The summer of 2013, complete with aheat wave in July, ended a run of six

dull and wet ones since 2007. The nationrejoiced but for the NHS it was a mere dis-traction from months of upheaval andfractious politicking. New Chief ExecutiveSimon Stevens will have his work cut out.Until recently a senior executive in a USprivate health insurance company, hewas adviser to Tony Blair when many ofNew Labour’s ideas were introduced inthe NHS.

Healthcare costsMoney – or talk of it – was everywhere.Staff returned from their Christmas holi-days with a warning from the NuffieldTrust ringing in their ears: if the NHS can’tmeet its productivity targets, the pre-dicted funding gap will not be £20 billionby 2021/22 but £50 billion. NHS Englandaxed the £50 million fund supportinginnovation in the NHS to divert spendingto reorganisation. The Prime Minister’s plan to increase

GP working hours would mean shifting £2billion into primary care, doctors’ leaderssaid, but there was already a £400 mil-lion black hole after three years of cuts.Outgoing Chief Exec Sir David Nicholsonrevealed that new laws promoting compe-tition in NHS England are hamperingefforts to improve services. Monitor announced that poor quality

data and weak contracting skills areundermining effective commissioning ofhealthcare, leaving providers with the bal-ance of power. Surprising, then, that qual-

ity of care in NHS England was being sus-tained, according to the Nuffield Trust andthe Health Foundation. Waiting listsreached a five-year high, though, and theNHS received 3000 complaints per weekin 2012/13.Against that background, GP prescrib-

ing costs in England fell by about £300million in a year when prescription num-bers increased by about 40 million, top-ping one billion for the first time. (The fallin spending was probably due to thelaunch of generic atorvastatin, whichsaved £350 million.) The newly-agreedPPRS will freeze prices until 2016.

Enter CCGsCCGs grasped the reins on 1 April, amomentous event to which patients werelargely oblivious (unless they were tryingto get referred for a hip replacement). GPsmay have wondered if they’d beenhanded a poisoned chalice when severalFoundation Trusts – supposedly the jew-els of the NHS – were found to havebehaved appallingly badly. In Mid-Staffordshire NHS Foundation Trust, theFrancis Report found ‘an institutional cul-ture in which the business of the systemwas put ahead of the priority that should

have been given to the protection ofpatients’. The Care Quality Commission – which

Francis labelled ‘defensive’ – wasaccused of concealing a report critical ofits regulation of University Hospitals ofMorecambe Bay NHS Foundation Trust,where the deaths of babies and mothersmay have been associated with poor care.Most recently, managers at ColchesterHospital University NHS Foundation Trusthave been accused of bullying staff intofalsifying waiting times for cancer treat-ment.

Pharmacist adviceThe pharmacy New Medicines Servicewas extended for the second time and willnow end on 31 December pending a for-mal evaluation in February 2014. Theservice is available to people withasthma, which is just as well becauseAsthma UK found that only 14 per centreceive all the interventions they should. Responding to a survey showing that

only half of people taking a medicinewere aware of its side-effects, the RoyalPharmaceutical Society published a listof questions patients should ask pharma-cists about their treatment.

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The prescribing year: 20132013 witnessed the emer-gence of clinical commission-ing groups but ended withworrying stories of poor hos-pital care. NICE guidance con-tinued apace and there werean encouraging number ofnew cancer drugs.

Forxiga: first sodium-glucose co-transporter 2 inhibitor for type 2 diabetes

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Good timing: a Which?mystery shop-per survey again found that over 40 percent of pharmacists were giving unsatis-factory advice – no change from 2008 –with independent pharmacists the worstand supermarkets and chains perform-ing best.

