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Weekly roundup: The NHS needs to be restructured, combating COVID-19 vaccine hesitancy, and screening for Gastric Cancer

In this week we take a look at how the Lancet believes the NHS should be restructured, ways of combating vaccine hesitancy, the effect of parental deprivation on the cardiovascular risks of children, and screening for gastric cancer.
Weekly roundup: The NHS needs to be restructured, combating COVID-19 vaccine hesitancy, and screening for Gastric Cancer

The LSE–Lancet Commission commission came out with a report on the state of the NHS earlier this week. In the light of the pandemic, the authors argue, the United Kingdom faces a once in a lifetime opportunity to restructure the NHS and reorient it towards facing issues more relevant to the zeitgeist.

There is much to criticise and praise the NHS about when it comes to their handling of the pandemic. The flexibility and sense of duty demonstrated by its staff in working long hours to keep health services running cannot be overstated. Unlike places like India, where government hospitals struggled and people had to pay exorbitant amounts for private care, the presence of the NHS made sure that most people in the UK received quality care without having to pay a lot. The equality of resource access and allocation also made a big difference in the outcomes of patients with chronic diseases (such as chronic kidney disease, diabetes, etc.) who were fairly well-taken care of. And most importantly, the clinical trials of many vaccines in production today (most notably the Vaccitech-AstraZeneca vaccine) were first conducted through the NHS. There is a lot to be thankful about.

But there are many places where the NHS can still use improvement. The high number of deaths per capita represents a deep failure of the health system. The inability of the NHS to increase testing, a lack of hospital capacity, the lack of personal protective equipment (PPE), and a failure to test and trace properly all led to the pandemic getting out of hand very fast. Local branches were unable to get the equipment they needed, labs ran out of testing kits, many testing sites were unable to use the National Pathology Exchange properly, and procurement was not done in a standardised manner. This was patched up very quickly, but the mistakes committed in the early days of the pandemic snowballed as thousands of untested covid positive people were released back into the country.

Of course, most of this can be traced back to inadequate support from Westminster and the devolved national legislatures at Edinburgh, Cardiff, and Belfast. The NHS's funding has been dropping for years and to expect the NHS to be able to perform perfectly after having emerged from a period of long austerity after the 2008 financial crisis would be stretching the credulity of any sane person. Unfortunately, the effects of this reduction in funding can be felt in many other metrics of healthcare measurement as well. The UK has seen a reduction in the rate of improvement of life expectancy as compared to its peers in the G7 and the EU and has seen inequalities grow between richer, more urban regions and rural, more deprived regions. The number of doctors and nurses employed by the NHS is now below average when it comes to high-income countries. The NHS has also not been able to fundamentally change the way it interacts with patients: patient engagement is also firmly stuck in the twentieth century.

The authors' responses to these problems are fairly straightforward at first glance. Increase NHS funding, spend it wisely. The direction of that funding, however, is somewhat important. The authors stress on increasing social funding and integrating it with the NHS. Social care has been a neglected part of the UK budget for a long time: it has been proposed to tie this in more closely with healthcare. Another recommendation talks about increasing access to diagnosis and improving the availability of cheap diagnostic tests. The NHS has already done this for COVID by supplying OTC home diagnostic kits across the country for individuals to monitor themselves. The kits remain a means of screening: if one gets a positive result, a confirmatory test is carried out through PCR-based tests. The authors also recommend tightening up the NHS's workforce strategy in order to retain more workers and train doctors and nurses to fill in existing gaps in the system.

The state of Health Information Technology (HIT) systems also remains a reason for concern. There is widespread agreement that the current HIT systems seem to hinder rather than facilitate care. A good HIT ought to ease data entry operations, allow working with big data to strategically improve healthcare, aggregate data from multiple endpoints, and be easy to use. Current NHS workers seem to be inadequately trained to use available HIT systems, leading to frustration and a desire to not use the ones in place.

Finally, the authors also talk about integrating the different parts of the NHS more closely together in order to make the patient experience more seamless and wholesome. The integration of health and care, as is being done in Northern Ireland and Scotland might be a good place to start.

Voluntary Healthcare Insurance

Xu and Yang write about the pitfalls of implementing voluntary healthcare insurance schemes in a country. In a nutshell, Voluntary Healthcare Insurance Schemes (VHIS) require a population to pay a flat rate regardless of their age, existing preconditions, or any other reason in order to cover everyone else. However, as the name suggests, VHIS are voluntary, so one can drop out of actually being part of them. This causes the structure to become untenable, because there isn't enough money to actually cover everyone.

The authors focus on China and the effect of VHIS in the country. Their findings line up well with prior studies reporting young and healthy individuals tend to shun VHIS because the costs are too high for their risk profiles. The authors also report that the most socio-economically vulnerable parts of a population also tend to shun VHIS (because the cost is too high for them to afford or due to insufficient knowledge or understanding of insurance), which, again, lines up well with previous studies. And finally, people with worse health indicators tend to remain signed up to VHIS in both China as well as elsewhere.

