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.

Global deaths, prevalence and disability for chronic obstructive pulmonary disease and asthma

A recent paper from the Global Burden of Disease (GBD) Chronic Respiratory Disease Collaborators examined the burden of ill-health caused by chronic obstructive pulmonary disease (COPD) and asthma. The paper was published in the journal The Lancet Respiratory Medicine.

COPD and asthma are common diseases with a heterogeneous distribution worldwide. In the paper, we presented findings for COPD and asthma from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2015 study. The GBD study provides annual updates on estimates of deaths, prevalence, and disability for over 300 diseases and injuries, for 188 countries from 1990 to the most recent year.

We found that in 2015, 3.2 million people died from COPD worldwide, an increase of 11·6% compared with 1990. There was a decrease in age-standardised death rate of 41·9% but this was counteracted by population growth and ageing of the global population. From 1990 to 2015, the prevalence of COPD increased by 44%, whereas age-standardised prevalence decreased by 14·7%.

In 2015, 0·4 million people died from asthma globally, a decrease of 26·7% from 1990. The age-standardised death rate decreased by 58·8% (39·0 to 69·0). The prevalence of asthma increased by 12·6% whereas the age-standardised prevalence decreased by 17·7%.

Smoking and ambient particulate matter were the main risk factors for COPD followed by household air pollution, occupational particulates, ozone, and second-hand smoke. Together, these risks explained 73% of disability due to COPD. Smoking and occupational asthma precipitants were the only risks quantified for asthma in GBD, accounting for 16.5% (disability due to asthma.

In conclusion, asthma was the commonest chronic respiratory disease worldwide in 2015, with twice the number of cases of COPD. Deaths from COPD were eight times more common than deaths from asthma.

We also concluded that although there are laudable international collaborative efforts to make surveys of asthma and COPD more comparable, no consensus exists on case definitions and how to measure disease severity for population health measurements like GBD. Comparisons between countries and over time are important, as much of the chronic respiratory burden is either preventable or treatable with affordable interventions.

Impact of the organisation and performance of health systems on the control of the Ebola outbreak in West Africa

An Ebola outbreak started in December 2013 in Guinea and spread to Liberia and Sierra Leone in 2014. The health systems in place in the three countries lacked the infrastructure and the preparation to respond to the outbreak quickly and the World Health Organisation (WHO) declared a public health emergency of international concern on August 8 2014. We conducted a study to determine the effects of health systems’ organisation and performance on the West African Ebola outbreak in Guinea, Liberia and Sierra Leone and lessons learned. The WHO health system building blocks were used to evaluate the performance of the health systems in these countries.

A systematic review of articles published from inception until July 2015 was conducted following the PRISMA guidelines. The review was supplemented with expert interviews where participants were identified from reference lists and using the snowball method.  Ensuring an adequate and efficient health workforce is of the utmost importance to ensure a strong health system and a quick response to new outbreaks. Adequate service delivery results from a collective success of the other blocks. Health financing and its management is crucial to ensure availability of medical products, fund payments to staff and purchase necessary equipment. However, leadership and governance needs to be rigorously explored on their main defects to control the outbreak.

The findings from this study were published in the journal Globalization and Health.

Addressing polypharmacy in older people

A major challenge in healthcare, particularly for older people, is that patients are ending up on many medicines, termed ‘polypharmacy’. Polypharmacy can be either ‘appropriate’ or ‘problematic.’ With the latter, prescribing professions are traditionally better at starting medicines than stopping them (for a variety of reasons), which means that patients are too often left with problematic polypharmacy that can lead to side effects, interactions, and an inability to manage to take them all.

The NIHR Collaboration for Leadership in Applied Health Research and Care for Northwest London (CLAHRC NWL) have an active Medicines Optimisation work stream. A lot of work has been done around the need for medication review and stopping unnecessary medicines when problematic polypharmacy occurs. The term ‘deprescribing’ has emerged strongly in the literature and CLAHRC NWL have put together what we think is the first journal issue devoted to the topic of deprescribing.

