In an article published in the Journal of the Royal Society of Medicine, Paul Jewell and I discuss the issue of foundation doctors and specialist training. Only around 43% of junior doctors entered straight into a UK specialty training programme after completion of their foundation programme in 2017, a substantial decrease from 71% in 2011. Given the National Health Service in the UK is under ever-increasing workforce pressures, this is a worrying trend. The decline in entry to specialty training can be partly explained by the rise in what is known as ‘the F3 year’. Concerns over this ‘junior doctor exodus’ are not new, having been previously raised in 2010, when the figures were far more favourable than they are now. Similar trends can also be seen at earlier stages, with fewer school students applying to medical school, and fewer medical students applying to the foundation programme,4 indicating wider issues. To reverse this trend and the shortage of doctors in many specialties, solutions to encourage more foundation doctors to enter specialty training need to be considered.
England is currently experiencing an outbreak of measles, with around 440 laboratory confirmed cases between January to May 2018. The outbreak is linked to ongoing outbreaks in Europe. Most cases are unimmunised teenagers and young adults. Children and young adults who did not receive MMR vaccine when they were younger, and people from under-vaccinated communities, are particularly at high risk.
Measles is a highly infectious illness that can sometimes cause serious complications such as pneumonia and encephalitis, and which can occasionally be fatal. Anyone who missed out on their Measles, Mumps and Rubella (MMR) vaccine or is unsure if they had 2 doses should therefore ensure they are fully immunised.
The outbreak also reinforces the importance of parents to ensure their children receive two doses of the MMR vaccine, the first at around 12 months of age and the second around 3-4 years of age.
An article from Imperial College London published in the Lancet discusses vaccination from migrants in Europe. Ensuring high levels of coverage is a key priority of the European Vaccine Action Plan, whereby all WHO Europe Member States have committed to eliminating endemic measles and rubella (>95% coverage with the measles mumps rubella vaccine), sustaining polio-free status, and controlling hepatitis B infection.
Our recent paper in BMJ Open Gastroenterology examines trends in endoscopic, medical and surgical admissions for inflammatory bowel disease in England from 2003–2013. In the last decade, there have been major advances in inflammatory bowel disease management but their impact on hospital admissions requires evaluation. We aim to investigate nationwide trends in inflammatory bowel disease surgical/medical elective and emergency admissions, including endoscopy and cytokine inhibitor infusions, between 2003 and 2013.
We used Hospital Episode Statistics and population data from the UK Office for National Statistics. Age-sex standardised admission rates increased from 76.5 to 202.9/100 000. Rising inflammatory bowel disease hospital admission rates in the past decade have been driven by an increase in the incidence and prevalence of inflammatory bowel disease. Lower GI endoscopy and surgery rates have fallen, while cytokine inhibitor infusion rates have risen. There has been a concurrent shift from emergency care to shorter elective hospital stays. These trends indicate a move towards more elective medical management and may reflect improvements in disease control.
Health inequalities start very early in life. By the time of school reception year (4-5 years of age), children from the most deprived areas of England are twice as likely to be obese as children from the most affluent areas. This illustrates the importance of the implementing policies to improve health at a very early stage, starting before conception, continuing through pregnancy, and then into infancy and childhood.
Source: NHS Digital http://digital.nhs.uk/catalogue/PUB30258
Workforce and resource pressures in the UK National Health Service (NHS) mean that it is currently unable to meet patients’ expectations of access to primary care. In an era of near-instant electronic communication, with mobile online access available for most shopping and banking services, many people expect similar convenience in healthcare. Consequently, increasing numbers of web-based and smartphone apps now offer same-day ‘virtual consulting’ in the form of Internet video conferencing with private general practitioners.
While affordable and accessible private primary care may be attractive to many patients, the existence of these services raises several questions. A particular concern, given continued development of antimicrobial resistance, is that some companies appear to use ease of access to treatment with antibiotics as an advertising strategy. We examine online video consulting with private general practitioners in the UK, considering its potential impact on patients and the National Health Service, and its particular relevance to antimicrobial stewardship in an article published in the Journal of the Royal Society of Medicine.
