Finance, Commissioning and Contracting Handbook

NHS England | August 2019 | Finance, Commissioning and Contracting Handbook

NHS England have published the Finance, Commissioning and Contracting Handbook for the NHS England Comprehensive Model for Personalised Care. It aims to provide finance, commissioning and contracting staff with the information required to implement personalised care locally.

Finance, Commissioning and Contracting Handbook

Cancer overtakes CVD to become leading cause of death in high income countries

Mahase, E.| 2019|  Cancer overtakes CVD to become leading cause of death in high income countries| 

Cancer is now responsible for twice as many deaths as cardiovascular disease (CVD) in high income countries, according to two new papers published in The Lancet.

The studies said that while CVD remains the leading cause of mortality among middle aged adults globally, accounting for 40% of all deaths, this is no longer the case in high income countries. The researchers estimated that of 55 million deaths that occurred in the world in 2017, approximately 17.7 million were from CVD.

The findings come from the PURE study, a large prospective international cohort study that involves substantial data from a large number of middle, low, and high income countries.

Countries analysed in the two reports include: Argentina, Bangladesh, Brazil, Canada, Chile, China, Colombia, India, Iran, Malaysia, Pakistan, Palestine, Philippines, Poland, Saudi Arabia, South Africa, Sweden, Tanzania, Turkey, United Arab Emirates, and Zimbabwe (Source: BMJ).

The full story is available from the the BMJ 

These are the full-text journal articles featured in the The BMJ article:

Dagenais, G. R. | 2019| Variations in common diseases, hospital admissions, and deaths in middle-aged adults in 21 countries from five continents (PURE): a prospective cohort study |The Lancet |



To our knowledge, no previous study has prospectively documented the incidence of common diseases and related mortality in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) with standardised approaches. Such information is key to developing global and context-specific health strategies. In our analysis of the Prospective Urban Rural Epidemiology (PURE) study, we aimed to evaluate differences in the incidence of common diseases, related hospital admissions, and related mortality in a large contemporary cohort of adults from 21 HICs, MICs, and LICs across five continents by use of standardised approaches.



The PURE study is a prospective, population-based cohort study of individuals aged 35–70 years who have been enrolled from 21 countries across five continents. The key outcomes were the incidence of fatal and non-fatal cardiovascular diseases, cancers, injuries, respiratory diseases, and hospital admissions, and we calculated the age-standardised and sex-standardised incidence of these events per 1000 person-years.



This analysis assesses the incidence of events in 162 534 participants who were enrolled in the first two phases of the PURE core study, between Jan 6, 2005, and Dec 4, 2016, and who were assessed for a median of 9·5 years. During follow-up, 11 307 (7·0%) participants died, 9329 (5·7%) participants had cardiovascular disease, 5151 (3·2%) participants had a cancer, 4386 (2·7%) participants had injuries requiring hospital admission, 2911 (1·8%) participants had pneumonia, and 1830 (1·1%) participants had chronic obstructive pulmonary disease (COPD). Cardiovascular disease occurred more often in LICs (7·1 cases per 1000 person-years) and in MICs (6·8 cases per 1000 person-years) than in HICs (4·3 cases per 1000 person-years). However, incident cancers, injuries, COPD, and pneumonia were most common in HICs and least common in LICs. Overall mortality rates in LICs (13·3 deaths per 1000 person-years) were double those in MICs (6·9 deaths per 1000 person-years) and four times higher than in HICs (3·4 deaths per 1000 person-years). This pattern of the highest mortality in LICs and the lowest in HICs was observed for all causes of death except cancer, where mortality was similar across country income levels. Cardiovascular disease was the most common cause of deaths overall (40%) but accounted for only 23% of deaths in HICs ( vs 41% in MICs and 43% in LICs), despite more cardiovascular disease risk factors (as judged by INTERHEART risk scores) in HICs and the fewest such risk factors in LICs. The ratio of deaths from cardiovascular disease to those from cancer was 0·4 in HICs, 1·3 in MICs, and 3·0 in LICs, and four upper-MICs (Argentina, Chile, Turkey, and Poland) showed ratios similar to the HICs. Rates of first hospital admission and cardiovascular disease medication use were lowest in LICs and highest in HICs.



Among adults aged 35–70 years, cardiovascular disease is the major cause of mortality globally. However, in HICs and some upper-MICs, deaths from cancer are now more common than those from cardiovascular disease, indicating a transition in the predominant causes of deaths in middle-age. As cardiovascular disease decreases in many countries, mortality from cancer will probably become the leading cause of death. The high mortality in poorer countries is not related to risk factors, but it might be related to poorer access to health care.
Article available here

Yusuf, S. | 2019| Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study | The Lancet | DOI:



Global estimates of the effect of common modifiable risk factors on cardiovascular disease and mortality are largely based on data from separate studies, using different methodologies. The Prospective Urban Rural Epidemiology (PURE) study overcomes these limitations by using similar methods to prospectively measure the effect of modifiable risk factors on cardiovascular disease and mortality across 21 countries (spanning five continents) grouped by different economic levels.



