An article from the Department of Primary Care and Public Health published in the London Journal of Primary Care discusses the diagnosis and management of Scarlet Fever. There has been a recent increase in the incidence of scarlet fever with most cases presenting in General Practice and Emergency Departments. Cases present with a distinctive macro-papular rash, usually in children. In patients who have the typical symptoms, a prescription of a suitable antibiotic such as phenoxymethylpenicillin (Penicillin V) should be made immediately to reduce the risk of complications and the spread of infection.
A typical presentation of scarlet fever
An 8-year-old girl is brought to see you at your practice. She has a sore throat, abdominal pain and has been vomiting. Her health was fine until two days ago. Initially, she noticed pain on swallowing and had a temperature of 38 °C. Her parents decided to seem medical advice once they noticed the ‘sandpaper-like’ rash on her trunk and the inside of her elbows. When you examine her tongue, the enlarged papillae become immediately obvious giving it a ‘strawberry’ like appearance. Petechiae are also visible on her soft palate. Her anterior-cervical nodes are swollen and tender.
Heart attack symptoms might have been missed in many patients, according to a study on all heart attack hospital admissions and deaths in England from Imperial College London. More research is urgently needed to establish whether it is possible to predict the risk of fatal heart attacks in patients for whom this condition was not recorded as the main reason for hospital admission. The study was published in The Lancet Public Health.
Heart disease is one of the leading killers in the UK. According to the British Heart Foundation, heart attacks lead to one hospital visit every three minutes. They are caused by a decrease in blood flow to the heart, usually as a result of coronary heart disease. Symptoms may include sudden chest pain or a ‘crushing’ sensation that might spread down either arm. Patients might also experience nausea or shortness of breath. However, some heart attacks have more subtle symptoms and may therefore be missed or overlooked.
In this study, we examined records of all 446,744 NHS hospital stays in England between 2006 and 2010 that recorded heart attacks, as well as the hospitalisation history of all 135,950 heart attack deaths. The records included whether or not patients who died of a heart attack had been admitted to hospital in the past four weeks and if so, whether signs of heart attack were recorded as the main cause of admission (primary diagnosis), additional to the main reason (secondary diagnosis), or not recorded at all.
Of the 135,950 patients who died from heart attack, around half died without a hospital admission in the prior four weeks, and around half died within four weeks of having been in hospital. 21,677 (16 per cent, or one in six) of the patients who died from heart attack had been hospitalised during the four weeks prior, but heart attack symptoms were not mentioned on their hospital records.
There were certain symptoms, such as fainting, shortness of breath and chest pain, that were apparent up to a month before death in some of these patients, but doctors may not have been alert to the possibility that these signalled an upcoming fatal heart attack, possibly because there was no obvious damage to the heart at the time.
These results suggest that possible signs of upcoming fatal heart attack may have been missed. The authors’ next step is to look into why this pattern emerged, and to try to prevent more heart attack deaths. We also found that of all patients admitted with a heart attack, those whose heart attack was recorded as secondary to the main condition were two to three times more likely to die than patients whose records stated heart attack as the main condition.
This summer, the Department of Primary Care and Public Health kicked off an exciting new programme: Widening Access to Careers in Community Healthcare (WATCCH). We hosted twenty 16-17 year olds who are aspiring to be the first in their families to go to university – at the Charing Cross campus for the inaugural WATCCH project. Our aim was to change perceptions of wider healthcare careers and provide vital work experience for their University applications. Competition was high and the team was very impressed by the number of high calibre students that applied for a place.
Year 12 Pupils from 19 London secondary schools attended an induction day in late July. During the workshop, an experienced multi-professional panel consisting of five professionals including an Imperial final year medical student, shared their career journeys with the pupils from their A level to postgraduate degrees. This was followed by pupils creating individual mind maps, which they thoroughly enjoyed, of where they are now and where they would like to be in the future. This was followed by a fun exercise in the clinical skills lab at Charing Cross where they could experience clinical skills such as phlebotomy, measuring blood pressure, and inserting nasogastric tubes into mannequins.
The pupils, in pairs, will now attend a 3-day work experience attachment at a General Practice over the summer, where they shadow various health care professionals ranging from pharmacists, to phlebotomists, nurses, physiotherapists and GPs.
