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.

Alternative providers of GP services perform worse than traditional practices

A study from Imperial College London reports that alternative providers of primary care in the NHS, including private sector companies, do not perform as well as traditional GP practices when their performance is assessed using a range of measures of quality of care.

Alternative providers have been contracted to offer primary care in the NHS since 2004 under reforms designed to increase competition. These providers performed worse than traditional GP practices on 15 out of 17 indicators after adjusting for the characteristics of the practices and the populations they serve.The study was published in the Journal of the Royal Society of Medicine.

“This study provides data to inform the debate about the growing role of the private sector in the NHS,” said Dr Christopher Millett, lead author of the study, from the School of Public Health at Imperial. “New providers were allowed into the primary care market to stimulate competition, but our findings suggest that their introduction has not led to improvements in quality and may have resulted in worse care.

“The lesson is that increasing diversity does not necessarily lead to better quality. Regulators should ensure that new providers of NHS services are performing to adequate standards and at least as well as traditional providers.”

Three hundred and forty-seven general practices – 4.1 per cent of practices in England – are run by alternative providers, including private companies and voluntary organisations. These practices tend to be smaller, and serve younger, more diverse and more deprived populations than traditional providers.

The study looked at a range of performance indicators from the Health and Social Care Information Centre and the national GP Patient Survey. These included access measures such as how easily patients can get appointments, clinical measures such as how well they manage patients’ blood pressure, and efficiency measures.

Among the differences between types of practices, alternative providers had worse results for patients’ diabetes control, higher hospital admission rates for chronic conditions, and lower overall patient satisfaction.

“So far, alternative providers have not been widely contracted to delivery primary care services,” said Dr Millett. “However, private sector providers have secured a third of contracts to deliver NHS clinical services since the Health and Social Care Act was enacted in 2013. Our findings highlight the need for careful and independent evaluation of how this legislation has impacted quality of care.”

The article was covered by a number of media outlets including the IndependentPulseDaily MailBMJGP OnlineBT.Com and OnMedica.

Coverage of the NHS Health Check programme in England: national evaluation

An article from my research group examined coverage of the NHS Health Check programme in England. The article was published in the journal Preventive Medicine. We found that coverage of the programme was low in the first four years and there was a wide variation in coverage between general practice.

There was an increase in statin prescribing but only about one in three people who attended for a Health Check and who were found to have a cardiovascular risk score (20% or more 10-year risk of cardiovascular disease) were prescribed a statin.

We concluded that unless coverage of the NHS Health Check programme improved and uptake of statins in high-risk groups increased, the programme would not deliver its predicted benefits in reducing morbidity and mortality from cardiovascular disease.

The article was covered by a number of media outlets including the Daily Mail and Pulse.

What does the future hold for CCGs?

One of the key aims of establishing clinical commissioning groups (CCGs) in England’s NHS was to place general practitioners at the heart of NHS commissioning. And yet surveys consistently show that many GPs feel that their view are ignored by their CCGs. For example, an NHS England survey reported that only 44% of GPs said that their CCGs acted on their views. A BMA survey reported that nearly two-thirds of GPs feel they either had limited influence on their CCGs or that they were dictated to by their CCGs rather than being asked to contribute to CCG decision making.

Another key aim of creating CCGs was to make use of GPs’ clinical expertise in commissioning health services to improve health outcomes and patients’ experience of the NHS. However, a Pulse survey found that more than twice as many GPs think that the introduction of CCGs has been detrimental to patient care than think have improved it.

In many ways, the fate of CCGs is linked with inextricably the consequences of the 2012 Health and Social Care Act that created them. The disruption caused by the changes the Act brought about, at a time when the NHS was entering a period of unprecedented financial pressure, have clearly made it difficult for both GPs and CCGs to function effectively. One example of this was the transfer of key public health functions to local authorities – rather than to CCGs – when primary care trusts (PCTs) were abolished. GPs suddenly found themselves with little or no influence in determining local policies for services in areas such as smoking cessation and sexual health.

Many GPs have worked very hard to try to ensure that CCGs delivered what they set out to do when they were established. They will argue that the financial pressures on the NHS – and the declining share of the NHS budget spent on primary care along with the large increase in workload that primary care teams have experienced in recent years – that are largely responsible for the perception among many GPs that CCGs have failed to achieve their key objectives. But it is CCGs who now control the majority of NHS funds in England and they could have done more to protect and expand primary care services, and taken a stronger line against the demands of NHS hospital trusts.

