Medical Centre

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...

An article in the journal Diabetes Research and Clinical Practice looks at the current state and future predictions of diabetes in the Middle-East and North Africa. In recent decades, the prevalence of diabetes has risen dramatically in many countries of the International Diabetes Federation's (IDF) Middle-East and North Africa (MENA) Region. This increase has been driven by a range of factors that include rapid economic development and urbanisation; changes in lifestyle that have led to reduced levels of physical activity, increased intake of refined carbohydrates, and a rise in obesity. These changes have resulted in the countries of MENA Region now having among the highest rates of diabetes prevalence in the world. The current prevalence of diabetes in adults in the Region is estimated to be around 9.2%. Of the 34 million people affected by diabetes, nearly 17 million were undiagnosed and therefore at considerable risk of diabetes complications and poor health outcomes. Enha...

Recent studies have raised the issue of ‘obesity paradox’ in patients with type 2 diabetes mellitus (T2DM). Sanjoy Paul and colleagues evaluated the cardiovascular and mortality risks associated with normal and overweight patients compared to obese at diagnosis of diabetes, separately for patients with and without cardiovascular disease (CVD) before diagnosis. The study was published in the journal  Diabetes, Obesity and Metabolism . They carried out a retrospective study with two study cohorts with/without prior CVD with complete measures of body mass index (BMI) at diagnosis of T2DM from UK General Practice Research Database. Primary outcomes were long-term risks of cardiovascular events (CVEs) and all-cause mortality in patients with normal weight, overweight and obesity at diagnosis. They reported that mortality rates per 1000 person-years in normal weight, overweight and obese patients among patients without prior CVD were 13.1, 8.6 and 6.0, respectively, during 5 years o...

Although statins reduce cardiovascular events even in people at low risk,[1] population benefits from their more widespread use will occur only if a sufficiently high proportion of people at lower cardiovascular risk (whether based on a formal risk assessment or on age alone) are prescribed statins.[2] Some of these issues were discussed in a commentary published in the BMJ . Early evidence from the NHS Health Check programme suggests that it will be difficult to achieve high statin uptake in people at low cardiovascular risk. NHS Health Check is a population-wide primary prevention programme that was established in England by the Department of Health in 2009.[3] The programme represents a major investment in the prevention and early detection of cardiovascular disease. In early results from the programme, prescription of statins in people at high cardiovascular risk (≥20%) increased from around 25% to only 45%.[4] The prescription of statins is likely to be substantially lower th...

Sickle cell disease (SCD) is a frequent cause of emergency readmissions. In a paper published in the Journal of Public Health , Ghida Aljuburi and colleages examined trends in SCD emergency readmissions and inpatient mortality in England in relation to socio-economic status. Data from Hospital Episode Statistics were extracted for all SCD patients admitted in 2005/06. The financial year 2005/06 was taken as the index year for analysis. We calculated readmission rates and inpatient mortality for patients admitted with a primary or secondary diagnosis of sickle cell anaemia with crisis and without crisis in the index year during the subsequent 5 years (2006/07–2010/11). Charlson Score was used to measure comorbidity. Using Cox proportional hazards models, we also examined the relationship between patient characteristics and both emergency readmissions and inpatient mortality. In 2005/06, there were 7679 SCD index admissions. Over the subsequent 5-year period, patients livin...

Risk prediction is one of the key strategies for the prevention of cardiovascular disease (CVD). Two of the main CVD risk calculators in use in the United Kingdom are QRISK2 and Framingham. In a paper published in Heart , the SABRE Study Group evaluated the performance of the QRISK2 and Framingham scores as predictors of CVD outcomes over 10 years of follow-up in European, South Asian, and African Caribbean men and women in a UK population based cohort in West London. The sample was obtained by randomly selecting from local general practices. Follow-up data were available for 87% of traced participants, comprising 1866 white Europeans, 1377 South Asians, and 578 African Caribbeans. The outcome measures included in the study were myocardial infarction, coronary revascularisation, angina, transient ischaemic attack or stroke reported by participant, primary care or hospital records or death certificate. During follow-up, 387 CVD events occurred in men (14%) and 78 in women (8%). Both ...

In a publication in the Annals of Internal Medicine , Thomas Cowling and colleagues describe how discussion of acute unscheduled care in the United States resembles the debate on the same topic in England, where the National Health Service is conducting a comprehensive review of unscheduled care services. In England, general practices staffed by primary care physicians and hospital emergency departments (EDs) form the 2 “silos of acute care delivery”. Approximately 9% of patients who try but are unable to obtain a convenient appointment at their general practice office subsequently visit an emergency department. Consequently, recent national policies have attempted to improve access to general practice, using financial incentives to reduce demand for acute unscheduled care at emergency departments. A potential unintended consequence of expanding alternative care settings is that the “question of where patients with acute care needs should go for unscheduled care” becomes more conf...

