Health means more than just healthcare

The relevance of a medical journal to its readership depends on more than just presenting updates on clinical topics. It is also important to lean into those aspects of public policy that are major drivers of health outcome. Clin Med has a central role in publishing content relevant to all aspects of what influence the daily practice of physicians in the UK and abroad. This edition has the usual wealth of clinical learning, but also a number of articles highlighting the influence of national policy decisions on health outcomes and health care.

There are an estimated 300,000 homeless people in the UK - that equates to approximately 1 in 200 people, a proportion as shaming as it is astonishing. It is plain that this population, who are typically underserved in clinical studies, also experience a significantly greater burden of disease. At its most shocking, the average life expectancy of a homeless woman is 43 (compared to 81 for the average UK female population): expressed differently, the historic data shows that the last time life expectancy for the population was 43 years was in 1880.¹ Homeless people are in frequent contact with services, and this offers an opportunity to optimise both medical and social care for this population. Taylor and Medcalf² summarise the Homeless Assessment Tool, a recently developed instrument to standardise and more comprehensively evaluate the needs of this vulnerable group. As the model of care in the UK moves to integrated care systems, this provides opportunities to treat these patients in a more holistic fashion, and adoption of this tool is presented as a first and pivotal step in making that happen.

The protective pandemic-related restrictions on social contact placed by governments across the world have been the subject of much discussion from the outset, increasingly so, as countries move towards a ‘living with COVID’ strategy. Wurm and colleagues from Vienna³ report how these constraints had a disproportionate effect on patients with dementia. Surveying patients and caregivers after the initial easing of lockdown regulations, they identified notable increases in neuropsychiatric symptoms associated with reduced social contacts and reduced physical activity. The importance of balancing the effect of measures as impactful as lockdown restrictions on the needs of vulnerable populations with cognitive impairments is highlighted in this manuscript.

The evolving story of COVID vaccine-induced thrombosis in association with thrombocytopenia (VITT) is updated by Toh et al.⁴ While certain aspects of the pathogenesis have been established, there remain key unresolved questions relating to relative infrequency of the condition. What innate protective factors exist, and how may this impact the critical issue of worldwide vaccination for what is a global pandemic? This review is complemented by a case description from Wills et al.⁵ They present an elegant report of a patient presenting with arterial and venous thrombosis post-vaccination, illustrating the timeline and clinical variation of this new disease.

The increase in emergency presentations and medical admissions has prompted the principle of same-day emergency care (SDEC), the management of acute medical patients in secondary care settings without requirement for inpatient hospital admission, as a potential innovation to reduce pressures on acute beds. Although highlighted as a priority in the NHS Long Term Plan, there remain large gaps in the knowledge base. There is considerable variation nationally in how these services are delivered, and Atkin et al⁶ provide a narrative summary of triage scoring systems, virtual wards and ambulatory pathways. The manuscript is not a blueprint of how to implement SDEC, but a critical review of the knowledge gaps, stressing the need to tailor services according to locality.