Author: Azeem Majeed

I am Professor of Primary Care and Head of the Department of Primary Care & Public Health at Imperial College London. I am also involved in postgraduate education and training in both general practice and public health, and I am the Course Director of the Imperial College Master of Public Health (MPH) programme.

Health outcomes in the UK: how do we compare with Europe?

In an article published in the British Medical Journal, I discuss the health outcomes achieved by the NHS in the UK and how these compare with other European countries. Health outcomes in the UK have improved substantially since the NHS was established in 1948. The NHS also performs well in many international comparisons on measures such as efficiency, equity, and access.

Despite these achievements, however, problems with health outcomes remain. Moreover, other European countries have also improved their health outcomes in recent decades, often at a faster rate than the UK. Consequently, the UK now lags behind many other European countries in key health outcomes in areas such as child health and cancer survival.

I conclude that new health policies in the UK should help the NHS to focus on improving health outcomes and that politically expedient schemes that are not evidence-based – such as extended opening hours in primary care – should be abandoned. Continued progress is also needed on wider determinants of health such as poverty, housing, education, employment, and the environment.

Telling the truth about antibiotics: benefits, harms and moral duty in prescribing for children

In a paper published in the Journal of Antimicrobial Chemotherapy, we discuss key issues in applying an evidence-based approach to the prescribing of antibiotics to children.

Antimicrobial resistance is a growing threat to global health, yet antibiotics are frequently prescribed in primary care for acute childhood illness, where there is evidence of very limited clinical effectiveness. Moral philosophy supports the need for doctors to consider wider society, including future patients, when treating present individuals, and it is clearly wrong to waste antibiotics in situations where they are largely clinically ineffective at the expense of future generations.

Doctors should feel confident in applying principles of antibiotic stewardship when treating children in primary care, but they must explain these to parents. Provision of accurate, accessible information about the benefits and harms of antibiotics is key to an ethical approach to antimicrobial stewardship and to supporting shared decision making. Openness and honesty about drivers for antibiotic requests and prescribing may further allow parents to have their concerns heard and help clinicians to develop with them an understanding of shared goals.

All this requires adequate time in the consultation; for both a thorough clinical assessment of the child; and a full discussion with the parents about the appropriateness, benefits and risks of antibiotic treatment.

DOI: https://doi.org/10.1093/jac/dky223

Patients value the quality of care they receive from their GP over extended access

In recent years, the NHS has invested in ‘extended hours’ schemes, whereby general practice are encourage to open beyond their contracted hours of 8am to 6.30pm Monday to Friday. In a study published in the British Journal of General Practice, we examined associations between overall experience of general practice and patient experience of making appointments and satisfaction with opening hours using data from the General Practice Patient Survey.

We found that patient experience of making appointments and satisfaction with opening hours were only modestly associated with overall experience. Patient satisfaction was most strongly associated with GP interpersonal quality of care

We concluded that policymakers in England should not assume that recent policies to improve access will result in large improvements in patients’ overall experience of general practice.

The article was covered by the medical magazine Pulse.

The F3 year: Why increasing numbers of foundation doctors are deciding against specialty training programmes

In an article published in the Journal of the Royal Society of Medicine, Paul Jewell and I discuss the issue of foundation doctors and specialist training. Only around 43% of junior doctors entered straight into a UK specialty training programme after completion of their foundation programme in 2017, a substantial decrease from 71% in 2011. Given the National Health Service in the UK is under ever-increasing workforce pressures, this is a worrying trend. The decline in entry to specialty training can be partly explained by the rise in what is known as ‘the F3 year’. Concerns over this ‘junior doctor exodus’ are not new, having been previously raised in 2010, when the figures were far more favourable than they are now. Similar trends can also be seen at earlier stages, with fewer school students applying to medical school, and fewer medical students applying to the foundation programme,4 indicating wider issues. To reverse this trend and the shortage of doctors in many specialties, solutions to encourage more foundation doctors to enter specialty training need to be considered.

https://doi.org/10.1177/0141076818772220

Measles outbreak in England

England is currently experiencing an outbreak of measles, with around 440 laboratory confirmed cases between January to May 2018. The outbreak is linked to ongoing outbreaks in Europe. Most cases are unimmunised teenagers and young adults. Children and young adults who did not receive MMR vaccine when they were younger, and people from under-vaccinated communities, are particularly at high risk.

Measles is a highly infectious illness that can sometimes cause serious complications such as pneumonia and encephalitis, and which can occasionally be fatal. Anyone who missed out on their Measles, Mumps and Rubella (MMR) vaccine or is unsure if they had 2 doses should therefore ensure they are fully immunised.

The outbreak also reinforces the importance of parents to ensure their children receive two doses of the MMR vaccine, the first at around 12 months of age and the second around 3-4 years of age.

Who is responsible for the vaccination of migrants in Europe?

An article from Imperial College London published in the Lancet discusses vaccination from migrants in Europe. Ensuring high levels of coverage is a key priority of the European Vaccine Action Plan, whereby all WHO Europe Member States have committed to eliminating endemic measles and rubella (>95% coverage with the measles mumps rubella vaccine), sustaining polio-free status, and controlling hepatitis B infection.

