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Showing posts from 2015

Bariatric surgery - Should we prioritise patients with type 2 diabetes?

The results of recent research studies illustrate the importance of prioritizing obese people with type 2 diabetes mellitus when it comes to selecting patients for bariatric surgery. For example, the number of people eligible for bariatric surgery in England far exceeds the bariatric surgery capacity of its National Health Service. If the aim of bariatric surgery is to reduce mortality and morbidity among obese patients, then the focus should be on selecting patients for surgery based on the presence of the conditions that have the greatest detrimental effect on health status. It may therefore be appropriate to reconsider the importance of body mass index alone as a predictor of mortality and put more emphasis on the presence of comorbidities when assessing eligibility for bariatric surgery. Given the significant benefits for people with type 2 diabetes that bariatric surgery offers and the resulting major improvements in their health status, there is a strong case that type 2 diabet…

Moving forwards with research on the “weekend effect”

Two articles published in The BMJ in 2015 on the “weekend effect” have sparked considerable debate in The BMJ and on social media. A number of previous studies have reported that hospital mortality is higher for patients admitted at weekends than for patients admitted on other days of the week. This higher mortality for patients admitted at weekends has also been found in studies carried out in other countries as well as in England’s NHS. However, the key question which this prior research has not answered is whether the higher mortality is “avoidable” and not simply due to the patients who are admitted on weekends having more complex health needs and a poorer health status than patients admitted on weekdays.

You can read the full article on BMJ Blogs.

Sharing images of patients electronically

In a recent article in a medical magazine, I and two other commentators discuss issues around the electronic sharing of images of patients that clinicans should be aware of.

The very high use of information technology in modern society has resulted in the practical uses of sending and sharing information electronically rapidly outstripping published guidance in this area. For example, many NHS organisations have draconian policies about sending patient information by email – in some cases describing sending information by unencrypted email as similar to ‘sending it on a postcard’. No empirical evidence is ever presented in such guidance that sending information electronically is any less secure than sending it by post or telephone. Guidance from such organisations has also yet to catch up with the now near-ubiquitous access to smartphones, high-speed Internet connections and high-resolution cameras in our society. In my opinion, it is acceptable for the photo to be stored on your pho…

What future for primary care in England?

When Jeremy Hunt, the Secretary for State for Health in England, presented his ‘New Deal for General Practice’ in June 2015, he described general practice as the jewel in the crown of the NHS. Many general practitioners (GPs) though will not be reassured by his statement. Despite Jeremy Hunt’s words of support, the future for GPs, their teams and their patients looks very uncertain. It is hard to see how planned levels of funding for the NHS in England can sustain a readily accessible, high-quality primary care service. It seems likely that primary care in England will increasingly be delivered by non-medical professionals, such as pharmacists, nurses, physician assistants and health care assistants. The acceptability to patients – and the impact on quality of care, patient outcomes and the other parts of the NHS – of this model are all unknown. An alternative scenario is that we gradually move to a ‘two-tier’ primary care system with those patients who can afford to do so paying to …

How do the costs charged by private GPs compare to NHS general practice?

As I was returning home via my local tube station, I was handed a flyer for a newly established private general practice. I live in a relatively affluent part of London so there may well be demand for private primary care services, particularly as many local NHS general practices are under considerable workload and funding pressures, and are struggling to meet demand. The new private general practice offers individual insurance plans that start ‘from’ £35 per month (£420 per year). For patients without insurance, a one-off 20 minute consultation is £110 and an ECG is £95. A private prescription (excluding cost of medication) is £15. I compared this to my own practice where the entire sum we receive annually for each patient on our list is about £120 (this includes the annual capitation fee plus various other payments such as reimbursement of costs of premises). The average payment per patient to general practices in England is around £136 annually. It made me realise what good value …

Improving nutrition and hydration care in the NHS

NHS England has recently published new guidance to help ensure patients receive good nutrition and hydration care. Malnutrition is an important issue for the NHS. Around 1 in 3 patients admitted to hospital or who are in care homes are malnourished or at risk of becoming so. Poor nutrition and hydration not only harms patients’ health and well-being, it can also reduce their ability to recover and leads to increased risk of hospital admission. The new guidance draws together up-to-date evidence based resources to help ensure good nutrition and hydration care in place in both the acute sector and in the community. The full guidance can be accessed at:

Advice on How to Apply for Medical School

I am sometimes asked by friends for advice on entry to medical school. Entry to medical school is very competitive with around 11 people applying for each place in 2013 - and it seems to be getting more competitive. All medical schools have slightly different methods of selecting medical students but the selection process usually involves:

