Medical Centre

In their paper on the effect of illness adjustment on regional mortality and spending rates using standard and visit corrected illness methods for adjustment, Wennberg and colleagues compare adjustment using diagnoses listed in administrative databases with additional adjustment for the frequency of doctors’ visits.1 They acknowledge that data on the use of healthcare cannot be used directly as a proxy for need or risk because these data also reflect differences in access to and supply of healthcare services. However, the methods of risk adjustment developed by these and other authors are based exactly on these data. Steventon’s editorial does not challenge this approach.2 Myself and Michael Soljak suggest in a letter published in the BMJ that this problem should be approached using the fundamental public health principle of disease prevalence in a population (“health needs assessment”). Good measures of the incidence and prevalence of disease known to primary healthcare services a...

Text4baby is a mobile health (or mHealth) education programme sending free text-messages to women who are pregnant or have a young infant, that was launched in February 2010. The programme is a public–private partnership supported by a number of industry and public sector partners that include government agencies, the White House Office of Science and Technology Policy, corporations, academic institutions, professional associations and non-profit organizations. By covering all of USA and now spreading into other countries, such as Russia, it is the largest scale up of an mHealth intervention globally. In an article published in the Journal of the Royal Society of Medicine , Michelle Van Velthoven and colleagues concluded that As the first national programme of its kind, text4baby should be rigorously evaluated to ensure that pregnant women and their babies benefit from the programme, and that the programme truly becomes a role model for public–private partnerships in mHealth.

End-stage renal disease (ESRD) has emerged as an important public health issue worldwide, because of the marked increase in its incidence and prevalence. In a study published in the journal Diabetes Research & Clinical Metabolism , Amal Hassanien and colleagues examined pre-ESRC care in the Al-Noor Kidney Centre and Jeddah Kidney Centre in the western region of Saudi Arabia. Participants were patients with ESRD on regular haemodialysis during 2011. Main outcome measures were pre-ESRD care including: reason of referral to nephrology care, source of referral to nephrology care, duration of pre-ESRD care, and vascular access at the first dialysis; and primary causes of ESRD. Preliminary indicators of pre-ESRD care showed that endocrine, nutritional and metabolic diseases, and immune disorders were the principal reason for patient referral. The predominant causes of ESRD were hypertension and diabetes. Hassanien and colleagues concluded that pre-ESRD care needs to be improved in ...

A well-established primary care sector has allowed England’s National Health Service (NHS) to make efficient use of resources through the gatekeeping role that general practitioners have in controlling access to specialist services. Because of the poor economic situation in the United Kingdom, there is now considerable pressure on the NHS to use its resources more efficiently. These financial challenges are putting enormous pressure on general practices at a time when the NHS is also going through other major structural changes. Consequently, general practitioners in England increasingly find themselves having to make difficult decisions about the future of their practices. In an article published in the Journal of Ambulatory Care Management , I discuss the impact of these financial challenges on the career intentions of physicians. In recent years, primary care has been an attractive career choice for young physicians because of the flexible, diverse nature of the work and the rela...

In an article published in the journal Evidence Based Nursing , I comment on a recent Cochrane review of general health checks. These are checks that aim to detect risk factors and diseases in healthy people, with the aim of either preventing a disease from developing, or treating a disease earlier in its course. The systematic review of randomised controlled trials (RCTs) of general health checks found that they did not reduce morbidity or mortality, but did increase the number of new diagnoses. The review did though have several limitations. The trials included differed markedly in their definition of what constituted a ‘general health check’ and in the disease they were aiming to address. They also differed in how any newly identified risk factors or disease would be managed. In many studies, the only intervention offered was brief lifestyle advice. Some of the trials were also old, dating from the 1960s. Many of the currently available risk reduction interventions (such as the wid...

In a letter published in The Lancet , in response to their recent series on universal health coverage, John Lee and colleagues from the Department of Primary Care & Public Health at Imperial College London comment that many people still need to pay a high proportion of total health expenditure out of pocket. Patients’ costs must be reduced to further improve health and provide financial protection in health systems with universal health coverage  Governments should continue to lower user charges in health systems with universal health coverage  Rather than seeing lower financial contributions from patients as an efficiency loss, they should see it as a means to promote prevention and the use of cost-effective services. 

Sickle cell disease (SCD) is the most common and fastest growing genetic disorder in England. SCD is an illness in which recurrent pain, also referred to as vaso-occlusive crisis, is a chronic concern. Primary care professionals therefore play a key role during the initial presentation of symptoms, as well as the management of long-term complications including such recurrent pain. In England, London residents account for approximately three quarters of all SCD admissions to hospitals, with the London Borough of Brent being one of the highest risk areas for SCD. Many aspects of SCD can be effectively and efficiently managed in primary care. Previous studies have shown successful interventions that move management of SCD, particularly uncomplicated sickle cell pain episodes, from tertiary towards primary care. Focus groups may be useful for obtaining developmental input in managing SCD in primary care. In a paper published recently in JRSM Short Reports , Ghida AlJuburi and colleagues...

