Basics of Glucocorticoids and its Use in Dental Clinic

Inflammation Process and the Necessity of Anti-inflammation Medication

Inflammation is a primary defense mechanism designed to protect and promote healing, and to restore homeostasis of injured tissues, ultimately leading to resolution and tissue repair.  An inflammation process consists of primarily vascular changes as well as cellular events in concert with the immune system. The familiar clinical signs, including redness, heat, pain, and swelling comes from vascular changes. Inflammation is initiated at the site of injury by resident mast cells and macrophages which release pro-inflammatory mediators including bioactive amines, lipid mediators and cytokines (eg. TNF-alpha and IL-1) causing i) vasodilation that saccommodates hyperemia, producing redness and heat; ii) increase in capillary permeability that allows  exudation of plasma, generating swelling and pain; and iii) chemotactic gradient to recruit leukocytes to the site of injury ( a process called chemotaxis), performing phagocytosis and other processes conventiaonally atrriuted to the immune response.

If its intensity and duration are inappropriate, the inflammatory response, as a normal protective process may become destructive and result in inflammatory disease, where drugs with anti- inflammatory actions are indicated. By interrupting the synthesis and/or release of mediators that initiate vascular changes, anti-inflammatory drugs thereby suppress the cardinal signs like redness, heat, pain and swelling. Glucocorticoids not only suppresses the cardinal signs of inflammation as anti-inflammatory drugs but also depress leukocyte function, especially lymphocytes as immunosuppressant agents.

Mechanism of Action

The anti-inflammatory and immunosuppressive properties of glucocorticoids are largely used in clinic via i) inhibiting the vasodilation and the increased vascular permeability that occurs following inflammatory insult ii) decreasing leukocyte emigration into inflamed sites by altering leukocyte distribution and trafficking; iii) inhibiting phagocytosis of macrophages; iv) reducing the number and activity of specific subsets of T lymphocytes. At molecular level, glucocorticoids bind to their receptors of target cells to form functioning complex that migrate into the nucleus, where the complex binds to DNA and alters genetic synthesis of proteins. By a mechanism termed “transrepression”, glucocorticoids down regulate gene transcription commonly overexpressed during chronic non-resolving inflammation, including NF-kapaB and AP-1. These genes encode pro-inflammatory cytokines (eg IL-10) and chemokines, cell adhesion molecules and key enzymes involved in the initiation and/or maintenance of the host inflammatory response. However, it should also be mentioned that it is within minutes from the injury for some anti-inflammatory effects of glucocorticoids to occur, which may be independents of the transcriptional effects of receptor-steroid complex.

Phamacokinetics and Pharmacodynamics

Only less than 30% of the synthetic glucocorticoids are free and pharmacologically active while the rest of them are moderately to highly (more than seventy percent) protein bound as pharmacologically inactive forms. Currently, dosing regimens are based on total drug concentrations rather than free plasma concentrations. In linear kinetics the free drug concentration increases proportionally with increasing total concentration whereas in the case of nonlinear kinetics this relationship is unproportional leading to higher free concentrations.

Prednisolone has a higher potency, efficacy and longer duration of action than hydrocortisone (about four times). The systemic availability of prednisolone is as high as eighty percent and limited not by incomplete absorption but by first-pass liver metabolism. However, prednisolone has nonlinear pharmacokinetics in humans, which make it hard to calculate the plasma concentration of free drugs. Prednisolone binds to two proteins, albumin and human corticosteroid binding globulin (CBG, transcortin), leading to its nonlinear pharmacokinetics. Albumin has a low affinity but high capacity for prednisolone while transcortin (a glycoprotein) has a high affinity but low capacity for binding prednisolone. At low concentrations a constant free fraction of prednisolone was observed because it binds to both proteins transcortin and albumin. As concentrations approach and exceed the binding capacity of transcortin, a nonlinear free fraction was shown increasingly until transcortin is saturated. With saturation of transcortin the binding becomes linear again as only linear binding to albumin occurs. As a result, it may be more accurate and predictable to use the free, unbound concentration of prednisolone to predict its concentration-time profile, to calculate pharmacokinetic parameters, and to evaluate the degree of systemic side effects by determining the suppression of endogenous cortisol.

