Author: Azeem Majeed

I am Professor of Primary Care and Public Health, 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.

GPs should not be made scapegoats for political failings

A recent article in the Daily Telegraph article asked “If the GPs went on strike, would anybody notice?” The article claimed that no one would notice if GPs went on strike and the author suggested that making all GPs salaried, forcing them to work longer hours, would help improve general practice for patients. The author quoted “a now retired GP in his 90s from Bristol who continued doing locum work until five years ago,” who apparently said, “Many GPs are using covid-19 as an excuse for not providing good clinical services. Being able to opt out of night/weekend cover and only working two or three days a week have caused the demise of general practice to the detriment of patients.”

As GPs we have worked throughout this pandemic often face-to-face in the most basic of personal protective equipment (PPE), and we were disheartened to read this piece.

GPs and their teams have played an essential role throughout the pandemic. GP teams in England alone deal with over 300 million contacts each year. General Practices have been running community hot covid clinics, and supporting NHS 111 and the Covid Clinical Assessment Service (CCAS). We are supporting 5.5 million patients on NHS waiting lists, who are often in severe pain and in need of extra support, as well as supporting about 1 million patients with the effects of long covid, and adapting to new ways of working enforced by a global pandemic. In addition, our teams have delivered the majority of covid vaccinations thus far. We are currently being asked to recall our most clinically vulnerable patients for their third covid booster vaccination. All this has been achieved despite the proportion of the NHS budget spent on NHS general practice and the number of GPs per person both declining in England in recent years.

We are already seeing that any small reduction in GP access causes rapid spill over into Emergency Departments, so just imagine if there were no GP service at all. The NHS would collapse. When GPs began to pull back from the covid-19 vaccination programme because of the mass vaccine sites taking over, for example, the rate of vaccination slowed—especially in the hardest to reach groups—and complaints increased from patients unable to access vaccine appointments.

If we look at prescriptions, GPs and their teams issue a vast number every year. If another part of the NHS tried to take on this work, an army of people would be needed—doctors, pharmacists, and administrative staff. Many higher risk medications need careful monitoring and regular review. Patients on most regular medication also require medication reviews, checks (e.g., blood tests, measuring blood pressure) to monitor safe prescribing and prevent drug interactions, and to deal with queries and frequent shortages and changes of medicines. The efficient systems that GPs have developed for prescribing means that they issue many prescriptions that would be given by hospital specialists in other countries.

Moreover, every patient seen in secondary care generates a letter, often with requests for GP teams to follow up patients, monitor their treatment, arrange blood tests, or prescribe.

The work of a GP can be incredibly rewarding as we build long term relationships with people over years, and there is strong evidence for the benefits of continuity of care (for both patients and the care provider).  GPs are true “generalists” and the uncertainty of undifferentiated illness is stressful, especially when working remotely. GPs in the UK work at a higher level of intensity than elsewhere in Europe. GPs in the UK have the shortest consultation times in Europe, and UK GPs tend to see more than twice the safe recommended number of patients per day.

BMA appointment data show huge increases in activity over the past 18 months. Yes, there are more telephone appointments and fewer face to face appointments, but this is the same in all sectors of society—and the same for both community and hospital care. It should come as no surprise, or make headline news, because remote working is in line with direct government policy and is there to protect both patients and staff from a highly infectious and potentially lethal virus. It is especially important to protect the many vulnerable individuals we look after in general practice, in a time when there are over 30,000 covid-19 cases reported daily in the UK.

Despite political promises for an additional 6000 additional GPs in England by 2024, there has been a reduction in numbers rather than an increase. While there is a clear link between ratios of family doctors and life expectancy, the number of patients per practice is now 22% higher than it was in 2015, and the GP workforce has not grown with this demand. As a result, there are now just 0.46 fully qualified GPs per 1000 patients in England, down from 0.52 in 2015, which, when added to growing demand from the rising number of people living with complex chronic illness and poverty along with an ageing population, means that primary care is in a desperate situation. GP turnover is higher in deprived areas further exacerbating health inequalities.