What does the future hold for CCGs? The former Chancellor, George Osborne, stated that major cities in England will be offered the opportunity to control their health budgets. GPs were not consulted about this proposal which will effectively remove from many CCGs much of the influence they currently have in commissioning NHS services. Other CCGs have opted to take on the co-commissioning of primary care services in addition to secondary care commissioning, effectively recreating PCTs (but still without responsibility for key public health functions). To prevent conflicts of interests, the role of GPs in CCGs that take on co-commissioning will have to be carefully regulated. Other CCGs have begun to merge their commissioning functions, thereby creating much larger organisations.

Hence, in many parts of England, we will start to see the end of GP-led commissioning. GPs will continue to have a role in commissioning health services but increasingly this will be an advisory rather than a leadership role.

A version of this article was first published in Pulse.

Sharing images of patients electronically

In an article in the medical magazine Pulse, I and two other commentators discuss issues around the electronic sharing of images of patients that clinicans should be aware of.

The very high use of information technology in modern society has resulted in the practical uses of sending and sharing information electronically rapidly outstripping published guidance in this area. For example, many NHS organisations have draconian policies about sending patient information by email – in some cases describing sending information by unencrypted email as similar to ‘sending it on a postcard’. No empirical evidence is ever presented in such guidance that sending information electronically is any less secure than sending it by post or telephone. Guidance from such organisations has also yet to catch up with the now near-ubiquitous access to smartphones, high-speed Internet connections and high-resolution cameras in our society. In my opinion, it is acceptable for the photo to be stored on your phone as long as you take reasonable precautions to secure your device.

Most patients would generally be happy to have an image of their skin condition shared with your colleague if this helped in getting a better diagnosis or a more appropriate treatment plan. You should though obtain consent from the patient before sharing the image with your colleague. If you are apprehensive about using a photo or file sharing app, you could send the image from one NHS Net email account to another. NHS email is a fully encrypted method of communication and can be used for sending sensitive patient information. If you want to use the image in a presentation, then you should get explicit consent for this from the patient, ideally in writing, as is now standard for case reports in medical journals.

We should encourage the use of technology as a tool for improving quality of care, patient experience and health outcomes; but at the same time, we must ensure that we respect patient confidentiality and always obtain informed consent from patients before sharing their information electronically.

You can read the full article in Pulse.

Routes to the diagnosis of heart failure in primary care: why linear guidelines don’t always work well

Timely diagnosis and management of heart failure (HF) is critical, but identification of patients with suspected HF can be challenging, especially in primary care where patients can present with a range of symptoms of varying severity. In a paper published in the journal Heart, we describe the journey of people with HF in primary care from presentation through to diagnosis and initial management.

We used the Clinical Practice Research Datalink (primary care consultations linked to hospital admissions data and national death registrations for patients registered with participating primary care practices in England) to describe investigation and referral pathways followed by patients from first presentation with relevant symptoms to HF diagnosis, particularly alignment with recommendations of the National Institute for Health and Care Excellence guideline for HF diagnosis.

36 748 patients had a diagnosis of HF recorded that met the inclusion criteria between 1 January 2010 and 31 March 2013. For 29 113 (79.2%) patients, this was first recorded in hospital. In the 5 years before diagnosis, 15 057 patients (41.0%) had a primary care consultation with one of three key HF symptoms recorded, 17 724 (48.2%) attended for another reason and 3967 (10.8%) did not see their general practitioner. Only 24% of those with recorded HF symptoms followed a pathway aligned with guidelines (echocardiogram and/or serum natriuretic peptide test and specialist referral), while 44% had no echocardiogram, natriuretic peptide test or referral.

We concluded that patients follow various pathways to the diagnosis of HF. However, few appear to follow a pathway supported by guidelines for investigation and referral. Although there are likely to be missed opportunities for earlier HF diagnosis in primary care, it is also the case that it can be difficult to condense the management of conditions that present in complex ways in primary care using simple linear guidelines.

Bariatric surgery – Should we prioritise patients with type 2 diabetes?

The results of recent research studies illustrate the importance of prioritizing obese people with type 2 diabetes mellitus when it comes to selecting patients for bariatric surgery. For example, the number of people eligible for bariatric surgery in England far exceeds the bariatric surgery capacity of its National Health Service. If the aim of bariatric surgery is to reduce mortality and morbidity among obese patients, then the focus should be on selecting patients for surgery based on the presence of the conditions that have the greatest detrimental effect on health status. It may therefore be appropriate to reconsider the importance of body mass index alone as a predictor of mortality and put more emphasis on the presence of comorbidities when assessing eligibility for bariatric surgery. Given the significant benefits for people with type 2 diabetes that bariatric surgery offers and the resulting major improvements in their health status, there is a strong case that type 2 diabetes should be considered as the preferred comorbidity when selecting patients for surgery.

The full letter can be read in JAMA Surgery.

