Medical Centre

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...

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 ...