Medical Centre

There is uncertainty about the best size for the primary care organisations responsible for commissioning health services in England. This includes the concern that small commissioning units are more exposed to financial risk, due to their smaller populations. Smaller commissioning units may also not have sufficient expertise or the required ‘market power’ to be able to negotiate effectively with health care providers to achieve good-value contracts. Alternatively, smaller organisations may have better local engagement and responsiveness for clinicians and patients. In a study publishedin the British Journal of General Practice , Felix Greaves and colleagues from the Department of Primary Care & Public Health at Imperial College London investigated whether there is a relationship between the size of commissioning organisations and how well they perform on a range of performance measures. This included a comparison of primary care trust (PCT) size against 36 indicators of co...

The Quality and Outcomes Framework (QOF), a pay for performance programme, was introduced into United Kingdom (UK) primary care as part of a new General Practitioner (GP) contract in April 2004. Before the introduction of QOF, most British family doctors were earning a large proportion of their income from capitation payments. This system rewarded family doctors for having a large list of registered patients rather than for the quality of care that they provided. There is limited definitive information about the impact of the QOF on level disparities in health care. In a study published in the journal PLoS One , John Lee and colleagues from Imperial College London investigated the following research questions: has QOF resulted in a step change in the quality of care for coronary heart disease, stroke and hypertension in white, black and south Asian patients? Has QOF reduced disparities in the quality of care for these conditions between these ethnic groups? Did general practices wi...

Hospital admission rates for stroke are strongly associated with population factors. The supply and quality of primary care services may also affect admission rates, but there is little previous research on this association. In a paper published recently in the British Journal of General Practice , Michael Soljak and colleagues from the Department of Primary Care & Public Health at Imperial College London investigated whether the hospital admission rate for stroke is reduced by effective primary and secondary prevention in primary care. This was a national cross-sectional study in an English population (52 763 586 patients registered with 7969 general practices in 152 primary care trusts). They found that mean annual stroke admission rates per 100 000 population varied from zero to 476.5 at practice level. In a practice-level multivariable Poisson regression, observed stroke prevalence, deprivation, and smoking prevalence were all risk factors for hospital admission. Protectiv...

Financial incentives are seen as one approach to encourage more systematic use of smoking cessation interventions by healthcare professionals. In a study published in the journal Tobacco Control , Dr Fiona Hamilton and colleagues from the Department of Primary Care & Public Health at Imperial College London carried out a systematic review to examine the evidence to support financial incentives for health professionals as a method for improving smoking cessation activities.They found 8 studies examined smoking cessation activities alone and 10 that studies that examined the UK's Quality and Outcomes Framework, which contains quality measures for chronic disease management including smoking recording and smoking cessation activities. Five non-Quality and Outcomes Framework studies examined the effects of financial incentives on individual doctors and three examined effects on groups of healthcare professionals based in clinics and general practices. Most studies showed imp...

Google Scholar Citations Open To All - Google Scholar Blog I've been using Google Scholar Citations since it was launched earlier this year and have found it a very useful tool for tracking citations of my work. The service was launched with a limited number of users but has now been opened up. I'll be encouraging my colleagues in the Department of Primary Care & Public Health at Imperial College London to sign up for Google Scholar Citations. You can find out how to do this on the Google Scholar Blog .

The National Health Service (NHS) Health Check Programme aims to identify and manage patients in England aged 40-74 years with a 10-year cardiovascular disease (CVD) risk score over 20%. In an article published in the European Journal of Cardiovascular Prevention & Rehabilitation . Andrew Dalton and colleagues from the Department of Primary Care & Public Health at Imperial College London assessed the prevalence of high CVD risk in the English population, using the two CVD risk scores and the 20% cut off mandated in national policy, and the prevalence of risk factors within this population. They found that of those eligible for an NHS Health Check, 10.5% (2,012,000) had a risk score greater than 20% using the QRISK2 risk score; 22.0% (4,267,000) using Joint British Societies' (JBS2) score. To reduce risk in those at high CVD risk, we estimate the total costs of the Programme to be £176 million using QRISK2 or £378 million using JBS2. They concluded that a large number of ...

