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Showing posts from 2014

How can medical students be encouraged to consider primary care as a career?

In a letter published in the January 2014 edition of the British Journal of General Practice, medical students Fahmida Mannan and Zain Chaudhry from the Imperial College London School of Medicine discuss how the NHS and medical schools can encourage students to consider general practice as a career option. They suggest the focus in medical schools should shift towards improving the quality of general practice placements and promoting the integration of primary care and specialist teaching, rather than consuming more time in an already overstretched curricula.

They also consider that prestige has never been the main incentive for pursuing a specialty. Their own experience is that many medical students are attracted to a career in general practice because of other factors, such as a good work–life balance, continuity of care and career flexibility. With many GPs now concerned about their workload, this inevitably influences students and junior doctors in their career choices.

Another k…

Results of the 2014 Research Excellence Framework

The results of the 2014 Research Excellence Framework (REF) were published today. The REF is carried out to assess the quality of research in UK universities. The Times Higher Education Supplement's analysis ranked Imperial College as having the highest REF score among major UK universities. Among the 'Public Health, Health Services and Primary Care', category, Imperial College achieved a 57% 4-star rating, which was the joint highest in the UK (along with Oxford University).

WHO Meeting on Strengthening Health Systems

I am at a World Health Organization meeting in Cairo where we will be discussing how we can strengthen health systems so that they are able to cope with the rising burden of non-communicable diseases such as diabetes and hypertension; as well as the challenges posed by infectious diseases such as Ebola. I’ll be giving one of the key note speeches as well as chairing one of the sessions.

Use of social media by health professionals

I was invited to speak at the Best Practice 2014 Conference where I spoke about the use of social media in healthcare, drawing upon my experience as an academic clinician. My lecture was well-attended with many delegates standing because all the seats had been taken. This illustrates doctors' interest in the use of social media and in particular its role in patient education, promoting the use of preventive activities such as immunisation and improving the quality of care that patients receive. You can view a copy of my presentation at the event.

Supporting clinical trials in primary care

I was at St. Mary's Hospital earlier this week to attend a meeting with Professor Neil Poulter and the Imperial Clinical Trials Unit team. We discussed methods of boosting recruitment to clinical trials - particularly industry sponsored trials - and how hospitals and general practices could work together to achieve this objective. Research on new drugs is a key area for the UK both for the benefits it can bring for people's health and the NHS, and also for its economic benefits.

Proportion of emergency admissions via A & E increasing while the proportion via GPs falling

In a paper published in the Journal of the Royal Society of Medicine, a team from Imperial College London examined time trends in emergency hospital admissions via accident and emergency departments in England. The proportion of emergency hospital admissions in which patients were admitted via an A and;E department increased markedly in England between 2001–2002 and 2010–2011.

There are several possible explanations for this trend. These include coding changes and the greater use of A and E departments to assess patients before they are admitted as emergencies. Changes in access to general practitioners - both during normal working hours and out of hours - may also have contributed to these changes.

The findings of the study in the JRSM are similar to those from studies in the United States. Future health policy should address gatekeeping in A  and E departments and the provision of urgent care in general practice  New models of care such as urgent care services that employ GPs in A …

Public support for increased tobacco taxation in Europe is highest in more affluent counties.

Increased taxation on tobacco products is an effective method of reducing tobacco use. In a study published in the Scandinavian Journal  Public Health, Filippos Filippidis and myself, along with colleagues from Harvard University, assessed support for increased taxation on tobacco products and other tobacco control measures among people aged ≥15 years in 27 European Union (EU) during the period 2009-2012.

We obtained nationally representative data from the 2009 (n=26,788) and 2012 (n=26,751) cross-sectional Eurobarometer surveys. Estimates were compared using chi-square statistics. The effect of the relative change in gross domestic product (GDP) on the change in support for increased taxation during 2009-2012 was calculated using the Pearson correlation coefficient and linear regression models.

We found that between 2009 and 2012, support for increased taxes on tobacco products declined (56.1% to 53.2%. However, support for other tobacco control measures increased significantly. Aft…

Why do patients attend general practitioner-led urgent care centres with minor illnesses?

The demand for urgent care is increasing, and the pressure on emergency departments is of significant concern. General practitioner (GP)-led urgent care centres are a new model of care developed to divert patients to more appropriate primary care environments. In a study published in the Emergency Medicine Journal, I along with colleagues from Imperial College London explored why patients with minor illnesses choose to attend an urban urgent care centre.

