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Does the use of point-of-care testing improve the cost-effectiveness of the NHS Health Check programme?

A paper published in the journal BMJ Open examines if the use of point of care testing is less costly than laboratory testing to the National Health Service (NHS) in delivering the NHS Health Check programme in primary. To address this question, we carried out an observational study, supplemented by a mathematical model with a micro-costing approach.

We collected data on cost, volume and type of pathology services performed at seven general practices using point of care testing and a pathology services laboratory. We collected data on response to the NHS Health Check invitation letter and DNA rates from two general practices.

We found that the costs of using point of care testing to deliver a routine NHS Health Check is lower than the laboratory-led pathway; with savings of £29 per 100 invited patients up the point of cardiovascular disease risk score presentation. Use of point of care testing can deliver NHS Health Check in one sitting, whereas the laboratory pathway offers patients…

Gender differences in hospital admissions for cardiovascular events and procedures in people with and without diabetes

An article published in the journal Cardiovascular Diabetology examines gender differences in hospital admissions for major cardiovascular events and procedures in people with and without diabetes.

Secondary prevention of cardiovascular disease (CVD) has improved immensely during the past few decades but controversies persist about the cardiovascular benefits among women with diabetes. We investigated 11-year trends in hospital admission rates for acute myocardial infarction (AMI), stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in people with and without diabetes by gender in England.

We found that diabetes-related admission rates remained unchanged for AMI, increased for stroke by 2% and for PCI by 3%; and declined for CABG by 3% annually. Trends did not differ significantly by diabetes status. Women with diabetes had significantly lower rates of AMI and stroke compared with men with diabetes. However, gender differences in admission rates f…

The diagnosis and management of Scarlet Fever in primary care

An article published in the London Journal of Primary Care discusses the diagnosis and management of Scarlet Fever. There has been a recent increase in the incidence of scarlet fever with most cases presenting in General Practice and Emergency Departments. Cases present with a distinctive macro-papular rash, usually in children. In patients who have the typical symptoms, a prescription of a suitable antibiotic such as phenoxymethylpenicillin (Penicillin V) should be made immediately to reduce the risk of complications and the spread of infection.

A typical presentation of scarlet fever
An 8-year-old girl is brought to see you at your practice. She has a sore throat, abdominal pain and has been vomiting. Her health was fine until two days ago. Initially, she noticed pain on swallowing and had a temperature of 38 °C. Her parents decided to seem medical advice once they noticed the ‘sandpaper-like’ rash on her trunk and the inside of her elbows. When you examine her tongue, the enlarged …

Is there still a role for smaller hospitals in the NHS?

A paper published in the British Journal of Hospital Medicine asks the questions "Is there a role for smaller hospitals in the future NHS?"

The NHS is challenged by rising demand as a consequence of a population with more complex conditions and the rising costs of paying for that care. Inefficiencies resulting from fragmented primary, secondary and social care services highlight the need for greater coordination and continuity to improve patient outcomes at lower cost. Financial constraints can drive health system review, providing impetus to modify health service delivery within the NHS to maximize value and better align with the needs of our population.

The Naylor (2017) review calls for urgent rationalization of the NHS estate to meet the mandate of the Five Year Forward View. Smaller acute hospitals could be seen as a potential starting point for reconfiguring health services in England. However, local change is not always welcome and the perceived loss of services is o…

The burden of disease in the World Health Organization's Eastern Mediterranean Region

I contributed to a series of papers on health in the World Health Organization's Eastern Mediterranean Region. Key steps that need to be taken to improve the health and well-being of people in the region must include ending the wars and conflicts in the region, as well as improving education and employment opportunities, particularly among women. Health systems must be strengthened as well, for example, through building up primary care and using health programmes to target the causes of ill-health, such as high-calorie diets, smoking, physical inactivity and obesity. In addition, health workers and governments should aim to improve maternal and child health and ensure that immunisation rates are high, as well as addressing environmental factors such as air pollution. You can read more on the Imperial College Website.

The papers were published in the International Journal of Public Health. Papers in the series include:

Diabetes mellitus and chronic kidney disease in the Eastern Med…

NHS England’s plan to reduce wasteful and ineffective drug prescriptions

I published an article in the British Medical Journal in August 2017 on NHS England’s plan to reduce wasteful and ineffective drug prescriptions. In the article, I explain why national rules on prescribing are a better approach than the variable local policies being implemented by clinical commissioning groups (CCGs, the NHS organisations responsible for funding local health services).