Demand on general practice is increasing, while at the same time general practices are struggling to recruit staff. The current deepening GP crisis that we are facing is having widespread effects on patient care nationwide. The current crisis long predated covid-19, but the pandemic has highlighted the large cracks in the NHS. GP teams should not be made scapegoats for the political failings, under-funding, and shortages of essential staff, which are the root cause of the issue.

General practice is often described as the “Bedrock of the NHS,” and the NHS Five Year NHS View states that “if General Practice Fails the NHS Fails.” We must be mindful of that, and instead of blaming GPs for the current crisis, look at what can be urgently done to alleviate the crisis.

Simon Hodes, GP partner in Watford, GP trainer, appraiser and LMC rep. Twitter: @DrSimonHodes

Frances Mair, Norie Miller professor of general practice. Twitter: @FrancesMair

Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, London, UK, Twitter @Azeem_Majeed

This article was first published in BMJ Opinion.

Covid infections are high in the UK – these are the reasons why

Covid-19 case numbers remain high in the UK. In this article, I discuss why this is and why vaccines are working as expected, and protecting us from serious illness and death.

What is a breakthrough infection?

No vaccine is 100% effective against preventing infection. An infection in a fully vaccinated person is sometimes described as a breakthrough infection because the infective agent has “broken through” the protection from infection provided by the vaccine.

How common is Covid-19 infection in fully vaccinated people?

Data from Public Health England show that the Covid-19 vaccines used in the UK reduce the risk of  infection by about 70-90% in people who are fully vaccinated, so vaccines prevent the majority of people who are vaccinated from becoming infected. However, some people who are fully vaccinated will still become infected. Over time, as the number of people in the population who are vaccinated increases, a greater proportion of infections will occur in vaccinated people. It is possible that the immunity from vaccination will weaken over time, with breakthrough infections therefore becoming more common, which is why the government is now considering giving booster doses of vaccine to some people.

How serious is Covid-19 infection in vaccinated people?

Research shows that vaccines are very effective in reducing the risk of serious illness from a Covid-19 infection, with around a 95% reduction in the risk of hospitalisation and death. However, some people who are vaccinated will still have a serious illness. As with infections in unvaccinated people, the risk of a serious illness is highest in the elderly and people with medical problems such as diabetes and obesity.

What makes a breakthrough infection more likely?

The more people you come into close contact with, the more likely you are to have a breakthrough infection. People whose work involves a lot of contact with other people, such as health professionals, will be at greater risk of a breakthrough infection. The risk of a breakthrough infection is also higher in people with weak immune systems because vaccines work less well for them. The risk of becoming infected with Covid-19 is highest in poorly-ventilated, crowded indoor spaces. To reduce your risk of infection, you should as far as possible, avoid these kinds of settings. A face mask can provide some protection from infection, particularly if you use a higher specification mask such as FFP2 mask.

How do new variants like delta effect the risk of infection?

The delta variant of the coronavirus that spread across the world in 2021, and which is now responsible for nearly all cases of Covid-19 in the UK, is more infectious than other variants. Vaccines will be a little less effective at preventing infection from the delta variant than the variants that were previously circulating in the UK. However, vaccines still remain very effective at preventing serious illness, hospitalisation and death, even against infections caused by the delta variant. So far, we have not yet come across a variant of the coronavirus against which vaccines are ineffective.

How well are vaccines working in the UK?

Vaccines are working very well in the UK. Around 81% of people aged 16 and over have been fully vaccinated. Public Health England estimates that around 24 million infections, 144,000 hospitalisations and 112,000 deaths have been prevented by vaccination. Without vaccines, the number of cases, hospitalisations and deaths in the UK would be much higher than now, requiring further Covid-19 restrictions and lockdowns to control the pandemic. It is vaccines that have allowed the government to relax these restrictions and let people to live more normally.

First published in the Daily Mirror.

Risk of Covid-19 in shielded and care home patients

Early in the Covid-19 pandemic, the elderly and people who were clinically extremely vulnerable were asked to shield to reduce their risks of Covid-19 infection and its complications. We evaluated the effectiveness of shielding in a study published recently in the journal BJGP Open.