1. Academic achievements (i.e. GSCE, AS Level, A Level grades)
2. UKCAT or BMAT score
3. Personal statement
4. Interview The first thing to say is that the academic achievements are the most important. If you don’t get the required grades, then you won’t get an offer no matter how spectacular your personal statement or work experience might be. For example, the medical course at Imperial College London requires 3 grade A results at A level. Hence, it’s important to have good GSCE and AS results when you come to apply so that you get an offer from a medical school on the assumption you will perform well at A level. Most universities also have an asses…

Launch of the Imperial College London Antimicrobial Research Collaborative

I attended the launch event of the Imperial College London Antimicrobial Research Collaborative this week. The Antimicrobial Research Collaborative (ARC@Imperial) consolidates world leading, multidisciplinary research across Imperial College London to address the urgent global threat of antimicrobial resistance. I had the opportunity to meet Dr Martin Cole. Dr Cole led the team that developed the antibiotic Augmentin (also known by its generic name of Co-Amoxiclav) by adding Clavulanate Potassium to Amoxicillin.
Dr Martin Cole who led the team that developed the antibiotic Augmentin Sir Richard Sykes, Chairman of the Imperial College Healthcare NHS Trust and Professor Alice Gast, President of Imperial College London

Changes in per capita spending on healthcare in the UK since 2005

For those of you who are wondering why the NHS in England is in so much difficulty at present, look no further than this OECD graph for the main reason. Until 2009, per capita healthcare spending in the UK was increasing by around 3.6% per year. Since 2009, per capita healthcare spending in the UK has actually been declining by around 0.1% per year. Since 2009, the NHS has also had to manage the growing number of older people in the UK (who have the greatest need for health and social services) and deal with (in England) the consequences of the major organisational changes brought about by the 2012 Health and Social Care Act.

You can view more healthcare statistics on the OECD Health Statistics 2015 website.

Should GPs give up their independent contractor status?

In a recent article in the British Journal of General Practice, I give the academic perspective on the question of whether GPs give up their independent contractor status. An increasing proportion of GPs are salaried (around 28% in England in 2014), and currently employed on contracts that can vary considerably in salary and employment rights. Medical students and junior doctors who want to pursue a career in specialist medicine know under what terms they are likely to be employed when they become consultants. The same is not true for people who would like to pursue a career in primary care. This uncertainty is one of the factors deterring junior doctors from applying for GP training schemes and for these schemes not meeting their recruitment targets.

You can read the full article in the British Journal of General Practice.

Response to the British Orthopaedic Association

In a recent statement, the British Orthopaedic Association (BOA) criticised general practitioners (GPs) for their management of patients with knee problems and seemed to be blaming GPs for high rates of inappropriate arthroscopy in the UK. The statement was subsequently revised after criticism from GPs. The BOA seemed to be unaware that GPs refer patients to specialists for an opinion on further management. The decision to proceed to an intervention such as arthroscopy lies with the specialist - in consultation with the patient who has to agree to a procedure being carried out. The BOA also seemed unaware of how services for musculoskeletal problems are delivered in the NHS, both in primary care and in specialist settings, which is very worrying if true.

Where I practise in London, referrals for musculoskeletal problems are made to an Integrated Musculoskeletal Service in which the initial assessment is made by a physiotherapist. Most patients are generally then referred for physioth…

What does the future hold for CCGs?

One of the key aims of establishing clinical commissioning groups (CCGs) in England’s NHS was to place general practitioners at the heart of NHS commissioning. And yet surveys consistently show that many GPs feel that their view are ignored by their CCGs. For example, an NHS England survey reported that only 44% of GPs said that their CCGs acted on their views. A BMA survey reported that nearly two-thirds of GPs feel they either had limited influence on their CCGs or that they were dictated to by their CCGs rather than being asked to contribute to CCG decision making.
Another key aim of creating CCGs was to make use of GPs’ clinical expertise in commissioning health services to improve health outcomes and patients’ experience of the NHS. However, a Pulse survey found that more than twice as many GPs think that the introduction of CCGs has been detrimental to patient care than think have improved it.
In many ways, the fate of CCGs is linked with inextricably the consequences of the …

Coverage of the NHS Health Check programme in England: national evaluation

A recent article from my research group examined coverage of the NHS Health Check programme in England. The article was published in the journal Preventive Medicine. We found that coverage of the programme was low in the first four years and there was a wide variation in coverage between general practice.

There was an increase in statin prescribing but only about one in three people who attended for a Health Check and who were found to have a cardiovascular risk score (20% or more 10-year risk of cardiovascular disease) were prescribed a statin.

We concluded that unless coverage of the NHS Health Check programme improved and uptake of statins in high-risk groups increased, the programme would not deliver its predicted benefits in reducing morbidity and mortality from cardiovascular disease.

The article was covered by a number of media outlets including the Daily Mail and Pulse.