The National Health Service (NHS) in England must produce around £22 billion of efficiency savings by 2020. A key component of the NHS budget in England is primary care prescribing costs, currently around £9.2 billion annually. Inevitably, the NHS has begun to look at the drugs prescribed by general practitioners to identify areas in which savings could be made; ideally without compromising patient care or worsening health inequalities. This process was initially led by CCGs, focusing on drugs that are either of limited clinical value or which patients can buy from retailers without a prescription (ref…

Imperial College joins the UK's effort to tackle global health challenges

The Department of Primary Care and Public Health at Imperial College London has been awarded funding as part of a UK drive to tackle global health challenges. The work is funded by Research Councils UK as part of the Global Challenges Research Fund (GCRF), a £1.5 billion fund launched by the UK government in 2015. The fund aims to support cutting-edge research which addresses the global issues faced by developing countries in areas including agriculture, medicine, well-being and infrastructure.

The GCRF funding will also enable Imperial Professors Azeem Majeed, Toby Prevost and Mala Rao to investigate low cost technologies for screening for diabetic eye disease, a leading cause of blindness in India, in partnership with clinicians from Moorfield’s Eye Hospital in London. Professor Mala Rao, who is leading Imperial’s contribution to the project, said: “This award offers a very exciting opportunity for us to work together to transform the lives of people with diabetes and diabetic eye …

Advice on the management of the transgender patient in primary care

A recent article in the journal BJGP Open provides advice on the management of transgender patients in primary care. With referrals to gender identity clinics rising rapidly, general practitioners (GPs) and primary care physicians are more likely to meet patients who are transgender (whose gender identity, or internal sense of gender, does not match their gender assigned at birth) or diagnosed with gender dysphoria (the severe psychological distress that is experienced by an individual as a result of the conflict between their gender identity and gender assigned at birth).1 Teaching on transgender medicine is lacking in both undergraduate and postgraduate curricula, leading to a perceived lack of expertise in this area. Furthermore, General Medical Council (GMC) guidelines on the GP’s role in prescribing are vague, resulting in some controversy. As waiting times for appointments at specialist clinics are often at least 18 months, GPs and primary care physicians will increasingly be i…

Visit to DeepMind

I was invited Google’s headquarters in London today to discuss the work in healthcare being carried out by DeepMind. We had a very interesting discussion about the scope for the use of artificial intelligence in healthcare to improve clinical outcomes and population health. We also discussed the use of predictive modelling to identify patients with long-term conditions at high risk of death, readmissions and complications.

Prioritizing medication safety in care of people with cancer

A recent study from Imperial College London published in the Journal of Global Health examined clinicians’ views on main problems and solutions in medication safety in the care of people with cancer. The top ranked problems focused on patients' poor understanding of treatments due to language or education difficulties, clinicians' insufficient attention to patients' psychological distress, and inadequate information sharing among health care providers. The top ranked solutions were provision of guidance to patients and their carers on what to do when unwell, pre–chemotherapy work–up for all patients and better staff training.

Why I became a mental health champion at Imperial College London

As a doctor with many years experience of working in the NHS, I am aware of the impact that mental health problems can have on people’s health, well-being and quality of life, as well as on their family and friends. Mental health problems are also important for employers, and result in considerable financial costs in lost production and in staff absences from the work-place due to ill-health. However, even though mental health problems are very common, many people find it difficult to talk about them.

Encouraging a supportive environment in the workplace that reduces the risk of mental health problems developing – and in supporting staff to seek help when mental health problems do arise – is very important for employers. It improves employees’ health and well-being, and creates a more productive and pleasant working environment.

As a Mental Health Champion, I see my role as supporting my departmental colleagues to achieve these objectives and ensure that mental health issues in the w…

Shortage of general practitioners in the NHS

In an article published in the British Medical Journal, I discuss the implications of the current shortage of NHS general practitioners. Ensuring that countries have sufficient primary care doctors is a key challenge for health planners globally because of the important role that primary care plays in supporting cost-effective health systems that promote equity in health outcomes. For example, the USA is predicted to need 7,800 to 32,000 additional primary care physicians by 2025.[1] We also know that the National Health Service (NHS) in the United Kingdom is short of general practitioners.[2] What we do not know is the size of the shortage; and how many additional general practitioners the NHS needs to provide comprehensive primary care services.