The themed issue is particularly noteworthy due to the international contributorship, including key thinkers on this topic from Australia, Ireland, Israel, and UK. Barry Jubraj, Honorary Pharmacist for Medicines Optimisation at CLAHRC NWL, co-edited this themed issue and the CLAHRC NWL team contributed to several papers, including outlining a strategy for educating students and junior clinicians about the need to undertake medication reviews. This is a novel piece of work covering an issue close to the working practice of healthcare professionals in Imperial and beyond; the web version is currently available and the print version is forthcoming.

Improving discharge planning in NHS hospitals

Factors that need to be considered in discharge planning that have been identified in previous projects include:

  1. Ensuring that discharge arrangements are discussed with patients, family members and carers; and that they are given a copy of the discharge summary.
  2. Adequate coordination between the hospital, community health services, general practices, and the providers of social care services.
  3. There is a follow-up after discharge of patients at high risk of complications or readmission – either in person or by telephone – to ensure that the discharge arrangements are working well.
  4. Medicines reconciliation is carried out. This is the process of verifying patient medication lists at a point-of-care transition, such as hospital discharge, to identify which medications have been added, discontinued, or changed from pre-admission medication lists.
  5. Ensuring that any outstanding test results at discharge are obtained and passed on to primary care teams; and ensuring there are clear arrangements for carrying out and acting on any proposed post-discharge tests. In general, dealing with tests results is the responsibility of the clinical team that carried out the test.
  6. Give patients clear instructions about any post-discharge tests that are needed and how these will be carried out.
  7. Ensure that hospitals comply with the National NHS Standard Contract – for example, issuing Fit Notes for the expected duration of sick leave and supplying patients with an adequate amount of medication.

A useful summary of previous work on discharge planning (mainly based on US studies) can be viewed in UpToDate.

Does use of point-of-care testing improve the cost-effectiveness of the NHS Health Check programme?

A paper published in the journal BMJ Open examines if the use of point of care testing is less costly than laboratory testing to the National Health Service (NHS) in delivering the NHS Health Check programme in primary. To address this question, we carried out an observational study, supplemented by a mathematical model with a micro-costing approach.

We collected data on cost, volume and type of pathology services performed at seven general practices using point of care testing and a pathology services laboratory. We collected data on response to the NHS Health Check invitation letter and DNA rates from two general practices.

We found that the costs of using point of care testing to deliver a routine NHS Health Check is lower than the laboratory-led pathway; with savings of £29 per 100 invited patients up the point of cardiovascular disease risk score presentation. Use of point of care testing can deliver NHS Health Check in one sitting, whereas the laboratory pathway offers patients several opportunities to miss an appointment.

We concluded that the costs of using point of care testing to deliver an NHS Health Check in the primary care setting is lower than the laboratory-led pathway. Using point of care testing minimises non-attendance rates associated with laboratory testing and enables completion of NHS Health Check in one appointment.


Improving the safety of care of people with dementia in the community

Dementia care is predominantly provided by carers in home settings. We aimed to identify the priorities for homecare safety of people with dementia according to dementia health and social care professionals using a novel priority-setting method. The study was published in BMC Geriatrics.

The project steering group determined the scope, the context and the criteria for prioritization. We then invited 185 North-West London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to homecare safety of people with dementia. 76 clinicians submitted their suggestions which were thematically synthesized into a composite list of 27 distinct problems and 30 solutions. A group of 49 clinicians arbitrarily selected from the initial cohort ranked the composite list of suggestions using predetermined criteria.

Inadequate education of carers of people with dementia (both family and professional) is seen as a key problem that needs addressing in addition to challenges of self-neglect, social isolation, medication non-adherence. Seven out of top 10 problems related to patients and/or carers signalling clearly where help and support are needed. The top ranked solutions focused on involvement and education of family carers, their supervision and continuing support. Several suggestions highlighted a need for improvement of recruitment, oversight and working conditions of professional carers and for different home safety-proofing strategies.