In this multinational, prospective cohort study, we examined associations for 14 potentially modifiable risk factors with mortality and cardiovascular disease in 155 722 participants without a prior history of cardiovascular disease from 21 high-income, middle-income, or low-income countries (HICs, MICs, or LICs). The primary outcomes for this paper were composites of cardiovascular disease events (defined as cardiovascular death, myocardial infarction, stroke, and heart failure) and mortality. We describe the prevalence, hazard ratios (HRs), and population-attributable fractions (PAFs) for cardiovascular disease and mortality associated with a cluster of behavioural factors (ie, tobacco use, alcohol, diet, physical activity, and sodium intake), metabolic factors (ie, lipids, blood pressure, diabetes, obesity), socioeconomic and psychosocial factors (ie, education, symptoms of depression), grip strength, and household and ambient pollution. Associations between risk factors and the outcomes were established using multivariable Cox frailty models and using PAFs for the entire cohort, and also by countries grouped by income level. Associations are presented as HRs and PAFs with 95% CIs.



Between Jan 6, 2005, and Dec 4, 2016, 155 722 participants were enrolled and followed up for measurement of risk factors. 17 249 (11·1%) participants were from HICs, 102 680 (65·9%) were from MICs, and 35 793 (23·0%) from LICs. Approximately 70% of cardiovascular disease cases and deaths in the overall study population were attributed to modifiable risk factors. Metabolic factors were the predominant risk factors for cardiovascular disease (41·2% of the PAF), with hypertension being the largest (22·3% of the PAF). As a cluster, behavioural risk factors contributed most to deaths (26·3% of the PAF), although the single largest risk factor was a low education level (12·5% of the PAF). Ambient air pollution was associated with 13·9% of the PAF for cardiovascular disease, although different statistical methods were used for this analysis. In MICs and LICs, household air pollution, poor diet, low education, and low grip strength had stronger effects on cardiovascular disease or mortality than in HICs.



Most cardiovascular disease cases and deaths can be attributed to a small number of common, modifiable risk factors. While some factors have extensive global effects (eg, hypertension and education), others (eg, household air pollution and poor diet) vary by a country’s economic level. Health policies should focus on risk factors that have the greatest effects on averting cardiovascular disease and death globally, with additional emphasis on risk factors of greatest importance in specific groups of countries.
Full article available from The Lancet 

How does UK healthcare spending compare with other countries?

Office for National Statistics | September 2019| How does UK healthcare spending compare with other countries?

The Office for National Statistics (ONS) has issued its latest release of UK healthcare spending relative to comparable countries. It forms an analysis of UK healthcare spending relative to comparable countries, using data produced to the international definitions of the System of Health Accounts (SHA 2011).
business-1676138_640.jpgKey points 

  • In 2017, the UK spent £2,989 per person on healthcare, which was around the median for members of the Organisation for Economic Co-operation and Development: OECD (£2,913 per person).
  • Of the G7 group of large, developed economies, UK healthcare spending per person was the second-lowest, with the highest spenders being France (£3,737), Germany (£4,432) and the United States (£7,736).
  • As a percentage of GDP, UK healthcare spending fell from 9.8% in 2013 to 9.6% in 2017, while healthcare spending as a percentage of GDP rose for four of the remaining six G7 countries.
  • The UK’s publicly funded NHS-based health system contributes to the UK having one of the highest shares of publicly funded healthcare (79%) in the OECD.
  • In 2017, the UK spent the equivalent of £560 per person on health-related long-term care, which was less than most other northern or western European countries, but a similar amount to France (£569) and Canada (£556).

The article is available to download from the ONS


Do no harm: a roadmap for responsible machine learning for health care

Wiens, J. et al. | 2019 | Do no harm: a roadmap for responsible machine learning for health care|Nature medicine| 1-4.

Nature Medicine has published a new article which presents a framework, context and ultimately guidelines for accelerating the translation of machine learning-based interventions in health care. To be successful, translation will require a team of engaged stakeholders and a systematic process from beginning (problem formulation) to end (widespread deployment).

Interest in machine-learning applications within medicine has been growing, but few studies have progressed to deployment in patient care.

Source Wiends et al, 2019
Image source: Wiends et al, 2019


Interest in machine-learning applications within medicine has been growing, but few studies have progressed to deployment in patient care. We present a framework, context and ultimately guidelines for accelerating the translation of machine-learning-based interventions in health care. To be successful, translation will require a team of engaged stakeholders and a systematic process from beginning (problem formulation) to end (widespread deployment).

