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Showing posts from 2016

Preventing delayed diagnosis of cancer: clinicians' views on main problems and solutions

Delayed diagnosis is a major contributing factor to the UK's lower cancer survival compared to many European countries. In the UK, there is a significant national variation in early cancer diagnosis. Healthcare providers can offer an insight into local priorities for timely cancer diagnosis. In a study published in the Journal of Global Health, we aimed to identify the main problems and solutions relating to delay cancer diagnosis according to cancer care clinicians.

We developed and implemented a new priority–setting approach called PRIORITIZE and invited North West London cancer care clinicians to identify and prioritize main causes for and solutions to delayed diagnosis of cancer care. Clinicians identified a number of concrete problems and solutions relating to delayed diagnosis of cancer. Raising public awareness, patient education as well as better access to specialist care and diagnostic testing were seen as the highest priorities. The identified suggestions focused mostly…

Clinical impact of lifestyle interventions for the prevention of type 2 diabetes

In a study published in the journal BMJ Open, we reviewed the clinical outcomes of combined diet and physical activity interventions for people at high risk of type 2 diabetes. We looked at combined diet and physical activity interventions including ≥2 interactions with a healthcare professional, and ≥12 months follow-up. Our primary outcome measures included glycaemia, diabetes incidence. Secondary outcomes included behaviour change, measures of adiposity, vascular disease and mortality.

We identified 19 recent reviews for inclusion in our study. Most reviews reported that interventions were associated with net reductions in diabetes incidence, measures of glycaemia and adiposity. Small effect sizes and potentially transient effect were reported in some studies, and some reviewers noted that durability of intervention impact was potentially sensitive to duration of intervention and adherence to behaviour change. Behaviour change, vascular disease and mortality outcome data were infr…

Priorities for improvement of medication safety in primary care

Medication error is a frequent, harmful and costly patient safety incident. Research to date has mostly focused on medication errors in hospitals. In this study, we aimed to identify the main causes of, and solutions to, medication error in primary care. The resuls of the study were published in BMC Family Practice.

In the study, we used a novel priority-setting method for identifying and ranking patient safety problems and solutions called PRIORITIZE. We invited 500 North West London primary care clinicians to complete an open-ended questionnaire to identify three main problems and solutions relating to medication error in primary care. 113 clinicians submitted responses, which we thematically synthesized into a composite list of 48 distinct problems and 45 solutions. A group of 57 clinicians randomly selected from the initial cohort scored these and an overall ranking was derived. The agreement between the clinicians’ scores was presented using the average expert agreement (AEA). T…

NIHR Research Design Service

On Tuesday 15 November 2016, I spoke to Academic Clinical Trainees at Imperial College London the topic of the NIHR Research Design Service). The Research Design Service provides support to NHS staff and academics preparing research proposals for submission to peer-reviewed funding competitions for applied health or social care research. My presentation can be viewed on slideshare.

Are diagnoses of dementia being delayed by over-complex referral criteria?

Complex and time-consuming memory clinic referral criteria may be contributing to delays in the diagnosis of dementia, according to a paper published today by the Journal of the Royal Society of Medicine. Around 850,000 people are living with dementia in the UK but the number thought to have dementia substantially exceeds those with a formal diagnosis. Early diagnosis is a priority for the government and the NHS.

Currently GPs are responsible for referring patients for assessment and diagnosis by specialists, usually in dedicated memory clinics which set referral criteria. There is considerable variation in referral criteria, with requirements set by some memory clinics that exceed national guidelines. Requirements can include different combinations of cognitive tests, laboratory blood tests, urine tests and physical examination that vary between clinics.

Lead author Dr Benedict Hayhoe, of the School of Public Health at Imperial College London, says: “GPs have difficulty assessing pa…

What impact will Brexit have on the UK's life sciences sector?

