Month: September 2017

We need activity-based funding and a more tightly defined contract for NHS general practices

In a letter published in the British Medical Journal, I respond to comments from Dr David Shepherd and Dr Hendrik Beerstecher about an editorial I wrote on shortages of general practitioners in the NHS. Dr Shepherd argues that capitation-based funding for general practice can work if the total amount of funding was increase and better methods were used to allocate funds to general practices. Dr Beerstecher argues that there is a mismatch between the supply of general practitioners and demand for their services.

In my response, I state that that increasing the amount of funding for primary care would be a step forward. Moving from the current Carr-Hill formula for allocating budgets to general practices to a formula with more patient level clinical data would also be helpful. But case mix adjusted formulas such as the Johns Hopkins adjusted clinical groups (ACG) system have limitations—particularly when used for smaller populations such as those covered by the typical NHS general practice.

Furthermore, an entirely capitation based formula would not prevent the shift of unfunded work from specialist care to primary care, which is one of the major problems currently facing general practices and one that clinical commissioning groups in England seem unwilling or unable to tackle.

I agree with Dr Beerstecher about the mismatch between the supply of GPs in the NHS and demands for their services. I allude to this when I state that GP services might need to be scaled back to fit the public funding available. Demands on GPs could be reduced if practices had a more tightly defined contract with the NHS.

The current GP contract is vague and open ended, setting few limits on the quantity or range of services that GPs are expected to offer the NHS and their patients. Furthermore, government policy in recent years has been to encourage GPs to offer even more services and make themselves more available to patients—for example, by requiring GPs to open their practice for longer hours without a substantial increase in the GP workforce. These policies have led to higher demands on primary care.

GPs are also faced with patients expecting them to fill gaps in local health services. For example, patients with dental problems often present (inappropriately) to their GPs because of problems accessing dental services. These are all problems that need to be tackled by NHS commissioners.

Clinician-identified problems and solutions for delayed diagnosis in primary care

Delayed diagnosis in primary care is a common, harmful and costly to patients and health systems. Its measurement and monitoring are underdeveloped and underutilised. A study from Imperial College London published in BMC Family Practice created and implemented a novel approach to identify problems leading to and solutions for delayed diagnosis in primary care. We developed a novel priority-setting method for patient safety problems and solutions called PRIORITIZE. We invited more than 500 NW London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to delayed diagnosis in primary care. 113 clinicians submitted their suggestions which were grouped into a composite list of 33 distinct problems and 27 solutions. A random group of 75 clinicians from the initial cohort scored these and an overall ranking was derived.

The top ranked problems were poor communication between secondary and primary care and the inverse care law, i.e. a mismatch between patients’ medical needs and healthcare supply. The highest ranked solutions included: a more rigorous system of communicating abnormal results of investigations to patients, direct hotlines to specialists for GPs to discuss patient problems and better training of primary care clinicians in relevant areas. A priority highlighted throughout the findings is a need to improve communication between clinicians as well as with patients. The highest ranked suggestions had the highest consensus between experts.

The novel method we have developed is highly feasible, informative and scalable, and merits wider exploration with a view of becoming part of a routine pro-active and preventative system for patient safety assessment. Clinicians proposed a range of concrete suggestions with an emphasis on improving communication among clinicians and with patients and better GP training. In their view, delayed diagnosis can often be prevented with interventions requiring relatively minor investment. Rankings of identified problems and solutions can serve as an aid to policy makers and commissioners of care in allocating healthcare resources.

Rethinking primary care’s gatekeeper role

Gatekeeping is the term used to describe the role of primary care physicians or general practitioners (GPs) in authorising access to specialist services and and diagnostic tests. Gatekeeping has important influences on service utilisation, health outcomes, healthcare costs, and patient satisfaction. In an article published in the British Medical Journal, we discuss the role of gatekeeping in modern health systems.

In the UK access to NHS and private specialists is generally possible only after a referral from a GP. Gatekeeping was developed as a response to a shortage of specialists and a desire to control healthcare spending and has been an accepted practice in the UK for many years. The NHS is under considerable pressure to use its resources efficiently, and GPs have helped the NHS to achieve this goal through managing a large proportion of NHS workload in primary care. However, GPs in the UK now find themselves under considerable workload pressures. In an 11-country survey of primary care physicians, it was GPs in the UK who had the shortest consultation lengths and were the most stressed. Could direct access to some NHS services help reduce GP workload and facilitate greater patient choice?

Internationally, there is a large variation in the role of primary care physicians in “gatekeeping”. In many countries, patients can access specialist services directly without a referral from a primary care physician (sometimes with a co-payment). Although it is often assumed that gatekeeping will help control healthcare costs, there is little association between the strength of gatekeeping in countries and the proportion of GDP spent on healthcare. Some countries with weak gatekeeping spend a relatively small proportion of GDP on healthcare (e.g. Singapore).

