Arussa Beyond the Bench.

Author: arussa

  • Episode 1. Neurosurgery

    This week we have Dr F currently working within the Neurosurgery department, in a London hospital. They share their personal anecdotes as a doctor within the NHS…

    From your clinical perspective, what is the most significant unmet need amongst your patients?

    The most significant unmet need is timely access to definitive care and rehabilitation. In neurosurgery, many patients present with conditions where early intervention can dramatically alter outcomes for example, spinal cord compression, brain tumours and hydrocephalus. Yet, delays are common at multiple points: primary care referral, imagining and theatre availability due to a shortage of beds or competing emergencies. There are ways around this where you “bluelight” the patients requiring urgent intervention in the event of a bed shortage, but that still burdens the workforce to arrange for beds in impossible situations.

    An equally important, and often overlooked, challenge is the access to neuro-rehabilitation and social support after the acute phase. Surgery is only one part of the journey. Many patients face prolonged waiting times for physiotherapy, occupational health or community neuro-rehabilitation. Often in our Acute Neurosurgery department this is exacerbated by repatriation delays to local hospitals, which subsequently impacts bed availability within the department. Without continued support, patients may never regain their baseline function, even if the surgery itself was technically successful. This phenomena disproportionately affects those without a strong family support system or financial resources to seek private rehabilitation.

    What part of your job feels needlessly difficult due to the structure of the UK healthcare system?

    A major challenge is navigating system fragmentation and capacity constraints. A significant proportion of my time is spent coordinating care – chasing scans, locating beds, arranging transfers, and facilitating patient discharge – rather than delivering direct clinical care. These insufficiencies are not due to a lack of effort from staff, but rather structural limitations in capacity and coordination between services.

    Delayed discharges are common; patients who are medically fit for discharge often remain in hospital due to limited social care post-treatment or surgery. This creates a compounding effect with patients waiting in emergency departments or referring hospitals for neurosurgical beds. As a result, patients and staff experience preventable delays and the NHS operates at its limits. An additional factor contributing to delayed patient discharge (as well as delayed patient assessments and management) is a low doctor:patient ratio, with a single junior doctor managing multiple patients daily. This also adds to the administrative burden placed on junior doctors, which could be streamlined with improved systems, staffing and digitalisation.

    How do social or economic factors show up in your day-to-day clinics?

    Socioeconomic factors manifest in every setting. Patients from more deprived backgrounds often present later in the course of their illness, sometimes due to a lack of access to primary care, competing priorities, or limited health literacy. By the time they reach specialist care, their condition is often more advanced and their prognosis is worse. Recovery is also influenced by a patient’s social circumstances; those with stable housing, family supports and financial security tend to recover more smoothly whilst those living alone, lacking familial and financial support defer seeing a doctor or struggle to attend follow-up appointments.

    Within Neurosurgery, employment is an important consideration. Many patients of working age suddenly face neurological disability. The psychological and financial implications of losing one’s independence or employment can be profound – something that is not addressed within the healthcare pathway.

    In your opinion, what one change in policy, training or funding would have the biggest impact on patient care?

    Increased investment in downstream capacity, particularly in rehabilitation services, social care and step-down facilities. Hospital flow is frequently limited not by surgical capacity, but due to a lack of community support. Improving social care provisions would free up hospital beds, reduce delays and improve outcomes for patients. This would also allow clinicians to focus more on delivering care rather than managing system bottlenecks. Investments into workforce retention is equally as important. NHS staff surveys consistently show high levels of burnout and workload-related stress. By retaining experienced staff efficiency of care and patient safety would be improved.

    What do you wish policymakers understood about your speciality or your patients?

    It is important to understand that neurosurgical patients are often extremely vulnerable, and small delays can have life-changing consequences. Conditions like spinal cord compression or brain tumours are not just acute medical problems – they affect mobility, cognition, independence, and identity. I also wish policymakers understood how dependent neurosurgery is on the wider healthcare and social care ecosystem; surgical skill alone is not enough, with outcomes depending on timely diagnosis, access to imaging, theatre availability, ICU beds, rehabilitation, and social support.