Our budding health professionals reported that they had their eyes opened to new and different careers in healthcare they were not previously aware of. One pupil commented that they had learnt “how the different healthcare professionals work together to provide the best quality care”. Another said they had “learnt more about the opportunities available and how to find them”. Pupils also felt they got an insight into how to provide the best quality care, with admiration for the way in which different healthcare professionals worked as a team. It was even said that you “will never get bored” in healthcare!
In early September, we will run a final workshop day to review their reflections of what they have learnt and gained from their work experience. They have been advised to do a placement project to showcase something they have learnt from their attachment which they will share at the final workshop. The mind maps will be revisited to review if their thoughts have changed following the placement. We also hope to discuss how to incorporate their work experience into their personal statements for UCAS applications.
The WATCCH project is needed now more than ever. Figures from the Office for Fair Access (OFFA) show that in 2016 entry rates to “higher tariff” universities for 18-year-olds from the most disadvantaged neighbourhoods stood at just 3.6%. This is exaggerated within the health sector, where there is also a shortage of work experience, despite it being essential for applications. The shortage is particularly acute for those who have no family or social connections to healthcare professionals, despite good GCSE grades.
The NHS workforce is certainly facing a recruitment crisis and our aim is to help channel and support able and enthusiastic applicants towards a brighter future in healthcare. A well-functioning multi-professional team in the community will aid primary care in delivering better patient care
The GP teaching team at the Department of Primary Care and Public Health were instrumental in facilitating the induction day. If you would like further information about the WATCCH programme contact Dr Farah Jamil, lead GP for the WATCCH programme, at email@example.com.
The NHS is challenged by rising demand as a consequence of a population with more complex conditions and the rising costs of paying for that care. Inefficiencies resulting from fragmented primary, secondary and social care services highlight the need for greater coordination and continuity to improve patient outcomes at lower cost. Financial constraints can drive health system review, providing impetus to modify health service delivery within the NHS to maximize value and better align with the needs of our population.
The Naylor (2017) review calls for urgent rationalization of the NHS estate to meet the mandate of the Five Year Forward View. Smaller acute hospitals could be seen as a potential starting point for reconfiguring health services in England. However, local change is not always welcome and the perceived loss of services is often met with staunch political and public opposition.
The NHS Chief Executive Officer, Simon Stevens, has expressed his support for smaller hospitals. In the Five Year Forward View, smaller hospitals have an opportunity to once again be at the centre of defining patient pathways. This will require some change in provision of services. Gaining local public and clinician support will be crucial and small hospital leaders must be visionary. Support programmes such as the New Cavendish Group and New Care Models programme will be increasingly important in helping to ensure that smaller hospitals remain part of the fabric of the English NHS.
I contributed to a series of papers on health in the World Health Organization’s Eastern Mediterranean Region. Key steps that need to be taken to improve the health and well-being of people in the region must include ending the wars and conflicts in the region, as well as improving education and employment opportunities, particularly among women. Health systems must be strengthened as well, for example, through building up primary care and using health programmes to target the causes of ill-health, such as high-calorie diets, smoking, physical inactivity and obesity. In addition, health workers and governments should aim to improve maternal and child health and ensure that immunisation rates are high, as well as addressing environmental factors such as air pollution. You can read more on the Imperial College Website.
The papers were published in the International Journal of Public Health. Papers in the series include:
Policy-makers in many countries are increasingly considering charging people different fees for using primary and secondary care services (differential user charges). The aim of such ‘differential fees’ is to encourage use of primary health care in health systems with limited gate keeping.
We carried out a systematic review to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published from January 1990 until June 2015. We extracted data from the studies meeting defined eligibility criteria and assessed study quality using an established checklist. We synthesized evidence narratively.
Eight studies from six countries met our eligibility criteria. The overall study quality was low, with diversity in populations, interventions, settings, and methods. Five studies examined the introduction of or increase in user charges for secondary care, with four showing decreased secondary care utilisation, and three showing increased primary care utilisation. One study identified an increase in primary care utilisation after primary care user charges were reduced. The introduction of a non-referral charge in secondary care was associated with lower primary care utilisation in one study. One study compared user charges across insurance plans, associating higher charges in secondary care with higher utilisation in both primary and secondary care.
Our conclusion was that the impact of introducing differential user-charges on use of primary care remains uncertain. Further research is required to understand their impact, including implications for health system costs and on utilisation among low-income patients.