In a  recent article in the New Perspectives Part II Section of  the SGIM Forum , the newsletter of the US Society of General Internal Medicine, I discuss the NHS Health Checks Programme. The burden of cardiovascular disease, type 2 diabetes and kidney disease will increase, both in developed countries with ageing populations, and in developing and middle income countries that are undergoing economic and demographic transitions. These diseases all share risk factors that include smoking, hypertension, obesity, physical inactivity, and impaired glycemic status. Integrated approaches to their prevention, early identification and effective management could therefore have major public health and economic benefits, and help limit the impact of the predicted future rise in non-communicable diseases. For example, even very modest reductions in population risk factor prevalence could prove to be highly effective in reducing the impact of these diseases. Despite downward secul...

Childhood vaccines are among the most successful and cost-effective public health interventions available. Within England, vaccination coverage is lowest in deprived, urban areas with mobile populations, such as London. Barriers to immunisation can stem from parental concerns about risks, inadequate knowledge and provision by providers, and generalized system barriers involving the organization of the health system and access to services. In an article published recently in JRSM Short Reports , Nia Willaims and colleagues from the Department of Primary Care & Public Health at Imperial College London carried out a systematic literature review aimed at providing GPs with up-to-date, evidence-based guidelines on how to improve uptake rates of primary immunisations for children registered under their care. Forty-six studies were included for analysis, published between 1980 and 2009. A number of interventions were found to increase vaccination rates in children. These inclu...

Errors in journal articles are common. Most journals now have policies to correct errors in research articles. However, errors in other types of articles often remain uncorrected. I've listed below a few statements in BMJ articles that are either wrong or that are highly unlikely to be true but which remain uncorrected. The BMJ is probably no worse in this respect than other medical journals, but as a member of the BMA, I receive a weekly copy of the print edition and therefore spend more time reading it than other medical journals. This means that I am more likely to pick up errors in the BMJ than in other journals. The reported incidence [of polycystic ovary syndrome] varies between 3% and 15% of women of reproductive age. http://www.bmj.com/content/343/bmj.d6407.full An annual incidence of 15% would imply that after 10 years, a women of childbearing age would have around an 80% risk of developing PCOS. Even the 3% incidence figure would mean that a women of childbearing a...

On an average weekday in England, there are over1 million consultations with general practitioners. The limited data on errors and patient harm in primary care obstructs the development of strategies to improve patient safety. In an article published recently in Family Practice , Carmen Tsang and colleagues reported the results of a systematic review to determine the types of adverse events that are routinely recorded in primary care. They found that there is limited use of routinely collected data to measure adverse events in primary care despite large volumes of data generated in the electronic patient records now used by most general practitioners in the UK. 

Patient safety measures can be derived from routinely collected hospital data. Carmen Tsang and Colleagues from the Department of Primary Care & Public Health at Imperial College recently carried out a review of such measures, the results of which were published in the American Journal of Medical Quality . They found that many studies were frequently conducted in the United States between using Agency for Healthcare Research and Quality patient safety indicators. They concluded that these indicators need further development, refinement and validation. Patient safety indicators that can be used  in ambulatory care settings were also needed. 

A recent commentary published in the Lancet by Allyson Pollock and colleagues concluded that there is no evidence that competition for patients in the NHS saves lives or improves quality of care, Improvements in area such as survival following acute myocardial infarction are likely to be due to the development of cardiac networks that encourage collaboration between hospitals and the wider provision of services such as percutaneous coronary interventions (PCI). The article was widely quoted in the media, including in the Independent and Pulse . 

A newly published Cochrane systematic review by Nik Tuah and Colleagues reported that there is currently limited evidence that the transtheoretical model stages of change (TTM SOC) method is effective in producing weight loss. The transtheoretical model describes a step-by-step way in which people move from unhealthy behaviours to healthy ones. The five stages of change that the model anticipates are pre-contemplation, contemplation, preparation, action and maintenance. The BBC reported on the study and noted that behavioural change to promote weight loss was very difficult to achieve.

