Welcome to the Hot Topics podcast from NB Medical with Dr Neal Tucker. NHS Long Term Workforce Plan is all over the news today. In this episode we have a look at some of the key statements, seeing what is positive for general practice, what is wishful thinking, and what could be even worse.
In research we look at new observational data from Denmark, published in the BMJ, finding an association between HRT and dementia; also a study examining the effectiveness of an intra-pulmonary artery device for identifying earlier deterioration of heart failure; and two papers in the NEJM on more weight loss medications for obesity.
References
NHS Long term workforce plan
BMJ HRT & dementia
Lancet HF device
NEJM Retatrutide & Orforglipron
www.nbmedical.com/podcast
Welcome to the Hot Topics podcast from NB Medical with Dr Neal Tucker. NHS Long Term Workforce Plan is all over the news today. In this episode we have a look at some of the key statements, seeing what is positive for general practice, what is wishful thinking, and what could be even worse.
In research we look at new observational data from Denmark, published in the BMJ, finding an association between HRT and dementia; also a study examining the effectiveness of an intra-pulmonary artery device for identifying earlier deterioration of heart failure; and two papers in the NEJM on more weight loss medications for obesity.
References
NHS Long term workforce plan
BMJ HRT & dementia
Lancet HF device
NEJM Retatrutide & Orforglipron
www.nbmedical.com/podcast
We've been together since medical school. Lovers have come and gone, but you and me we made it through. You made it easier to get closer to people. You meant I didn't have to put my ear on their skin. You kept it legal. And when I hold you, when you touch them, a little magic happens. You always fill my ears with the sound of beating hearts, a rush of breath of quiet. Mama, let's never be apart. Without you around my neck I just don't know how I would cope. You've always been there for me. My trust is at the scope.
Speaker 1:People say you're a relic of a bagon age. We can't rely on you. We need an echo or a chest x-ray. But they don't understand. You're quite a power. You're not a doubt. You're by my side. I just look like a middle-aged manager. When I hold you, when you touch them, a little magic happens. You always fill my ears with the sound of beating hearts, a rush of breath of quiet. Mama, let's never be apart. Without you around my neck, i just don't know how I would cope. Together we can face the day. My trust is at the scope.
Speaker 1:Then came the day Too much hard-disk and I left you. Someone took you away. And what am I to do? I really can't examine patience If I don't have hold of you and Tried one from the nurse's room A stethoscope like object, creptually. No one can hear enough through that dent. Then I discovered Amazon's, so lit now in loads of different colors. You always fill my ears with the sound of beating hearts, a rush of breath of quiet. Mama, let's never be apart. Without you around my neck I just don't know how I would cope. You've always been there for me. My trust is at the scope, i'm sorry. Tuning fork, tendon, hammer, electric fig. You're useful, i have no doubt, but you just know what makes me tick, and even posiximitors Couldn't cold my heart away. It's you and me. Let's hear the world. Stethoscope. We're here to stay.
Speaker 2:It's Friday, the 30th of June and this is the Hot Topics Podcast.
Speaker 2:Welcome everyone. Thanks for joining us once again on the Hot Topics Podcast from MB Medical, neil Tucker here as usual to take you through this episode. We'll be chatting about the latest news, and there's quite a lot to cover in the news today, with the new NHS Long-Term Workforce Plan being published. Then we're going to have a think about some research and we've got a BMJ paper on menopause and a possible link with dementia. Also, we've got a Lancet paper really interesting one on the future of heart failure management, and then a couple of papers from the New England Journal of Medicine on medications, so new medications for managing obesity. It feels like there's a strong emphasis on the future today, which might be best, because if you focus too much on the present, you're likely to get annoyed. Which brings us on nicely to our main news story, and that, of course, is the publication of NHS England historic 15-year plan to boost the NHS workforce. I guess if you're in Scotland, wales and Northern Ireland, you may be looking on at this with just a hint of jealousy. I know up in Scotland you've had an NHS recovery plan since 2021. How's that going, i wonder? You may just be looking on with a little dose of cynicism here.
Speaker 2:There are potential benefits for the wider country from this NHS England plan, such as the drive to double medical student places for student doctors by 2031. For us in general practice, the main headline here is a 50% increase in GP places. The current increase that we've seen is insufficient to replace GPs that are actively leaving general practice. A 50% increase should see it covered, should, of course, you be able to get anyone to actually fill those extra places. Of course, all of that's going to take more than a decade before it filters through to practices so sensibly. The plan is not just about creating new GPs. Greater number of training places for advanced practitioners, physician associates, greater emphasis on growing the numbers going into mental health, primary and community care All of this sounds very promising. Makes for some good media sound bites. When you actually read the NHS England document, however, you start getting the faintest width of BS coming through.
