Medical Centre

Statistics from the OECD show that the per capita use of statins in the UK is the highest in Europe and the second highest in all OECD countries. There are a number of reasons for this, which include the emphasis on evidence-based medicine in the training of UK doctors; the 2004 GP contract which introduced incentives for the management of long-term conditions such as coronary heart disease and diabetes; and the NHS Health Check programme which aims (amongst its objectives) to increase the use of statins for the primary prevention of cardiovascular disease (CVD) in people with a 20% or more 10-year risk of CVD. The National Institute for Health & Care Excellence (NICE) is now proposing to reduce the threshold for starting statins for the primary prevention of CVD from its current threshold of a 20% 10-year CVD risk to a 10% 10-year CVD risk. Although this could have significant benefits for the health of the population, there are three issues that need to be considered. These ...

In a response to an editorial published in the BMJ by Dr Fiona Godlee, I discuss the need for better information to be available on the side-effects of statins. This is a a key issue in the debate about trying to widen the use of statins because of the discordance between rates of side-effects of statins in clinical trials and in clinical practice. In clinical trials, the incidence of side effects from statins is low and similar in the intervention and placebo groups.[1] In contrast, observational studies using primary care databases report a much higher rate of potentially serious side effects (such as myopathy and renal failure) in people taking statins.[2, 3] Even these rates derived from clinical records may under-estimate the true incidence of side effects in people taking statins because not all patients with side effects will inform their doctor and not all doctors will enter a relevant diagnostic code in the patient’s electronic medical record. Many general practitioners ...

In a study published in the the journal JRSM Open , we examined the performance assessments and cognitive function of practitioners referred to the National Clinical Assessment Service (NCAS) in 109 practitioners over the age of 45 years referred to NCAS between 1 September 2008 and 30 June 2012. The main outcome measures were reasons for referral of practitioners and their characteristics; details of their assessments including screening for cognition using Addenbrooke's Cognitive Examination Revised (ACE-R); outcome of the process. Reasons for referral included ‘clinical difficulties’ and ‘governance or safety issues’. Eighty-seven practitioners scored above 88 on ACE-R. Twenty-two were found to have an ACE-R score of ≤88. On further assessment, 14 of these 22 practitioners were found to have cognitive impairment. The majority of all practitioners were found to be performing below the expected level of practice for someone at their grade and specialty. Of those scoring ≤88 o...

Charing Cross and Hammersmith Hospitals’ accident and emergency services will be reconfigured under current plans for reconfiguring health services in North West London. Both hospitals currently have a GP-led urgent care centre co-located with an emergency department. Patients who refer themselves for emergency care are unable to access the emergency department without being seen by a GP or emergency nurse practitioner in an urgent care centre. We present early data on the evaluation of the two the urgent care centres that was published in a letter in the BMJ . From 1 October 2009 to 31 December 2012, 282 947 unplanned attendances occurred at these centres, 63.2% of them at Charing Cross Hospital. The annual number of attendances increased by 9.4% (7911) from 2010 to 2012 (92 303 in 2012). Most attending patients (85.3%) were registered with a general practice, and 47.7% of attendances occurred outside of general practice core hours. The most common category of primary diagnosis was...

The requirement of bowel surgery is dramatically reduced by up to 60% in patients who develop Crohn's disease if they receive prolonged treatment with drugs called thiopurines concludes a new study published in the American Journal of Gastroenterology . Crohn’s disease affects more than quarter-of-a-million people in the UK leading to an inflamed intestine.Researchers from St George’s, University of London, St George's Hospital, London and the Department of Primary Care & Public Health at Imperial College, London analysed data from the medical records of more than 5,000 patients in the UK living with Crohn’s disease for more than 20 years and looked at the effect of thiopurine drugs that suppress inflammation in the gut. Gastroenterologist Dr Richard Pollok, an honorary senior lecturer at St George’s, University of London, said “ Our discovery is timely since new guidelines from the USA have played down the benefits of these drugs in favour of newer agents.  A year o...

