Medical Centre

Demand for urgent care in England continues to rise with increasing numbers of attendances at emergency departments, and the associated growth in unplanned hospital admissions and healthcare costs. With NHS budgets under severe pressure, using emergency services appropriately will be important in an era of financial austerity in healthcare. Estimates of patients attending with conditions deemed non-urgent or inappropriate for accident and emergency services vary widely, from 6 to 80%. Previous research suggests that general practitioners (GPs) working in emergency departments can reduce referral rates, diagnostic testing, the proportion of patients who become emergency hospital admissions, and inappropriate attendances. However, little of this previous research is recent (much of it was published nearly 20 years ago) and new models of care for GPs working in and alongside emergency departments have now been developed, which remain to be evaluated. In a paper published in JRSM Shor...

In a paper published in the journal PLoS One , Dr Jessica Jones Neilsen and colleagues from the Department of Primary Care & Public Health at Imperial College London reported that the number of children admitted to hospital for problems related to obesity in England and Wales quadrupled between 2000 and 2009. Nearly three quarters of these admissions were to deal with problems complicated by obesity such as asthma, breathing difficulties during sleep, and complications of pregnancy, rather than obesity itself being the primary reason. Although some of the increase is likely to be due to improved case ascertainment, conditions associated with obesity in children and young people are imposing greater challenges for health care providers in English hospitals. The authors concluded that most inpatient care is directed at dealing with associated conditions rather than primary assessment and management of obesity itself. With levels of admissions for obesity-related diagnos...

Patients with more timely access to general practitioner (GP) appointments make fewer visits to accident and emergency departments, suggests a study published in the journal PLoS One . The findings of the article reinforce the need for more investment in GP services . People living in more affluent areas areas also had lower rates of use of A & E. Improving access to GPs by employing more GPs in deprived, urban areas and giving primary care teams more resources could help improve access to health services, improve quality of care and reduce pressures on other parts of the NHS. Lead author Thomas Cowling, from the School of Public Health at Imperial College London, said: “ This is the first national evidence of an association between access to GP appointments and rates of A&E attendances in England. Policy makers should consider this relationship when designing plans to reduce the use of A&E departments. A new era of service commissioning, led by GPs, has just started in ...

Countries across the Eastern Mediterranean Region face unprecedented health challenges, and are buffeted by demographic change, a dual disease burden, rising health costs, and the effects of ongoing conflict and population movements – exacerbated in the near-term by instability arising from recent political upheaval in the Middle East. However, health agencies in the region are not well positioned to respond to these challenges because of a dearth of good quality health research. An article published in the Journal of the Royal Society of Medicine by Professor Salman Rawaf and colleagues presents an assessment of the current state of health research systems across the Eastern Mediterranean based on publicly available literature and data sources. The review finds that – while there have been important improvements in productivity in the Region since the early 1990s – overall research performance is poor with critical deficits in system stewardship, research training and human resour...

There are marked inequalities in cardiovascular disease (CVD) incidence and outcomes between ethnic groups. CVD risk scores are increasingly used in preventive medicine and should aim to accurately reflect differences between ethnic groups. Ethnicity, as an independent risk factor for CVD, can be accounted for in CVD risk scores primarily using two methods, either directly incorporating it as a risk factor in the algorithm or through a post hoc adjustment of risk. In a study published in the journal Ethnicity & Health , Andrew Dalton and colleagues compared these two methods in terms of their prediction of CVD across ethnic groups using representative national data from England. They carried out a cross-sectional study using data from the Health Survey for England. We measured ethnic group differences in risk estimation between the QRISK2, which includes ethnicity and Joint British Societies 2 (JBS2) algorithm, which uses post hoc risk adjustment factor for South Asian men. ...

Researchers from Imperial College London and the Nuffield Trust have published the findings from an evaluation of the first year of a project designed to deliver more integrated care to patients in North West London. The Inner North West London Integrated Care Pilot is a large-scale programme focused on developing new models of care planning and coordination for people with diabetes and those who are over 75 years of age. The pilot is being implemented at a time of major reform of the NHS in England, and has been the subject of significant attention among policy makers and commissioners wanting to encourage new models of integrated care. The benchmarks set in this first evaluation report provide a sound basis for the pilot to assess its progress against, particularly in relation to activity, cost, and health outcomes. The pilot was evaluated by Imperial College London and the Nuffield Trust between September 2011 and July 2012, with funding from the Imperial College Healthcare Char...

The ability to consult by telephone is now an integral part of any modern patient-centred healthcare system and the British Medical Association (BMA) has provided guidance for general practitioners ( Consulting in the modern world , which was published in 2001). The BMA concludes that "telephone consultations when correctly conducted can be considered to be safe and acceptable practice". In a protocol for a Cochrane Review , Rumant Grewal and colleagues explain how they will identify and measure the effectiveness of interventions that aim to improve the clinician telephone consultation skills of clinicians. Grewal and colleagues believe that their review will provide evidence about the most effective interventions for improving telephone consultation skills and thereby improve both quality of care and patients' experiences of their health care. 