An article published recently in Pulse by Michael Soljak and I examined the use of patient reported outcome measures. Patient-reported outcome measures (PROMs) estimate the effectiveness of healthcare delivered to patients as perceived by the patients themselves. The recent Government White Paper, ‘Equity and excellence: Liberating the NHS',2 envisages an increase in the scope and coverage of PROMs in future, starting from April 2011. For providers, PROMs will provide important data for quality improvement, in the form of comparative, casemix-adjusted pre- to post-operative changes in scores. They will also have a role in commissioning. For example, PROMs might be used to identify procedures with little benefit, or subgroups of patients who do not benefit greatly from surgery. This could allow more effective targeting of resources to improve health gain.

Type 2 diabetes mellitus is increasing worldwide. Recent growth has been particularly dramatic in the states of The Co-operation Council for the Arab States of the Gulf (GCC), and these and other developing economies are at particular risk. In a systematic review published recently in PLoS One , Layla Alhyas and colleagues review the quality of control of type 2 diabetes in the GCC, and the nature and efficacy of interventions. They found the the quality of diabetes management to be sub-optimal. Assessment of the efficacy of interventions was difficult due to poor quality studies and a lack of data, but the findings of the review suggested that there was considerable scope to improve the quality of diabetes care in this region.

In an article published recently in the Canadian Association Medical Journal , Eszter Vamos and colleagues from Imperial College examined the association between size of general practice and the quality of diabetes management in England between 1997 and 2005. They found improvements in the recording of process of care measures, prescribing and achieving intermediate diabetes outcomes in all practice sizes during the study period. They concluded that size of practice was not strongly associated with the quality of diabetes management in primary care; and that pay for performance programmes appear to benefit both large and small practices to a similar extent.

A systematic review published recently by Layla Alhyas and colleagues in JRSM Short Reports examined the prevalence of risk factors for diabetes and its major complications in the Co-operation Council of the Arab States of the Gulf (GCC) region. They reported high prevalences of risk factors such as obesity, hyperglycaemia, hypertension and abnormal blood lipids. Enhanced management of these risk factors will be essential if escalation of diabetes-related problems is to be averted as industrialization, urbanization and changing population demographics continue in the countries in the Gulf region.

A recent paper by Jo Murray and colleagues published in JRSM Short Reports examined the impact of patients' use of the NHS Choices website on primary care consultations in England and Wales. They found that NHS Choices did alter healthcare-seeking behaviour, attitudes and knowledge among its users. Using NHS Choices appeared to result in reduced demand for primary care consultations among young, healthy users in particular. The authors concluded that the use of online medical services should be explored further.

In the UK, quality standards for chronic kidney disease (CKD) are set out in a National Service Framework and in pay-for-performance indicators. As CKD is largely asymptomatic in its early stages, it is therefore generally detected following routine renal function testing. In a paper published recently in Family Practice , Simon de Lusignan and colleagues examined which groups of patients were most likely to have renal function testing in primary care. The found that testing rates were highest in people with diabetes, and slightly higher in women than men. The results will help in the planning of the new NHS Health Check programme.

Many doctors will already be familiar with Google Scholar. Google have recently launched a new linked service, Google Scholar Citations, which provides a web-based tool for academics to monitor citations to their articles. Academics can check who is citing their publications, view citations over time and examine citation metrics. Academics can also make their profile public so that other people can view their citation metrics. The service was launched with a small number of users and I was fortunate enough to be selected as one of the early users. You can view my Google Scholar Citations page to see the data available. Amongst the metrics that can be viewed are the total number of citations and the h-index, along with a chart showing the number of citations per year. Detailed citation counts are also available for individual papers. Many universities already have updateable publication pages for their academics (as an example, see my Imperial College London Publications page). Google...