We used a self-completed questionnaire among patients aged 18 years or over (N=649) who were triaged with a ‘minor illness’ on arrival at an urgent care centre co-located with an emergency department in London. The median age of participants was 29 years. 58% (649/1112) of patients attending the centre with minor illness during the study period took part. 72% of participants were registered with a GP; more women (59%) attended than men; and the majority of participants rated themselves as healthy (81%). Access to care (58%) was a key…

Rebuilding Immunity After Treatment for Haematological Malignancies

I attended a seminar on 11 September 2014 today on "Rebuilding Immunity After Treatment for Haematological Malignancies". The seminar was given by Professor Per Ljungman of the Karolinska University Hospital, Stockholm, Sweden. In the seminar, we discussed the use of vaccines to protect patients from infection following Haematopoietic Stem Cell Transplantation (HSCT) and after treatment for haematological malignancies.

The levels of antibodies to diseases that can be prevented by vaccination decrease during the first few years after a stem cell or bone marrow transplant. The immunities acquired by the patient before the transplant are also generally lost. For this reason, this group of patients are advised to start a full course of vaccinations starting 3-6 months after they finish their cancer treatment.

Tobacco control efforts in the Gulf Cooperation Council countries

A paper published in the Eastern Mediterranean Health Journal  reviews the current state of tobacco use, governance and national commitment for control, and current intervention frameworks in place to reduce the use of tobacco among the populations of the Gulf Cooperation Council (GCC) member states and Yemen. It further reviews structured policy-oriented interventions (in line with the MPOWER package of 6 evidence-based tobacco control measures) that represent government actions to strengthen, implement and manage tobacco control programmes and to address the growing epidemic of tobacco use.

The findings of the review show that tobacco control in the GCC countries has witnessed real progress over the past decades. These are still early days but they indicate steps in the right direction. Future investment in implementation and enforcement of the Framework Convention on Tobacco Control, production of robust tobacco control legislation and the establishment of universally available to…

Improved access to primary care is associated with lower hospital admission rates for epilepsy

Epilepsy is one of the commonest neurological conditions and is associated with major adverse health outcomes and has a significant impact on a person's quality of life. In an article published in the journal Seizure, Michael Soljak and colleagues from Imperial College London examined the association of primary care factors with hospital admissions for epilepsy in England, 2004–2010.

Hospital admission rates for epilepsy in England decreased from 2004–2005 to 2009–2010. Patient access to primary care appointments more than two days ahead, a measure of access to preventive care, and percentage of patients age 18 and over on drug treatment for epilepsy who have been seizure free for the last 12 months, were associated with a lower rate of admissions. However, the impact of these variables on admission rates is small compared to that of deprivation.

The study provides further evidence that improved access to primary care could help reduce admission rates for long-term conditions suc…

National Summit on Quality in General Practice

I attended the National Summit on Quality in General Practice on 31 July 2014, which was held at the RCGP Headquarters in Central London. The event was organised by the RCGP, the Health Foundation, and the BMJ. Among the attendees were Dr Maureen Baker, Chair of the RCGP, Dr Fiona Godlee, Editor of the BMJ, and Dr Richard Vautrey from the BMA's General Practice Committee. The National Summit was facilitated by Judy Oliver.

At the meeting, there were presentations and discussion on the current state of general practice in the UK, the challenges we need to overcome to provide high quality primary care services, the importance of adopting a patient-centred approach in the measurement of quality of care, and how we can make change happen in the current political and economic contexts. Delegates worked in groups to address these issues.

Amongst my group were Anna Damerell, Richard Vautrey, Bryan Fisher, Nick Steele and Tom Duncan.We had a stimulating debate on the many challenges facin…

Are federations the way forward for general practices in England?

As general practices in England come under increasing workload, funding, and contractual pressures, a new type of primary care organisation—the GP Federation—is becoming more common. The RCGP defines GP federations as practices “working together to share resources, expertise, and services.” In their simplest form, federations allow the general practices in one locality to share some administrative functions, and work together to bid collectively for NHS contracts.

You can read the rest of this article on BMJ Blogs.

Three key issues in trying to increase the use of statins in the UK

Statistics from the OECD show that the per capita use of statins in the UK is the highest in Europe and the second highest in all OECD countries. There are a number of reasons for this, which include the emphasis on evidence-based medicine in the training of UK doctors; the 2004 GP contract which introduced incentives for the management of long-term conditions such as coronary heart disease and diabetes; and the NHS Health Check programme which aims (amongst its objectives) to increase the use of statins for the primary prevention of cardiovascular disease (CVD) in people with a 20% or more 10-year risk of CVD.