Life expectancy at birth has been used as a measure of the health status of the population of England and Wales since the mid-nineteenth century. Recently published statistics from the  UK Office for National Statistics  show that the long-standing North-South divide in distribution of life expectancy across England continues, with people in the North of England generally living shorter lives than those living in the south. Life Expectancy at Birth Male life expectancy at birth was highest in East Dorset (82.9 years) and lowest in Blackpool (74.0 years). For females, life expectancy at birth was highest in Purbeck at 86.6 years and lowest in Manchester at 79.5 years. Life expectancy at birth increased across England and Wales by 1.3 years for males and 1.0 year for females between 2006–08 and 2010–12. This is part of a long-standing trend of improving life-expectancy, which is leading to a gradual increase in the average age of the population of England and Wales, and the ...

A recent analysis of causes of potentially avoidable deaths in England and Wales by the Mortality Team at the  Office for National Statistics  (ONS) showed that cardiovascular diseases were the largest cause of avoidable deaths between 2001 and 2006. In 2007, cancers became the leading cause of avoidable deaths and have remained so since then. This change in ranking has occurred because deaths from cardiovascular diseases have been falling for many years. Deaths from cancer in contrast have been falling much more slowly than deaths from cardiovascular disease and cancer has therefore now become the commonest cause of avoidable deaths. The rapid decline in age-standardised death rates from cardiovascular diseases have been driven by a range of factors. These include medical (e.g. statins) and surgical treatments (e.g. angioplasty); and changes in lifestyle (such as a reduction in the prevalence of smoking). The findings of this very useful analysis by the ONS illustrate th...

In a paper published in the Journal of Global Health , Michelle van Velthoven and colleagues describe a a collaboration between researchers in China and the UK that aimed to explore the use of mHealth in China. This is the first paper in a series of papers on a large mHealth project part of this collaboration. This paper includes the aims and objectives of the mHealth project, our field site, and the detailed methods of two studies. This large mHealth project is part of a collaboration between researchers in China and the UK. The mixed methods study evaluating factors that influence sample size calculations could help future studies with estimating reliable sample sizes. The cross–over study comparing face–to–face and text message survey data collection could help future studies with developing their mHealth tools. 

Simon Stevens has been appointed as the new Chief Executive of the NHS in England and will start in his post in April 2014. Stevens is the Executive Vice President of UnitedHealth Group and President for Global Health. He has been based in the USA in recent years. He has formerly worked as a NHS manager in England and as an adviser to Tony Blair when he as Prime Minister. Professor Malcolm Grant, Chairman of NHS England, said that Mr Stevens was the best man for the job because he could bring experience from many different models of healthcare delivery. His appointment has brought a mixed reaction in England. Many people view his appointment as NHS Chief Executive as a positive step, viewing him as someone who will bring innovative ideas and ways of working. Others are more wary and are concerned he may push further marketization and models of healthcare delivery derived from the USA.

Following the publication of her paper, " Evaluation of clinical threshold policies for cataract surgery among English commissioners ", in the Journal of Health Services Research and Policy, Sophie Coronini-Cronberg (Honorary Clinical Research Fellow in the Department of Primary Care & Public Health at Imperial College London) has been invited by the Royal College of Ophthalmologists to join its working group responsible for developing cataract surgery commissioning guidance. The work is due to be completed by the end of this year. 

In a letter published in the British Medical Journal (BMJ) , Michale Soljak, Chris Millett and I discuss the call by Krogsbøll to abandon the NHS Health Check Programme.As members of one of the research teams evaluating the national programme, we challenge their view that a randomised controlled trial (RCT) of the current programme should be the sole arbiter on which to base national health policy decisions. As noted in comments on the Cochrane review, the dearth of RCTs of screening for cardiovascular (CVD) risk since 1999 is unfortunate, but there were many RCTs of individual screening components over this period that have been used in subsequent NICE guidance. There are other reasons why Krogsbøll et al’s views should be challenged. Firstly, RCTs are expensive and time-consuming, and as a result, a lack of evidence from RCTs may deprive millions of people of potential benefits from interventions.  RCTs should therefore be complemented where possible by well-validated modelli...

The independent contractor model has been at the core of general practice in the UK since the NHS was first established and this model has many strengths. For example it has allowed the development of a s strong primary care sector that has allowed the NHS to operate efficiently - NHS general practices have typically used between 8-10% of the total NHS budget and dealt with up to 90% of all patient contacts with the NHS. However, in recent years, general practices have come under increasing pressure through a combination of rising workload, increased complexity of care, and a reduction in the resources allocated to primary care. Many general practitioners now find themselves struggling to cope with their day to day workloads. This makes it difficult for patients to gain timely access to their general practices and in turn increases pressure on other parts of the NHS, such as Emergency Departments. We are also now seeing a divide developing in the profession between salaried GPs and ...