We found that Covid-19 rates were much higher in the shielded group compared with non-shielded group (6.5% vs 1.8%). The increase in risk of infection in the shielded group persisted after adjustment for a wide range of factors in a Cox proportional hazards regression model.

We also found that Covid-19 rates were seven times higher in people living in care homes; and were also higher among people from ethnic minorities, those living in poorer areas, and in people with long-term medical conditions such as respiratory disease.

Our results suggest that shielding alone is not enough to protect clinically vulnerable people and that vaccination, along with suppressing community infection rates, remains the best way to protect these patients from the risk of serious illness and death from Covid-19.

Our results also refute suggestions that the UK could have avoided lockdowns by shielding vulnerable groups, whilst allowing society to otherwise function normally. This policy would probably have led to even higher infection, hospitalisation, and death rates in vulnerable people.

DOI: https://doi.org/10.3399/BJGPO.2021.0081

Having multiple sclerosis and depression is associated with an increased risk of early death

Depression is common in people with multiple sclerosis (MS), and a new study from our research group shows that people with both conditions are more likely to die over the next decade than people with just one or neither condition. The study was published in the September 2021, online issue of Neurology, the medical journal of the American Academy of Neurology. The study also found that people with MS and depression have an increased risk of developing vascular disease such as heart attack and stroke.

“These findings underscore the importance of identifying depression in people with MS as well as monitoring for other risk factors for heart disease and stroke,” said lead author Raffaele Palladino, MD, PhD, of Imperial College of London in the United Kingdom. “Future studies need to be conducted to look at whether treating depression in people with MS could reduce the risk of vascular disease as well as death over time.”

The study involved 12,251 people with MS and 72,572 people who did not have MS. We looked at medical records to see who developed vascular disease or died over a period of 10 years. At the start of the study, 21% of the people with MS had depression and 9% of the people without MS had depression.

We found that people with both MS and depression had a mortality rate from any cause of 10.3 per 100,000 person-years. Person-years take into account the number of people in a study as well as the amount of time spent in the study. The mortality rate for people with MS without depression was 10.6, for people who had depression without MS it was 3.6 and for people with neither condition it was 2.5.

Once we adjusted for other factors that could affect the risk of death such as smoking and diabetes, we found that people with both conditions were more than five times more likely to die during the next decade than people with neither condition. People with MS without depression were nearly four times more likely to die than people with neither condition and people with depression without MS were nearly twice as likely to die.

For the risk of vascular disease, the rate for people with both MS and depression was 2.4 cases per 100,000 person-years; 1.2 for people with MS without depression; 1.3 for people with depression without MS; and 0.7 for people with neither condition.

After adjusting for other factors, we found that people with both conditions were more than three times as likely to develop vascular disease as people with neither condition.

“When we looked at the risk of death, we found that the joint effect of MS plus depression equaled more than the effect for each individual factor alone — in other words, the two conditions had a synergistic effect,” Palladino said. “A total of 14% of the effect on mortality rate could be attributed to the interaction between these two conditions.”

Materials for this blog were provided by the American Academy of Neurology.

Journal Reference:

  1. Raffaele Palladino, Jeremy Chataway, Azeem Majeed, Ruth Ann Marrie. Interface of Multiple Sclerosis, Depression, Vascular Disease, and Mortality: A Population-Based Matched Cohort Study. Neurology, 2021; 10.1212/WNL.0000000000012610 DOI: 10.1212/WNL.0000000000012610

Impact of social restrictions during the COVID-19 pandemic on the physical activity levels of older adults

Physical inactivity adversely affects older adults, with more than 60% of those aged over 75 years not sufficiently physically active for good health as defined by meeting the WHO and UK guidelines. From March until June 2020 in the UK, a national ‘lockdown’ was implemented to reduce exposure to, and transmission of, COVID-19. Although applied to the whole population, adults aged over 70 years and those with underlying health conditions at higher risk of severe COVID-19 disease were asked to follow more stringent social distancing measures. These included remaining at home where possible; avoiding social mixing in the community; avoiding physically interacting with friends and family; and avoiding public transport.