NICE guidanceNICE continued at full tilt in the year ex-GP Professor David Haslam replacedProfessor Sir Mike Rawlins as Chair. Itpublished a total of 113 pieces of guid-ance, including 27 technology appraisalsand 17 clinical guidelines. It revivedClinical Knowledge Summaries, focusingon 300 conditions managed in primarycare, and took on responsibility forassessing devices. Drugs should be in the formulary

within 90 days of a NICE endorsement, itdeclared, as analysts criticised its QALYthreshold as too low and QALYs as insen-sitive to disability. The Cancer Drugs Fund, which cir-

cumvents NICE’s recommendations, wasrenewed and unified into a single nationallist. MPs told the Government to reportthe treatment outcomes and to get onwith value-based pricing because, asNICE Chief Exec Sir Andrew Dillon said,time is running out.The MHRA again warned against buy-

ing medicines online and revealed thatcorner shops were selling POMs made inPoland. It opened an ‘innovation portal’to fast-track approval of new productsand announced that all nicotine products,including the increasingly popular e-ciga-rette, would be licensed as medicines.Euro MPs disagreed and voted down theproposal. Safety reviews by the European

Medicines Agency concluded thatdiclofenac was no safer than COX-2 selec-tive NSAIDs and cleared insulin glargine(Lantus), the GLP-1 agonists and DPP4inhibitors of causing cancer.

New drugsFears that the well of new drugs is dryingup are unfounded, said the NationalInstitute for Health Research: there arejust good years and bad ones. New prod-ucts in 2013 included lubipristone(Amitiza) for constipation, linaclotide

(Constella) for constipation-predominantirritable bowel syndrome, dapoxetine(Priligy) for premature ejaculation, intra -vitreal fluocinolone (Iluvien), ocriplasmin(Jetrea) for vitreomacular traction, iva-caftor (Kalydeco) for cystic fibrosis,nalmefene (Selincro) for alcohol depend-ence, lixisenatide (Lyxumia) and dapagli-fozin (Forxiga) for type 2 diabetes,aflibercept (Eylea) for macular degenera-tion, the oral contraceptive Zoely, lisdex-amfetamine (Elvanse) for ADHD, thebeta-3 agonist mirabegron (Betmiga) foroveractive bladder, rifaximin (Xifaxanta)for traveller’s diarrhoea, the quadrivalentflu vaccine Fluarix Tetra, imiquimod(Zyclara) and ingenol mebutate (Picato)for actinic keratosis, and once-dailyinsulin degludec (Tresiba). New cancer drugs included pomalido-

mide (Imnovid), rigorafenib (Stivarga),ponatinib (Iclusig), bosutinib (Bosulif),pertuzumab (Perjeta), aflibercept(Zaltrap), brentuximab (Adcetris),decitabine (Dacogen), crizotinib (Xalkori)and notably enzalutamide (Xtandi) forprostate cancer. There were no new systemic anti -

biotics, a problem highlighted by the ChiefMedical Officer prior to the launch of a newstrategy to tackle antibiotic resistance.

Lightweight adviceAmid fears that public health will witherin the hands of local authorities, adults

with ‘normal’ weight are now in the minor-ity in the UK, a fifth of 10–11 year oldsare obese and Tesco and Diabetes UKhave become partners, offering diabetesinformation packs in the supermarket’sstores. Long spoons are on special offerthis year. The Government’s traffic light system

for labelling foods according to their salt,fat and sugar content was welcomed butsome food manufacturers opted to stickwith lists of ingredients in tiny print.Several companies pledged to cut satu-rated fat in their products but critics saidit was often replaced by sugar. No-oneexpected horsemeat to replace beef infrozen burgers. The Government attracted brickbats

by backtracking on a minimum price foralcohol in England and plain packagingfor cigarettes; instead, there will be newNICE standards for GPs to attain.

At lastBut amidst all the turmoil there was onemoment refreshingly free of flannel andNewspeak. Chief Medical OfficerProfessor Dame Sally Davies told MPs onthe Science and Technology Committee,‘I believe there’s a place for a holisticapproach with patients, but I am perpet-ually surprised that homeopathy is avail-able on the NHS. Why am I beingwishy-washy? It’s rubbish.’

Tresiba, new ultra-long-acting basal insulin

Constella, a new treatment for constipation-predominant irritable bowel syndrome