Prednisolone has a half-life 2.1 to 3.5h and has duration of action of 18 to 36h and low mineralocorticoid activity. It takes four biological half-lives (144 hours) to totally eliminate of prednisolone, which means that maximumly prednisolone can persist in the organism for six days. Plasma concentrations of prednisolone vary markedly among individuals. In fact, rate of elimination of prednisolone could be decreased by oral contraceptives. Topical ointments or rinses are usually preferred for treating mucosal lesions; A five day regimen (in the morning either at once or in 2 divided doses, once in the morning and once at noon) can be used for systemic administration to manage traumatic neuritis of dental nerve trunks caused by surgery or local anesthesia as well as phlebitis following intravenous sedation or anesthesia. Patient should be discouraged to take evening doses due to the circadian rhythm of endogenous steroid secretion at the highest level at night, which may lead to insomnia.

Management of the Dental Patient Receiving Glucocorticoid Medications.

The reason for patients to receive chronic therapy with glucocorticoids are because of their primary inflammatory disorders, especially those attributed to immunologic mechanisms, eg, autoimmune disease, asthma, and rheumatoid arthritis. Their anti-inflammatory efficacy surpasses that of the NSAIDs, but their potential for side effects is also greater. Although short-term use about one week is relatively safe, chronic use may cause many concerns regarding side effects.

Osteroporosis and osteonecrosis are well recognized complications for about fifty percentage of patients treated with glucocorticoids for longer than twelve months. It is shown that glucocorticoids inhibit osteoblast function and cause apoptosis of osteocytes, which leads to a rapid and focal deterioration of bone quality and has been implicated in the pathogenesis of the condition. However, what determines the individual susceptibility is still unknown When planning complex extractions or placement of dental implants, conditions including the possibility of steroid-induced osteoporosis, osteonecrosis and increased serum glucose concentrations associated with chronic glucocorticoid use, may compromise treatment outcome. Plus, all patients receiving chronic supraphysiologic doses of glucocorticoids will have a compromised immune status. There is increased risk for delayed healing and postoperative infection when planning surgical procedure for those patients. Thus prophylactic antibiotics may be indicated  Glucocorticoids, as a product of the adrenal cortex, produce physiological effects essential for life. The synthesis and release of cortisol normally appears highest in the morning and declines throughout the day until a new cycle begins. Although the normal daily secretion is ten to twenty mg, the cycle changes when the hypothalamic-pituitary region is excited by some conditions require more cortisol production, including stress, trauma, hypoglycemia. For patients who are receiving daily dosage (more than fifteen mg/d of prednisone or its equivalent) of exogenous glucocorticoid for more than three weeks, varying degrees of adrenal atrophy are observed due to decreased function of patients’ own adrenal cortex via negative feedback. However, the complications caused by the long-term usage of small dosage of glucocorticoids are highly variable among individuals. The dental provider should take it into consideration that the prescribed steroid not only provides therapeutic effects (anti-inflammatory), but also fulfills normal physiological requirements for those patients who potentially have some degree of adrenal dysfunction. This introduces two important considerations.

Firstly, for patients who have an abrupt discontinuation of chronic therapy with glucocorticoids. the hypothalamus-pituitary-adrenal axis will attempt to stimulate cortisol production in order to sustain normal cardiovascular function and glycemic control. However, those patients may not have enough adrenal tissues to respond to the stimulation from hypothalamus-pituitary axis due to adrenal atrophy caused by chronic usage of glucocorticoid. As a consequence, those patients may experience irritability, nausea, arthralgia, dizziness, and hypotension, as common symptoms of acute adrenal insufficiency. One regiment that can be applied to avoid this complication is to withdrawn steroid medication gradually by tapering the doses over 8months in order to promote the atrophied adrenal cortex to regain function. A complimentary dosage of glucocorticoid should be administered intravenously pre-operatively if normal oral medication consumption is limited.