The burden of chronic diseases such as chronic obstructive pulmonary disease (COPD) is increasing rapidly in low and middle-income countries. Despite this, their management in such countries has often not been well studied. In a paper published in JRSM Short Reports, Ailsa McKay and colleagues reviewed the nature and efficacy of current management strategies for COPD in India. They found information regarding current management – particularly on the implementation of national guidelines and primary prevention – to be very sparse. This led to difficulty in interpreting studies of management strategies, which were varied and generally of positive effect. Data regarding current management outcomes were very limited. They concluded that the current understanding of management strategies for COPD in India is limited due to a lack of published data. Determination of the extent of current use of management guidelines, availability and use of treatment, and current primary prevention strate...

Sickle cell disease (SCD) is the most common inherited blood disorder in England. Without prompt diagnosis and proper treatment, it can be a serious source of morbidity and mortality. The complications of SCD can lead to frequent hospital visits and appropriate management is needed to minimize the risk of developing such complications. SCD clinical guidelines recommend that patients see a general practitioner (GP) for routine examination every six months and more often if new problems arise or their treatment protocol changes. In addition, immunizations, prescriptions and other preventive care measures need to be delivered effectively by GPs to prevent recurring infections and pain crisis. In a questionnaire study published in JRSM Short Reports , Ghida AlJuburi and colleagues investigated the views of patients with SCD about the quality of care they have been receiving from their primary healthcare providers and what they thought was the role of primary care in SCD management. The ...

Research led by Dr Chris Millett from the Department of Primary Care and Public Health at Imperial College London reported that the introduction of smoke-free legislation in England was immediately followed by a fall in the number of children admitted to hospital with asthma symptoms, a new study has found. NHS statistics analysed Dr Millett and his colleagues show a 12.3 per cent fall in admissions for childhood asthma in the first year after the law on smoking in enclosed public places and workplaces came into effect in July 2007. Asthma admissions continued to fall in subsequent years, suggesting that the benefits of the legislation were sustained over time. The effect was equivalent to 6,802 fewer hospital admissions in the first three years of the legislation, in the analysis published in the US journal Pediatrics . Dr Millett said: " There is already evidence that eliminating smoking from public places has resulted in substantial population health benefits in England, ...

Email is widely used in many sectors of society and many people now use email regularly. The use of email in health care is however less common. One possible use of email in healthcare is for health professionals to use it to send patients information on disease prevention and health promotion. In a systematic review published by the Cochrane Collaboration , Prescilla Sawmynaden and colleagues examined how patients, healthcare professionals and health services may be affected by using email in this way. They reported that there was limited evidence on the effects of using email to give people information on disease prevention and health promotion. Consequently, they were unable to properly assess email’s impact on patient behaviours & actions. As there is a lack of good quality evidence for whether email can be used by healthcare professionals to provide information to patients on disease prevention and health promotion, Sawmynaden and colleagues concluded that future studies shou...

The benefits of tight glycaemic control in people with newly diagnosed type 2 diabetes need to be clarified. In a study using data from the UK GPRD on a group of people with newly diagnosed type 2 diabetes that was published in the British Journal of Diabetes & Vascular Disease , Kamlesh Khunti and colleagues examined the effect of HbA1C on all cause mortality, and also in relation to the presence of cardiovascular disease. They found differing mortality risks in individuals with and without cardiovascular disease before diagnosis of type 2 diabetes (median survival 15.8 years and 9.8 years respectively). A baseline HbA1C above 6.0% and less than 6.5% was associated with increased all cause mortality in people newly diagnosed with type 2 diabetes without prior cardiovascular disease. In individuals with established cardiovascular disease, HbA1C category levels above 6.5% were associated with a non-significant increase in mortality and only become significant at HbA1c levels abov...

Throat infections can cause considerable problems for children and their families. For example, in the UK, throat infections are among the most common reasons for consulting a general practitioner and, if severe, can result in admission to hospital. In the past, tonsillectomy was commonly performed in children with recurrent throat infections but in recent years, the implementation of clinical guidelines has led to a decline in tonsillectomy rates. In a paper published in the journal Archives of Diseases in Childhood , Elizabeth Koshy examined trends in admission rates from throat infections in children in England. They reported that age-standardised admission rates for throat infections increased by 76% from 107 to 188 admissions per 100 000 children. Koshy and colleagues concluded that this increase in admission rates was more likely to be due to changes in primary care and hospital services, rather than an increase in the number of children with severe infections or a consequence...