In a paper published in the journal BMJ Open, we examined self-reported physical activity before and after the introduction of lockdown, as measured by metabolic equivalent of task (MET) minutes. Associations of physical activity with demographic, lifestyle and social factors, mood and frailty were also examined. The study population comprised adults enrolled in the Cognitive Health in Ageing Register for Investigational and Observational Trials cohort from general practitioner practices in North West London from April to July 2020. 6219 cognitively healthy adults aged 50–92 years completed the survey.

Mean physical activity was significantly lower following the introduction of lockdown from 3519 to 3185 MET min/week (p<0.001). After adjustment for confounders and pre-lockdown physical activity, lower levels of physical activity after the introduction of lockdown were found in those who were over 85 years old (640 (95% CI 246 to 1034) MET min/week less); were divorced or single (240 (95% CI 120 to 360) MET min/week less); living alone (277 (95% CI 152 to 402) MET min/week less); reported feeling lonely often (306 (95% CI 60 to 552) MET min/week less); and showed symptoms of depression (1007 (95% CI 612 to 1401) MET min/week less) compared with those aged 50–64 years, married, cohabiting and not reporting loneliness or depression, respectively.

We concluded that markers of social isolation, loneliness and depression were associated with lower physical activity  following the introduction of lockdown in the UK. Targeted interventions to increase physical activity in these groups are needed to limit adverse health outcomes from lower levels of exercise.

DOI: http://dx.doi.org/10.1136/bmjopen-2021-050680

Vaccinating healthcare workers against Covid-19

In an article published in the British Medical Journal, we discuss the topic of vaccinating healthcare workers against Covid-19. Our conclusion is that compulsion is unnecessary and inappropriate.

Parliament’s decision to make vaccination against covid-19 a condition of employment for care home workers has fuelled the debate around compulsory vaccination for healthcare workers, which may follow. Compulsory vaccination is not a panacea and may harm the safety of patients and healthcare workers, as well as affecting workload and wellbeing. It is a dilemma familiar to occupational health services in many NHS trusts.

Is there a vaccine hesitancy problem in UK healthcare for which mandatory vaccination is an appropriate solution? Data suggesting pockets of poor uptake of covid-19 vaccination among care home staff led the government to make vaccination compulsory, abandoning a targeted but voluntary approach. The government’s Scientific Advisory Group for Emergencies (SAGE) has not published a recommended minimum acceptable level of staff vaccination for healthcare settings, but over 80% of frontline healthcare workers in NHS trusts have now received two vaccine doses,4 reaching over 90% in some trusts. The level of risk posed by the remaining minority is unlikely to justify policy change at a national level.

Vaccination is already compulsory for staff working in healthcare settings in France and Italy. However, both countries have a history of compulsory vaccinations in response to substantial vaccine hesitancy and outbreaks of vaccine preventable infections such as measles. In Italy, legislation introducing compulsory childhood vaccinations was followed by a decrease in the incidence of measles and rubella. Nevertheless, this policy is under review and may be made more flexible depending on regional vaccine coverage.

The full text of the article is available in the BMJ.

DOI: https://doi.org/10.1136/bmj.n1975

How long does immunity from Covid-19 vaccination last?

In a letter published in the British Medical Journal, I discuss the topic of how we assess the long-term safety and efficacy of Covid-19 vaccination. Vaccines for COVID-19 were eagerly awaited; and their rapid development, testing, approval and implementation are a tremendous achievement by all: scientists, pharmaceutical companies, drugs regulators, politicians and healthcare professionals; and by the patients who have received them.[1] Early real-world data from vaccine recipients in England, Scotland and Israel show that vaccination provides a high level of protection from symptomatic COVID-19 infection and serious illness, along with a large reduction in the risk of hospital admissions and death.

However, because these vaccines are new, we do not yet have information on how long the immunity generated by COVID-19 vaccines will last; or on how well they will protect against new variants of SARS-CoV-2. Longitudinal data on ‘vaccine failures’, or re-infections can help guide national policies on how frequently booster doses of vaccines are needed to maintain a good level of immunity in the population, and on whether vaccines need modification to provide protection against new variants of SARS-CoV-2.[2]

The UK is well-placed to collect these data and to secure its timely evaluation and integration with information provided by its strong life sciences research industry, to guide public health decision making. We also have a National Health Service that has developed computerised medical records for use in general practices on a population of around 67 million people. These electronic medical records provide longitudinal data on people’s health and medical experiences and can be used to estimate the longer-term efficacy of Covid-19 vaccines.[3] This will provide a valuable resource, not just for guiding public health policy in the UK, but also for global health.