Speaker 2:There's three main areas that the long term workforce plan focuses on. The first is growth. We've already talked a little bit about that in the context of general practice. The second is retain. This is very sensible. Growth is going to take many years. Retaining well, that can make a difference straight away. But unfortunately this is where we start getting the first serious management speak coming through. So under the title retain, it says embed the right culture and improve retention. By improving culture, leadership and well-being, we will ensure that up to 130,000 fewer staff leave the NHS over the next 15 years. Just in case you thought this was management speak nonsense, they then give a few examples. So they say that we will continue to build on what we know works, what we know works about retaining staff.
Speaker 2:Difficult to see on the ground any evidence that the government actually knows anything about how to retain their NHS staff. But I love a few bullet points down because they do come up with an idea. So rather than focusing on improving culture, leadership and well-being, they're going to explore measures with the government, such as a tie-in period to encourage dentists to spend a minimum proportion of their time delivering NHS care in the years following graduation. I think they may have got the word encouraged confused with mandatory. Look out dentists, they're coming for you. Look out everyone else, they'll be coming for you.
Speaker 2:Next. The third section is reform. Working differently means enabling innovative ways of working, with new roles as part of a multidisciplinary team, so that staff can spend more time with patients. Now, i think a lot of our experiences with working with multidisciplinary teams. Whilst there are potentially lots of benefits, one of the downsides for GPs is that they spend less time with patients and more time debriefing their colleagues. Or rather, you spend the same amount of time with patients than even more time debriefing with colleagues.
Speaker 2:Never fear that there are other ideas in this section. For example, work with regulators and others to take advantage of EU exit freedoms and capitalise on technological innovation to explore how nursing and medical students can gain the skills, knowledge and experience they need to practice safely and competently in the NHS in less time. Ah, thank you Brexit. Never mind that you ostracise many of our EU healthcare professionals that worked in the UK for years, sending them back to their own countries. At least you've given us the opportunity to under-train our new doctors and nurses, and I love the stuff about technology. There's even a bit in here. They had to throw in artificial intelligence. Ah, just like magic. It's going to save us all.
Speaker 2:Having watched Terminator 2 at the weekend, all I hope is that future GPs, a hundred years from now, out of the job due to chatbots, don't send back an evil Arnold Schwarzenegger robot to try and take out Amanda Pritchard and all the authors of this NHS long-term workforce plan. Please be kind to them and all your future patients. We have an opportunity to change the future ourselves without such radical means. It's not too late for us to all retrain as computer engineers and software designers. We can be the people that make the magic happen. Look, it's easy for us to be cynical, but who knows, this might be the time when the tide starts turning and things start improving in the NHS and in general practice. Let's keep our fingers crossed.
Speaker 2:Right on to the research, and first we are going to have a look at a BMJ paper. This was unsurprisingly picked up by various media outlets over the last couple of days because this is a paper that draws an association between HRT and dementia. So this is an observational study conducted in Denmark, pulling data out of their national registries, looking to try and assess the association between the use of menopausal hormone therapy and the development of dementia, according to the type of hormone that's been used, the duration that it's been used and the age at which it was started and stopped. In data between 2000 and 2018, they identify five and a half thousand cases of dementia and then match them against 56,000 aged matched controls. The authors found that, compared with people who had never used any kind of treatment, if women had been on estrogen and progesterone therapy, they had an increased rate of all-cause dementia, with a hazard ratio of 1.24. So they're 24% more likely to have all-cause dementia. The risk increased with duration of use. So if you'd been on it for less than one year, then your risk went up by 21%. If you've been on it for 12 years, then your risk went up by 74%. Cyclical and continuous regimes both still increases in dementia and also starting at an earlier age, so under 55 years old didn't remove the risk either. Should we be worried? Should our patients be worried?
Speaker 2:The authors seem to want to dampen down any hysteria that might be generated by their findings because in their conclusions they actually state further studies are warranted to determine whether these findings represent an actual effect of menopausal hormone therapy on dementia risk or whether they reflect an underlying predisposition in women in need of these treatments. This is very sensible advice that we need to take heed of. As observational data, this isn't proving causation. The associations that are demonstrated may still be driven by bias or confounders. It could be that early dementia symptoms are being misattributed to the menopause. It might be that women who are receiving menopause treatment are just followed up in healthcare settings more, and so you would identify dementia earlier. It may be that there's shared pathology between vasomositimptoms, or menopausal symptoms, and dementia, and actually it's nothing to do with whether you take hormone therapy or not. Also, as the editorial explains, there are other issues which suggest spurious findings here. So, for example, the fact that you can increase your dementia risk with less than one year of hormone therapy, it says, is not biologically plausible. Ultimately, this paper will hopefully drive conversation amongst researchers in this area, but I don't think that it necessarily changes our conversation with our patients coming to us with troubling menopausal symptoms.