Although email is now a very commonly-used method of communication, its use in health care is not yet routine. Email has been used for communication of clinical information between patients and healthcare professionals, but the effects of using email in this way are not known. In a recent review published by the Cochrane Collaboration , Helen Atherton and colleagues assessed the use of email for two-way clinical communication between patients and healthcare professionals. Atherton and colleagues concluded that the evidence was limited it was not possible to adequately assess the effect of email for clinical communication between patients professionals. They advised that future research should take into account the changing nature of technology when designing and conducting future studies and barriers to trial development and implementation should also be tackled. Potential outcomes of interest for future research include clinical effectiveness, cost-effectiveness and use of health ser...

A recent article in the Guardian newspaper by Juliette Jowit discusses the potential impact on patient care on cuts to primary care budgets. The article quotes from my experience as a general practitioner in Lambeth. " People will start to go to A&E: that costs a lot more and puts a strain on hospitals," he said. "And there's evidence from a number of studies that the better access to GPs is, the better you get in terms of low rates of inpatient admissions for things like strokes [and] lung infections. You end up with poorer health, more cases of hospital care and higher costs ." I also discussed these issues in a recent article in the British Journal of General Practice . 

High blood pressure is the main risk factor for cardiovascular disease. As cardiovascular risk is directly associated with blood pressure levels, the aim of interventions is to lower blood pressure. This aim results in a definition of the control of blood pressure which is currently understood as an achievement of specific blood pressure levels or targets. These targets have been established in different guidelines based on the consensus views of experts. In a study published in JRSM Short Reports , Lena Barrera and colleagues compared differences in the classification of hypertensive controlled patients between the quality indicator established in QOF guidance and the clinical target recommended in NICE guidelines using data from general practices in London. They found that 80% of patients were classified as controlled by the QOF target and 1% by the NICE target. 93% and 14% of practices had more than 70% of patients classified as controlled using the QOF and NICE targets respec...

General practitioners (GPs) in England are currently facing perhaps their most challenging financial circumstances since the NHS was founded in 1948. In an editorial published in the British Journal of General Practice , I discuss these the very difficult financial environment that general practitioners find themselves in. GPs will find themselves caught between the priorities of clinical commissioning groups (CCGs) and the NHS Commissioning Board; with CCGs requiring ever greater efficiencies in the use of secondary care services; and the NHS Commissioning Board demanding more ‘value for money’ from general practice contracts. A strong primary care sector has allowed the NHS to make efficient use of resources, through the gatekeeping role that GPs have in controlling access to specialist services, and through the wide range of medical, social, and psychological problems that GPs and their teams manage through a mix of person-based and population-centred care. The impact of cuts in ...

Obstructive sleep apnoea (OSA) affects between 2-3% of the population of the UK.  Interestin OSA has increased because of its association with hypertension, type 2 diabetes mellitus and coronary artery disease, and adverse health outcomes. In an article published in the Primary Care Respiratory Journal , Ravi Parekh and colleagues discuss the association of OSA with obesity and snoring. 

Primary care is a major component of England’s National Health Service , providing around 300 million consultations per year with GPs in England. In addition to providing healthcare to their patients, GPs are also charged with coordination and gatekeeping of access to services provided by secondary care, tertiary care and other allied healthcare providers; a responsibility that will become more important now that GPs will be undertaking the commissioning of health care. This new responsibility for GPs provides an opportunity to re-model care delivery to maximize outcomes, cost efficiency and patient access by focusing on diseases that are most amenable to management in primary care. In a paper published in the Journal of the Royal Society of Medicine , Daniel Gibbons and Colleagues review the evidence on what conditions are most sensitive to management in primary care – commonly referred to as primary care sensitive conditions (PCSCs) or ambulatory care sensitive conditions. Such de...

In a systematic review published in JRSM Short Reports , Josip Car and colleagues collated and critically evaluate the available scientific evidence on the negative health system effects of global health initiatives in developing countries. They identified 24 studies commenting on adverse effects on health systems arising from Global Fund investments. Sixteen were quantitative studies, six were qualitative and two used both quantitative and qualitative methods, but none explicitly stated that the studies were originally designed to capture or to assess health system effects (positive or negative). Only anecdotal evidence or authors’ perceptions/interpretations of circumstances could be extracted from the included studies. Dr Car and colleagues concluded that that much of the currently available evidence generated between 2002 and 2009 on global health initiatives potential negative health system effects is not of the quality expected or needed to best serve the academic or broader c...