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.

Patients are more satisfied with general practices managed by GP partners than those managed by companies.

General practices in England are independent businesses that are contracted to provide primary care for specified populations. Most are owned by general practitioners, but many types of organisation are now eligible to deliver these services. In a study published in the Journal of the Royal Society of Medicine, we examined the association between patient experience and the contract type of general practices in England, distinguishing limited companies from other practices.

We analysed data from the English General Practice Patient Survey 2013–2014 (July to September 2013 and January to March 2014). Patients were eligible for inclusion in the survey if they had a valid National Health Service number, had been registered with a general practice for six months or more, and were aged 18 years or over. All general practices in England with eligible patients were included in the survey (n = 8017).

Patients registered to general practices owned by limited companies reported worse experiences of their care than patients registered to other practices on average. This applied to practices recorded as limited companies in routine contract data and to practices owned by large organisations. The sizes of the differences in experience varied from moderate to large across four outcome measures and were largest for the frequency of consulting a preferred doctor. Limited company ownership of general practices is uncommon in England. Patient experience was not consistently associated with the contract type for practices not recorded as limited companies. Across all contract and ownership types, patients generally reported positive experiences of their general practices.

Although our results suggest that limited companies provide worse patient experiences on average, some practices owned by these companies provide a good experience; others provide the opposite. It is the responsibility of commissioners, regulators, clinicians and owners to guarantee that individual practices meet expected standards while ensuring that care quality is not systematically associated with the ownership. Commissioners also need to ensure that contracts offer good value for money, more so at a time when the National Health Service is under severe financial pressure.

Reorganisation of stroke care and impact on mortality in patients admitted during weekends

In a study published in BMJ Safety and Quality, we evaluated mortality differences between weekend and weekday emergency stroke admissions in England over time. We aimed to determine whether a reconfiguration of stroke services in Greater London was associated with a change in this mortality difference.

We extracted patient-level data from national routinely collected administrative data (Hospital Episode Statistics or HES) from 1 January 2008 to 31 December 2014. Records include information of all admissions to English National Health Service (NHS) hospital trusts. Each patient record contains information on demographics (such as sex, age and ethnicity), the episode of care (such as trust name, date of admission) and diagnosis.

Our study covers a 30-month period before (January 2008 to June 2010) the reorganisation of stroke service in Greater London, and a 54-month period afterwards (July 2010 to December 2014). All admissions during the same period in the rest of England were used as controls.

Across England, the higher 7-day and 30-day in-hospital mortality risk associated with patients with stroke admitted during weekends compared with weekdays declined during the study period, to the extent that it was no longer statistically significant in the most recent year (2014). In Greater London, an adjusted 28% (RR=1.28, 95% CI 1.09 to 1.47) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 9% higher risk (RR=1.09, 95% CI 0.91 to 1.32) in 2014. For the rest of England, a 15% (RR=1.15, 95% CI 1.09 to 1.22) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 3% higher risk (RR=1.03, 95% CI 0.97 to 1.10) in 2014. During the same period, in Greater London an adjusted 12% (RR=1.12, 95% CI 1.00 to 1.26) weekend/weekday 30-day mortality ratio in 2008 slightly increased to 14% (RR=1.14, 95% CI 1.00 to 1.30); however, it was not significant.

While other research has suggested that centralisation of stroke care in London is associated with better outcomes generally, we in addition observe a gradual reduction in the weekend effect for emergency stroke admissions across England between 2008 and 2014. Although we cannot rule out an effect from centralisation, we found no statistical association with the reorganisation of services in London. This is unlikely to be due to changes in casemix or coding, and is consistent with a more general pattern of service improvement across the country with increased specialisation, as well as improved 24/7 delivery of care. While we have not specifically looked at staffing levels, it has not escaped our notice that our observed reductions in the ‘weekend effect’ occurred before any contractual changes for medical staffing in the UK.