Presentation at the RCGP City Health Conference

I was at the RCGP in Euston (London) this morning where I a gave lecture on diabetes (Achieving diabetes management targets in primary care – impact on mortality and hospital admissions) at the RCGP City Health Conference. Diabetes is becoming increasingly common across the world because of lifestyle changes such as more sedentary lifestyles and an increased intake of high-calorie foods (such as refined carbohydrates). Prevention is clearly the best option but once diabetes becomes established, it is important that doctors and patients work towards meeting key management targets for glucose, blood pressure and cholesterol control.

Alternative providers of GP services perform worse than traditional practices

A new study from Imperial College London reports that alternative providers of primary care in the NHS, including private sector companies, do not perform as well as traditional GP practices when their performance is assessed using a range of measures of quality of care.

Alternative providers have been contracted to offer primary care in the NHS since 2004 under reforms designed to increase competition. These providers performed worse than traditional GP practices on 15 out of 17 indicators after adjusting for the characteristics of the practices and the populations they serve.The study was published in the Journal of the Royal Society of Medicine.

"This study provides data to inform the debate about the growing role of the private sector in the NHS," said Dr Christopher Millett, lead author of the study, from the School of Public Health at Imperial. "New providers were allowed into the primary care market to stimulate competition, but our findings suggest that their i…

Why election pledges from politicians on NHS primary care need careful examination

The likely effects of the Conservatives' and Labour's pledges to improve access to primary care are unclear. Both main parties have promised large increases in the number of GPs and significant improvements in access to appointments. In an article published in the the British Medical Journal, Thomas Cowling and Matthew Harris and myself - from the Department of Primary Care and Public Health at Imperial College London - say the pledges are unlikely to be achieved within a single parliamentary term.

The Labour Party have pledged to recruit 8,000 new GPs and plan to reintroduce their guarantee of an appointment within 48 hours. This target was far from being achieved under the last Labour government, with only 81 per cent of patients able to see a GP within two weekdays in 2009-10. As well as recruiting 5,000 extra GPs, the Conservatives have promised that if they are re-elected, patients in England will be able to see a GP between 8am and 8pm, seven days a week. This policy ha…

Setting more ambitious targets for general practices may not improve quality of care

Pay for performance programmes are being adopted in a growing number of countries as a quality improvement tool. In 2004, the United Kingdom introduced the Quality and Outcomes Framework (QOF) which primarily aimed to improve the management of common chronic conditions, such as diabetes and stroke, in primary care. The Department of Health in England is now considering allowing more flexibility in local pay for performance schemes, such as the introduction of higher payments for meeting tougher performance targets.

Research carried out at Imperial College London suggests that such local pay for performance schemes can improve target achievement by general practices but have no significant impact on the overall quality of clinical care. The study was funded by the NIHR and the NW London Collaboration for Leadership in Applied Health Research and Care (CLAHRC) and published in the journal PLoS One.

In the study, which was carried out by a team from the Department of Public Health and P…

Patients online access to their electronic health records and linked online services

Online access to medical records by patients has the potential to promote patient-centred care and improve patient satisfaction.  Online services may also offer patients greater convenience although concerns remain about privacy and confidentiality. However, online access and services may also prove to be an additional burden for healthcare providers who are already under considerable workload pressures.

In a study published in the British Journal General Practice, I and colleagues form other UK universities assessed the impact of providing patients with access to their general practice electronic health records (EHR) and other EHR-linked online services on the provision, quality, and safety of health care. We carried out a systematic review that focused on all studies about online record access and transactional services in primary care.

We identified 176 studies, 17 of which were randomised controlled trials, cohort, or cluster studies. Patients reported improved satisfaction with …

Meeting of the UK-Ireland Node of the InnoLife Consortium

The UK-Ireland node of the InnoLife Consortium met on Friday 30 January 2015 at 58 Princes Gate, South Kensington, London. InnoLife is a consortium of more than 50 core partners (and in addition 90 associate organisations) of leading businesses, research centres and universities from 9 European Union countries that has been selected by the European Institute of Innovation and Technology (EIT) as the Knowledge and Innovation Community (KIC) for EIT Health.
A group photo from the recent School of Public Health Away Day in Windsor

Electronic learning could enable millions more students to train as doctors and nurses worldwide

Electronic learning could enable millions more students to train as doctors and nurses worldwide, according to research carried out by the Department of Primary Care and Public Health at Imperial College London.

A review commissioned by the World Health Organization (WHO) and carried out by Imperial College London researchers concludes that eLearning is likely to be as effective as traditional methods for training health professionals.

eLearning, the use of electronic media and devices in education, is already used by some universities to support traditional campus-based teaching or enable distance learning. Wider use of eLearning might help to address the need to train more health workers across the globe. According to a recent WHO report, the world is short of 7.2 million healthcare professionals, and the figure is growing.

The Imperial team, led by Dr Josip Car, carried out a systematic review of the scientific literature to evaluate the effectiveness of eLearning for undergraduat…