Questions remain about the safety of online consulting and of the working practices of some private companies, and appropriate regulation is essential to ensuring that these services offer safe and effective care to patients. This will require a carefully tailored approach on the part of regulators such as the Care Quality Commission. For example, it has not been necessary to develop standards on advertising when assessing National Health Service general practices, but this will be essential in monitoring the actions of private online general practice services.
In a paper published in the Journal of the Royal Society of Medicine, we discuss the role that clinical pharmacists could play in primary care.
Primary care in the United Kingdom’s NHS is in crisis. Systematic underfunding, with specific neglect of primary care compared to other clinical specialties, has combined with ever-rising demand and administrative workload to place a now dwindling workforce under unsustainable pressure.
A major factor in the growing workload in primary care is prescribing. An aging population and higher prevalence of chronic diseases is leading to increased case complexity and polypharmacy, and consequently greater potential for prescribing errors. Nearly 5% of all prescriptions in general practices in England have prescribing or monitoring errors, while in some areas up to half of the prescriptions are prone to error. Although most errors are of mild or moderate severity, they can be life-changing for patients and costly for healthcare systems, accounting for around 3.7% of preventable hospital admissions.
Workload and time pressures exacerbate prescribing errors. Concerns about workload and access in primary care have led the UK Government to pledge increases in the general practitioner workforce, but general practitioners take at least 10 years to train and declining numbers of medical graduates internationally suggests a limited pool for recruitment. In this article, we discuss integration of clinical pharmacists in general practices as a potential solution to these problems.
While the pool of general practitioners is limited, the number of pharmacists is increasing. Pharmacists undertake shorter training than general practitioners, with four years undergraduate degree followed by one year of pre-registration experience. While the role of pharmacists has expanded beyond dispensing of medications and now involves provision of several other aspects of patient care, their knowledge and expertise is often under-utilised. Making use of their expertise in medication management, pharmacists could perform a variety of tasks in primary care, improving patient safety and clinical outcomes through optimised medication use, and potentially alleviating workload, freeing up general practitioners to deal with more complex cases and reducing waiting times for appointments.
Pharmacists have been working in primary care teams for some time in non-patient-facing roles. Areas in which they support practices include auditing for performance targets, implementation of enhanced services, preparation for inspections by the Care Quality Commission, training staff in repeat prescribing and providing medicines information for other clinicians. However, these roles currently vary from practice to practice. The widespread integration of pharmacists in both patient-facing and non-patient-facing roles therefore has the potential to have impact in three key areas: safety of prescribing; improved health outcomes; and access to primary care through reduction of general practitioner workload
NHS England estimates that approximately 37 000 deaths a year are caused by sepsis. This means that in the seven year period between 2011 and 2017, around 259 000 people died from sepsis in England. Only one of these deaths, that of Jack Adcock in Leicester in 2011, has resulted in the conviction of health professionals for manslaughter (Hadiza Bawa-Garba and Isabel Amaro).
Sepsis can be difficult to diagnose, and delays and omissions in its diagnosis and treatment contribute to the high death rate. Even the former chair of the General Medical Council, Graham Catto, has admitted that he failed to diagnose sepsis in a timely manner, an error that contributed to a patient’s death. Because of the problems diagnosing and treating sepsis, numerous initiatives have aimed to improve its management in both primary care and hospital settings. Details of one of the most recent of these initiatives were published by NHS England in September 2017.
Given the scale of death from sepsis and the many delays and errors so often seen in its management, why were Bawa-Garba and Amaro convicted of gross negligence manslaughter? Was their management of Jack Adcock so different from the management of other cases of sepsis that resulted in death that they were justly convicted? Or were they involved in just one of many cases where suboptimal management of sepsis contributed to death? NICE guidance NG51 and Quality Standards QS161 have only recently set out the expectations of best practice in sepsis care—several years after Bawa-Garba and Amaro were charged.[5,6]
We need an objective review of sepsis deaths to identify the contribution of suboptimal management to the death and to recognise lessons for the future in a non-judgmental manner, not the prosecution of health professionals, if we are to improve clinical outcomes for patients with sepsis.