Clinicians identified a range of suggestions for improving homecare safety of people with dementia. Better equipping carers was seen as fundamental for ensuring homecare safety. Many of the identified suggestions are highly challenging and not easily changeable, yet there are also many that are feasible, affordable and could contribute to substantial improvements to dementia homecare safety.

DOI: 10.1186/s12877-017-0415-6

A carer proposes covertly medicating a patient – what should I do?

You are called by a worker at a care home. She is concerned about a dementia patient who, despite all non-drug measures being tried, is causing distress to other residents. She asks you to prescribe a sedative to ‘slip into her food’. How should you proceed?

Giving medication covertly to sedate an agitated patient raises serious legal and ethical issues. Treatment without consent is only permissible where there is a legal basis for this. In the scenario described here, giving a sedative to the patient without her knowledge and consent would be a breach of her human rights. There is also a risk that the patient could suffer side effects from the medication she was given. For example, administration of a benzodiazepine or an antipsychotic drug could lead to a fall or a fracture that resulted in serious harm to the patient. Covert administration of medication is also a breach of trust on the part of the doctor who prescribed the medication. Hence, it may lead to a formal complaint against the doctor, which would be difficult to defend. Hence, covert administration of sedative medication is a practice that doctors should not collude in, and you should refuse to prescribe. You should also discuss the staff member’s request with the nursing home manager. The care home needs to ensure that it is adequately staffed and that its staff are trained in the appropriate management of people with dementia. If the patient is new to the care home, then her unfamiliar surroundings may be the cause of her agitation. In this case, her behaviour is likely to improve over time as she becomes more familiar with her new home and the staff who care for her. If the increased agitation and confusion are of recent onset, then an organic cause such as an infection or drug side-effect needs to be excluded. If the problem is ongoing and does not settle, advice and support should be obtained from the local nursing home support service and community mental health team; for example, on holding a  ‘best interests meeting’.

A version of this article was published in the medical magazine Pulse.

What makes a good clinical training placement?

Dr Kevin Patel from the Imperial GP Specialist Training Scheme takes a reflective look at the factors that go into making a good clinical attachment for trainees.

As GP trainees we are ‘encouraged’ to reflect; challenging encounters with patients, conversations with colleagues that could have gone better, moments when you felt like you were born to do this job. All of this is good fodder for your ePortfolio.

Not one to miss out on a reflective opportunity, I took a step back from a discussion that was taking place about difficult rotations, a conversation I imagine that is oft-repeated amongst GPs and hospital doctors up and down the country, and thought about how we could use our experience as GP trainees to feed into this.

As trainees we rotate into diverse placements, from paediatrics to public health to care of the elderly. I counted at least 15 distinct departments I have worked in since finishing medical school just over 5 years ago. This is more than any other specialty trainee and if only through sheer volume, it provides us with a unique perspective on what makes a ‘good’ or successful placement and allows us to see how things are managed differently between the numerous specialties both clinically and non-clinically.

Back to the conversation, I heard talk of punishing on-calls, a lack of support; unsympathetic supervisors and acting above one’s role though interestingly not necessarily competence. I then thought about my own experience of certain jobs and what it was that made me love one rotation and what it was about another that filled me with dread going to bed each night.

Below I’ve listed a number of factors that I think are key to influencing one’s experience of a ward or practice. And whilst not exhaustive, I feel they are fundamental determinants of that ‘holy grail’ of rotations which are enjoyable, challenging and ultimately fulfilling.  There are however, some factors that are somewhat beyond our immediate control:

Time – This is something that no matter how hard we try we simply cannot create more of. But all departments have this problem, what is it about those places that don’t seem to be creaking at the seams, and what is it about those places that do?

Patient load – If there are sick patients, we see them. Be that in A&E or in GP where we (wo)man the gateway to the rest of the NHS. Yes, hospitals can be closed to admissions and there might not be enough scheduled GP appointments but those who are in need get seen. How busy you are on a rotation invariably colours your opinion of that time and the upstream consequences of such scenarios is a whole other blog-piece.