References

1. Majeed, A, Molokhia, M. Vaccinating the UK against COVID-19. BMJ 2020; 371: m4654–m4654.

2. Majeed A, Papaluca M, Molokhia M. Assessing the long-term safety and efficacy of COVID-19 vaccines. Journal of the Royal Society of Medicine. May 2021. doi:10.1177/01410768211013437

3. Hodes S, Majeed A. Building a sustainable infrastructure for covid-19 vaccinations long term BMJ 2021; 373 :n1578 doi:10.1136/bmj.n1578

What are the arguments in favour of reducing the gap between doses of the Pfizer Covid-19 vaccine to 3-4 weeks?

Early on during the pandemic, the UK government took the decision to give second doses of the Pfizer Covid-19 vaccine after 12 weeks rather than the recommended 3-4 weeks. It has now reduced the gap to 8 weeks and is considering reducing the gap to 3-4 weeks. What are the arguments in favour of reducing the gap between doses to 3-4 weeks?

1. Giving the two doses of the Pfizer vaccine 3-4 weeks apart is in line with the manufacturer’s guidance.

2. This is what most other countries using the Pfizer vaccine are doing.

3. Evidence from randomised controlled trials and subsequent evidence from real-world data provides strong evidence that two doses of Pfizer vaccine given 3-4 weeks apart provide excellent protection against severe disease and death

4. Data from Public Health England shows that two doses of vaccine provide much better protection against the delta variant than one dose. Hence, giving second doses after 3-4 weeks instead of after 8-12 weeks could help reduce the current ratee of infection in the UK

5. Many people are keen to get their second dose of Pfizer vaccine quickly because of concerns about other family members or to help them travel.

 

Why we should continue to wear face masks

The government’s chief medical officer says he will continue to wear a face mask when appropriate. We should follow his example. Covid-19 is an infection that is largely spread indoors – particularly in crowded, poorly ventilated areas – through inhaling droplets and aerosols produced by infected people when they cough, sneeze, sing, talk, or breathe. Face masks are a simple method of reducing the risk of infection – but only if they are worn by large numbers of people. The main function of a mask is to reduce the emission of droplets from infected people into the air. The droplets are captured by the mask and hence less virus enters the air. Much of the benefit of wearing face masks goes to other people but they can also benefit the wearer, particularly if a high-specification FFP2 mask is worn that filters out more particles and droplets when the wearer breathes in air.

Wearing face masks will reduce the spread of the coronavirus and help protect others. This is very important in settings where we are in contact with older and more vulnerable people – such as in supermarkets and on public transport. Wearing a mask has no major side effects, and does not change a person’s oxygen or carbon dioxide levels. Widespread wearing of face masks has been an important part of the pandemic control strategies of countries that have been more successful in containing the spread of Covid-19. Vaccines are essential and can protect us from developing a more serious illness. But we must maintain the use of other control measures, such as the use of face masks, until we are past the worst of the Covid-19 pandemic.

Lifting of Covid-19 restrictions in England – What are the implications for public health?

Why are all restrictions being lifted even though Covid cases are rising?

The number of cases of Covid-19 has been increasing since May and there are now nearly 30,000 cases each day in the UK. In the past, such a high number of cases would have led to a large number of people admitted to hospital and also an increase in deaths. Fortunately, because of vaccination, the number of people with a severe Covid-19 illness is now much lower than previously. For example, in the last week, there have been around 20 deaths per day on average from Covid-19 across the UK. This compares to more than 1,000 deaths per day during some days in January. The number of hospital admission is also low, with around 300 hospital admission each day in the UK. The government believes that vaccination is breaking the link between the number of cases and the number of people with severe illness; and it therefore safe to end Covid-19 restrictions in England on 19 July. The government accepts that the number of Covid-19 cases will remain at a high level.

Will the 1m social distancing rule be scrapped everywhere?