The authors also report that dropping out of VHIS tends to affect the usage of secondary and tertiary healthcare services, in line with what other studies report. This is probably because primary services are much cheaper than secondary and tertiary services. One group which bucks this trend is rich people in rich provinces in China: the authors speculate this may be due to the more developed commercial healthcare systems in these places.

Policy Implications

A careful reading of the paper and the authors' comments recommends that VHIS, if implemented, needs more thought and some state support. It has been suggested previously that it might be a good idea to introduce well-thought out exemptions for the poor (not in the Chinese context, but in an African one), and Xu and Yang come to the same conclusion. Related work by Hall, Hamacher and Johnson in Michigan also suggests that a social safety net, if properly constructed, is better than local private insurers as well as Medicaid. In the context of China, the authors also suggest improving primary care and improving the distribution of healthcare services across China to assure uniform access for all.

However, the greater implication seems to be the introduction of a Mandatory Health Insurance Scheme (MHIS) for poorer and more rural areas. The major issue with a VHIS based on a fixed rate is that people with better healthcare indicators find it harder to justify paying for it given their considerably better risk profile. However, lack of insurance has been associated with decreased healthcare utilisation among people with similar healthcare indicators, which indicates that people fear incurring healthcare costs when not insured. From the point of view of a society, it might be a better idea to invest more in health insurance in order to increase health service utilisation and utility.

Factors behind COVID-19 Vaccine Hesitancy

COVID-19 has to feature extremely prominently in any newsletter talking about health issues. Serda and García sought to understand the reasons behind vaccine hesitancy amongst the population of Chile. This is an important step towards learning how to tailor one's approach towards pro-vaccination messaging. Vaccination campaigns need to target people's existing preconceptions, fears, and the real barriers they face when going to get a vaccine if they are to be successful.

The authors utilise a Health Belief Model (HBM) and apply logistic regression to understand the reasons behind vaccine hesitancy. To quote the authors:

In terms of public policy, the HBM reveals that the variables to be considered relate to perceived barriers, benefits, susceptibility, severity, and cues of actions, among others; in this vein, scarce literature exists regarding the COVID-19 vaccine.

The primary reasons which people cited fro not getting vaccinated were a lack of knowledge of side effects and the extent of risk, a lack of knowledge about the vaccines themselves, and a preference to see other people get vaccinated first. Interestingly, educated people tended to be more prone to rejecting getting a vaccine dose due to lack of knowledge about the vaccine itself or its side effects than less educated people. On the other hand, the reasons which motivated individuals to actually go and get vaccinated were the perceived benefits of protecting oneself and one's family, positive cues from family members, fear of the severity of complications from catching COVID-19, and an understanding that the vaccine would reduce chances of catching COVID and inducing immunity against the disease.

A more interesting thing to come out of this study was the fact that people were more likely to care about potential side-effects than effectiveness. In other words, people are more concerned about the safety profile of the vaccine than how effective it was. A very large number of people expressed his preference, which has major implications for targeting communication policy. Being convinced about the efficacy of the vaccine was also important for most people. The presence of an effective vaccine in the country made a significant difference to a lot of people. Another major factor was encouragement from their social network, or at least no negative pressure. This encouragement did not have to be direct. If a person's social network indicated that the severity of the symptoms of COVID-19 was high, or that the side effects were negligible, they were more likely to get vaccinated than not. Thus people whose family members had already suffered from COVID-19 were extremely likely to get vaccinated.

These results make a lot of sense. Behavioural economics has taught us that humans are not rational actors. We also have a tendency to see small negative probabilities as being bigger than they are, and small positive probabilities as being smaller than they actually are. These factors have to be kept in mind by policymakers when they create vaccination communication campaigns. Policymakers ought to focus on convincing people about the transient nature of side-effects and their lack of strength over talking about the efficacy and the effectiveness of vaccines. Another angle to look at is convincing people and teaching them about the short-term effects of COVID-19 as well as cautioning them about its unknown long-term effects.

Another major reason for vaccine hesitancy, not really discussed in-depth by the authors, was the issue of price. A previous paper by the same authors talks about the willingness of a person to pay for the vaccine, and they found that people in Chile were willing to pay a mean of around $232 for getting vaccinated. That study has been criticised for omitting some nuances: especially that the majority of the population was not very willing to pay the mean price if willingness to pay was analysed slightly differently. Both the paper and the comment are fairly interesting reads if one wishes to understand a couple of different perspectives on the same data. A small quote from that paper, however, caught my eye:

The main reasons for respondents refusing to pay for the vaccine are as follows: the government should pay for the vaccine (44%), the vaccine is not important (16%), I do not have enough money (11%), those who caused the virus must pay for it (10%), it is immoral to pay for a vaccine (10%), and society has bigger problems/I do not want to pay (8%). These results show that almost 90% of the refusal responses are protest responses.