Staffing Levels – Feeling like you have sufficient time to give to your patients is essential not only for your peace of mind but also patient safety:

Did I do everything I needed to for that man, or was it the minimum until I see him in 2 weeks?

This child needs a cannula for his antibiotics but I need to review the girl with asthma first.

I don’t want to leave this woman who is having a miscarriage but my registrar needs me in theatre to assist for an emergency caesarean section.

My own experience and that of my peers seems to be that those rotations where we did not routinely come across these dilemmas were better regarded and often because they had that one extra doctor or where the rota was designed with a minimum number of SHO’s per day or, like in one utopian department, where they have a stand-by doctor who can come in when the team are up against it. With the real-life examples above, you are left upset, demoralised and at risk of burn out.

Of course there are funding issues and these are not easy to resolve, but we have seen recommendations for safe nurse: patient ratios since the Francis Report into Mid-Staffordshire Foundation Trust [1]. Does something similar need to happen for the doctor to patient ratio to allow us to provide the level care the public want and deserve thus ensuring we are not forced to give a substandard service?

However, there are many aspects which, for me make for an enjoyable experience and a happy workplace which are less bound by absolutes.

Pace – Some of us thrive off pressure, battling through to the end of the day. Others will be the polar opposite, but most I suspect will want a happy medium; keeping our brains engaged, working together with patients to find solutions to their problems and not faced with scenarios akin to those above. The sense that I get from talking to some of my colleagues is that a happy workplace is also one which allows you to take 10 minutes to make a personal call, work on a research paper when it’s quiet or pop to the bank. There is something about having the space to do these things that makes you feel valued as an individual and not being able to do so leads to a sense of resentment.

Personal Development: A workplace that sees your value as a person as well as a doctor. This is often influenced by your immediate supervisor but jobs that I have found the most rewarding were those where you are not so much permitted but rather encouraged to attend courses that are related to, and also sometimes tangential to your training. This could be where personal interests are incorporated into projects or just the source of 5 minutes of conversation. For example, a consultant once heard me talking to the art therapist on the ward about how I was taking an evening class in ceramics. She then ensured I finished on time every Tuesday afternoon so I would not be late.

Respect – This is something that is hard won as a junior. Being recognised for your experience in a previous ENT or psychiatry rotation, for example, is something that is quite powerful but when none of your efforts are acknowledged and your previously acquired skill-set is side-lined your morale can take a knock. Equally, we all know we are here to learn and do not know everything and so acknowledging strengths is just as important as how weaknesses are nurtured.

Empathy – The job can be difficult. We know this and those above us definitely know this because they have been there before us. A simple acknowledgement or willingness to muck in makes you feel stronger as a team and less isolated. More often than not, you’re spurred on to work a little harder. However, when there is a shrug to your succinct history or sigh at your plea for help the seeds for an unhappy workplace are sown.

Fun! –  I think this is a product of all the positive aspects above. If you have these then you probably have some, if not most, of the key ingredients to a happy workplace. Friendships develop between staff regardless of role, dinners just seem to get organised and an after-work drink every so often becomes the norm as compared to a mandated evening of fun once every 6 months.

Going back to the conversation at the start, I concluded that there is actually very little between what makes a ‘good’ or ‘bad’ placement for a trainee or rather how there is a fine line between the two. I also thought about how much of the good or indeed bad seems to trickle from those in senior roles and how it is true leadership that creates a culture that is fulfilling for those that are passing through or for those who are there for the long run.

GP Tutor Dr Dana Beale gives a view from the community

As part of our View from the Community series of articles, our Year 6 Specialty Choice Lead Dr Ros Herbert interviewed community teacher Dr Dana Beale, to get the inside track on what it’s like being a teacher for Imperial College.

Dana, tell me what first got you interested in homeless medicine?