Public support for increased tobacco taxation in Europe is highest in more affluent counties

Increased taxation on tobacco products can be an effective method of reducing tobacco use. In a study published in the Scandinavian Journal  Public Health, Filippos Filippidis and myself, along with colleagues from Harvard University, assessed support for increased taxation on tobacco products and other tobacco control measures among people aged ≥15 years in 27 European Union (EU) during the period 2009-2012.

We obtained nationally representative data from the 2009 (n=26,788) and 2012 (n=26,751) cross-sectional Eurobarometer surveys. Estimates were compared using chi-square statistics. The effect of the relative change in gross domestic product (GDP) on the change in support for increased taxation during 2009-2012 was calculated using the Pearson correlation coefficient and linear regression models.

We found that between 2009 and 2012, support for increased taxes on tobacco products declined (56.1% to 53.2%. However, support for other tobacco control measures increased significantly. After adjusting for baseline GDP per capita (2009), a 10% increase in GDP per capita was associated with 4.5% increase in support of tax increases. There was a strong correlation between the change in GDP and support for increased taxes (correlation coefficient 0.64). Also, after adjusting for baseline GDP, support for higher taxes on tobacco increased by 7.0% for every 10% increase in GDP between 2009 and 2012.

We concluded that population support for tax increases declined in the EU between 2009 and 2012, especially in countries with declines in GCP. Nonetheless, public support for other tobacco control measures remains high, thus indicating a viable environment for the use of more comprehensive tobacco control policies.

How can medical students be encouraged to consider primary care as a career?

In a letter published in the British Journal of General Practice, medical students Fahmida Mannan and Zain Chaudhry from the Imperial College London School of Medicine discuss how the NHS and medical schools can encourage students to consider general practice as a career option. They suggest the focus in medical schools should shift towards improving the quality of general practice placements and promoting the integration of primary care and specialist teaching, rather than consuming more time in an already overstretched curricula.

They also consider that prestige has never been the main incentive for pursuing a specialty. Their own experience is that many medical students are attracted to a career in general practice because of other factors, such as a good work–life balance, continuity of care and career flexibility. With many GPs now concerned about their workload, this inevitably influences students and junior doctors in their career choices.

Another key factor is the funding that a specialty receives. In recent years, the proportion of the NHS budget spent on primary care has decreased, GPs’ workload has increased and the income of GPs has fallen. To recruit more GPs, medical schools should improve the quality of students’ experiences in their primary care placements. However by itself, this will not be sufficient to improve recruitment and the onus falls upon the NHS to once again make general practice a rewarding career for doctors.

We are now seeing some signs of this. For example, the NHS England Five Year Forward Strategy emphasises the importance of primary care to the NHS and proposes new employment models for general practitioners. This includes the formation of GP Federations in which general practitioners will come together to work in larger groups; and the possibility that hospitals could also employ GPs and offer primary care services.

Community Outreach in West London

Members of the School of Public Health held a very productive and informative meeting today senior members of Imperial College including Sarah Waterbury, Vice President (Advancement); Maggie Dallman, Associate Provost (Academic Partnerships); Angela Bowen, Director of Development (Faculty of Medicine); and Tom Pearson, Head of Special Projects (Academic Partnerships).

The Department of Primary Care & Public Health in the School of Public Health works with local community stakeholders – such as voluntary groups, local authorities, and general practitioners – on a range of community-based outreach projects. These projects aim to improve the health and wellbeing of local residents; improve access to professional careers for children from deprived backgrounds; and give medical students experience of working with deprived and marginalised groups to develop skills in health coaching and behavioural change. This work is in addition to the very high-quality teaching and research programmes undertaken by the department.

Objectives for the future include developing a central coordinating function to bring this outreach work together; and integrate better with ongoing academic work in the Department of Primary Care and Public Health, the School of Public Health, the Faculty of Medicine, and Imperial College. We also need to expand the academic outputs from this work – such as conference presentations and journal articles – and give our students and clinical trainees greater opportunities to play a role in this work, thereby improving their skills and also the well-being of our local population.