In a paper published in the journal PLOS ONE . Jo Murray and colleagues examined the timing and duration of hospital admissions from respiratory syncytial virus (RSV) bronchiolitis among term and preterm infants in England and to identify risk factors for admission. We carried out a population-based birth cohort with follow-up to age 1 year, using the Hospital Episode Statistics (HES) database using data from 71 hospitals across England. We identified 296618 individual birth records from 2007/08 and linked to subsequent hospital admission records during the first year of life. In our cohort, there were 7189 hospital admissions with a diagnosis of bronchiolitis, 24.2 admissions per 1000 infants under 1 year (95% CI 23.7–24.8), of which 15% (1050/7189) were born preterm (47.3 bronchiolitis admissions per 1000 preterm infants (95% CI 44.4–50.2)). The peak age group for bronchiolitis admissions was infants aged 1 month and the median was age 120 days (IQR = 61–209 days). The median leng...

I attended a very interesting seminar today organised by C3Health at Barnabas House in London at which Dr Lara Fairall from the University of Cape Town presented on the PACK (Practical Approach to Care Kit) programme. The PACK programme has been developed over the last 12 years in South Africa. PACK is a set of comprehensive clinical practice guidelines that aims to equip nurses and other clinicians to diagnose and manage common adult conditions at primary care level. It includes information on symptoms, clinical evidence, policy-based guidelines and training. Dr Fairall spoke about the background to the programme, how the information sources were complied and how the programme (which is nurse-led and based in primary care) was delivered. PACK is led from the Knowledge Translation Unit at the University of Cape Town. Thanks to Dr Richard Smith for the invitation.  Dr Richard Smith and Dr Lara Fairall  Some of the delegates networking before the start of the pr...

On Tuesday 4 March 2014, I attended the launch of the NIHR CLAHRC for North-West London  at the Royal College of Physicians of London. NIHR Collaborations for Leadership in Applied Health Research and Care ( CLAHRCs ) undertake high-quality applied health research focused on the needs of patients and support the translation of research evidence into practice in the NHS. CLAHRCs are collaborative partnerships between a university and the surrounding NHS organisations, focused on improving patient outcomes through the conduct and application of applied health research. They create and embed approaches to research and its dissemination that are specifically designed to take account of the way that health care is increasingly delivered across sectors and a wide geographical area. You can view a selection of pictures from the event below. Dr Vasa Curcin and Dr Tom Woodcock are pictured outside the Royal College of Physicians building in Regent's Park. Dr Chris Millett, Read...

In a paper published in the Emergency Medical Journal , my colleagues and I investigated why patients with 'minor; illnesses choose to attend a GP-led urgent care centre rather than their own general practice. The demand for urgent care is increasing, and the pressure on emergency departments is a significant concern for the NHS. General practitioner (GP)-led urgent care centres are a new model of care developed to divert patients from emergency departments to more appropriate primary care environments. We administered a self-completed questionnaire among patients aged 18 years or over (N=649) who were triaged with a ‘minor illness’ on arrival to an urgent care centre, co-located with an emergency department in London. We found that the median age of patients was 29 years. 58% of patients attending the centre with minor illness during the study period took part. 72% of participants were registered with a GP; more women (59%) attended than men; and the majority of participants r...

In a study led by Imperial College London and published online in the journal Diabetic Medicine , researchers from the Department of Primary Care & Public Health at Imperial College London examined if hospital admission rates for diabetes complications (acute complications, chronic complications, no complications and hypoglycaemia) were associated with the management of diabetes in primary care. We performed an observational study in the population in England during the period 2004–2009 (54 741 278 people registered with 8140 general practices). We used multivariable negative binomial regression to model the associations between indirectly standardized hospital admission rates for complications and primary healthcare quality, supply and access indicators, diabetes prevalence and population factors. In multivariate regression models, we found that increasing deprivation and diabetes prevalence were risk factors for admission, while most healthcare covariates, i.e. a larger prac...

A study looking at the data of thousands of patients who suffered heart attacks has suggested treatment with high-potency statins offers a significantly improved chance of survival compared to those taking normal statins. Results of the study were published online in the journal  Heart . The study, led by the University of Dundee and on which I was a collaborator, also found a combination of statins and the drug ezetimibe showed no improved survival rate, although researchers caution this finding needs further testing. ' There is presently a lot of interest in ezetimibe as a potential treatment for heart patients ,' said Professor Chim Lang, from the Division of Cardiovascular and Diabetes Medicine at the University of Dundee Medical School. 'Ezetimibe has been shown to be very effective at lowering cholesterol but we do not know its effect on s urvival. The key question really is whether it is better than statins, especially high potency statins such as rosuvastatin...