Speaker 2:Next up, we've got a paper in the Lancet from last week, and you all know that I love a bit of future medicine. Sometimes it feels like medicine is the future, but actually it's happening right now. That's the case with this paper. The title is Remote Hemodynamic Monitoring of Pulmonary Artery Pressures in Patients with Chronic Heart Failure. Fair enough, you may be wondering what has this got to do with general practice?
Speaker 2:Well, on the Hot Topics course currently, we've been talking a lot about heart failure. We've talked about it over the years, we've got growing numbers of treatment for heart failure. The SGLT2 inhibitors are one of the newer ones. They're now kind of one of the fundamental bedrocks of heart failure therapy. And yet, as we're managing to keep up with these medications, i'm always conscious that I'm getting well behind in the increasingly clever world of heart failure technologies that our secondary care colleagues may employ.
Speaker 2:Now we all know that prevention is better than a cure. This is true of heart failure. If you listen to the podcast with Jim Moore from the Primary Care Cardiovascular Society last week, you'll know that with heart failure we have this opportunity to modify the disease process through early treatment leading to remodeling of the heart. The converse is true. If people have an acute episode of decompensating heart failure, it's hard to come back from that. We can make a permanent step down. We're going to have our patients on some protective medications.
Speaker 2:But how do we work out if they're getting worse? Well, clinically we typically think about fluid overload symptoms. So maybe they get some peripheral edema, maybe they get pulmonary edema, fatigue, breathlessness, perhaps you'd even risk a look at their JVP. Well, what if there was a device that could show you that a patient was deteriorating before any clinical signs became apparent, giving you a window into which you could maybe make some changes to their treatments and help them. Well, that is exactly what remote hemodynamic monitoring of pulmonary artery pressures does. A very small pressure sensor is inserted into someone's pulmonary artery in a cath lab, which then sits there and then communicates the pressure readings with a device, a monitoring device that patients keep at home. That data can then be analysed by a computer system by a healthcare professional. An existing data from the manufacturers show that it helps prevent worsening heart failure, lowers mortality rates and improves quality of life.
Speaker 2:Now, most of this data has come out of the US, and the US, i get the impression and it's probably unfair, but I get the impression it's a bit like the Wild West for medical devices. Their laws are quite lax. Their population love to have a bit of new technology randomly inserted into parts of their bodies. That may kill them, but it might just make them live forever. They don't know. Let's give it a go.
Speaker 2:This study, then, aims to ease those concerns, because it is performed in the Netherlands, part of the EU, which tends to have fairly strict rules about this kind of thing. This study was funded by the Dutch Ministry of Health and the Health Care Institute. There was still funding from Abbott, who is the manufacturer of this device, so it's not without potential bias here. But I guess it's also true of any relatively new medical device that's not widely commercially available that there's going to be some manufacturer input into the studies.
Speaker 2:Almost 350 people were randomised to either have the heart's MEMS-HF device that's the name of this device or to be in the control group. In age was 69 years old, which seems quite young for a heart failure group to me, and the median ejection fraction was 30%, which seems like a pretty poor ejection fraction, which is why they're getting these treatments. Over the course of the 12 months follow up, whilst there was no statistically significant changes in cardiovascular or all-cause death, there was substantially fewer heart failure hospitalisations 117 with the device compared with 212, so just about half the number. Quality of life was also reported as significantly improved in the device group. I've said it before on the podcast and I'll say it again do we want to make people live longer or do we want to make people live better? And this device definitely seems to be doing the latter.
Speaker 2:There are certain challenges with this kind of trial. It was a randomized control trial, but it's an open-label trial, not a placebo-controlled one. That would be very complicated because you would need to have a fake cath lab insertion of the device. Patients would have to have fake monitoring devices at home linking up to their fake device that isn't in their chest. So this could certainly influence quality of life results, presumably skewing it towards those who were doing something active by using the device rather than the control group. It does make you wonder if this device was compared to perhaps more systematic review of clinical features, if maybe we did get good at weighing a patient every day, seeing how much fluid they were carrying at that moment, if they had any more subtle symptoms, if they maybe reported that through some kind of symptom app, for example, could you get closer at identifying earlier deterioration? Could this all be achieved without the need for a very invasive procedure? Wouldn't that be an interesting piece of research? And wouldn't it also be interesting if, actually, this clever technology ended up informing clinicians and researchers about how good predictive heart failure management could be using simple clinical measures? Now onto our last piece of research.