Secondly, supplymentary steroid may be required to equal a cortisol surge caused by stressful events such as severe infection or surgery, which may put patients into jeopardy. This extra need for cortisol can be easily produced by a functional adrenal cortex of a healthy patient. However, for a patient who has chronic therapy with glucocorticoids that may cause adrenal atrophy, it is indicated to double or triple the patient’s dose on the morning of surgery as an arbitrary regiments. Then the dose is gradually modified to baseline over the next two days.

Ultimately, a regimen of alternate-day steroid dosing is known to lessen the adverse impact of chronic steroid therapy. It may promote the adrenal cortex to regain function during the drug free day in between. It has been shown that patients who receives this regimen will seldom develop significant adrenal atrophy or immunocompromise.

Use in dental practice

Due to their excellent anti-inflammatory and immuno-modulatory effects, they have been used extensively in managing many oral diseases. However, chronic use of supraphysiologic dosages of glucocorticoids unavoidably results in a series of side effects. Termed as “double-edged “sword in medicine, their successful use depends on the comprehension of the disease process, including appropriate diagnosis, types of treatment prognosis and a clear view of purpose of the treatment-whether it is for managing a chronic disease or accelerating resolution of a short-term condition.

Management of oral lesions with glucocorticoid are considered at different level of applications, from topical to intralesional to systemic, or a combination of any two or three of those applications, depending the severity and stages of the condition. Those conditions treated by long term therapy with glucocorticoid includes recurrent aphthous stomatitis, Behcet’s disease, oral lichen planus, erythema multiforme, pemphigus, mucous membrane pemphigoid and bullous pemphigoid.

Controlling postoperative edema is the most common use of glucocorticoids in dental practice for short-term condition.  Ideally, regimens should be initiated pre-operatively and coverage extended post-operatively. This may be only a day or two for minor procedures, or as long as a week for more traumatic procedures. Because of its low cost, prednisolone is commonly prescribed in dental clinic. It was shown that a combination of a single dose of prednisolone and

NSAID (eg. diclophenac, ketoprofen and ibuprofen) is well shown for treatment of postoperative pain, trismus and swelling after dental surgical procedures. Prednisolone is available in both oral and injectable (intramuscular, and submucosal) forms. Oral administration may be unpredictable in term of systemic availability and usually associated with gastrointestinal disturbances; Submucosal administration on the other hand is fast in effect without the possibility of associated gastrointestinal disturbances. However, due to their extreme irritation to tissues, prednisolone should not be administered near nerve branches exiting the mandible or maxilla.

Another short term use of glucocorticoid in restorative dentistry is to dress deep cavities with exposed pulp tissue to control the inflammatory pulp response and decrease postoperative pain. Studies show that glucocorticoid can be applied as cavity liner to decrease or prevent postoperative thermal sensitivity. Furthermore, intracanal use of the combined regime of glucocorticoid and antibiotic has been reported to successfully control the post endodontic pain. Just to be clear, it has not been shown that this brief use of glucocorticoids would increase the risk of postoperative infection, thus it is unwarranted to prescribe additional antibiotic coverage solely for this purpose.

References:

1. Rhen T, Cidlowski JA. Antiinflammatory action of glucocorticoids—new mechanisms for old drugs. N Engl J Med. (2005); 353:1711–1723.
2. Ibikunle AA, Adeyemo WL, Ladeinde AL. Oral health-related quality of life following third molar surgery with either oral administration or submucosal injection Oral Maxillofac Surg. (2016) 20:343–352
3. Coutinho AE, Chapman KE. The anti-inflammatory and immunosuppressive effects of glucocorticoids, recent developments and mechanistic insights. Mol Cell Endocrinol. (2011) Mar 15; 335(1): 2–13.
4. Sanghavi J, Aditya A., Application of Corticosterids in Dentistry. Journal of Dental and Allied Science. (2015); 4:19–24
5. Gibson N., Ferguson JW.  Steroid cover for dental patients on long-term steroid medication: proposed clinical guidelines based upon a critical review of the literature.British Dental Journal. (2004), 197(11):681–685