This seems to strengthen the argument that good messaging can lead to a lot of change in vaccination uptake.

There is some evidence from animal studies that a child's health is often invariably linked to the conditions endured by the parent as a child. Some evidence exists in humans as well, but there is not a lot of literature that explicitly looks at conditions apart from obesity, and very little literature from South Asia on this phenomenon. Mallinson et. al. explore the effect of the socioeconomic status of parents and the incidence of cardiovascular disease in their children. Prior literature looking at obesity has focussed on rich countries such as the United States and Sweden, where are being rich is associated with being thin. However, poorer countries in South Asia tend to have a positive relationship between obesity and socio-economic status, which is seen in the results. The higher the standard of living of the parents during childhood, the higher the wast circumference and the BMI of the offspring.

Of course, this study was conducted in rural South India and its results may not be applicable elsewhere. Nonetheless this study does put something in perspective. In the West, the richer you are, the less your chances of actually getting heart disease. But in India, the richer you are, the fatter you are likely to be. This is a well-known and understood part of the country. But the more interesting part was that parents' childhood circumstances had little bearing on the risk of heart disease for a child. The science of epigenetics is not very advanced yet, so there may be scope for increasing our understanding of these links with future studies.

Managing Gastric Cancer

Gastric cancer is an extremely significant cause of death worldwide. More than 1 million people get diagnosed every year, making it the fourth most common sort of cancer. Among cancers, it accounts for the third highest number of deaths worldwide.And more unfortunately, it seems as if the incidence of this cancer worldwide is rising, not falling. There were an estimated 356,000 more cases and 96,000 more deaths from gastric cancer in 2017 compared to 1990.

An interesting thing to note about gastric cancer is that it is similar to cervical cancer in one sense: one sees both their numbers rise with certain infections. Human papillomavirus is strongly linked to an increase in chances of cervical cancer, and Helicobacter pylori (H. pylori) infections are considered a strong biological risk for developing gastric cancer. In fact, H. pylori has been designated as a class I carcinogen by the International Agency for Cancer Research (IARC).

Fortunately, H. pylori infections can be controlled using antibiotics. While many Western countries have a low prevalence of gastric cancer, it has been found that treatment for H. pylori infections can still lead to significant reductions in deaths caused by gastric cancer. Regions with high gastric cancer prevalence such as China, Japan and South Korea have begun testing for H. pylori infections through endoscopies and shown a reduction in gastric cancer mortality by up to 40%. Lansdorp-Vogelaar et. al. have reviewed publications looking at the cost-effectiveness of such interventions in Western countries to see what the overall picture looks like. Nine studies looked at the long-term costs and the quality adjusted life years (QUALYs) gained by H. pylori testing and treatment in Western countries for the overall population.

All studies evaluated once-only serology testing for H. pylori, with one study comparing this strategy with faecal antigen testing and C-urea breath test (C-UBT) screening. Assumed test characteristics were high with sensitivity estimates exceeding 85% and specificity estimates of around 80–90%. Test costs mostly varied between US$10–30, with the exception of New Zealand where inclusion of costs for the invitation and promotion campaign resulted in costs exceeding US$70. Eradication was generally assumed to be successful 80–90% of the time. Two studies assumed lower eradication rates of 50% and 64% respectively. Costs for eradication therapy differed significantly between the studies, from as low as US$ 20 to US$ 125. None of the studies considered the potential adverse effects of widespread antibiotics use.

Three studies looked at the cost-effectiveness for screening for pre-malignant lesions through serum pepsinogen testing and upper endoscopies. Three studies looked at differences between the sexes when it came to the effectiveness of gastric cancer screening, and four looked at the effect of race. One study also compared the cost-effectiveness of screening between smokers and non-smokers (smoking is a risk for gastric cancer).

A surprisingly interesting conclusion to come out is that screening is cost-effective in Western countries. The average cost of screening was $35,000 per QALY gained, which is less than the typical threshold of $50,000. Testing for pre-malignant lesions through pepsinogen tests or endoscopy was seen to not be cost-effective in people with an average probability of developing gastric cancer. However, as the authors point out, there is more research to be done in this arena. One, most studies do not consider the effect of H. pylori eradication after gastric ulcers have started to develop (the Correa cascade). Second, many studies do not look at the other effects of H. pylori eradication, such as the effect on peptic ulcers and dyspepsia, nor have they considered the effects of increased antibiotic prescriptions. The authors also suggest combining endoscopies with colonoscopies for screening, but posit that this might not be a good idea in Europe, where stool samples are more commonly used for screening.