Ninety per cent of HIV infections in children under the age of 15 are caused by mother-to-child transmission of HIV during pregnancy, delivery and breastfeeding. In high-income countries introduction of prevention of mother-to-child HIV transmission (PMTCT) programmes substantially reduce the rate of transmission of HIV from mothers to infants. In a recent systematic review published in the Cochrane Database of Systematic Reviews , Lorraine Car and Colleagues examined the effectiveness of integrated PMTCT programmes compared to non-integrated and partially integrated care. They found very little evidence of evidence on this area and suggested that additional research is needed to allow clinicians and policy makers to make a definitive conclusion about the effectiveness of integration of PMTCT interventions with other health services.

In a letter published recently in the Lancet , Helen Atherton and I argue for a more pragmatic  approach to the use of social networking in healthcare. For example, we should be using current evidence on how social  networking might be used to improve communication with patients. This could involve considering the use of social networking in terms of wider clinical behaviour. Concerns about the eff ect of new  technology on the doctor–patient  relationship were probably being  expressed when telephones were first  introduced more than 100 years ago. Rather than viewing new technology as a threat, we should use the opportunities it offers to improve the efficiency and effectiveness of health systems and to improve people’s knowledge of their health and illnesses.

Access to health information allows people to take a more active role in their health care by making them more informed about their health and the management of their illnesses. The internet is an increasingly popular way for people to obtain this kind of health information, but there are many barriers that prevent people making full use of such information. In particular, people may lack the motivation or the skills to use the internet. In a recent systematic review published in the Cochrane Database of Systematic Reviews , Josip Car and colleagues examined whether teaching people to find, evaluate or use online health information (online health literacy) improves those skills and improves their health. They found only two studies met the inclusion criteria for the review. They concluded that there is limited evidence on which to draw conclusions about the effect of these interventions and that further high-quality research on this topic was necessary.

Electronic health databases that contain data obtained from health records generated by routine clinical practice are widely in biomedical research. Because of the large number of patients in such databases and long patient follow-up, these databases have unique characteristics that are very valuable for academic researchers. An article published recently in PLoS One describes the use of the United Kingdom's General Practice Research Database (GPRD). The authors identified 749 studies published between 1995 and 2009 based on the GPRD. The studies included authors from 22 countries published in 193 journals across 58 study fields The findings of the study illustrate how valuable the data collected in UK primary care by primary care teams is for research and public health.

Over 30 million people in the United Kingdom now use the Internet every day, and around 12 million people use mobile phones to access the Internet. Can the NHS start to make effective use of this rapid development in information technology to improve communication between professionals and patients, and patients’ experience of their healthcare? This question is discussed by Helen Atherton and I in an article published in the Journal of the Royal Society of Medicine . We also give some examples of how clinicians and managers can begin to incorporate online technologies into their day-to-day practice. Online technologies and the ‘information revolution’ are changing the delivery of health services in the NHS and health systems in many other countries. Clinicians and managers need to act to take advantage of these developments now or risk being left behind, as their patients become increasingly familiar with the use of online and mobile communication technologies. This will in turn lead t...

NHS Health Checks, a cardiovascular risk assessment programme for all adults aged 40–74 years in England, was introduced in 2009. The programme aims to both decrease the incidence of cardiovascular disease (CVD), and reduce socio-economic and ethnic inequalities in cardiovascular health. The programme involves systematic screening, measurement of CVD risk factors, the generation of global risk estimates, risk communication and lifestyle counselling. In a study published in the Journal of Public Health , Andrew Dalton and colleagues examine the uptake of the programme in Ealing, London. They found that uptake of the programme and subsequent prescribing of statins in high risk patients was lower than predicted in the first year of the NHS Health Checks programme. Efforts to increase the uptake of the programme, particularly amongst patients more likely to have undiagnosed CVD or uncontrolled CVD risk factors, is needed. 

In an article published recently in the Student BMJ , Ms Zineb Mehbali, a UROP student in the Department of Primary Care & Public Health discusses the use of medical students as interpreters. This is a role that is often taken on informally by students and for which they may not be full trained or comfortable with doing. Medical schools should consider regulating this area more closely to avoid undue pressure being placed on students.

Dr Utz Pape , a statistician in the Department of Primary Care & Public Health , recently co-authored an article in Nature. For a synopsis of the article, see Utz's blog . 