Introduction

I have chosen to focus on discussing topic 1 (Financialisation) and topic 6 (Critical drivers of the modern business environment), including discussing why these topics are important in contemporary business, by using the NHS as an example where I have previously worked as a Doctor.  I will be dividing this essay in to two sections, first focussing on financialisation and how it is impacting the NHS, and secondly focussing on the critical drivers for modern day business and how these are being implement in the NHS.

Topic 1-Finanancialisation

In the last thirty years, and more the world economy has undergone rapid transformations.  The role of the government is diminishing while that of markets has increased; domestic and internal financial transactions have grown remarkably, including economic transactions between countries have been on the rise. This changing landscape has been characterised by the rise of neoliberalism, globalisation and financialisation. (Epstein, 2005) A system of financial capitalism has emerged in which companies are viewed as merely assets to be bought and sold, and vehicles for maximising profits through financial strategies. (Batt R et al, 2013) The financial strategies for marking profits without regard to the effects organisational productivity, quality, or long term competitiveness include trading, buying and selling companies or divisions of companies, selling off assets, and using debt for tax advantages or share price manipulation. (Batt R et al, 2013 )

The subject of Financialisation is relatively new, where neoliberalism and globalisation has extensively been researched and discussed. There have been different meanings over the years of what Financialisation actually means, and Krippner summarises the discussion, some writers use the term ’Financialisation’ to mean the dominance of ‘shareholder value’ as a mode of corporate governance; some use it to refer to growing dominance of capital market financial systems over bank-based financial systems; some follow Holferding’s lead and refer to it as increasing political and economic power of a particular class grouping: the rentier class; for some it represents the expansion of financial trading with a variety of new financial instruments; finally, for Krippner the term refer to a ‘pattern of accumulation in which profit making occurs increasingly through financial channels rather than through trade and commodity production.’ (Krippner 2004:14)

All these definitions capture some aspect of the phenomenon we have called financialisation. A widely commended definition of financialisation is offered by Epstein (2001,p.1): “Financialisation refers to the increasing importance of financial markets, financial motives, financial institutions, and financial elites in the operation of the economy and its governing institutions, both at the national and international level.” Financialisation is transforming the economic system at both macro and microeconomic levels. It’s key impacts are (1) elevate the significance of the financial sector (Growing size of capital, credit and derivatives markets) relative to the real sector; (2) transfer income from the real sector to the financial sector; and (3) contribute to increased income inequality and wage stagnation. (Palley et al, 2013)

The next question to ponder is why does finance matter? Since the 1970s, finance matters because continuous financial innovation has led to new relations with financial markets that mediate the macro-economy and our experience as individual subjects. (Erturk et al, 2008) For example, in the late 1970’s the financial innovation of new instruments called derivatives from nothing lead to a value to more than $595 million trillion in terms of amounts outstanding by 2018 (BIS,2018).  In addition, deregulation, liberalisation and globalisation of financial markets, and technological advance since 1980s has led to the size of finance to grow multiples of global GDP. As most of the economic growth in finance has been debt-driven, asset inflation-driven creating inequality and instability. Figure 3 shows how the global debt 110% of GDP at the end of 2007 and risen to approximately 350% of GDP at the end of 2017. As debt increases this leads to a reduction in money spent on good and services which in hindsight slows down the economy causing a reduction in government taxes, thereby leading to more borrowing.  In addition, we can see that the financial economy (figure 2) is continuing to grow more than the real economy (Figure 3), as it increased from 28.3 trillion US dollars to approximately 36.5 trillion U.S dollars in 2017, whereas the  real economy (Figure 3) has merely grown approximately by 5 trillion US dollars. As people are in more debt, they search for high yields by investing in stock markets, corporate and sovereign bonds, and derivative markets, leading to the financialised global economy to continue growing greater than the real economy. Therefore, this increases the risk of financial crisis creating uncertainty and instability.