On Thursday 3 November 2016, I spoke at a seminar at the Imperial College Business School on the topic of the impact of Brexit on the UK's life sciences sector (the NHS, universities, and pharmaceutical and biomedical companies). I emphasised the important role played in the life sciences sector by EU-trained professionals and the need to ensure that the UK continued to attract highly-qualified professionals to work, for example, in our National Health Service. I also discussed the need to increase spending on research and development to ensure that the UK remained a world leader in the biomedical industry. The other speakers at the seminar were Andrew Lansley (former Secretary of State for Health) and Richard Phillips (Director of Healthcare Policy at the Association of British Healthcare industries). The event was chaired by Andrew Brown. A copy of my talk can be viewed on Slideshare.

Bringing together physical and mental health within primary care

Reducing fragmentation between different parts of the health system is a key priority for the National Health Service (NHS) and for health systems internationally, if they are to meet the challenges they face. One of the deepest fault-lines in the NHS is the disconnection of mental healthcare from the rest of the system; this has to be addressed as part of efforts to improve integrated care and make care more person centred.

In an article published in the Journal of the Royal Society of Medicine, Preety Das, Chris Naylor and I discuss this issue. Developing integrated approaches towards mental and physical health is increasingly becoming a policy priority; the report of the independent mental health taskforce to the NHS identified this as one of the top three priorities for the next five years. There has been recent investment in integrating mental and physical health within secondary care, for example, liaison psychiatry in acute general hospitals and perinatal mental healthcare. Wh…

Government’s anti-immigration stance following the vote for Brexit alarms UK scientists

I was interviewed this week by the scientific journal Nature on the impact of the vote for Brexit and recent statements from government ministers on the recruitment and retention of scientific staff from outside the UK. I made the point that the success of our universities and their world-leading status depends in part on their ability to recruit leading scientists from across the globe. If this recruitment is threatened, then our universities - which make an essential contribution to our society - will be weakened.

Should all GPs become NHS employees?

In a debate article in the BMJ, Laurence Buckman and I discuss the arguments for against GPs in England becoming NHS employees. Primary care in England’s NHS is in crisis. Recruitment of GPs is difficult throughout England, with many practices reporting vacant posts; many GPs are considering retiring early, and others want to cut down on their clinical work. The problems faced by GPs are partly due to the contracts that general practices have to provide NHS services and the way secondary care is organised. These contracts encourage the NHS to transfer work to primary care with the expectation that GPs will pick up this work at little or no extra cost. Most GPs would have no problem with taking on such work if they were given time to deal with it during their current working week. If GPs had employment contracts similar to NHS consultants they could have job plans, with time allocated for clinical work and for activities such as administration, teaching, training, and research.

Read t…

Rethinking primary care’s gatekeeper role

Gatekeeping is the term used to describe the role of primary care physicians or general practitioners (GPs) in authorising access to specialist services and and diagnostic tests. Gatekeeping has important influences on service utilisation, health outcomes, healthcare costs, and patient satisfaction. In an article published in the British Medical Journal, we discuss the role of gatekeeping in modern health systems.

In the UK access to NHS and private specialists is generally possible only after a referral from a GP. Gatekeeping was developed as a response to a shortage of specialists and a desire to control healthcare spending and has been an accepted practice in the UK for many years. The NHS is under considerable pressure to use its resources efficiently, and GPs have helped the NHS to achieve this goal through managing a large proportion of NHS workload in primary care. However, GPs in the UK now find themselves under considerable workload pressures. In an 11-country survey of prim…

What impact will Brexit have on the NHS and universities?

I spoke recently at a Public Policy Exchange Symposium on the topic of ‘Brexit: What impact will it have on the NHS and universities?” The event was chaired by Dr Philippa Whitford MP. In my presentation, I outlined how Brexit will lead to major challenges for the UK’s NHS and universities, as well as for public health and the life sciences industry in the UK.