The National Institute for Health & Care Excellence (NICE) is now proposing to reduce the threshold for starting statins for the primary prevention of CVD from its current threshold of a 20% 10-year CVD risk to a 10% 10-year CVD risk. Although this could have significant benefits for the health of the population, there are three issues that need to be considered. These iss…

Why we need better information on the side-effects of statins

In a response to an editorial published in the BMJ by Dr Fiona Godlee, I discuss the need for better information to be available on the side-effects of statins. This is a a key issue in the debate about trying to widen the use of statins because of the discordance between rates of side-effects of statins in clinical trials and in clinical practice.

In clinical trials, the incidence of side effects from statins is low and similar in the intervention and placebo groups.[1] In contrast, observational studies using primary care databases report a much higher rate of potentially serious side effects (such as myopathy and renal failure) in people taking statins.[2, 3] Even these rates derived from clinical records may under-estimate the true incidence of side effects in people taking statins because not all patients with side effects will inform their doctor and not all doctors will enter a relevant diagnostic code in the patient’s electronic medical record.

Many general practitioners will…

Cognitive function in doctors and dentists with suspected performance problems

In a study published in the the journal JRSM Open, we examined the performance assessments and cognitive function of practitioners referred to the National Clinical Assessment Service (NCAS) in 109 practitioners over the age of 45 years referred to NCAS between 1 September 2008 and 30 June 2012.

The main outcome measures were reasons for referral of practitioners and their characteristics; details of their assessments including screening for cognition using Addenbrooke's Cognitive Examination Revised (ACE-R); outcome of the process.

Reasons for referral included ‘clinical difficulties’ and ‘governance or safety issues’. Eighty-seven practitioners scored above 88 on ACE-R. Twenty-two were found to have an ACE-R score of ≤88. On further assessment, 14 of these 22 practitioners were found to have cognitive impairment. The majority of all practitioners were found to be performing below the expected level of practice for someone at their grade and specialty. Of those scoring ≤88 on th…

Most patients requiring urgent care can be managed by a GP or emergency nurse practitioner

Charing Cross and Hammersmith Hospitals’ accident and emergency services will be reconfigured under current plans for reconfiguring health services in North West London. Both hospitals currently have a GP-led urgent care centre co-located with an emergency department. Patients who refer themselves for emergency care are unable to access the emergency department without being seen by a GP or emergency nurse practitioner in an urgent care centre. We present early data on the evaluation of the two the urgent care centres that was published in a letter in the BMJ.

From 1 October 2009 to 31 December 2012, 282 947 unplanned attendances occurred at these centres, 63.2% of them at Charing Cross Hospital. The annual number of attendances increased by 9.4% (7911) from 2010 to 2012 (92 303 in 2012). Most attending patients (85.3%) were registered with a general practice, and 47.7% of attendances occurred outside of general practice core hours. The most common category of primary diagnosis was “…

Drugs cut need for surgery by more than half in patients with Crohn’s disease

The requirement of bowel surgery is dramatically reduced by up to 60% in patients who develop Crohn's disease if they receive prolonged treatment with drugs called thiopurines concludes a new study published in the American Journal of Gastroenterology.

Crohn’s disease affects more than quarter-of-a-million people in the UK leading to an inflamed intestine.Researchers from St George’s, University of London, St George's Hospital, London and the Department of Primary Care & Public Health at Imperial College, London analysed data from the medical records of more than 5,000 patients in the UK living with Crohn’s disease for more than 20 years and looked at the effect of thiopurine drugs that suppress inflammation in the gut.

Gastroenterologist Dr Richard Pollok, an honorary senior lecturer at St George’s, University of London, said “Our discovery is timely since new guidelines from the USA have played down the benefits of these drugs in favour of newer agents.  A year of treat…

Risk Factors for Hospital Admission with RSV Bronchiolitis

In a paper published in the journal PLOS ONE. Jo Murray and colleagues examined the timing and duration of hospital admissions from respiratory syncytial virus (RSV) bronchiolitis among term and preterm infants in England and to identify risk factors for admission. We carried out a population-based birth cohort with follow-up to age 1 year, using the Hospital Episode Statistics (HES) database using data from 71 hospitals across England. We identified 296618 individual birth records from 2007/08 and linked to subsequent hospital admission records during the first year of life.

