater focus on the prevention and management of chronic, long-term conditions. There needs to be much greater emphasis on creating a strong Scottish Health Ecosystem that keeps people healthier and out of hospital to free up the NHS acute and chronic trauma services to be able to provide the standard of care its highly professional staff are capable of delivering.
There are c13,500 hospital beds in Scotland with approximately 1,000,000 inpatients and 4,000,000 outpatients per year. There are nearly 700,000 on Scottish hospital waiting lists. The average cost per day of a hospital bed is c£550 and average length of stay around 7 days so about £3bn per year. Any reduction in inpatients and outpatients will have a significant impact on freeing up hospital resources to manage waiting lists and create significant economic efficiencies.
The majority of hospital beds are for acute patients (33%) with the next largest being for dementia (18%). The ten most treated conditions in acute care are cardiovascular conditions, respiratory infections, traumatic injuries, UTI inflections, mental health crisis, diabetes management, orthopaedic injuries, gastrointestinal disorders, skin/burn injuries and neurological emergencies.
In order to reduce the requirement for hospital beds there are 3 broad areas
- Keeping people healthier so avoiding/delaying onset on chronic disease
- Early diagnostics to detect issues before they become acute or chronic
- Managing inpatients to reduce average length of stay
There are many aspects to improving each of these areas and some are easier to address than others. These aspects of health should all be pulled together to form a Scottish Health Ecosystem to reduce the requirement for acute care. As part of that Scottish Health Ecosystem testing has an important part to play in keeping people healthy, early diagnostics and getting inpatients back to health quicker as set out in this paper.
2. Keeping People Health
There are now more and more tests that can be used to focus on health areas such as hormones, cardiovascular, gastrointestinal, environmental toxins, food allergies and genetics to allow practitioners to monitor the day to day health of their patients. All the tests can be taken at home or through networks of phlebotomists in the UK and used by the practitioner to guide their patients’ health needs.
Most healthcare practitioners using these tests for health are private sector regulated healthcare practitioners such as functional and private doctors, clinical specialists (such as gastroenterologists) and nutritional therapists. At present primary care NHS is not focussed on health or health testing to keep patients healthy but rather their primary role is to identify clinical illness and then refer patients towards secondary care. Individuals are increasingly seek advice on addressing health problems such as fatigue, stress, weight and gut issues or simply to understand the areas they might be susceptible to and need to keep an eye on. However, getting access to testing through the public sector is often difficult and sporadic across the country. If we are to protect the secondary system then primary care healthcare practitioners need to be more focussed on health.
An example of an area of focus of keeping people healthy for instance is women’s health as outlined below.
Women’s Health – Example of Keeping People Healthy
The Scottish government’s Women’s Health Plan “aims to reduce avoidable health inequalities for women and girls across the course of their lives – from puberty to the later years – focussing on those areas that are stigmatised, disregarded or dismissed as ‘women’s problems’. By supporting health in women and girls we can expand their choices and opportunities to achieve their potential.” Part of the plan is about improving women’s knowledge in areas such as menstruation. Hormone testing however, which is central in looking at abnormal menstruation (heavy/painful periods), PMS, perimenopause, decreased sex drive, mood swings, fatigue, anxiety and depression, breast tenderness, endometriosis, fibroids, acne or hormonal weight gain, is not readily available in the NHS. The DUTCH Complete Hormone Test is used extensively by Functional Doctors to look for hormone imbalances. It would improve understanding of women’s health if adopted into the NHS women’s health program. There are also tests for detecting the microbes contributing to UTIs and vaginal infections important to assessing women’s health. All these tests can be taken at home and could be prescribed to patients by a GP and available in pharmacists. The results would then be uploaded onto a platform allowing GPs to analyse the results to better support the patient.
3. Early Diagnostics
Early diagnosis is crucial in preventing chronic health conditions, as it allows for timely intervention before diseases progress to more severe stages. Among the top acute conditions, some are more easily identified than others, but early detection is particularly important for cardiovascular disease, diabetes, urinary tract infections (UTIs), cancers, neurodegenerative diseases and gastrointestinal infections. These conditions, if diagnosed early, can often be managed or treated effectively, reducing the risk of complications and long-term damage. If GPs were equipped to diagnose and prescribe treatments at the earliest stages, patients could benefit from more personalised care, preventing the progression of these illnesses into chronic, life-altering conditions. Early treatment also lessens the burden on healthcare systems, reducing hospital admissions and improving overall public health outcomes.
Cardiovascular Disease & Diabetes (Metabolic Syndrome) – Example of Early Diagnosis
Metabolic syndrome is a cluster of conditions that occur together which increases the risk of heart disease, stroke, and type 2 diabetes and is on the rise in Scotland. Despite significant reductions in coronary heart disease (CHD) death rates over the past decade, heart and circulatory diseases cause nearly 29% of all deaths in Scotland. CHD is the leading cause of death in Scotland, affecting approximately 7% of men and 4% of women, making its treatment and prevention a national priority under Scotland’s Heart Disease Action Plan. Diabetes, the most common metabolic disorder, poses an increasing health challenge for Scotland, with most registered cases being Type 2 Diabetes. Cost to the NHS in Scotland is £950m and the cost to the Scottish economy is estimated to be £2.5bn including the costs of lost jobs and disability benefits.