The United Arab Emirates has one of the the highest prevalences of diabetes in the world. Improving the care of people with Type  2 diabetes is therefore a priority for its health system. In a paper published in JRSM Short Reports , Layla Alhyas and colleagues aimed to identify facilitators of and barriers to healthcare professionals' motivation in a specialist diabetes centre. A qualitative research approach was employed using semi-structured interviews to assess perceptions and attitudes regarding healthcare professionals' motivation in providing good quality diabetes care. The participants included specialist physicians, dieticians, podiatrists, health educators and nurses. Important facilitators and barriers related to patient, professional, organization and cultural factors were identified. Barriers that related to heavy workload, disjointed care, lack of patient compliance and awareness, and cultural beliefs and attitudes about diabetes were common. Key facilitators in...

Over the course of 2013-14, a new national vaccination programme for Rotavirus will be introduced for babies. The vaccine (Rotarix) will be given to babies at two months of age, followed by a second dose at three months of age. Rotavirus is a virus that causes gastroenteritis, leading to diarrhoea and vomiting, in particular in infants and young children. Almost all children have had a Rotavirus infection by the time they are 5 years old, with the maximum risk of infection occurring at around one year of age. Many children with Rotavirus infection will be managed by their parents without needing medical treatment but around 130,000 children will see their general practitioner each year because of Rotavirus infection and around 12,700 children will be admitted to hospital. The new vaccination programme should substantially reduce both the number of children infected with Rotavirus and the number of children admitted to hospital each year. Early studies suggest that the vacci...

Multidisciplinary Group Meetings (MDGs) are seen as key facilitators of integration, moving from individual to multi-disciplinary decision-making, and from a focus on individual patients to a focus on patient groups. In an article published in the International Journal of Integrated Care , Matthew Harris and colleagues describe the development of a method for coding MDG transcripts to identify whether they are or are not vehicles for delivering the anticipated efficiency improvements across various providers and apply it to a test case in the North West London Integrated Care Pilot. Harris and colleagues defined ‘integrating’ as the process within the MDG meeting that enables or promotes an improved collaboration, improved understanding, and improved awareness of self and others within the local healthcare economy such that efficiency improvements could be identified and action taken. Utterances within the MDGs are coded according to three distinct domains grounded in concepts from ...

Although randomized control trials (RCTs) are the ‘gold standard’ to evaluate treatment effects in health care, they are frequently not practical, ethical or politically acceptable in the evaluation of many health system or public health interventions. In the absence of an RCT, evaluations often use quasi-experimental designs such as a pre-post study design with measurements before and after the intervention period, such as interupted time series (ITS). An ITS compares the intercept and slope of the regression line before the intervention with the intercept and slope after intervention. A one-time baseline effect of the intervention without influencing the secular trend can be detected as an intercept change. If the intervention changed the secular trend, there will also be a significant difference in the slope between the two periods. Use of ITS in biomedical research is described in more detail in an article published by Utz Pape and colleagues in the Journal of the Royal Society of...

The NHS Health Check programme aims to improve prevention, early diagnosis and management of cardiovascular disease (CVD) in England. High and equitable uptake is essential for the programme to effectively reduce the CVD burden. In a study published in the journal Family Practice  and reported on by Pulse , Macide Artac and colleagues assessed the impact of a local financial incentive scheme on uptake and statin prescribing in the first 2 years of the programme. They carried out a cross-sectional study using data from electronic medical records of general practices in Hammersmith and Fulham, London on all patients aged 40–74 years. They assessed uptake of complete Health Check, exclusion of patients from the programme (exception reporting) and statin prescriptions in patients confirmed with high CVD risk. They reported that Health Check uptake was 32.7% in Year 1 and 20.0% in Year 2. Older patients had higher uptake of Health Check than younger (65- to 74-year-old patients: The ...

In a systematic review published in the journal PLoS One , Dr Lorraine Tudor Car and colleagues assessed the uptake of WHO recommended integrated perinatal prevention of mother-to-child transmission (PMTCT) of HIV interventions in low- and middle-income countries. The proportion of women attending antenatal care who were counselled and who were tested was high; 96% (range 30–100%) and 81% (range 26–100%), respectively. However, the overall median proportion of HIV positive women provided with antiretroviral prophylaxis in antenatal care and attending labour ward was 55% (range 22–99%) and 60% (range 19–100%), respectively. The proportion of women with unknown HIV status, tested for HIV at labour ward was 70%. Overall, 79% (range 44–100%) of infants were tested for HIV and 11% (range 3–18%) of them were HIV positive. Around 22% of all HIV positive women attending antenatal care and 11% of all HIV positive women delivering at labour ward were not...

Several local attempts to introduce integrated care in the English National Health Service have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to improve the quality of care of the elderly and people with diabetes by providing a novel integration process across primary, secondary and social care organisations. It involves predictive risk modelling, care planning, multidisciplinary management of complex cases and an information technology tool to support information sharing. This paper sets out the evaluation approach adopted to measure its effect. In an article published in the International Journal of Integrated Care , Felix Greaves and colleagues present a mixed methods evaluation methodology. It includes a quantitative approach measuring changes in service utilization, costs, clinical outcomes and quality of care using routine primary and secondary data sources. It also contains a qualitative component, involving observations, interviews and...

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.