In its plan for general practice published in 2016, NHS England set a target of 5,000 additional general practitioners by 2020.[3] However, no data was presented to show that this was a sufficient number to meet the needs of primary care in…

Key priority areas for patient safety improvement strategy in Libya

A paper published in the journal BMJ Open describes a protocol for a study examining patient safety in Libya. Patient safety is a global public health problem. Estimates and size of the problem of patient safety in low-income and developing countries are scarce. A systems approach is needed for ensuring that patients are protected from harm while receiving care. The primary objective of this study will be to use a consensus-based approach to identify the key priority areas for patient safety improvement in Libya as a developing country.using a modified Delphi approach.

A three-phase modified Delphi study will be conducted using an anonymous web-based questionnaires. 15 international experts in the field of patient safety will be recruited to prioritise areas of patient safety that are vital to developing countries such as Libya. The participants will be given the opportunity to rank a list of elements on five criteria. The participants will also be asked to list five barriers that th…

The divergence of minimum unit pricing policy across the UK

A paper published in the Journal of the Royal Society of Medicine discusses the implementation of a minimum unit pricing policy across the UK. Above recommended levels of intake, alcohol use is associated with harm including hypertension, haemorrhagic stroke, liver disease, mental health disorders and cancers, as well as accidents, injuries and assaults. The 2015 UK Global Burden of Disease study indicates that 2.9% of disability-adjusted life years and 1.9% of mortality are attributable to alcohol use, and the 2013 Health Survey for England found that 23% of men and 16% of women in England drink at levels associated with risk to health. Despite the ongoing discussion about minimum unit pricing policy across the UK, and although it is difficult to predict what it would take for the Westminster Government to revert to a minimum unit pricing policy, any minimum unit pricing policy that does come to be implemented in Scotland or England and Wales will only be implemented because the rel…

Evaluation of the NHS Health Check Programme in reaching under-served groups

A recent paper from my department published in the journal BMC Health Services Research assessed how effective the NHS Health Check Programme was in reaching under-served groups.

Cardiovascular disease (CVD) is the leading cause of premature mortality and a major contributor of health inequalities in England. Compared to more affluent and white counterparts, deprived people and ethnic minorities tend to die younger due to preventable CVD associated with lifestyle. In addition, deprived, ethnic minorities and younger people are less likely to be served by CVD prevention services. This study assessed the effectiveness of community-based outreach providers in delivering England’s National Health Services (NHS) Health Check programme, a CVD preventive programme to under-served groups.

Between January 2008 and October 2013, community outreach providers delivered a preventive CVD programme to 50,573 individuals, in their local communities, in a single consultation without prescheduled appo…

Health Effects of Overweight and Obesity in 195 Countries

Globally, more than 2 billion children and adults suffer from health problems related to being overweight or obese, and an increasing percentage of people die from these health conditions, according to a new study published in the New England Journal of Medicine.

They are dying even though they are not technically considered obese. Of the 4.0 million deaths attributed to excess body weight in 2015, nearly 40% occurred among  people whose body mass index (BMI) fell below the threshold considered “obese.”

The findings represent “a growing and disturbing global public health crisis,” according to the authors of the paper published today in The New England Journal of Medicine.  In the UK, nearly a quarter of the adult population – 24.2% or 12 million people – is considered obese. Additionally, 1 million British children are obese, comprising 7.5% of all children in the UK.

Among the 20 most populous countries, the highest level of obesity among children and young adults was in the Unite…

Sophie the very helpful dragon

A story for five-year olds

Written by Professor Azeem Majeed

Sophie the dragon was sad. Why was Sophie sad? Because the children in the nearby village wouldn’t play with her. Each time Sophie approached the children, they would run away screaming. She often asked her mother why the children would not play with her.

“It’s because the people of the village are afraid of dragons.” Her mother said. “The village chief, Donald, has told the villagers that dragons are terrible creatures; that we will burn down their houses, eat their farm animals, and carry off their children.”

“That’s a horrible thing to say.” Said Sophie. “We dragons are kind and gentle, and want to help others”.

“True.” Said Sophie’s mother. “But Donald is their chief and the other villagers believe what he says.”

One day, Sophie could see the villagers collecting wood and placing it into a big pile in the middle of the village green.