Within countries, there can also be differences in gatekeeping policies. In England, for example, there are large variations between clinical commissioning groups (CCGs) in policies for giving patients direct access to services. For example, some CCGs allow patients to have direct access to physiotherapy services.

In the article, we look at the pros and cons of gatekeeping, describe gatekeeping policies in various countries, and highlight the need for more evidence to devise policy. We conclude that gatekeeping policies should be revisited to accommodate the government’s aim to modernise the NHS in terms of giving patients more choice and facilitate more collaborative work between GPs and specialists. At the same time, any relaxation of gatekeeping should be carefully evaluated to ensure the clinical and non-clinical benefits outweigh the costs.

Former MPH Student Vasundhra Khanna selected to present her research at the World Innovation Summit for Health

Former MPH student Vasundhra Khanna was selected to present her research at the World Innovation Summit for Health in Doha this November. Vasundhra told us about her research and her next steps.

“During my MPH at Imperial College in the 2014/15 academic year, I was inspired to pursue health promotion, primarily the nuances of formulating effective public health policy with greater relevance and utility in society. An opportunity to engage in such policy innovation was presented to me via the ‘Mini-Project’, coursework where students are asked to develop an innovative ‘health-intervention’ targeting real-world problems. The topic that caught my eye was inappropriate use of antibiotics and the serious consequences related to ‘antibiotic resistance’.

Antibiotic resistance in the developing world represents a major public health challenge. It is estimated that 10 in 10,000 people in Africa die as a result of antibiotic resistant bacteria, whereas, in Asia this is estimated to be 9 per 10,000 people. The incidence of resistance, however, seems to be worse in India, where up to 95% of adults carry bacteria resistant to β-lactam antibiotics. As a result, I decided to focus my intervention on India, the largest consumer of antibiotics globally. Antibiotic resistance in India emanates from patterns of inappropriate antibiotic prescription and consumption. Specifically, poorly managed health systems result in the unregulated over-the-counter sale of antibiotics and create a supportive environment for self-medication – the leading cause of improper antibiotic use throughout the country. This multifaceted nature of irrational antibiotic usage makes it difficult to develop a solution for regulating supplier and consumer attitudes.

Keeping that in mind, I chose to focus on affecting current consumer behaviours to curb inappropriate antibiotic consumption. Thus, my intervention concerns the development of home-based testing kits capable of distinguishing between bacterial and viral infections: Bac-Kits (Bacterial infection diagnosing-Kits). In this regard, I adopted a fully integrated Lab-on-a-disc ELISA system developed by Ulsan National Institute of Science and Technology (UNIST), Republic of Korea, and applied it to a novel signature of proteins, whose blood concentrations differ in response to bacterial and viral infections. The microbeads structure of the immunoassay on the discs allows the kits to have a competitive advantage over traditional ELISA by generating results using half the blood sample (150 μL) and within ~30 minutes. Each kit comes with pre-treated discs and a portable blood analyser with an easy interface – thereby, eliminating the need for technical skills and providing accurate diagnosis within the convenience of one’s home. This ensures scale-up to resource-constrained areas, where shortages of medical equipment and health workforce act as a barrier to healthcare. Although privately manufactured, cost-efficiency can be achieved through economiesof- scale.

Ultimately, by reducing inappropriate consumption of antibiotics in non-bacterial cases, Bac-Kits can contribute towards decreasing burden of resistance in the country. While the Mini-Project allowed me to develop the concept of this public health solution, the opportunity to make it a reality was presented to me by the World Innovation Summit for Health (WISH), where my idea was selected under the Young Innovator Programme 2016. WISH is a global healthcare community dedicated to identifying and disseminating the best evidence-based ideas and practices. At the summit in Doha in November, over 1,200 delegates are expected to attend, including national Ministers of Health, healthcare experts, industry leaders, investors and researchers. I aim to use this platform to establish my idea within the global public health community and gain guidance from industry experts and enthusiasts on making it a more robust intervention. Subsequently, I hope to collaborate with public health agencies in India to bring my innovation to life and contribute my share to curb the global disease burden.”

Why we need workload-based funding for general practices in England

The NHS is currently aiming to develop a new capitation-based formula for funding general practices in England. My view is that a revised formula won’t address the fundamental problem with the current method of funding primary care: the disconnect between workload and funding. All the new formula will do – no matter how well-designed – is shuffle money between general practices. Some practices will gain substantial sums, some will lose substantial sums; but most practices will see no major changes in their funding.