For the NHS, key issues include the retention of NHS employees from other EU countries; and the future recruitment of health professionals after the UK leaves the EU. The NHS will need to implement policies to train considerably more health professionals (including doctors) and retain them in the workforce. Another key issue is the right to publicly-funded healthcare of the EU nationals living in the UK and the UK nationals living in other EU countries. The future of the EHIC card also needs to be determined.

For public health, a key issue will be how the UK participates in future EU-wide public health initiatives. These cover …

Clinician-identified problems and solutions for delayed diagnosis in primary care

Delayed diagnosis in primary care is a common, harmful and costly to patients and health systems. Its measurement and monitoring are underdeveloped and underutilised. A recent study from Imperial College London published in BMC Family Practice created and implemented a novel approach to identify problems leading to and solutions for delayed diagnosis in primary care. We developed a novel priority-setting method for patient safety problems and solutions called PRIORITIZE. We invited more than 500 NW London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to delayed diagnosis in primary care. 113 clinicians submitted their suggestions which were grouped into a composite list of 33 distinct problems and 27 solutions. A random group of 75 clinicians from the initial cohort scored these and an overall ranking was derived.

The top ranked problems were poor communication between secondary and primary care and the inverse care law, i.e. a misma…

Can GPs issue private prescriptions to NHS patients?

The NHS prescription charge in England is currently £8.60 per item. At this level, many commonly prescribed drugs will cost less than the prescription charge and so some NHS patients may occasionally ask if they can have a private prescription rather than an NHS prescription.

In the past, some GPs have been advised that they could issue both an NHS FP10 and a private prescription, and let the patient decide which to use. But the British Medical Association's General Practice Committee has obtained legal advice that said under the current primary care contract, GPs in England may not issue a private prescription alongside or as an alternative to an NHS FP10 prescription. In any consultation where a GP needs to issue an FP10, the concurrent issue of a private prescription would be a breach of NHS regulations.

The issuing of a private prescription in such circumstances could also be seen as an attempt to deprive the NHS of the funds it would receive from the prescription charge. Fur…

Why we need workload-based funding for general practices in England

The NHS is currently aiming to develop a new capitation-based formula for funding general practices in England. My view is that a revised formula won’t address the fundamental problem with the current method of funding primary care: the disconnect between workload and funding. All the new formula will do – no matter how well-designed - is shuffle money between general practices. Some practices will gain substantial sums, some will lose substantial sums; but most practices will see no major changes in their funding. Capitation-based formulas for general practices are a 20th century solution that the government is trying to continue to use in the 21st century. We need to move away from a capitation-based funding model to one based on actual workload. Under such a model, any work done by general practices – whether generated through government policy, patient demand or transfer of work from specialist settings into the community – would be paid for at its full cost. There would then be …

Why do some children not attend their hospital outpatient appointments?

A recent study from my research group published in JRSM Open examined why some children do not attend their hospital outpatient appointments. The study found that the commonest reason for non-attendance is unawareness of the appointment due to incorrect contact details being held by the hospital. Potential strategies for reducing non-attendance at paediatric clinics include developing a confirmation or reminder system and improved communication with parents.

How to monitor patient safety in primary care: Healthcare professionals' views

A recent study from my research group published in JRSM Open aimed to identify ideas for patient safety monitoring strategies that could be used in primary care. People who took part in the survey offered 188 suggestions for monitoring patient safety in primary care. The content analysis revealed that these could be condensed into 24 different future monitoring strategies with varying levels of support. Most commonly, respondents supported the suggestion that patient safety can only be monitored effectively in primary care with greater levels of staffing or with additional resources. About one-third of all responses were recommendations for strategies which addressed monitoring of the individual in the clinical practice environment (e.g. GP, practice nurse) to improve safety. There was a clear need for more staff and resource to encourage better safety monitoring. Respondents recommended the dissemination of specific information for monitoring patient safety such as distributing the …

Flu vaccine may reduce the risk of death and hospital admission in people with type 2 diabetes

The flu vaccine may reduce the likelihood of being hospitalised with stroke and heart failure in people with type 2 diabetes, according to new research. The study from Imperial College London also found the patients who received the influenza vaccination had a 24 per cent lower death rate in the flu season compared to patients who weren't vaccinated.