“What are they doing?” Sophie asked her mother. “It will be bonfire night soon.” Replied …

Current and future perspectives on the management of polypharmacy

A paper published in the journal BMC Family Practice discusses the management of polypharmacy (the concurrent use of multiple medications by one individual). Because of ageing populations, the growth in the number of people with multi-morbidity and greater compliance with disease-specific guidelines, polypharmacy is becoming increasingly common.

Although the correct drug treatment in patients with complex medical problems can improve clinical outcomes, quality of life and life expectancy, polypharmacy is also associated with an increased risk of adverse drug events, some severe enough to result in hospital admission and even death. Hence, having systems in place to ensure that medications are started only when there is a suitable indication, ensuring patients are fully aware of the benefits and complications that may arise from their treatment, and reviewing patients regularly to ensure their medication regime remains appropriate, are essential.

The development and rapid uptake of el…

Changes in the Roles of Health Care Professionals in Primary Care in England's National Health Service

In an article published in the Journal of Ambulatory Care Management, Dr Sonia Kumar and I discuss the change in the roles of doctors and other health professionals in England’s NHS. Primary care in England has seen a slow but steady expansion in the roles and numbers of non-medical health care professionals over the last 50 years. In the next 5 to 10 years, the use of non-medical professionals will expand rapidly in primary care, with currently unknown consequences for patient outcomes and England’s NHS. Doctors in England will find their traditional professional autonomy slowly decreasing as they increasingly work in multi-professional teams; and the education and professional development of our medical students and doctors need to change to reflect these new ways of working.

A further challenge (and opportunity) for doctors arises from the rapid advances we are seeing in information technology. Through the Internet and Web sites such as NHS Choices, patients in the United Kingdom …

Does charging different user fees for primary and secondary care affect first-contacts with primary healthcare?

Policy-makers in many countries are increasingly considering charging people different fees for using primary and secondary care services (differential user charges). The aim of such 'differential fees' is to encourage use of primary health care in health systems with limited gate keeping.

We carried out a systematic review to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published from January 1990 until June 2015. We extracted data from the studies meeting defined eligibility criteria and assessed study quality using an established checklist. We synthesized evidence narratively.

Eight studies from six countries met our eligibility criteria. The overall study quality was low, with diversity in populations, interventions, settings, and methods. Five studies examined the introduction of or increase in user charges for secondary care, with four showing decreased secondary care utilisation, and three showing increased pr…

What will Brexit mean for the NHS?

On the 29 March 2017, the Prime Minister of the UK Theresa May, formally notified the European Union (EU) Council President, Donald Tusk, of the UK’s intention to leave the EU. Theresa May’s letter to Donald Tusk triggers a two-year process during which the UK will have to negotiate both the terms of its exit from EU and the arrangements that will replace those we have had for over 40 years with the other member states of the EU. The consequences of the United Kingdom’s departure from the EU (commonly referred to as ‘Brexit’) will be wide-ranging and will affect all areas of UK’s society, including the National Health Service (NHS).

For the NHS, Brexit comes at a time when it faces many other major challenges. These include severe financial pressures, rising workload, increased waiting times for both primary care and specialist services, and shortages of health professionals in many key areas (such as in general practice and in emergency departments). The NHS also faces challenges fr…

Gender identity and the management of the transgender patient: a guide for non-specialists

A recent article published in the Journal of the Royal Society of Medicine discusses the management of transgender patient. Transgender people, whose gender identities, expressions or behaviours differ from those predicted by their sex assigned at birth, are receiving increased attention both in the general media and in the medical press. Recent guidelines in the UK have proposed placing much of the responsibility of care for transgender patients on primary care physicians and their teams. With waiting lists for most gender identity clinics extending beyond 12 months and increasing numbers of patients coming forward for treatment, hospital doctors are also likely to encounter transgender patients in their clinical practice.

General Medical Council guidance published in 2016 recommended that general practitioners play a key role in the care of transgender patients. This includes counselling or appropriate referral (which can be done directly by general practitioners, without an interi…

National rules are needed about restriction of NHS prescriptions for drugs available over the counter

A recent news article in the BMJreported that many clinical commissioning groups (CCGs) in England are trying to restrict NHS prescriptions for drugs that are also available over the counter (OTC). This would include, for example, drugs such as antihistamines. This raises a number of issues. Firstly, CCGs have no legal power to limit the prescribing of drugs by GPs (although many CCGs and GPs don’t seem to know this). The only drugs that GPs are not allowed to prescribe are those listed in Part XVIIIA of the NHS Drug Tariff (sometimes referred to as the ‘blacklist’). 