Speaker 2:In one area where simple clinical measures haven't really helped that much is obesity. Diet, of course, can lead to weight reduction, but most people put the weight back on. Bariatric surgery is an effective way of losing weight and keeping it off for many, and, of course, now we have these medications, which can do something similar, and in the news recently we've had WeGoV, which is some agglotide used for weight loss. We're gonna be talking about that on the hot topics course. I've spent most of the week writing about it, which is possibly why I was drawn to these two papers in the New England Journal of Medicine. They're two different medications. They are phase two trials, so I feel like I am getting a little bit more removed, i'm afraid, from day-to-day clinical practice, but this does look like the future.
Speaker 2:Would people with obesity want medications to help get their weight down? Should we be actively recommending weight loss medication for the long-term health of these populations? Do we want to be prescribing these drugs on population scales? Should, in the UK, the NHS be paying for these? It's a fascinating area with loads of difficult questions that don't necessarily have a definitive answer. Make no mistake, though pharmaceutical companies are going all in on this and we are going to see an explosion of medicines in this area. The difference that we have in this new crop of medications is that they actually do help people lose weight. They don't necessarily keep it off if you stop them. A lot of people will lose a lot of weight on these medications. So we've had recently loraglotide and then somaglotide recommended for use via NICE. Both of these are injectable GLP1 analogs.
Speaker 2:The first paper in the New England Journal of Medicine is looking at a medication that takes it one step further. Well, maybe two steps further, because this is a triple hormone receptor agonist Retitrutide, retatratide. I think sometimes drugs sound better if you do them in American accent. I'm taking retatratide. Yeah, yeah, yeah, retatratide. It doesn't roll off the tongue as well in Queens English. Anyway, retatratide takes things one step further. So not only is it an agonist of glucagon-like peptide one GLP1, it is also an agonist of glucose-dependent insulinotrophic polypeptide and glucagon receptors. I know what you're thinking Just hitting a GLP1 receptor was never gonna cut it.
Speaker 2:So this was a double-blind, randomized, placebo-controlled trial of adults with a body mass index of 30 or higher or 27 plus at least one weight-related condition, and they were looking at different doses of subcutaneous retat No, i've still not got it Retatratide Comparing them against placebo over 48 weeks, in the main primary endpoint was the percentage change in body weight. I will spare you all the different percentages for all the different doses, but the highest dose, 12 milligrams of Rattatratide, led to 17.5% body mass loss, compared with 1.6 in the placebo group. This isn't a head-to-head trial against somaglotide, this is a phase two trial. I haven't looked at all the different patient characteristics between this and somaglotide trials, but all you can say is that that is a pretty impressive result if losing body mass is your goal. However, the second trial is possibly the game changer here. This is all forglipron or something to that effect.
Speaker 2:This is just a GLP1 receptor agonist, but the difference here is it's oral. If someone said to you you need or can have a treatment and you can either inject it every day or you can just swallow it, almost every single person, apart from some weird outliers, are gonna say I'll take a tablet, thank you. This is what will really bring people, bring patients, bring the population into the medicinal weight loss arena. Very similar trial randomized double-blind adults with obesity or overweight with at least one weight-related coexisting condition. 36 weeks they used the medication for at various doses versus placebo. Mean weight loss in this study was up to 14.7% with the treatment, compared with 2.3% on the placebo, an oral drug for weight loss which actually makes you lose weight. This is the future. Now there are caveats, of course, and the big caveat is tolerability. Lots of people get side effects, particularly GI side effects. You have to up-titrate the dose gradually, otherwise loads of people drop out. Long-term safety has yet to be established with any of these treatments in this kind of context, particularly as they're definitely positioning themselves and the manufacturers are positioning these as long-term medications for obesity, as a chronic disease. The second paper does at least comment that the safety profile is consistent with that of the GLP-1 receptor agonist class Generally reassuring, i suppose, but none of these studies for any of this class have been greater than two years, so we really do lack long-term safety data. Nevertheless, it will not be long before we have a whole menu of options on the table for helping treat obesity.
Speaker 2:Okay, that's it for the podcast today. Thanks for listening everyone. Don't forget to check out the website for everything that's going on with mbmedicalcom. We've just done a live webinar today of the latest Hot Topics course. Tomorrow we've got an urgent care course. Next week we've got the diabetes course. If you can't catch any of those live. You can always watch it on demand. Don't forget to check out our subscription service, nb Plus just over 300 pounds a year for everything that we do online. You can pay monthly, you can pay annually. It's fantastic. Do take a look, and I will be back on the podcast in two or three weeks. See you then. Bye-bye, music.