    Finally, I think there is a lack of appreciation for the amount of time clinicians’ spend on managing system limitations (especially on documentation), rather than practising medicine. Improving system efficiency would benefit both patients and staff.

    Where do you feel evidence or data is lacking in your field?

    There is limited high-quality data on long-term functional and socioeconomic outcomes for neurosurgical patients, particularly in the UK. We often measure success in terms of surgical metrics e.g. mortality, complication rates, or imaging findings, but pay less attention to the functional recovery, return to work rates and quality of life (although there have been some improvement in recent years).

    There is also little data on how socioeconomic deprivation affects neurosurgical presentation, access, and outcomes. Clinically, the disparities are visible, but better data would help quantify the problem and inform targeted interventions. Additionally, more research is needed into workforce sustainability, training and the impact of system pressures on both clinician wellbieng and patient outcomes.

  • Prevention: The Health inequality contributor that needs more attention

    Prevention is the policy we keep ignoring…

    Modern healthcare systems excel in intervening once people are already unwell – clinicians diagnose, treat, and manage complications whilst we absorb the rise in costs. What these systems are far less structured to do, is prevent the disease from occurring in the first place. An estimated 40% of ill health in the UK is preventable, yet the health system is overwhelmingly focused on treating diseases rather than preventing them.

    This imbalance is not limited to the clinic, but also poses major moral and socioeconomic risks. Whilst the NHS is continuously overburdened with budgets and resources being unrealistically overstretched, preventable diseases continue to drive avoidable suffering, widening health inequalities and pushing public spending. Yet, despite prevention-focused initiatives such as the NHS Prevention Programme, measures remain significantly under-prioritised in policy and funding frameworks. If prevention is evidently beneficial, why is it not at the core of healthcare system policies and frameworks?

    What do we mean by prevention?

    Prevention is multi-tiered:

    • Primary prevention – stopping the disease before it develops, for example vaccination, obesity prevention and smoking cessation.
    • Secondary prevention – detecting the disease early, when outcomes are better and costs are manageable, for example early screening and diagnosis.
    • Tertiary diagnosis – reducing complications when the disease is established, for example glucose monitoring and physiotherapy. This is synonymous with disease intervention.

    In the UK, a substantial budget is spent on tertiary prevention where the disease is most advanced, complicated and costs are highest. By contrast, primary prevention receives a lower proportion of healthcare spending despite its long – term advantages, with only 6% of total healthcare expenditure focused on primary prevention initiatives.

    The true cost of preventable disease in the UK – real world examples

    Many of the major health conditions placing the greatest strain on the UK’s national healthcare service are not inevitable – they are highly preventable through modifiable risk factors, social structures and policy changes. They’ve also been a part of the prevention conversation for many years. Below are 3 key examples:

    Cardiovascular disease (CVD)

    CVD remains the leading cause of death and disability in the UK; it is also one of the most preventable through limiting risk factors. Key drivers include smoking, high blood pressure, poor diet and lack of physical activity. A substantial proportion of CVD cases could be delayed or prevented entirely through population-level prevention measures such as tobacco tax, active commuting initiatives and restricting access to unhealthy foods. Yet, treatment (intervention) of CVD takes priority and dominates spending through emergency hospital admissions, long-term medication prescriptions and invasive surgical procedures. Currently, CVD intervention costs the UK health service over £18 million.

    CVD burden is not evenly distributed, with rates of CVD being higher in more deprived communities, thus further contributing to health inequalities. As such, prevention is not the sole responsibility of the individual but a combined effort to change food and lifestyle systems, health education and access to support.

    Top 6 modifiable risk factors

    Smoking, high blood pressure, high blood sugar levels, high BMI, dietary risk and alcohol use

    Type 2 Diabetes (T2D)

    T2D is a prime example demonstrating the cost of late intervention, currently consuming approximately 10% of the NHS budget. Key risk factors include obesity, ethnicity, access to healthcare and socioeconomic deprivation. Once established, T2D drives long-term health costs through further complications including CVD, amputations and vision loss – it is often these further complications that overburden healthcare services.