Figure 1.(Source: BIS, 2018) Chart showing the global debt in USD tn to % of GDP


.

Figure 2. (Source: WFE, 2018) Global domestic equity market capitalisation from 2013 to 2017, by region (In trillion US. Dollar)

Figure 3. (Source: IMF, 2018) Global gross domestic product (GDP) at current prices from




2012 to 2022 (In billion U.S dollars.

Financialisation is not only a macroeconomic phenomenon that is only observed in financial markets but also affects household balance sheets and wealth. (Ertuk et al, 2008) As stagnation of payments, income inequalities, and less labour security, and insecure employment have changed household behaviour.  As a result, there is a shift in household savers to switch from bank deposits and government bonds into potential high yielding riskier assets that could go up or down in value. We can see in

(figure 4)

shows that from 2005 to 2015, household saving almost doubled, and are growing at an average rate of 5.7%. In addition, we can see in

(figure 5)

that majority of household financial assets are in securities which are of higher risk compared to band deposits and continued to grow between 2008-2015.

Figure 4 – (Source: Allianz, 2017) One chart showing household savings in financial assets from 2005-2015 and the other showing household savings




by comparison 2015, in EUR tn.

Figure 5-




(Source: Allianz, 2017) one chart showing the growth by asset classes in % during 2016/2015, including another chart showing the breakdown of each asset class from 2006-2016.

Financialisation has evolved within the National Health Service (NHS). First, since the 1980’s the NHS has been subject to continuous reforms to introduce market like structures, which has been accelerated by the introduction of the 2012 Health and Social Care Act (HSCA). The growing financial deficit in the NHS created a platform for the HSCA reform, which has led to greater private sector intervention, and for NHS trusts to increase revenue from private sources.  The neoliberal policies in health are opening pathways for more financialised structures in the provision of health in the UK.  Four key “mechanisms” of Financialisation prevail in the NHS in England, (1) internal “markets” and financial structure; (2) NHS funding for non-NHS providers; (3) Private income for NHS providers; (4) Private finance initiative (PFI). (Bayliss, 2016)

The HSCA has fuelled the growth of health service contracts to private companies, including through the private finance initiative, with private health providers often backed by institutional financial investors. (Bayliss, 2016). Prior to the 2012 HSCA, an internal market already existed in health provision with a division between purchasers and providers of healthcare, with mainly providers of care being public NHS hospital and community trusts. However, following the 2012 HSCA there has been a development of a competitive tender with all providers, including for-profit health companies as well as NHS providers, all treated equally. (Bayliss, 2016) The “purchasers” or commissioners of care consist of 209 clinical commissioning groups (CCGs) whom are responsible for about 60% of the NHS budget (Bayliss,2016) The British Medical journal stated following the HSCA in 2014, 1149 contracts (33% of total) were to private sector providers, 335 (10%) to voluntary  and social enterprise, 100 (3%) to joint ventures and local authorities, and 1910 (55%) of contracts were to NHS providers. (BMJ, 2014) Many of these private sector companies are listed on the stock exchange and backed by private equity investors who engage in financial practices to maximise shareholder returns.  For example, Financialisation had disastrous results in once case. The Southern cross Healthcare group was bought by Blackstone (private equity firm), in 2004, which then implemented a “sale and leaseback” operation. (Horton, 2017) The care home properties were sold to a sperate company owned by Blackstone called NHP, and then leased back by Southern Cross, and was later sold for £1.1 Billion to a fund backed by Qatar Investment authority. (Bayliss, 2016) Post financial crisis NHP could not afford payments to NHP, including being reported as providing poor care standards by the CQC, which lead to permanent closure in October 2011. In an enquiry, the company’s financial structure was linked to poor care and the deaths of five residents. (Bayliss, 2016) In addition, other private equity investors are present from the likes of Advent international investing in mental health service in the NHS,  Cinven investing in the Spire the second largest private hospital operator in England, including health companies from overseas where private provision is more entrenched, such as the Hospital Corporation of America (HCA) the largest for profit hospital chain in America.  (Appendix 1) As more private companies enter the healthcare sector, this will transform the provision of health being a local community service to several global investment portfolios of international private finance. (Bayliss, 2016) Ideally, we need to stop this financialisation within the NHS as it can have detrimental affects to patient care, such as in the case of Southern Cross, and so more services to be provided by local NHS trusts than private companies that engage in financial practice to maximise shareholder returns.