The child transgender patient in primary care: practical advice for a 10-minute consultation

Children and adults with gender identity concerns are increasingly presenting for treatment, with referrals to specialist clinics rapidly rising. The percentage of children with gender identity disorder that self-harm or attempt suicide is estimated at 50%, so it is essential that it is recognised early and managed appropriately.

Gender identity disorder of childhood usually manifests before puberty. The child typically experiences distress resulting from an incongruence between their current gender identity (sense of themselves as ‘male’, ‘female’, or otherwise), and their gender assigned at birth. Behaviour and activities of the child may stereotypically be associated with that of the opposite gender and the child may be preoccupied with wanting to change their name and gender pronoun (‘she’, ‘he’). Depending on the age, they may also have a strong desire to acquire secondary sexual characteristics of the opposite gender. This may cause significant distress and can impact their performance and experiences at school or at home. Six months of persistent gender non-conforming behaviour has been proposed as an indicator that this is more than ‘a phase’, which is common and not necessarily pathological for many individuals in childhood.

Example case
Tom is 13 years old and has come with his mother to see you. She tells you he becomes distressed when people address him as Tom, and asks to be called Kelly. He hates wearing boys’ clothes, and most of his friends at school are girls, leading to teasing about him being ‘gay’. Recently, his mother found a skirt in his room, which he eventually admitted to having stolen from a friend’s house. He has asked his mother if he can ‘become a girl’, and seems so preoccupied with this idea that he is struggling to complete his school homework. Today Tom’s mother wants to know what to do.

The full article can be read in the journal BJGP Open.

Better funding for GPs could reduce use of Accident and Emergency Departments by children

Children whose GPs are easy to access are less likely to visit A&E than those whose GPs are less able to provide appointments. These are the findings of a new study, led by researchers from Imperial College London, and published in the journal Pediatrics. The research also found that during weekdays, children’s visits to A&E peak after school hours.

The study, which was funded by the National Institute for Health Research, suggests that modest changes in the provision of GP appointments – such as providing more after-school appointments between the times of 5-7pm – could prevent thousands of visits to emergency departments a year. Although the study does not show that difficulty in accessing GP services is the direct cause behind increased emergency admissions, it raises important questions about the provision of GP services.

The study’s lead author, Dr Sonia Saxena, from the Department of Primary Care and Public Health at Imperial College London, and a practising GP, says: “Use of emergency departments for problems that could be dealt with in primary care is an inefficient use of the service, and could detract resources from more seriously ill children.  Our study was not a trial, which means that we don’t know whether difficulty accessing GPs is the cause of increased emergency department usage, or whether there is some other explanation for the link. However, given recent debates surrounding GP opening hours, our results suggest that additional resources to provide GP appointments for children when they need it – for instance after school rather than at weekends – may be a better investment for the NHS than blanket proposals to increase access hours.”

What role should general practitioners play in a modern health system?

Health systems across the world are faced with many challenges – such as rising patient expectations, increased workload, ageing populations, and an increased number of people with long-term conditions. At the same time, health systems also face significant financial problems. Consequently, governments, other funders of healthcare and patients expect more from their doctors without necessarily offering them additional resources.

As the first point of contact with patients, what role should general practitioners (in some countries, referred to as primary care physicians or family practitioners) play in meeting these challenges? General practitioners (GPs) have to deal daily with large numbers of patients, cope with a very wide range of clinical problems, meet performance targets, and provide continuity of care. At the same time, GPs also have to provide easy access to health services, show they are addressing issues such as the rise of antimicrobial resistance; and play a public health role in addressing unhealthy lifestyles and improving the uptake of preventive programmes such as screening and immunization.

Can GPs meet all these challenges? What support do GPs need to meet them? Could more be done to support GPs by non-medical health professionals? What do patients expect from their GPs? Does the training and continuous professional development of GPs need to change? How do we make use of staff from other professional groups such as nurses, pharmacist and healthcare assistants? How should we fund primary care services? These are important questions that we will aim to examine in future work at Imperial College London.

Real World Data and Pharmacoepidemiology in Europe: What are the implications of Brexit?

I am in Vienna this week for the Annual Meeting of the European Epidemiological Forum, which this year is on the topic of “Real World Data and Pharmacoepidemiology in Europe”. It’s been a good opportunity to catch up on biomedical research using ‘Big Data’. There is a lot of work going on in this field that will have a big impact on health. There was also some sadness among European colleagues about Brexit and uncertainty about the future role academics and companies from the UK will play in European research collaborations. At the meeting, I was asked to give one of the keynote presentations on the topic of Brexit and how it might affect the UK contribution to research on areas such as pharmaco-epidemiology. In my talk, I outlined some of the current uncertainties for UK researchers and the what the future might look like for the UK’s universities, NHS and life sciences sector, depending on the type of Brexit we negotiate with the other countries of the European Union.