The full article is available from Nature Medicine 

Manchester study: Smartphones could transform patient care

University of Manchester | August 2019 |Smartphones could transform patient care, finds study 

A smartphone app used remotely to provide information on parents with arthritis could have the potential to transform the care of patients with long-term conditions reports a study now published in the journal Rheumatology.

Remote Monitoring of Rheumatoid Arthritis (REMORA) study designed and tested a system to support clinical care and research, enabling people living with RA to report daily symptoms using a smartphone app with data integrated into the electronic health record (EHR). The study  evaluated the system’s acceptability and feasibility including exploration of participants’ views and experiences of remote monitoring, with specific focus on how integration of smartphone data into the EHR in graphical format influenced consultation


A sample of 20 patients’ data from the app was uniquely integrated into their EHR at their hospital, with the data summarised as a graph visible at their outpatient visit.

The app, jointly designed by patients, clinicians and researchers, allowed patients to input what symptoms they were experiencing each day and the impact it had on their lives.

Their doctors used the data generated by the app when carrying out face to face consultations.

The system provided a “bigger picture” than doctors would otherwise get, capturing “symptoms that would otherwise have been missed”.

And the graphs generated by the app made it easier for patients to participate in consultations and treatment, enabling a shared discussion between the patient and their doctor (Source: University of Manchester).

The authors’ report that:

  • Daily remote monitoring using a smartphone app was viewed positively by patients and completed regularly.
  • Graphs of patients’ daily data identified changes in disease that would otherwise have been missed.
  • Patients valued consultations being focused around their own data, supporting person-centred care.

Read the full news story from University of Manchester



To establish the acceptability and feasibility of collecting daily patient-generated health data (PGHD) using smartphones and integrating PGHD into the electronic health record, using the example of RA.


The Remote Monitoring of RA smartphone app was co-designed with patients, clinicians and researchers using qualitative semi-structured interviews and focus groups, including selection of question sets for symptoms and disease impact. PGHD were integrated into the electronic health record of one hospital and available in graphical form during consultations. Acceptability and feasibility were assessed with 20 RA patients and two clinicians over 3 months. A qualitative evaluation included semi-structured interviews with patients and clinicians before and after using the app, and audio-recordings of consultations to explore impact on the consultation. PGHD completeness was summarized descriptively, and qualitative data were analysed thematically.


Patients submitted data on a median of 91% days over 3 months. Qualitative analysis generated three themes: RA as an invisible disease; providing the bigger picture of RA; and enabling person-centred consultations. The themes demonstrated that the system helped render patients’ RA more visible by providing the ‘bigger picture’, identifying real-time changes in disease activity and capturing symptoms that would otherwise have been missed. Graphical summaries during consultations enabled a more person-centred approach whereby patients felt better able to participate in consultations and treatment plans.


Remote Monitoring of RA has uniquely integrated daily PGHD from smartphones into the electronic health record. It has delivered proof-of-concept that such integrated remote monitoring systems are feasible and can transform consultations for clinician and patient benefit.

The full article can be read at Rheumatology

Alternatively, download a copy here 


NICE Consultation: Safe prescribing and withdrawal management of prescribed drugs associated with dependence and withdrawal

NICE |  August 2019 | Safe prescribing and withdrawal management of prescribed drugs associated with dependence and withdrawal | In development [GID-NG10141]

NICE has published draft consultation of Safe prescribing and withdrawal management of prescribed drugs associated with dependence and withdrawal

The consultation is open until 26 September 2019

Full details are available from NICE 

NICE Consultation: Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management

NICE |  August 2019 | Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management | In development [GID-NG10091]

NICE need evidence from the areas listed below for the guideline we are developing on Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome:

1. Studies that evaluate:

  • Management strategies that are adopted while someone is being assessed for a diagnosis of ME/CFS.
  • Methods of monitoring and/or reviewing people with a diagnosis of ME/CFS

NICE are looking for trials that compare different strategies or different methods of monitoring and review. Systematic reviews, randomised controlled trials, non- randomised trials that are prospective or retrospective cohort studies will be considered for inclusion in the guideline.

NICE would like studies that report measurable outcomes on:

  • Mortality
  • Quality of life
  • Fatigue /fatiguability
  • Physical functioning
  • Cognitive function
  • Psychological status
  • Pain
  • Sleep quality
  • Treatment-related adverse effects
  • Activity levels
  • Return to school or work
  • Exercise performance measures.
  • Care needs
  • Impact on families and carers

Full details from NICE

NICE: Hypertension in adults: diagnosis and management

NICE | August 2019 | Hypertension in adults: diagnosis and management | NICE guideline [NG136]

NICE has published Hypertension in adults: diagnosis and management, the guideline covers identifying and treating primary hypertension (high blood pressure) in people aged 18 and over, including people with type 2 diabetes. It aims to reduce the risk of cardiovascular problems such as heart attacks and strokes by helping healthcare professionals to diagnose hypertension accurately and treat it effectively.

Full details from NICE