In our cohort, there were 7189 hospital admissions with a diagnosis of bronchiolitis, 24.2 admissions per 1000 infants under 1 year (95% CI 23.7–24.8), of which 15% (1050/7189) were born preterm (47.3 bronchiolitis admissions per 1000 preterm infants (95% CI 44.4–50.2)). The peak age group for bronchiolitis admissions was infants aged 1 month and the median was age 120 days (IQR = 61–209 days). The median length …

PACK: Practical Approach to Care Kit

I attended a very interesting seminar today organised by C3Health at Barnabas House in London at which Dr Lara Fairall from the University of Cape Town presented on the PACK (Practical Approach to Care Kit) programme. The PACK programme has been developed over the last 12 years in South Africa.

PACK is a set of comprehensive clinical practice guidelines that aims to equip nurses and other clinicians to diagnose and manage common adult conditions at primary care level. It includes information on symptoms, clinical evidence, policy-based guidelines and training.

Dr Fairall spoke about the background to the programme, how the information sources were complied and how the programme (which is nurse-led and based in primary care) was delivered. PACK is led from the Knowledge Translation Unit at the University of Cape Town. Thanks to Dr Richard Smith for the invitation.
 Dr Richard Smith and Dr Lara Fairall  Some of the delegates networking before the start of the presentation Dr Lara Faira…

Launch of the North-West London CLAHRC

On Tuesday 4 March 2014, I attended the launch of the NIHR CLAHRC for North-West London at the Royal College of Physicians of London. NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) undertake high-quality applied health research focused on the needs of patients and support the translation of research evidence into practice in the NHS.

CLAHRCs are collaborative partnerships between a university and the surrounding NHS organisations, focused on improving patient outcomes through the conduct and application of applied health research. They create and embed approaches to research and its dissemination that are specifically designed to take account of the way that health care is increasingly delivered across sectors and a wide geographical area.

You can view a selection of pictures from the event below.
Dr Vasa Curcin and Dr Tom Woodcock are pictured outside the Royal College of Physicians building in Regent's Park. Dr Chris Millett, Reader in Public H…

Why do patients attend GP-led urgent care centres rather than their own general practice?

In a paper published in the Emergency Medical Journal, my colleagues and I investigated why patients with 'minor; illnesses choose to attend a GP-led urgent care centre rather than their own general practice. The demand for urgent care is increasing, and the pressure on emergency departments is a significant concern for the NHS. General practitioner (GP)-led urgent care centres are a new model of care developed to divert patients from emergency departments to more appropriate primary care environments.

We administered a self-completed questionnaire among patients aged 18 years or over (N=649) who were triaged with a ‘minor illness’ on arrival to an urgent care centre, co-located with an emergency department in London. We found that the median age of patients was 29 years. 58% of patients attending the centre with minor illness during the study period took part. 72% of participants were registered with a GP; more women (59%) attended than men; and the majority of participants rated…

Higher quality primary healthcare associated with reduced hospital admissions for diabetes complications

In a study led by Imperial College London and published online in the journal Diabetic Medicine, researchers from the Department of Primary Care & Public Health at Imperial College London examined if hospital admission rates for diabetes complications (acute complications, chronic complications, no complications and hypoglycaemia) were associated with the management of diabetes in primary care.

We performed an observational study in the population in England during the period 2004–2009 (54 741 278 people registered with 8140 general practices). We used multivariable negative binomial regression to model the associations between indirectly standardized hospital admission rates for complications and primary healthcare quality, supply and access indicators, diabetes prevalence and population factors.

In multivariate regression models, we found that increasing deprivation and diabetes prevalence were risk factors for admission, while most healthcare covariates, i.e. a larger practice…

High potency statins linked to better outcome following a heart attack

A study looking at the data of thousands of patients who suffered heart attacks has suggested treatment with high-potency statins offers a significantly improved chance of survival compared to those taking normal statins. Results of the study were published online in the journal Heart.

The study, led by the University of Dundee and on which I was a collaborator, also found a combination of statins and the drug ezetimibe showed no improved survival rate, although researchers caution this finding needs further testing.

'There is presently a lot of interest in ezetimibe as a potential treatment for heart patients,' said Professor Chim Lang, from the Division of Cardiovascular and Diabetes Medicine at the University of Dundee Medical School.

'Ezetimibe has been shown to be very effective at lowering cholesterol but we do not know its effect on survival. The key question really is whether it is better than statins, especially high potency statins such as rosuvastatin or atorva…

Funding for GP services for people living in care homes

The Chief Inspector of Primary Care, Dr Steve Field, has criticised GPs for charging ‘retainer’ fees for treating patients in care homes. Perhaps Dr Field is unaware that the current funding mechanism for general practice does not reflect the needs of patients with complex health problems such as those patients living in care homes? The current capitation-based payment is insufficient to fund the level of primary care support these patients need from primary care teams and should be supplemented by need-based funding. The GMS weighted capitation formula used to allocate resources to general practices is a blunt instrument and does not work well for the small groups of patients with complex health needs. For these groups of patients, needs-based funding mechanisms are more appropriate.