A study from my department published in the journal BMC Health Services Research assessed how effective the NHS Health Check Programme was in reaching under-served groups.
Cardiovascular disease (CVD) is the leading cause of premature mortality and a major contributor of health inequalities in England. Compared to more affluent and white counterparts, deprived people and ethnic minorities tend to die younger due to preventable CVD associated with lifestyle. In addition, deprived, ethnic minorities and younger people are less likely to be served by CVD prevention services. This study assessed the effectiveness of community-based outreach providers in delivering England’s National Health Services (NHS) Health Check programme, a CVD preventive programme to under-served groups.
Between January 2008 and October 2013, community outreach providers delivered a preventive CVD programme to 50,573 individuals, in their local communities, in a single consultation without prescheduled appointments. Community outreach providers operated on evenings and weekends as well as during regular business hours in venues accessible to the general public. After exclusion criteria, we analysed and compared socio-demographic data of 43,177 Health Check attendees with the general population across 38 local authorities (LAs).
Using Index of Multiple Deprivation, the mean deprivation score of the population reached by community outreach providers was 6.01 higher (p < 0.05) than the general population. Screened populations in 29 of 38 LAs were significantly more deprived (p < 0.05). No statistically significant difference among ethnic minority groups was observed between LAs. Nonetheless some LAs – namely Leicester, Thurrock, Sutton, South Tyneside, Portsmouth and Gateshead were very successful in recruiting ethnic minority groups. The mean proportion of men screened was 11.39% lower (p < 0.001) and mean proportion of 40–49 and 50–59 year olds was 9.98% and 3.58% higher (p < 0.0001 and p < 0.01 respectively) than the general population across 38 LAs.
We concluded that community-based outreach providers effectively reach under-served groups by delivering preventive CVD services to younger, more deprived populations, and a representative proportion of ethnic minority groups. If the programme is successful in motivating the under-served groups to improve lifestyle, it may reduce health inequalities.
In an article published in the Journal of Ambulatory Care Management, Dr Sonia Kumar and I discuss the change in the roles of doctors and other health professionals in England’s NHS. Primary care in England has seen a slow but steady expansion in the roles and numbers of non-medical health care professionals over the last 50 years. In the next 5 to 10 years, the use of non-medical professionals will expand rapidly in primary care, with currently unknown consequences for patient outcomes and England’s NHS. Doctors in England will find their traditional professional autonomy slowly decreasing as they increasingly work in multi-professional teams; and the education and professional development of our medical students and doctors need to change to reflect these new ways of working.
A further challenge (and opportunity) for doctors arises from the rapid advances we are seeing in information technology. Through the Internet and Web sites such as NHS Choices, patients in the United Kingdom now have easy access to medical information. We are also now seeing developments in artificial intelligence (AI) leading to alternative routes for accessing medical and health promotion advice. For example, the NHS has now begun trialing AI-based “chatbots” that will be used to offer health advice to patients when they contact the NHS telephone advice line (NHS 111) for medical advice. If these trials are successful, we may see a rapid development in the capabilities and use of AI-driven health chatbots in England and elsewhere.
Globally, more than 2 billion children and adults suffer from health problems related to being overweight or obese, and an increasing percentage of people die from these health conditions, according to a new study published in the New England Journal of Medicine, to which I contributed.
They are dying even though they are not technically considered obese. Of the 4.0 million deaths attributed to excess body weight in 2015, nearly 40% occurred among people whose body mass index (BMI) fell below the threshold considered “obese.”
The findings represent “a growing and disturbing global public health crisis,” according to the authors of the paper published today in The New England Journal of Medicine. In the UK, nearly a quarter of the adult population – 24.2% or 12 million people – is considered obese. Additionally, 1 million British children are obese, comprising 7.5% of all children in the UK.
Among the 20 most populous countries, the highest level of obesity among children and young adults was in the United States at nearly 13%; Egypt topped the list for adult obesity at about 35%. Lowest rates were in Bangladesh and Vietnam, respectively, at 1%. China with 15.3 million and India with 14.4 million had the highest numbers of obese children; the United States with 79.4 million and China with 57.3 million had the highest numbers of obese adults in 2015.
The study was reported by many media outlets including the Guardian and CBS News.