The team, who published their findings in CMAJ (Canadian Medical Association Journal) studied 123,503 UK adults with type 2 diabetes between 2003 and 2010. Around 65 per cent of these patients received the flu vaccine. We found that, compared to patients who had not been vaccinated, those who received the jab had a 30 per cent reduction in hospital admissions for stroke, 22 per cent reduction in heart failure admissions and 15 per cent reduction in admissions for pneumonia or influenza. Furthermore, people who were vaccinated had a 24 per cent lower death rate than patients who were not vaccinated.

We also found a 19 per cent reducti…

Some of the many negative consequences of Brexit for the NHS

I've started to list some of the many negative consequences of Brexit for the NHS

The future employment of the 50,000 EU and EEA nationals who work in the NHS (including around 9,000 doctors).The development and implementation of reciprocal agreements to recognise the qualifications of doctors and other health professionals from the EU.More limited rights for UK health professionals to live and work in other EU countries.The access to NHS care of the three million EU nationals in the UK and the access to European healthcare of the two million UK nationals living in other EU countries.Disruption to Pan-European initiatives to protect public health.Loss of funding from the EU for medical research.Relocation out of London of the European Medicines Agency.Reduced funding for the NHS if predictions of lower economic growth for the UK are correct.Threats to the development of health IT standards.Imported NHS drugs and supplies may be more expensive.The UK may be a less favoured site for …

Message from the President of Imperial College London on the EU Referendum

"Imperial College London is, and will remain, a European university, whatever your view of the referendum outcome. We are very proud of the innovations, ideas and inspiration that come from the European members of Imperial’s global community. We are determined that political changes will not hold Imperial back from delivering excellence in research and education for the benefit of global society. We will vigorously defend our international values if they are threatened and will continue to think and act internationally. Our European students, staff and partners are crucial to the current and future success of this great university, and we look forward to continued strong ties with Europe and the world over the coming years. We are urgently seeking clarification from the government on the visa and fee status of non-UK European Union students, as well as other key policy areas for the College as the UK negotiates its future relationship with Europe. We will update the community, a…

Healthcare use among preschool children attending GP-led urgent care centres

Urgent care centres (UCCs) were developed with the aim of reducing inappropriate emergency department (ED) attendances in England. We aimed to examine the presenting complaint and outcomes of care for young children attending two general practitioner (GP)-led UCCs in West London with extended opening times. The findings were published in BMJ Open

Only 3% of all attendances to the GP-led UCCs were among preschool children over a 3-year period, with nearly a quarter of them being repeat attenders. Although the large majority of children attending were registered with a GP, over two-thirds attended out of hours. The most common reason for attending the GP-led UCC was for a respiratory disease, mainly an upper respiratory tract infection. The most commonly prescribed medications were for infections. Only one in five preschool children who attended required a referral to a paediatrician or an emergency doctor. 

Two-thirds of preschool children attending GP-led UCCs do so out of hours, desp…

How would a decision to leave the European Union affect medical research and health in the United Kingdom?

In an article published in the Journal of the Royal Society of Medicine, I argue that the UK must remain in the European Union (EU) to protect the health of UK residents. Also at risk following a vote to leave the EU would be the recruitment of doctors and healthcare workers to the NHS, medical research and teaching and the continued world-leading status of the top UK universities.

The most important impact of a ‘leave’ vote on health would arise from its economic effects, A Treasury analysis concluded a vote to leave the EU could lead to a £36 billion a year drop in tax receipts. The economic shockwaves following a departure from the EU could lead to substantial cuts to health and social care, and there would be an immediate negative impact on the health of UK residents. Lower levels of spending on social care would further increase pressures on both community and hospital services. For example, it would become more difficult to discharge frail, elderly patients from hospitals.