Dr Dana Beale aboard her narrowboat

“Incredibly I was inspired by the same module I did as a student at Imperial College that I am now teaching on! Back then it was ‘medical and social care of the homeless’ and was based at the surgery for the homeless in Great Chapel Street – a fabulous service that showed me that primary care tailored to this vulnerable and challenging group existed and I promised myself there and then that I would return to work in this field.”

What makes you so enthusiastic about this work?

“I find this line of work a breath of fresh air; at times incredibly challenging but hugely rewarding. I feel privileged to be able to delve into patients’ lives at often their most chaotic and vulnerable, to reach out and essentially say ‘right…. How can we help you out here?’ I love the fact that it can range from helping those with complex medical cases and advanced pathology to psychiatric and psychological support with all sorts of things thrown in along the way. It feels natural to me to be faced with someone who needs an intense and complex team-based approach and to figure out where on earth to start – and to recognise that sometimes all that is needed is to show basic human kindness and just listen. The team around me makes my job a thousand times easier every day.”

What challenges does this “specialty” have?

“It can be a big challenge dealing with people who have often had difficult childhoods then have lost everything and are at rock bottom. Behaviour can be aggressive or defensive and it can be hard to strike the right balance between being approachable but also staying safe; between being supportive whilst also not acquiescing to every request – for example drug seeking behaviour. But over time I have learned how to help people to see that what they think they need RIGHT NOW may be the most detrimental thing to them in the long-run. We don’t always get it right and are always still learning. Risk management and good team communication is vital.”

If you were PM (not a bad idea?!) what would you do to improve the lot of the homeless?

“As PM I would make reducing health and wealth inequalities a key priority. I would seek to steer away from the perception that these are lazy people who want something for nothing and are just a drain on society. Epidemiological studies tell us that countries that support their unemployed and incapacitated will see a quicker and more sustained return to working life and being ‘productive’ in society – rather than focusing on ever more brutal sanctioning and impossible hoops to jump through.”

You obviously love teaching the students, tell us why?

“I feel honoured to be charged with fresh young minds to teach – so much of the time they really do teach me too! I like finding out about my students and which paths they hope to take and to perhaps plant a few seeds that will blossom in their later practice. Even if just one person looks at the homeless heroin addict they are dealing with in A+E, on the wards or in a GP surgery through a different filter and remembers that they are a human being with their own unique story, I feel I will have achieved something.”

Sex differences in cardiovascular events and procedures in people with and without diabetes

An article published in the journal Cardiovascular Diabetology examines gender differences in hospital admissions for major cardiovascular events and procedures in people with and without diabetes.

Secondary prevention of cardiovascular disease (CVD) has improved immensely during the past few decades but controversies persist about the cardiovascular benefits among women with diabetes. We investigated 11-year trends in hospital admission rates for acute myocardial infarction (AMI), stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in people with and without diabetes by gender in England.

We found that diabetes-related admission rates remained unchanged for AMI, increased for stroke by 2% and for PCI by 3%; and declined for CABG by 3% annually. Trends did not differ significantly by diabetes status. Women with diabetes had significantly lower rates of AMI and stroke compared with men with diabetes. However, gender differences in admission rates for AMI attenuated in diabetes compared with the non-diabetic group.

While diabetes tripled admission rates for AMI in men, it increased it by over four-fold among women. Furthermore, while the presence of diabetes was associated with a three-fold increase in rates for PCI and a five-fold increase in rates for CABG in men; among women, diabetes was associated with a 4.4-fold increased admission rates for PCI and 6.2-fold increased rates for CABG. Proportional changes in rates were similar in men and women for all study outcomes, leaving the relative risk of admissions largely unchanged.

We concluded that diabetes still confers a greater increase in risk of hospital admission for AMI in women relative to men. However, the absolute risk remains higher in men. These results call for intensified CVD risk factor management among people with diabetes, consideration of gender-specific treatment targets, and treatment intensity to be aligned with levels of CVD risk.