    There is ample evidence demonstrating how early lifestyle interventions can delay or prevent T2D disease progression in high-risk individuals. However, these programmes remain low priority and vulnerable to funding cuts.

    Cancer

    Cancer care is one of the fasted growing areas of NHS expenditure. Whilst not all cancers are preventable, over one third are linked to modifiable risk factors including smoking (lung cancer), infection (HPV, cervical cancer), alcohol consumption (liver cancer) and obesity (bowel cancer).

    Here, primary and secondary prevention with early screening and detection not only improve survival rates but also drastically reduce treatment complexity, quality of life and cost (both direct and indirect). Late stage cancer care is physiologically, emotionally, logistically and financially taxing and often less effective than early stage disease. At late stage, productivity loss, absenteeism and out-of-pocket expenses compound adding to the pressure felt by a cancer diagnosis. Important to note here, is that late stage diagnosis and a lower standard of care are most common in deprived populations, widening the inequality gap (another growing health issue we will discuss in the future).

    So why has prevention remained a low priority?

    We know that prevention is effective, so why has it remained under-prioritised and under-funded? Well, this is due to several barriers not limited to:

    • Measurement and data collection challenges – it is easier to count the number of treatments delivered than it is to model the number of diseases avoided and attributing that to specific prevention factors. Although QALYs and DALYs model avoided disease burden, prevention is measured by events that don’t occur and aren’t accurately recorded, such as admissions avoided or complications prevented.
    • Budget pressure – as costs are constantly fluctuating, prevention budgets are usually amongst the first to be reduced often due to delayed returns. In contrast, spending on treatments provides immediate, visible outputs so is prioritised.
    • Political priorities – prevention-associated benefits are often beyond the scope of electoral campaigns, with focus and funding redirected to alternative initiatives.

    From a political and financial perspective, prevention sits in an uncomfortable policy space at the intersection of health, education, housing, transport and employment. As a result, prevention is frequently discussed but rarely implemented.

    The socioeconomic case for shifting focus

    Healthcare economic analyses increasingly reinforce what evidence has long shown: prevention delivers strong returns that extend beyond healthcare budgets into productivity, social care and consistent workforce participation.

    The more people we have in good health, the more they can contribute to our society and economy.

    If government policies redirected funding to prevention, it could unlock substantial long-term savings and increase returns; every £1 invested in prevention can generate multiple pounds in return, with wider social and economic value. Lowering preventable mortality even marginally, would save thousand of lives annually whilst also relieving pressure from public health services – a critical consideration given the current climate of the NHS.

    Shifting focus does not require drastic policy changes; it only requires consistent prioritisation. Key changes could include:

    • Scaling up intervention measures that have proven effectiveness e.g. smoking cessation through tobacco tax , and exercise through community-wide initiatives.
    • Ring-fenced funding for evidence-based programmes and studies e.g. provide councils with budgets to maintain park runs to promote social exercise regimes. This also supports mental health and the loneliness epidemic.
    • Targeting investments towards communities with the highest preventable disease burden to close the inequality gap, as seen with CVD.
    • Strengthening data collection infrastructure to link prevention, outcomes and cost to help guide future investment strategies.

    Conclusion: Prevention can no longer be an afterthought

    The lack of focus on prevention reflects a system failure; one that is currently optimised for illness rather than for health.

    Health experts understand disease – the evidence is robust and the economic case is unavoidable. What is missing is not knowledge, it is commitment. Every year that prevention remains under-prioritised, the system pays more for late-stage disease interventions applying pressure to health services, whilst individuals pay with avoidable disease and reduced quality of life. Combined, these factors are generating a system set up to fail.

    Without strong leadership and advocates for change, how long can we continue to prioritise intervention over prevention?