In t…

How do I encourage a patient to see a pharmacist?

We are employing a pharmacist to help with treatment reviews and to see minor acute illness but we are finding resistance from some patients to seeing him, with receptionists reporting that patients are requesting appointments with 'a proper doctor' instead. How do we respond?

Pharmacists offer many potential benefits to general practices. They can free up doctors’ time, deliver cost-savings to the NHS through more rational prescribing, and improve the quality of patient care. For example, pharmacists can improve patients’ understanding of their medication and their adherence to their drug regime. An increasing number of general practices are now using pharmacists and their role will be further expanded when the GP Forward View is implemented. However, some patients may be unwilling to see a pharmacist and insist on seeing a doctor.

To overcome this resistance, it is essential that all staff are briefed about the role of the pharmacist and what to say to patients who express c…

Public Health and Primary Care in England: What does the future look like?

Earlier this week, I spoke at a joint training day for primary care and public health registrars in London on the topic of Public Health and Primary Care in England: What does the future look like?

The key points from my presentation were:
Some new NHS investment – but investment is very low by historical standardsWill the new models of healthcare delivery deliver the £22 billion efficiency savings the Treasury expects?What impact will contractual changes have? Junior doctors, consultants, GPs, public health consultantsCan primary care attract and retain enough doctors?What impact will cuts in public health budgets have on health improvement programmes and on careers in the specialty? My presentation can be viewed on Slideshare.

Impact of the National Health Service Health Check Programme on cardiovascular disease risk

Our analysis of impact of the NHS Check programme on cardiovascular disease risk was published in the Canadian Medical Association Journal on 2 May 2016. The programme had statistically significant but clinically modest impacts on the risk for cardiovascular disease (CVD) and individual risk CVD factors, although diagnosis of vascular disease increased.

Overall program performance was substantially below national targets, which highlights the need for careful planning, monitoring and evaluation of similar initiatives internationally. The effect of the programme on CVD risk was the equivalent of one CVD event (e.g. heart attack) prevented for every 4,762 people who attended a health check in a year.

For the NHS health check scheme to be effective, it needs to be better planned and implemented – our work will help highlight how this can be done. In future we plan to evaluate whether particular groups – for instance older patients – have greater health benefits from the check than young…

TASME Conference 2016

It was a great privilege to be invited to speak at the 2016 TASME Conference (Trainees in the Association for the Study of Medical Education), where I spoke on the topic of "Writing in medicine - How to Capture an audience: Social media, editorials, letters and clinical commentaries". The standard of the presentations and posters was excellent, and reflects very well on clinical trainees and medical students.

Social media differentiates itself from more traditional forms of media by its immediacy and its focus on social interaction. Websites and online forums allow users to share information through interactive electronic exchanges. Many businesses now incorporate social media into their marketing strategies to deliver key messages, advertise services or improve communication with clients. The NHS, doctors and health professionals have been slower to take up the use of social media but we are now also now seeing increased use of social media in the health sector. In this wo…

Implications of the imposition of the junior doctor contract in England

In an article published in the Journal of the Royal Society of Medicine, Ailsa McKay, Ravi Parekh and I  discuss some of the implications of the imposition of the new junior doctor contract in England's NHS. For doctors, the contract's imposition is distressing for several reasons. First, the contract is incompletely developed, and there are errors in the associated ‘pay calculator’, and heavily criticised, unrealistic rotas have been published. Doctors are therefore unable to determine the hours they are likely to work under the new contract, how these will be distributed across the week, and the impact on their salaries. This uncertainty is compounded by lack of clarity around the government’s rationale for imposition: provision of a ‘seven-day National Health Service’. The government has not clearly defined what it means by this, and the proposed rotas do not redistribute services evenly across the week. Indeed it is unclear whether the new rotas will provide any enhanceme…