A Cardiometabolic Profile Test can evaluate risk factors for cardiovascular disease (CVD), metabolic factors related to metabolic syndrome, and type 2 diabetes. Along with traditional CVD risk factors currently assessed by doctors in the NHS, this test includes clinically sensitive atherogenic lipoprotein subspecies, key apolipoproteins, arterial inflammation, and lipoprotein-associated phospholipase activity, a sensitive marker for atherogenesis and arterial plaque instability. These markers are good early indicators of CVD. It also assesses cystatin C for kidney function and 1,5-anhydroglucitol (Glycomark®) for detecting hyperglycemic episodes, alongside adipokines related to insulin sensitivity and liver fat metabolism to give key insights into risk of developing Type 2 Diabetes. Early detection and then change of lifestyle/diet and medication before cardiometabolic conditions become chronic can significantly delay and reduce the need of acute care. These tests could be prescribed by GPs and purchased through pharmacists with access to phlebotomy services.
Urinary Tract Infections (UTIs) – Example of Early Diagnosis
An NHS report shows there were over 1.8 million hospital admissions in England involving UTIs between 2018-19 and 2022-23, the majority of which involved patients aged 65 and older (there is no comparable data in Scotland). The average stay for an acute inpatient with UTI is 4 days so the cost to the NHS is about £3bn over this period not to mention the discombobulating impact of UTI on an older person that can lead to other injuries. Much of this could be reduced by earlier detection of UTI especially in high-risk parts of the population such as the over 65s. The UroKey test is a highly accurate diagnostic tool for detecting bacteria and fungi in urine samples that may cause urinary tract infections, interstitial cystitis, and bladder infections. The test uses next-generation sequencing technology, which identifies over 57,000 potential pathogens with 99% accuracy. Studies show that culture methods, currently used in the NHS, may miss up to 50% of UTI cases and only a 30% chance of finding the dominant species driving the infection. Once known the UTI can be addressed early and most importantly with the right antibiotic for the particular bacteria. If this was available through nursing homes or GPs on prescription from pharmacists, it could prevent many of the hospital-related UTIs which use expensive acute beds as well as patient pain for what is often an avoidable condition.
4. Managing Inpatients’ Health
Patients’ health is important not just when healthy but also when suffering chronic illness and even in acute wards. There is strong evidence to support a good diet and hospital environment can aid quicker recovery and shorter stays in hospital. At present there is little testing for inpatients outside those tests needed for clinical procedures. For instance dieticians in hospitals will rarely test an individual to see what nutrition is right for the patient’s needs but rather prescribe a diet to match the clinical procedure.
Dieticians – Example of Managing Inpatients’ Health
Nutritional healthcare practitioners in the UK belong broadly to two bodies – BANT (British Association of Nutritional Therapists) and BDA (British Dietetic Association). The former is mostly private sector practitioners where testing is a key part of a patient’s treatment protocol. The latter is mostly public sector and is broadly focused on matching the correct diet with the medical procedure. Although this is a simplification – for example, dietitians do sometimes purchase tests – the vast majority of testing is conducted by nutritional therapists, not dietitians. However, there are certain tests that, if incorporated into a dietitian’s diagnostic process, could significantly improve patient outcomes by better addressing individual needs. For instance, a simple SIBO Test could greatly enhance the understanding of a more personalised treatment plan to improve digestive and overall health. It is currently used by some gastroenterologists in the NHS and available in some parts of the country, but not all, and typically not by dieticians. A plan to incorporate SIBO testing into Scottish dieticians’ analysis of symptoms would improve recovery outcomes for patients in hospital.
5. Conclusion & Recommendations
Like many countries, the UK is facing challenges in restructuring public health services to reduce the strain on acute and chronic care systems. Scotland has the potential to lead the way in developing new healthcare approaches, focusing on keeping people healthy and reducing hospital admissions. A key aspect of this strategy is the use of effective testing to maintain public health and prevent disease progression.
It is recommended
- To establish a Scottish Health Ecosystem directly under the Scottish Government, chaired by the Health Minister, bringing together the NHS, academics, SNIB, Scottish Enterprise, and others. The goal would be to create an integrated health system focused on keeping people healthier and reducing hospital admissions.
- That testing becomes a key part of the Scottish Health Ecosystem to better inform and educate practitioners and patients to stay healthy. GPs prescribing at-home tests could become important tools that provide valuable insights into a patient’s health, enabling earlier diagnosis and more informed care.
Ben Thomson is a former Chair/Founder of Enlighten and currently Chair/Founder of Regenerus. Regenerus, based in Scotland is the largest provider of health tests to UK healthcare practitioners. It providers around 150 tests to over 5,000 practitioners in the UK backed by a clinical support team to advice practitioners about the test results and a data management platform that enables the practitioner to upload, manage and interpret the patients data.