 

Proportion of emergency admissions via A & E increasing while the proportion via GPs falling

In a paper published in the Journal of the Royal Society of Medicine, a team from Imperial College London examined time trends in emergency hospital admissions via accident and emergency departments in England. The proportion of emergency hospital admissions in which patients were admitted via an A and;E department increased markedly in England between 2001–2002 and 2010–2011.

There are several possible explanations for this trend. These include coding changes and the greater use of A and E departments to assess patients before they are admitted as emergencies. Changes in access to general practitioners – both during normal working hours and out of hours – may also have contributed to these changes.

The findings of the study in the JRSM are similar to those from studies in the United States. Future health policy should address gatekeeping in A  and E departments and the provision of urgent care in general practice  New models of care such as urgent care services that employ GPs in A and E departments as the gatekeepers to specialist urgent care may help in addressing this challenge but must be evaluated before they are scaled up.

The article was covered in Pulse and GP.

Electronic learning could enable millions more students to train as doctors and nurses worldwide

Electronic learning could enable millions more students to train as doctors and nurses worldwide, according to research carried out by the Department of Primary Care and Public Health at Imperial College London.

review commissioned by the World Health Organization (WHO) and carried out by Imperial College London researchers concludes that eLearning is likely to be as effective as traditional methods for training health professionals.

eLearning, the use of electronic media and devices in education, is already used by some universities to support traditional campus-based teaching or enable distance learning. Wider use of eLearning might help to address the need to train more health workers across the globe. According to a recent WHO report, the world is short of 7.2 million healthcare professionals, and the figure is growing.

The Imperial team, led by Dr Josip Car, carried out a systematic review of the scientific literature to evaluate the effectiveness of eLearning for undergraduate health professional education. They conducted separate analyses looking at online learning, requiring an internet connection, and offline learning, delivered using CD-ROMs or USB sticks, for example.

The findings, drawn from a total of 108 studies, showed that students acquire knowledge and skills through online and offline eLearning as well as or better than they do through traditional teaching. The authors suggest that combining eLearning with traditional teaching might be more suitable for healthcare training than courses that rely fully on eLearning because of the need to acquire practical skills.

Dr Josip Car, from the Department of Primary Care and Public Health in the School of Public Health at Imperial College London said: “eLearning programmes could potentially help address the shortage of healthcare workers by enabling greater access to education, especially in the developing world the need for more health professionals is greatest.

There are still barriers that need to be overcome, such as access to computers, internet connections, and learning resources, and this could be helped by facilitating investments in ICT. Universities should encourage the development of eLearning curricula and use online resources to reach out to students internationally.”

The full text of the review can be viewed online.

News items on the report were published in the Nursing Times and in the Examiner as well as by Reuters.

Giving patients online access to their electronic health records and linked online services

Online access to medical records by patients has the potential to promote patient-centred care and improve patient satisfaction.  Online services may also offer patients greater convenience although concerns remain about privacy and confidentiality. However, online access and services may also prove to be an additional burden for healthcare providers who are already under considerable workload pressures.

In a study published in the British Journal General Practice, I and colleagues form other UK universities assessed the impact of providing patients with access to their general practice electronic health records (EHR) and other EHR-linked online services on the provision, quality, and safety of health care. We carried out a systematic review that focused on all studies about online record access and transactional services in primary care.

We identified 176 studies, 17 of which were randomised controlled trials, cohort, or cluster studies. Patients reported improved satisfaction with online access and services compared with standard provision, improved self-care, and better communication and engagement with clinicians. Safety improvements were often patient-led; for example, through identifying medication errors and facilitating increased use of preventive services.

Provision of online record access and services resulted in a moderate increase of e-mail contact but no change on telephone contact. There were variable effects on face-to-face contact. However, other tasks were necessary to sustain these services, which impacted on clinician time. There were no reports of harm or breaches in privacy. In general online access to EHRs and online services was generally positive in its impact on areas such as patient satisfaction and patient safety.