Despite financial incentives to encourage general practices to register new cases, there is still under-diagnosis of cardiovascular disease (CVD) in England. In a paper published recently in BMC Cardiovascular Disorders , Michael Soljak colleagues compared the modelled (expected) and diagnosed (observed) prevalence of three cardiovascular conditions- coronary heart disease (CHD), hypertension and stroke- at local level, their geographical variation, and population and healthcare predictors which might influence diagnosis. They found that  9,682,176 patients were on practice CHD, stroke and transient ischaemic attack, and hypertension registers. There was wide spatial variation in observed: expected prevalence ratios for all three diseases, with less than five per cent of expected cases diagnosed in some areas. They concluded that despite access to universal, free primary healthcare, there may be substantial under-diagnosis of CVD across England.

The British Medical Association prides itself on its supposed commitment to tackling societal inequalities, particularly inequalities in health. One of the key drivers of health inequalities is income inequalities. In a letter published in the BMJ by one of the BMA's staff, the BMA claimed that it pays all its staff well above the minimum wage. However, it did not state what staff whose services were contracted out - such as catering staff - were paid. What the BMA representative seemed to be saying in her letter was that the BMA had subcontracted the employment of workers who are most likely to receive the minimum wage to external companies and had no idea (and perhaps doesn't care?) what they are paid. In a follow on letter also published in the BMJ , I asked for further clarification from the BMA on this point. Nearly three months after publication of my letter, there has been no further response from the BMA. Does the BMA really care about inequalities - or ...

In an article published in the BMJ , Dr Adrian Raby - a Senior Teaching Fellow in the Department of Primary Care & Public Health at Imperial College London - and one of his patients discuss how they dealt with his patient's alcoholism. Health problems caused by excessive alcohol intake are increasing in society. The article highlights the importance of clinicians in all fields of medicine being able to detect problem levels of drinking in their patient and wither intervening to aim to limit the harms associated with excessive alcohol intake or referring patients to specialist services or to voluntary groups such as Alcoholics Anonymous. One of the respondents to the article also highlighted the need for doctors to act as good role models for their patients.

The Introduction of the Quality and Outcome Framework (QOF) in 2004 was a major change in how family practitioners are paid in the United Kingdom. The scheme rewards family practitioners for the achievement of predetermined targets. Diabetes is one of the most important components of QOF and accounts for approximately 15 percent of the QOF clinical domain points (650 points are available in the clinical domain out of he total 1,000 points). Currently half of the points available for diabetes care are directed towards the achievement of intermediate outcome targets such as the control of blood pressure, cholesterol and HbA1c. Although financial incentives have gained momentum in recent years and are seen as a way to improve quality of care, many commentators raised their concerns regarding the potential negative consequences of using pay for performance to improve the quality of care, such as its impact on care delivered to patients from ethnic minority groups and how this may contrib...

Public reporting of physician and provider performance has become a key component of strategies to improve the quality of health care. Public reporting of performance is also increasingly being linked to provider pay through pay for performance programmes. Many pay for performance schemes permit physicians to exclude selected patients from performance indicators. For example, the Quality and Outcomes Framework (QOF), a major pay for performance scheme introduced into UK primary care in 2004, permits general practitioners to ‘exception report’ patients using set criteria. The criteria include circumstances where a treatment is not clinically appropriate, e.g. achieving tight blood glucose control in a diabetes patient with terminal cancer, or where a patient refuses to attend a review after three clinic invitations. In a paper published recently in the Journal Diabetic Medicine , Andrew Dalton and colleagues examined associations between patient and practice characteristics and exclus...

I now also have a blog on the BMJ Group's Doc2Doc site. The doc2doc site is an networking community for healthcare professionals.

Primary health care services are important in establishing an effective, efficient, and equitable health system and in improving population health. This has led governments in many countries to increase their investment in primary care and introduce initiatives to improve quality, such as pay for performance. In the United Kingdom, this includes the Quality & Outcomes Framework (QOF), a national pay for performance programme. There is interest in devolving some aspects of national pay for performance programmes to local primary care organisations, to give greater flexibility and the ability to focus on local priorities. In a recent BMJ paper, Christopher Millett and colleagues discuss one such local programme, QOF+ , which was implemented in NHS Hammersmith & Fulham . The review of the scheme in NHS Hammersmith & Fulham suggests that local pay for performance incentive schemes may allow for opportunities to improve quality, encourage innovation, and tackle local public h...