Capitation-based formulas for general practices are therefore a 20th century solution that the government is trying to continue to use in the 21st century. We need to move away from a capitation-based funding model to one based on actual workload as well as on capitation. Under such a model, any work done by general practices – whether generated through government policy, patient demand or transfer of work from specialist settings into the community – would be paid for at its full cost. There would then be no need for any ‘funding formula’. The more work a practice did, the more it would get paid.

This is how primary care funded in many other developed countries and results in improved access to primary care services. Critics of workload-based funding for general practices might argue it would dramatically increase costs as well as being administratively complex to administer. However, the alternative is the continuation of current trends, with worsening access for patients to primary care services; and an exacerbation of GP recruitment and retention problems.

This blog was originally posed as a rapid response on the BMJ website.

Faculty of Medicine Postgraduate Newsletter Features MPH Course Director, Professor Azeem Majeed

MPH Course Director, Professor Azeem Majeed from the School of Public Health, was interviewed for the Faculty of Medicine Postgraduate Newsletter.

Q: Tell us a bit about yourself and what you do.
A: I am the Course Director of the Imperial College London Master of Public Health (MPH) programme. My other roles include being Professor of Primary Care and Head of the Department of Primary Care and Public Health at Imperial College London. I am also Associate Medical Director with the Imperial College Healthcare NHS Trust and an adviser to the World Health Organization (WHO) on primary care and public health. I remain active in clinical practice as a GP in the Clapham area of London.

Q: What were you doing before you joined Imperial?
A: I was formerly Professor of Primary Care & Public Health at University College London. I have also worked as a GP in the Clapham area of London since 1995.

Q: What (and who) inspired your research and teaching interests?
A: I undertook my GP training in the Pontypridd area of South Wales. I was struck by how many young patients I saw with problems such as heart disease and cancer. It was during this period I began to realise the importance of the wider non-medical determinants of health and the importance of topics such as health promotion, disease prevention and early diagnosis.

Q: What are the biggest challenges in your research field?
A: Health systems throughout the developed world are under increasing pressure to provide universal access to high quality services while at the same time trying to limit public spending on healthcare. This has led to an increased emphasis on ensuring that health services are of high quality, safe and cost effective; and that doctors and other health professionals base their clinical decisions on high quality evidence. There is also increased awareness of addressing risk factors for poor health such as smoking, unhealthy diets, physical inactivity and obesity.

Q: What do you enjoy doing in your free time?
A: I was formerly a qualified football referee but have had to give this up because of other commitments. In my spare time, I enjoy reading. I am also a member of the National Trust and enjoy visiting their parks and gardens.

Q: What advice would you give to new Masters students?
A: Attend your lectures, study hard, and practise academic writing. Read articles in relevant journals such as the BMJ and Lancet. Try to contribute to public and global health through membership of student societies and by writing for blogs.

The full newsletter can be viewed online

Dr Javier Salerno reflects on his experience of teaching medical students

Dr Javier Salerno won a 2017 Lifetime Teaching Award from the School of Public Health for his contribution to teaching medical students from Imperial College London on primary care attachments. Dr Salerno accepted his award by sharing some reflections of what students have said to him over the years.

“I like this rotation as we do hands on medicine: it gives students the experience of seeing patients from very early days in their illness and the opportunity to see a lot of different patients. 

I learned more medicine in this practice than in hospitals. I did not have a clue what I was going to do as a post graduate studies however after this rotation I am considering general practice very seriously. I will read my BMJ, NEJM, Lancet, JAMA on a weekly basis! 

After diagnosing 3 melanomas on young people, they asked how did I find them if they had come for a flu like illness and chest infections. I asked them to remove their tops and melanomas were in rear dorsal areas and behind the arms. But why did you do that…..? Because of a 4 letter word which does not beginning with f (they did not have an idea of such word)…the word is CARE which they should also take as part of their education in medicine and humanity. 

You are not just a GP, are you? (Stated several times by medical students) You are a reader of medicine aren’t you (most flattering compliment to me)?

Dr Salerno comments that “My aims for medical students: to make it very interesting, to share enthusiasm and humanity, care and compassion, friendship, up-to-date knowledge and above all fun! This is what they taught me in my medical school: San Fernando medicine faculty/San Marcos University, Lima, Peru.”

Lambeth CCG 2017 Award for Outstanding Contribution to Primary Care

I was very honoured to have won the 2017 Lambeth CCG Award for Outstanding Contribution to Primary Care. Lambeth CCG noted that “Dr Majeed has made a huge contribution to primary care research and teaching, as well as providing high quality kind care to his patients in Clapham, where he has worked as a GP for over 20 years. Dr Majeed was also recognised recently in Pulse magazine as one of the 50 most influential GPs in the UK.”