Overall, too much finance damages economic stability and growth, changes the distribution of income, undermines confidence in the market economy, and manipulates politics. So, what is to be done? As Prof Zingales argues, if those financiers believe they can do whatever they want trust will break down, and we need to be able to trust financiers. (Wolf, 2015) Secondly, reduce incentives for excessive finance, such as tax deductibility of interest, and thirdly get rid of the too big  to fail and too big to jail. (Wolf, 2015) However, the likelihood of this happening is unlikely as the markets are exposed to continuous corruption, and the large multinational companies are deeply involved in government to ensure shareholder-oriented capitalism. for example, funding political campaigns ensuring they are unaffected by new regulations. If nothing is done and we allow the financialised global economy to grow exponentially, then we should expect uncertainty and instability with an increase number of financial crises.

Topic 6 Critical drivers of the modern business environment.

Digital globalisation, including the use of ‘big data’ and algorithms have become critical drivers of the modern business environment.  Soaring flows of data and information now generates more economic value than the global good trade (Manyika et al, 2016). The world is now more connected than ever. The rapid increase in the cross-border bandwidth has grown 45 times larger since 2005 and is projected to increase 9 times over the next 5 years (Manyika et al, 2016) For example, in 2005 the cross-border interregional bandwidth was 1.6 gigabits per second, increasing to 70.5 gigabits per second in 2014. (Manyika et al, 2016) Digital globalisation has opened the doors for developing counties, start-ups and SMEs, enabling them to compete against the advance companies and large multinational companies. Using digital platforms and tools companies are connected in real time and are becoming leaner, more efficient and can compete in fast growing markets. McKinsey report that over a decade, all types of digital flows acting together have raised world GDP by 10.1% amounting to $7.8 trillion in 2014 alone, and data flows account for $2.3 trillion of this impact. (Manyika et al, 2016).

The power of big data includes the epistemological and ontological possibilities of being able to simultaneously derive breadth and depth, quantitative and qualitative, insights from the same data-set, enabling us to generate insights thatwere previously impossible, with the aura of truth, objectivity and accuracy. (McFall et al, 2017) Companies now have the capacity to search, aggregate, and cross-reference large data sets allowing them to understand their customer and sell products which are tailored to their needs. For example, Wonga one of the largest UK payday lending companies use digital data techniques that include algorithms combining 1000s of datapoints, enabling them to listen to their customer and target their product offers accordingly. (McFall et al, 2017) The use of big data has a variety of functions for modern day business, including improving their efficiency. For example, financial companies reach a decision in lending within minutes through using set data points and algorithms.

Customer needs are constantly changing and for companies to be competitive and continue growing they need to understand who their customers are, including their journey, changing needs, and requirements. The quality of the relationship is essential to a marketing strategy, which uses the combination of qualitative and quantitative data points and algorithms to work out who their customers are, and especially predict what they might do next. For example,Amazon in 2015 patenting ‘anticipatory shipping’, a logistics system designed to ship products before they are purchased, so when the customer makes the purchase it can be instantly shipped and delivered within the promised time frame. (McFall et al, 2017) In addition, Customer relationship management systems ‘mass personalise’ consumers into individual profiles and deploy feedback technologies that automate consumption and modify marketing systems. (McFall et al, 2017)