The findings from this review are important for health systems and professionals. Although online access may be achievable, there remain challenges about clinicians’ adoption of systems because of workload and workflow concerns. The business model for primary care may also need to change to enable more effective utilisation of information technology in everyday practice.

Research using primary care databases in the United Kingdom

Data collected in electronic medical records for a patient in primary care can span from birth to death and can have enormous benefits in improving health care and public health, and for research. Several systems exist in the United Kingdom (UK) to facilitate the use of research data generated from consultations between primary care professionals and their patients.

In a study published in the Journal of Innovation in Health Informatics, we carried out a bibliometric review to analyse the research outputs and the longitudinal growth in the number of publications that harness the three main UK primary care databases: CPRD, QResearch and THIN.

These databases collectively produced 1,296 publications over a ten-year period, with CPRD producing 63.6% (n=825 papers), THIN 30.4% (n=394) and QResearch 5.9% (n=77). Pharmacoepidemiology and General Medicine were the most common specialities featured.

The growth in publications from these databases shows that they are making an important contribution to biomedical research in the UK. To continue to promote academic research using primary care databases, General Practitioners will need to continue to provide complete and accurate data; set standards will also need to be provided to General Practitioners to encourage enthusiasm and willingness to enter the required data;and public support encouraged for the continued use of
these databases for research that benefits the health of the population of the UK.

DOI: http://dx.doi.org/10.14236/jhi.v24i3.942

Setting more ambitious targets for general practices may not improve quality of care

Pay for performance programmes are being adopted in a growing number of countries as a quality improvement tool. In 2004, the United Kingdom introduced the Quality and Outcomes Framework (QOF) which primarily aimed to improve the management of common chronic conditions, such as diabetes and stroke, in primary care. The Department of Health in England is now considering allowing more flexibility in local pay for performance schemes, such as the introduction of higher payments for meeting tougher performance targets.

Research carried out at Imperial College London suggests that such local pay for performance schemes can improve target achievement by general practices but have no significant impact on the overall quality of clinical care. The study was funded by the NIHR and the NW London Collaboration for Leadership in Applied Health Research and Care (CLAHRC) and published in the journal PLoS One.

In the study, which was carried out by a team from the Department of Public Health and Primary Care at Imperial College London, the impact of a local pay for performance programme (QOF+), which rewarded financially more ambitious quality targets (‘stretch targets’) than those used nationally in the Quality and Outcomes Framework (QOF) was examined. The research team focused on targets for intermediate outcomes in patients with cardiovascular disease and diabetes. The team also analysed patient-level data on exception reporting. Exception reporting allows practitioners to exclude patients from target calculations if certain criteria are met, e.g. the patient has a terminal illness or gives informed dissent from treatment.

The team found that the local pay for performance program led to significantly higher target achievements for the management of hypertension, coronary heart disease, diabetes and stroke. However, the increase was driven by higher rates of exception reporting in patients. There were no statistically significant improvements in mean blood pressure, cholesterol or HbA1c levels. Thus, achievement of higher payment thresholds in the local pay for performance scheme was mainly due to increased exception reporting by practices. This may have been because the patients who were not exception-reported would not have benefited from more intensive treatment. There were no significant improvements in overall quality of clinical care once exception reporting was taken into account.

Hence, active monitoring of exception reporting should be considered when setting more ambitious quality targets for primary care teams. Some policy-makers and health service managers may consider giving practices less scope to exclude patients from pay from performance targets in an attempt to improve quality of care. Conversely, pay for performance programmes should not encourage over-treatment or inappropriate treatment; and exception reporting of suitable patients should always be allowed. Patients should also always be fully involved in decisions about their care and decide whether the incremental benefits of more intensive treatment will outweigh the potential problems (for example, from more intensive control of glucose in people with diabetes).