The 1m social distancing rule will end in England on 19 July, meaning that people can mingle indoors and outdoors in larger groups. Indoor businesses like night clubs will also be allowed to open.

Will we still be advised to wear masks even though it’s no longer a rule, and why?

The government has said that wearing masks will be a personal choice, except in a few higher risk settings such as care homes. Many scientists, doctors and public health specialists disagree with this decision and would like to have seen mask wearing remaining compulsory until the number of Covid-19 cases was at a much lower level than it is now.

Should I keep wearing a mask in public transport?

My advice would be to continue to wear a mask on public transport after 19 July as this protects others from the risk of infection. However, this will be optional once Covid-19 regulations end in England. It is possible though that some airlines will continue to make mask use mandatory on their flights.

What’s the risks of maskless shopping?

The risk of acquiring an Covid-19 infection is much higher in crowded, poorly-ventilated indoor settings. Once the 1m rule is scrapped, shops will be much more crowded than they are now, which will make them a higher-risk setting for transmission of infection. If you are in a vulnerable group – such as the elderly or with a serious medical problem – you may wish to consider wearing a more protective FFP2 mask when you are shopping or in other crowded, indoor spaces.

And of singing in church?

A number of large Covid-19 outbreaks have been linked to places of worship. When people sing, they expel more air and make transmission of infection more likely in crowded, indoor settings, such as churches. Because churchgoers are often elderly, churches may wish to retain some social distancing measures after 19 July to protect the members of their congregation.

If my employer wants me to go back to the office but I don’t feel safe, can I refuse?

Employees with at least 26 weeks of service have the right to ask for flexible working, which can include working from home. Employers must consider the request but can decline it if there are good business or operational reasons for doing so. If you do have to work in the office, your employer should carry out a risk assessment to ensure your working environment is safe for you.

What might happen in schools if measures are scrapped but children aren’t vaccinated?

In recent weeks, many schools have experienced Covid-19 outbreaks, with around 640,000 children across England currently at home because there has been a case in their bubble. As most schools will close around 19 July for the summer holiday, there won’t be an immediate effect on schools. However, when schools re-open in September, there will be a risk that we will see further outbreaks in schools because children have not been vaccinated. We should be looking at implementing other mitigation measures to reduce the risk of infection in schools, such as ventilation and air cleaning systems, as has been done in countries such as the USA.

I’ve had both vaccines – can I still catch it, and how bad could it be?

The vaccines used in the UK provide good protection against symptomatic infection (around 80% after two doses) and even better protection (over 90%) against hospital admission and death. However, some people who are fully immunised can still get infected and a small proportion of these people will develop a severe illness that could result in hospital admission or death as no vaccine is 100% effective.

I haven’t had the vaccine – what precautions should I take?

You should continue to follow government regulations on social distancing and wearing face masks until 19 July. After then, you need to bear in mind that Covid-19 infections remain at a high level and so you should continue to be cautious in crowded, poorly-ventilated indoor spaces; particularly if you are from a more vulnerable group at higher risk of a serious illness if you become infected.

Is there a risk scrapping Covid measures could send us back into lockdown?

It’s likely that Covid-19 cases will remain at a high level during the summer because of the ending of Covid-19 rules and greater mixing of people in indoor settings. However, vaccination should keep deaths and, to a lesser extent, hospital admissions at a low enough level to avoid another lockdown. There is though always a risk that even more infectious variants of the coronavirus may emerge that will make current vaccines less effective and precipitate another lockdown.

What about vaccination?

Currently, around 86% of adults in the UK have had one dose of vaccine and 64% have had two doses. As two doses of vaccine are needed to provide effective protection, this means there are still many people who are at risk. Do attend for your first vaccination if you have not already done so and attend for your second vaccination when this is due. Many areas are offering walk-in vaccination clinics, which you can attend without an appointment.

How risky are pubs now people can order and drink at the bar?

Crowded, poorly ventilated locations such as pubs will be high risk settings for transmission of Covid-19 once restrictions end on 19 July. Because people in pubs will be drinking and lose some of their social inhibitions, and also speaking loudly, this adds to the infection risk.