Imperial MPH Students win first prize in the “Vaccines Today Communication Challenge”

Two MPH students, Yewande Adeleke and Riham Arab, won the first prize in the “Vaccines Today” competition with their video promoting the MMR vaccine. We would like to congratulate them for their success. You can watch their video here.
This is the text accompanying the video: “Social media is a highly effective tool to use to improve awareness, encourage uptake and dispel myths associated with the MMR vaccine. So for the Vaccines Today Communication Challenge, we tried to display the content in an innovative, humorous and informative manner. The initial scene is to evoke a sense of duty and moral obligation amongst viewers. The target audience is both male and female adults. The transition from monochrome to coloured imaging is in parallel with the start of self-efficacious messaging and the MMR vaccination schedule is incorporated in the content. Finally, the video concludes with a herd of cows symbolising herd immunity and the #GetImmooonised slogan, can be used to encourage MMR vaccination on a variety of social media platforms”.

Imperial College GP Tutor Dr Christine Scott wins a 2017 Lifetime Teaching Award

Imperial College GP Tutor, Dr Christine Scott, won a 2017 Lifetime Teaching Award for her contribution to teaching medical students from Imperial College London. Here, she reflects on her experiences of teaching medical students.

Were you aware you were students’ inspiration and role model?
I think we often underestimate our impact on students. Now, as I read my feedback I recognise once again how extremely influential we are. What a great privilege, and what a great responsibility!

How long have you been teaching Imperial Medical Students for?
A lot of my embarrassment in receiving a lifetime teaching award is that I’ve only really been teaching at Imperial for about eight years. In a former era, I taught undergraduates from my alma mater, Newcastle University.

Why so long?
It hasn’t really been a very long time but I have been privileged to teach a number of different courses from first-year communication skills and First Clinical Attachment (FCA), doing some lecturing and teaching both in my practice and in the Department for Year 5 students on GP placement.

Why Imperial?
I really became involved in Imperial when I came along with a colleague to an introductory teaching session. It was a pragmatic decision, sessions were available and it’s my local medical school.

What kind of qualifications / CPD did you build up when teaching and how did this help you in this role?
Early on in my time teaching, I attended the Deanery Introduction to Teaching in Primary Care course (ITPCC). This really inspired me to be creative about the way I taught and gave me confidence to experiment, I really got a taste for it. Over the years, the annual GP teachers’ day and foundations of clinical practice (FoCP) conferences have been wonderful opportunities to learn. I always come not only with CPD credits but with my mind buzzing with new ideas of ways to teach and a whole new PDP for myself.

In what ways has teaching changed you and the way you practice medicine?
I think teaching has helped me to be more reflective and self-critical but also more confident. There is nothing like teaching something to ensure that you understand it well yourself and this is particularly true teaching within the clinical setting. My students have inspired me and challenged me to look at my practice through their young eyes. The skills of facilitation and feedback that I have learnt have had wider applicability working within the practice team. Lots of the teaching provided to us GP tutors at Imperial has also been extremely helpful. I look back gratefully on a number of memorable sessions, particularly those led by Giskin Day. Her teaching on medicine in the humanities has rekindled my love of reading and given me the courage to become creative!

Do you think hosting students has benefitted your GP practice, or the community you serve, in anyway?
The patients love talking to students and the perspective they bring, both on individual patients and on the service in general have been really useful. I think it also gives the whole practice a sense that they are contributing to the development of future doctors. In these days when we often feel tired and under pressure, it’s great to have the refreshing medical student perspective.

With the current NHS admin and recruitment pressures what would you be telling a family member if they were a GP and considering teaching?
Do it! The students you meet and the support and training you gain will be part of keeping you enthusiastic. When it works well, and it mostly does, the tutor-student partnership is formative for both parties, we change students but they change us. It is also clear from students that GPs are the people that really recognise them as individuals, adapt teaching to suit their learning needs and care about them – and that really counts. Finally, when I am old and unwell I want well taught and caring doctors to look after me!

Is there a memorable funny story from teaching you can imagine still recounting in the future?
I can’t really think of any funny stories, but certainly touching ones. The student who after his patient project was given a small silver teaspoon to remind him of parts of her story. My first year students performing a ballad to tell their patients story. Most recently two students explaining their patient’s illness using a wonderful model of a computer they had made as an allegory for his life.

We’ve heard about a beautiful house in France – tell us more about ‘life after being an Imperial teacher’
The beautiful house is on the edge of Paris and is part of my husband’s job. The main thing that will happen in my life after Imperial is being able to spend much more time in Paris with him making the most of all Paris offers. I’m also hoping to do some work developing appraisal with doctors working abroad and take some of my counselling skills to support our local church community. There will be plenty of time for coffee and museum visits and my Imperial friends will be warmly welcomed so keep in touch!