1. NHS England. Improving outcomes for patients with sepsis A cross system action plan. December 2015. https://www.england.nhs.uk/wp-content/uploads/2015/08/Sepsis-Action-Plan-23.12.15-v1.pdf
2. Ladher N, Godlee F. Criminalising doctors. BMJ2018;360:k479.doi:doi:10.1136/bmj.k479pmid:29419388
3. NHS National Patient Safety Agency. Medical Error. August 2005. http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61579
4. NHS England. Sepsis guidance implementation advice for adults. September 2017. https://www.england.nhs.uk/publication/sepsis-guidance-implementation-advice-for-adults/
5. National Institute for Health and Care Excellence. Sepsis: recognition, diagnosis and early management. NICE guidance NG51. July 2016. https://www.nice.org.uk/guidance/ng51
6. National Institute for Health and Care Excellence. Sepsis. Quality Standard 161. September 2017. https://www.nice.org.uk/guidance/qs161
It is often assumed that providing easier access to community-based general practice during evenings and weekends can reduce demand for emergency and other unscheduled care services, promoting more appropriate care and reducing the costs associated with expensive hospital-based treatment. For example, in England’s NHS there is political pressure to expand general practice surgeries’ opening hours to progress towards a ‘seven-day NHS’.
When considering extension of primary care opening hours in England, it is useful to compare primary care access across other countries in the European Union. Despite differences in healthcare commissioning and funding, European countries face comparable challenges such as ageing populations and increases in chronic conditions and mental health problems, all of particular relevance to primary care. In a paper published in the Journal of the Royal Society of Medicine, we examined England’s current in-hours general practice services relative to those of European countries in order to better contextualise the debate on extending general practice opening hours.
We found that standard opening hours in England already exceed those of most other European countries, and patients in the UK are more satisfied with out-of-hours access to general practice than patients in many other European countries. Achieving easier access to primary care services seven days per week would require significant investment, and must compete with other NHS priorities; politically attractive priorities should not to have an undue influence in shaping resource allocation.
The existence of true patient demand for extension of general practice opening hours in England is not yet fully established and evidence for a correlation between increasing in-hours provision and decreased emergency department use is inconclusive. Furthermore, the demand for services likely varies based on local demographics and disease burden; if general practice opening hours were to be extended, those regions with the highest demand for care should be prioritised.
Hence, we suggest that policy-makers in England should focus on improving access to GP appointments during normal opening hours, instead of spending scarce NHS resources on very poor value for money extended opening hours schemes.
A study published in the journal BMJ Quality and Safety concluded that extending GP opening hours will not ease the rising burden on Accident and Emergency departments. The observational study was led by Imperial College London. Lead author Dr Thomas Cowling from Imperial College’s Department of Primary Care and Public Health and colleagues compared patients’ experiences of GP surgeries with the number of Accident and Emergency visits in their areas in England from 2011-2012 to 2013-2014. They examined reports from NHS England’s annual GP Patient Survey, and included patients registered to 8,124 GP surgeries.
We measured levels of patient satisfaction using three factors: the ease of making an appointment, opening hours, and overall experience. They then matched these responses with A&E departments in their area to observe any correlation with the number of visits to A&E. Overall, areas where patients were happier with the ease of making appointments, which could be for example by using online booking systems, saw slightly fewer visits to Accident and Emergency departments. However, satisfaction with surgery opening hours and overall patient experience seemed to have no impact on Accident and Emergency visit rates.
The study suggests that better satisfaction with GP hours, for example because of extended opening hours, does not affect the number of visits made to A&E in their geographical area. However, making the appointment booking process easier for patients was associated with slightly fewer Accident and Emergency visits in that area. Our research supports finding alternative options for easing the burden on Accident and Emergency departments, and casts doubt on the Government’s proposals to extend GP surgery hours to ease the burden on Accident and Emergency departments.
We measured satisfaction with hours without linking explicitly them to daytime weekday or evening and weekend appointment availability. We hypothesised that although weekend and evening appointments are convenient for healthy, working aged adults, those who are likely to need medical attention more urgently are older people or those who are chronically ill and not currently working full time.
Senior author Professor Azeem Majeed from Imperial’s School of Public health, who is a practising GP, said: “The government must find alternative ways to handle current pressures on Accident and Emergency departments. This could include for example improving access to GP appointments during normal opening hours rather than spending scarce NHS resources on extended opening schemes.”
Dr Cowling, also from Imperial’s School of Public Health, said: “It makes sense to think that extending GP hours will ease the burden on other NHS services, but our study suggests this might not be the case with Accident and Emergency.”