Secondly, rather than going through a formal process and asking the Department of Health to place additional drugs on the ‘blacklist’, CCGs seem content to let doctors decide who should have these drugs on NHS prescription and who should not. This will inevitably lead to considerable variation between GPs in their propensity to prescribe these drugs, thereby leading to ‘postcode prescribing’. 

Thirdly, it also raises legal…

Interview with the British Medical Journal

The BMJ published an interview with me in March 2017 for their 'Observations' section.

What was your earliest ambition?
As a boy I was keen to be a pilot. My poor eyesight put an end to that ambition.

Who has been your biggest inspiration?
Two of my former consultants, James Stuart and Keith Cartwright, who mentored me early in my career, helped me write my first scientific papers, and started me on my academic career path.

What was the worst mistake in your career?
Early in my career I admitted a man who had undergone some changes in behaviour after a minor head injury. I did not consider ordering a CT scan immediately, but fortunately my senior registrar did, and a diagnosis of a subdural haematoma was made. The patient underwent surgery that evening and had a good outcome.

What was your best career move?
Moving to London in the 1990s to take up my first academic post. Although I was unsure about moving to such a large city, having always lived in much smaller towns, working in Lond…

Brexit may exacerbate shortages of health professionals in the UK

The UK’s departure from the European Union will have wide ranging consequences, including doctors leaving the country. As a member of the EU for over 40 years, the UK is fully linked with Europe in all sectors of its society. This includes the NHS, which faces major risks if it fails to tackle the challenges that Brexit poses.

The NHS has faced shortages in its clinical workforce for many decades and has relied heavily on doctors, nurses, and other health professionals who were trained overseas to fill the gaps. This reliance will not end in the foreseeable future. Jeremy Hunt, the health secretary for England, has announced that the government will support the creation of an additional 1500 medical student places at England’s medical schools, but these students won’t complete their medical courses and postgraduate medical training for over 10 years.

The recruitment of medical staff trained overseas has been facilitated by EU legislation on the mutual recognition of the training of h…

A woman with a suspected viral rash in pregnancy

My article in the BMJ considers how doctors should approach the management of a woman with a suspected viral rash during pregnancy. Key points in the article include:

Consider country of origin in a woman presenting with a rash in pregnancy and ask for immunisation history.Test for measles and rubella IgM and IgG antibodies, particularly if immunisation history is not clear.Refer women with an active infection to the fetal medicine unit for fetal monitoring.
The full article can be read in the BMJ.

Warning signs might have been missed in one in six heart attack deaths in England

Heart attack symptoms might have been missed in many patients, according to a study on all heart attack hospital admissions and deaths in England from Imperial College London. More research is urgently needed to establish whether it is possible to predict the risk of fatal heart attacks in patients for whom this condition was not recorded as the main reason for hospital admission. The study was published in The Lancet Public Health.

Heart disease is one of the leading killers in the UK. According to the British Heart Foundation, heart attacks lead to one hospital visit every three minutes. They are caused by a decrease in blood flow to the heart, usually as a result of coronary heart disease. Symptoms may include sudden chest pain or a 'crushing' sensation that might spread down either arm. Patients might also experience nausea or shortness of breath. However, some heart attacks have more subtle symptoms and may therefore be missed or overlooked.

In this study, we examined re…

A carer proposes covertly medicating a patient - what should I do?

You are called by a worker at a care home. She is concerned about a dementia patient who, despite all non-drug measures being tried, is causing distress to other residents. She asks you to prescribe a sedative to ‘slip into her food’. How should you proceed?

Giving medication covertly to sedate an agitated patient raises serious legal and ethical issues. Treatment without consent is only permissible where there is a legal basis for this. In the scenario described here, giving a sedative to the patient without her knowledge and consent would be a breach of her human rights. There is also a risk that the patient could suffer side effects from the medication she was given. For example, administration of a benzodiazepine or an antipsychotic drug could lead to a fall or a fracture that resulted in serious harm to the patient. Covert administration of medication is also a breach of trust on the part of the doctor who prescribed the medication. Hence, it may lead to a formal complaint agains…