Now let’s look at how digital technology can help transform the NHS. Digital technology has the potential to revolutionise the way patients access services, improving efficiency and co-ordination of care, and support people to manage their health and wellbeing.  (Honeyman et al, 2016) McKinsey estimated that modern health systems can save between 7-11.5 % of their health expenditure. (London et al, 2016) In addition, a study commissioned by NHS England estimated annual savings of £10 billion or more after investing more in a digitised NHS. (Dunhill, 2015) Achieving this can be done in several ways as suggested in the Kings fund study ((Honeyman et al, 2016), include the following:

1. Data captured by digital technologies could improve service planning, help align capacity more closely with demand.
2. Advance medial practice- for example, using advanced analytic techniques, such as machine learning to support clinical decisions and personalise treatment based on analyses of people’s genomes.
3. Put patients in control to take a more active role in their own health and care, by providing access to apps and resources with high-quality information including peer support online.
4. For clinicians, it can help reduce the time spent accessing patient information; remote monitoring enables clinicians to better understand the patient progress and helps deliver better health outcomes.
5. IT, data systems and information sharing are critical in delivering integrated care and can improve the co-ordination of care delivered by professional across different organisations.

A more digital advanced NHS will improve the quality, efficiency and access to healthcare services. A digitised secondary care system is underway, as the appointment of a national chief clinical information office (CCIO) to oversee NHS clinical digitisation efforts, including every trust to have a CCIO to lead development of a more digitised NHS trust. To ensure this happens the Department of Health and NHS England have provided additional funding and a phased approach to implementation with a target for all trusts to reach digital maturity by 2023. (Honeyman et al, 2016) It is imperative the NHS achieves these targets to ensure that it is digitally advance and continues to be able to provide one of the best health care services in the world.

The use of artificial intelligence is a critical driver in modern day health care, as it will help improve quality, management, efficiency of patient health outcomes. For example, Deepmind a leading artificial intelligence company has developed AI technology that analyse optical cohenrence tomography scans (OCT), which automatically detects eye conditions in seconds, and prioritises those patients in urgent need of care. (Deepmind, 2016) This AI technology is currently being audited at Moorfeilds Eye Hospital NHS trust in partnership with clinicians. It has been found to help improve patient care by reducing waiting times, and prioritise those patients that require treatment first. (Deepmind, 2016)

The drive for healthcare to become digitised is evident throughout the world, as the size of the global market for digital health is continuously growing and is currently expected to be worth £43 billion, including £2.9 billion in the UK which makes up 7% of the global market. (Deloitte, 2015) Digital health systems represent the largest market both globally and, in the UK, where they contribute to 66% of digital health sales. (Deloitte, 2015). Digital globalisation of healthcare will continue to grow, but the fact of it being easy to capture, share and use data for direct care and secondary use poses a risk. If there is any lack of understanding on part of patient or staff to how it is handled can be obstacle to sharing data and hinder the progress in digital health-technology.(Honeyman et al , 2016) The vast amounts of data collected by the NHS, if shared using strong safeguards, has huge potential to support improvements in care and research. The benefits include improving an individual’s clinical care and protecting, and linking data from different sector to enhance our understanding of the populations health more broadly. (Honeyman et al, 2016) To tackle the issue of consent and security, and increase public confidence, Dame Fiona Caldicott, National data Guardian for Health and Care, proposed 10 new data security standards to apply to every organisation handing health and social care information, including a new consent and opt-out model for sharing of confidential patient data. (Honeyman et al, 2016)

Overall, the government consider better use of information and digital technology to be a critical driver of the NHS moving forward in the world of healthcare,and have set out an ambitious vision that seeks to digitally transform healthcare services within the UK. However, the backdrop of this occurring would be the unprecedented financial and operational pressures within the NHS organisations, and so in order to achieve cost savings from digitisation in health care in the UK, will require investment and will take time to deliver.

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Appendix 1

Table 1: (Source: Horton, 2017) Ownership of the ten largest providers of care homes, Jan 2011.