Prescribing for older people is complex and can lead to inappropriate prescribing, as well as side effects from prescribed medication. With a growing number of older people in the population, strategies to improve prescribing in this group are needed. Older people living in care homes are particularly at risk from polypharmacy and inappropriate prescribing. In a recent article published in the journal Age and Ageing , Malar Loganathan and colleagues reviewed the effects of interventions to optimise prescribing for people living in care homes. Four interventional strategies were identified from previously published research: staff education, multi-disciplinary team (MDT) meetings, pharmacist medication reviews and computerised clinical decision support systems (CDSSs). Complex educational programmes that focused on improving patients' behavioural management and drug prescribing were the most studied area, with six of eight studies highlighting an improvement in prescribing....

Many health systems are investing heavily in IT-based systems that aim to improve the quality and safety of health care. For example, England has invested at least £12.8 billion in a National Programme for Information Technology (NPfIT) for the National Health Service, and the Obama administration in the United States (US) has similarly committed to a US$38 billion eHealth investment in health care. Examples of such investment include electronic health records (EHRs), picture archiving and communication systems (PACS), electronic prescribing (ePrescribing) and associated computerised provider (or physician) order entry systems (CPOE), and computerised decision support systems (CDSSs). Policy makers hope that this investment will help address the problems of variable quality and safety in health care delivery. However, the scientific basis of such claims—remains to be established. A recent systematic review by Ashly Black and colleagues published in the journal PLoS Medicine aimed to...

For the past few years, the MRC has funded access to GPRD data for UK researchers. This has been very helpful in increasing expertise in the use of GPRD amongst UK researchers and boosting the number of academic papers that use the database. This scheme has now ended and the effects this might have on research were discussed in a recent BMJ news article. The UK has one of the highest uses of electronic patient records in primary care, and these records have been a great resource for biomedical researchers. Before the licence scheme was implemented the main users of the database were based in the United States, Spain, and Switzerland but that after it was set up this was no longer the case. Although the MRC will continue to fund access to the data via its research grants schemes, the process for applying for access to the database will be much lengthier and because applying for the council’s grants is highly competitive it is likely that most grant applications will be unsu...

Effective treatments exist for the acute management and prevention of stroke, but their uptake depends upon public awareness of stroke symptoms and risk factors. A recent study by Julia Slark and colleagues published in the Journal of Stroke and Cerebrovascular Disease assessed both types of knowledge amongst patients who had suffered a stroke and who were therefore at high-risk of suffering another stroke. The study found that knowledge was poor amongst many patients in this group. This is concerning as they are at high risk of stroke and other cardiovascular diseases.The findings suggest that more effective methods are needed about educating stroke patients about their risk factors; and how they can reduce their risk of a subsequent stroke, as well as recognising the symptoms of a new stroke should one occur.

The general practice where I work, Dr Curran and Partners , now has its own Facebook page . The page has some basic information about the practice that complements the information on the practice's website. With over 500 million Facebook users worldwide, the social networking site has become an important method for healthcare organisations to link with their patients.

An study published in the journal Informatics in Primary Care examined the recording of adverse events in English general practice. Although the majority of patient contact within the UK's National Health Service (NHS) occurs in primary care, relatively little is known about the safety of care in this setting compared to the safety of hospital care. This study aimed to identify the rate and types of adverse events that might be recorded in primary care through routinely collected data. Records from the calendar year 2007 were available for 69 682 registered patients from 25 practices, consisting of 680 866 consultations. A number of adverse events could be detected through terms contained in certain chapters of the Read code system. These events include injuries due to surgical and medical care (0.72 cases of per 1000 consultations) and adverse drug reactions (1.26 reactions per 1000 consultations). The findings suggested that there is scope to develop more accurate...