Junior Doctors in England Strike for the First Time in 40 Years

The UK government has announced the imposition a new junior doctor contract in England. Related negotiations between the British Medical Association and government representatives about a new junior doctors contract started in in 2013. These negotiations failed to reassure doctors, who were concerned about risks to their welfare, patient safety, and the future of England's National Health Service. With the impending imposition of the new contract, and lack of progress, junior doctors felt the risks of striking had fallen below those of inaction. Hence, the first strike staged by the English medical workforce for 40 years occurred in January 2016. This strike has been followed by subsequent strikes, with a full strike that will also include withdrawal of emergency care due to take place on 26-27 April 2016.

Read more in the Journal of Ambulatory Care Management.

Is it time to rethink the independent contractor status of GPs

Is it time to rethink the independent contractor status of GPs in areas of the UK where general practice is struggling? Mixing funding for patient services with funding for GP remuneration can lead to government reluctance to invest more in primary care for fear that money intended for service improvement will end up boosting GPs’ incomes. As practices close, it becomes clear that an individual practice is often too small a unit to carry the risk of unpredictable financial burdens such as maternity or sick leave. Ultimately, patients suffer, particularly in inner city or rural practices that receive little financial allowance for deprivation within current funding arrangements, and it is unlikely that a new “fairer funding formula” will rectify this.

The knock-on effects of the funding shortfall in these struggling practices are seen in the difficulties they have in recruiting GPs. Young doctors want clear job plans, career progression, time for management and clinical leadership, an…

Why the new junior doctor contract is bad for academic medicine and the UK's economy

As a clinician and academic, I was deeply saddened to see the Secretary of State for Health impose a new contract on junior doctors. The 55,000 junior doctors in England’s NHS are perhaps the most intelligent and highly educated and trained professional group in the country. They are perfectly capable of looking at the contractual changes being put forward by the NHS and drawing their own conclusions about the implications of the new contract for them. To say that they have been ‘brainwashed’ by extremist members of the British Medical Association, as some journalists and Conservative MPs have been implying, is ludicrous.

We also continue to hear from the Secretary of State for Health, Jeremy Hunt, that he believes that these contractual changes are needed to tackle higher weekend mortality in hospitals. This is an area in which I have and members of my department have published extensively. I am therefore fully aware of the research on this topic and the serious problems with some o…

What role should general practitioners play in a modern health system?

#Irishmed tweetchat 10pm GMT Wednesday 10 February 2016

Health systems across the world are faced with many challenges – such as rising patient expectations, increased workload, ageing populations, and an increased number of people with long-term conditions. At the same time, health systems also face significant financial problems. Consequently, governments, other funders of healthcare and patients expect more from their doctors without necessarily offering them additional resources.

As the first point of contact with patients, what role should general practitioners (in some countries, referred to as primary care physicians or family practitioners) play in meeting these challenges? General practitioners (GPs) have to deal daily with large numbers of patients, cope with a very wide range of clinical problems, meet performance targets, provide continuity of care while at the same time also providing easy access to health services, show they are addressing issues such as the rise of anti…

Better funding for GPs could reduce use of A & Departments by children

Children whose GPs are easy to access are less likely to visit A&E than those whose GPs are less able to provide appointments. These are the findings of a new study, led by researchers from Imperial College London, and published in the journal Pediatrics. The research also found that during weekdays, children’s visits to A&E peak after school hours.

The study, which was funded by the National Institute for Health Research, suggests that modest changes in the provision of GP appointments – such as providing more after-school appointments between the times of 5-7pm - could prevent thousands of visits to emergency departments a year. Although the study does not show that difficulty in accessing GP services is the direct cause behind increased emergency admissions, it raises important questions about the provision of GP services.

The study’s lead author, Dr Sonia Saxena, from the Department of Primary Care and Public Health at Imperial College London, and a practising GP, says: “…