Patients living in care homes have complex health problems that require significant input from GPs and community staff, as well as skilled care from the nurses who work in care homes. Residents of care …

MPH Student Presentations on the NHS Care.Data Programme

As part of a session on primary care data in the Health Informatics module on the Imperial Master of Public Health Programme, I asked students to work in two groups to present arguments for and against the NHS Care.Data programme. Care.Data is an NHS programme that will extract data from the medical records held by general practitioners (GPs) in England. The Care.Data programme takes advantage of the very high level of use of electronic medical records by GPs in England. After extraction, data will be uploaded to the NHS Health and Social Care Information Centre (HSCIC). The data will then be used for functions such as health care planning, monitoring disease patterns and research. The programme has been controversial with proponents arguing that the programme will bring many benefits for the NHS and the population of England; and opponents arguing it is a major breach of privacy. You can view the two presentations to help inform you further about these arguments:

Arguments for the Ca…

Improving discharge planning in NHS hospitals

Factors that need to be considered in discharge planning that have been identified in previous projects include:

Ensuring that discharge arrangements are discussed with patients, family members and carers; and that they are given a copy of the discharge summary.Adequate coordination between the hospital, community health services, general practices, and the providers of social care services.There is a follow-up after discharge of patients at high risk of complications or readmission - either in person or by telephone - to ensure that the discharge arrangements are working well. Medicines reconciliation is carried out. This is the process of verifying patient medication lists at a point-of-care transition, such as hospital discharge, to identify which medications have been added, discontinued, or changed from pre-admission medication lists.Ensuring that any outstanding test results at discharge are obtained and passed on to primary care teams; and ensuring there are clear arrangements …

Effect of financial incentives on delivery of alcohol screening and brief intervention in primary care

Alcohol screening and brief intervention (ASBI) is effective but often under-provided in primary care. Financial incentives may help address this. We assessed the impact of a local pay-for-performance programme on delivery of ASBI in UK primary care in a longitudinal study using data from 30 general practices in North-West London from 2008 to 2011 with logistic regression to examine disparities in ASBI delivery. The study was published in the Journal of Public Health.
Of 211 834 registered patients, 45 040 were targeted by the incentive (cardiovascular conditions or high risk; mental health conditions), of whom 65.7% were screened (up from a baseline of 4.8%, P < 0.001), compared with 14.7% of non-targeted patients (P < 0.001). Screening rates were lower after adjustment in younger patients, White patients, less deprived areas and in patients with mental health conditions (P < 0.05). Of those screened, 11.5% were positive and 88.6% received BI. Men and White patients were si…

Over two million people in England may be eligible for surgery to treat obesity

Over two million people in England may be eligible for surgery to treat obesity, according to new research published in JRSM Open. However, fewer than 7000 patients underwent these procedures in 2011.

Carrying out more bariatric surgery procedures would help to reduce obesity-related ill health, the study authors from Imperial College London said, but the NHS may need to invest in more resources to meet demand.

Bariatric surgery – a set of surgical procedures performed on obese people to decrease their stomach size – can greatly reduce the likelihood of death from obesity-related diseases such as type 2 diabetes, stroke or coronary heart disease.

Despite clear guidelines outlining who can undergo such surgery with the NHS, and evidence that these procedures are cost-effective in the long run, less than one per cent of those eligible have weight loss surgery each year. The researchers say this raises questions about why more procedures are not currently being carried out.

One possible…

Blood pressure study points to more equitable care in England than America

In the USA but not in England, patients on low incomes with high blood pressure have their condition managed poorly compared with those who earn more.

A new study from my department comparing blood pressure management in the US and England found that although there is little difference between the two countries overall, the level of socioeconomic inequality is much higher in the US, with wealthier Americans more likely to meet targets for bringing their blood pressure under control than poorer patients. The study was published in the journal PLOS ONE.

High blood pressure, or hypertension, is the leading cause of ill health worldwide and affects 76 million people in the US and 16 million in the UK. It is diagnosed if someone’s blood pressure consistently measures 140/90 millimetres of mercury or higher. Doctors usually recommend lifestyle changes to control blood pressure, and may prescribe antihypertensive drugs.

The research aimed to determine whether differences between the British…