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

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

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

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

Over two million people in England may be eligible for surgery to treat obesity, according to new research published in JRSM Open . However, fewer than 7000 patients underwent these procedures in 2011. Carrying out more bariatric surgery procedures would help to reduce obesity-related ill health, the study authors from Imperial College London said, but the NHS may need to invest in more resources to meet demand. Bariatric surgery – a set of surgical procedures performed on obese people to decrease their stomach size – can greatly reduce the likelihood of death from obesity-related diseases such as type 2 diabetes, stroke or coronary heart disease. Despite clear guidelines outlining who can undergo such surgery with the NHS, and evidence that these procedures are cost-effective in the long run, less than one per cent of those eligible have weight loss surgery each year. The researchers say this raises questions about why more procedures are not currently being carried out. One ...

I n the USA but not in England, patients on low incomes with high blood pressure have their condition managed poorly compared with those who earn more. A new study from my department comparing blood pressure management in the US and England found that although there is little difference between the two countries overall, the level of socioeconomic inequality is much higher in the US, with wealthier Americans more likely to meet targets for bringing their blood pressure under control than poorer patients. The study was published in the journal PLOS ONE . High blood pressure, or hypertension, is the leading cause of ill health worldwide and affects 76 million people in the US and 16 million in the UK. It is diagnosed if someone’s blood pressure consistently measures 140/90 millimetres of mercury or higher. Doctors usually recommend lifestyle changes to control blood pressure, and may prescribe antihypertensive drugs. The research aimed to determine whether differences between the ...

A letter published in the BMJ discusses the question: should general practices open for longer?’  The recent proposal for GPs in England to see patients from 8 am to 8 pm, seven days a week [2] tells us little about how much longer the hours in which GPs provide consultations would become. We therefore analysed data, obtained from NHS Choices [3] on 1st October 2013, on the ‘surgery’ (as opposed to ‘reception’) opening hours for 8,973 general practices in England. Surgery opening hours currently total 341,857 hours per week; the median value is 40 hours per week. The median for opening hours outside of core hours (8 am to 6.30 pm, Monday to Friday) is 1.25 per week. If the Government’s proposal was implemented nationally in each general practice, surgery opening hours would total 753,732 hours per week (a 120% increase). Each practice would provide consultations during 84 opening hours (a 110% increase over the current median), and 31.5 hours outside of core times (as defined...

In the context of integrated care, Multidisciplinary Group meetings involve participants from diverse professional groups and organisations and are potential vehicles to advance efficiency improvements within the local health economy. We developed a novel method to characterise the communication within Multidisciplinary Group meetings measuring the extent to which participants integrate and whether this integration leads to improved working. The findings of the study were published in the International Journal of Integrated Care . We purposively selected four Multidisciplinary Group meetings and conducted a content analysis of audio-recorded and transcribed Case Discussions. Two coders independently coded utterances according to their ‘integrative intensity’ which was defined against three a-priori independent domains - the Level (i.e. Individual, Collective and Systems); the Valence (Problem, Information and Solution); the Focus (Concrete and Abstract). Inter- and intra-rater relia...

The 10 NHS Trusts that are members of the Shelford Group see themselves as members of an elite group. But the members of this elite can be dealt with by general practitioners (GPs) and clinical commissioning groups. Here are my tips on how GPs and CCGs can do this. 1. Form your own consortia. General practices can work in federations and networks to share resources and expertise. CCGs can come together in joint commissioning activities. Working in larger groupings - whether it is of general practices or CCGs - will give you more bargaining power and greater consolidation of expertise to challenge the members of the Shelford Group. 2. Become skilled in using the language of evidence-based medicine, healthcare evaluation and data-driven healthcare in your dealings with the managers of the Shelford Group NHS Trusts. You will soon discover that many NHS managers are poorly trained in these essential components of modern healthcare delivery and in using NHS data to evaluate the perform...