Changing nationwide trends in endoscopic, medical and surgical admissions for inflammatory bowel disease: 2003–2013

Our recent paper in BMJ Open Gastroenterology examines trends in endoscopic, medical and surgical admissions for inflammatory bowel disease in England from 2003–2013. In the last decade, there have been major advances in inflammatory bowel disease management but their impact on hospital admissions requires evaluation. We aim to investigate nationwide trends in inflammatory bowel disease surgical/medical elective and emergency admissions, including endoscopy and cytokine inhibitor infusions, between 2003 and 2013.

We used Hospital Episode Statistics and population data from the UK Office for National Statistics. Age-sex standardised admission rates increased from 76.5 to 202.9/100 000. Rising inflammatory bowel disease hospital admission rates in the past decade have been driven by an increase in the incidence and prevalence of inflammatory bowel disease. Lower GI endoscopy and surgery rates have fallen, while cytokine inhibitor infusion rates have risen. There has been a concurrent shift from emergency care to shorter elective hospital stays. These trends indicate a move towards more elective medical management and may reflect improvements in disease control.

DOI: http://dx.doi.org/10.1136/bmjgast-2017-000191

Childhood obesity – the importance of early interventions

Health inequalities start very early in life. By the time of school reception year (4-5 years of age), children from the most deprived areas of England are twice as likely to be obese as children from the most affluent areas. This illustrates the importance of the implementing policies to improve health at a very early stage, starting before conception, continuing through pregnancy, and then into infancy and childhood.

Source: NHS Digital http://digital.nhs.uk/catalogue/PUB30258

 

The impact of private online video consulting in primary care

Workforce and resource pressures in the UK National Health Service (NHS) mean that it is currently unable to meet patients’ expectations of access to primary care. In an era of near-instant electronic communication, with mobile online access available for most shopping and banking services, many people expect similar convenience in healthcare. Consequently, increasing numbers of web-based and smartphone apps now offer same-day ‘virtual consulting’ in the form of Internet video conferencing with private general practitioners.

While affordable and accessible private primary care may be attractive to many patients, the existence of these services raises several questions. A particular concern, given continued development of antimicrobial resistance, is that some companies appear to use ease of access to treatment with antibiotics as an advertising strategy. We examine online video consulting with private general practitioners in the UK, considering its potential impact on patients and the National Health Service, and its particular relevance to antimicrobial stewardship in an article published in the Journal of the Royal Society of Medicine.

Questions remain about the safety of online consulting and of the working practices of some private companies, and appropriate regulation is essential to ensuring that these services offer safe and effective care to patients. This will require a carefully tailored approach on the part of regulators such as the Care Quality Commission. For example, it has not been necessary to develop standards on advertising when assessing National Health Service general practices, but this will be essential in monitoring the actions of private online general practice services.

The article was covered by a number of media outlets including PulseGP and the Sun.

https://doi.org/10.1177/0141076818761383

Clinical pharmacists in primary care: a safe solution to the workforce crisis?

In a paper published in the Journal of the Royal Society of Medicine, we discuss the role that clinical pharmacists could play in primary care.

Primary care in the United Kingdom’s NHS is in crisis. Systematic underfunding, with specific neglect of primary care compared to other clinical specialties, has combined with ever-rising demand and administrative workload to place a now dwindling workforce under unsustainable pressure.

A major factor in the growing workload in primary care is prescribing. An aging population and higher prevalence of chronic diseases is leading to increased case complexity and polypharmacy, and consequently greater potential for prescribing errors. Nearly 5% of all prescriptions in general practices in England have prescribing or monitoring errors, while in some areas up to half of the prescriptions are prone to error. Although most errors are of mild or moderate severity, they can be life-changing for patients and costly for healthcare systems, accounting for around 3.7% of preventable hospital admissions.

Workload and time pressures exacerbate prescribing errors. Concerns about workload and access in primary care have led the UK Government to pledge increases in the general practitioner workforce, but general practitioners take at least 10 years to train and declining numbers of medical graduates internationally suggests a limited pool for recruitment. In this article, we discuss integration of clinical pharmacists in general practices as a potential solution to these problems.

While the pool of general practitioners is limited, the number of pharmacists is increasing. Pharmacists undertake shorter training than general practitioners, with four years undergraduate degree followed by one year of pre-registration experience. While the role of pharmacists has expanded beyond dispensing of medications and now involves provision of several other aspects of patient care, their knowledge and expertise is often under-utilised. Making use of their expertise in medication management, pharmacists could perform a variety of tasks in primary care, improving patient safety and clinical outcomes through optimised medication use, and potentially alleviating workload, freeing up general practitioners to deal with more complex cases and reducing waiting times for appointments.

Pharmacists have been working in primary care teams for some time in non-patient-facing roles. Areas in which they support practices include auditing for performance targets, implementation of enhanced services, preparation for inspections by the Care Quality Commission, training staff in repeat prescribing and providing medicines information for other clinicians. However, these roles currently vary from practice to practice. The widespread integration of pharmacists in both patient-facing and non-patient-facing roles therefore has the potential to have impact in three key areas: safety of prescribing; improved health outcomes; and access to primary care through reduction of general practitioner workload

DOI: https://doi.org/10.1177/0141076818756618