A recent study from Imperial College London published in the Journal of Global Health examined clinicians’ views on main problems and solutions in medication safety in the care of people with cancer. The top ranked problems focused on patients’ poor understanding of treatments due to language or education difficulties, clinicians’ insufficient attention to patients’ psychological distress, and inadequate information sharing among health care providers. The top ranked solutions were provision of guidance to patients and their carers on what to do when unwell, pre–chemotherapy work–up for all patients, and better staff training.
The School of Public Health at Imperial College London has been awarded funding as part of a UK drive to tackle global health challenges. The work is funded by Research Councils UK as part of the Global Challenges Research Fund (GCRF), a £1.5 billion fund launched by the UK government in 2015. The fund aims to support cutting-edge research which addresses the global issues faced by developing countries in areas including agriculture, medicine, well-being and infrastructure.
The GCRF funding will also enable Imperial Professors Azeem Majeed, Toby Prevost and Mala Rao to investigate low cost technologies for screening for diabetic eye disease, a leading cause of blindness in India, in partnership with clinicians from Moorfield’s Eye Hospital in London. Professor Mala Rao, who is leading Imperial’s contribution to the project, said: “This award offers a very exciting opportunity for us to work together to transform the lives of people with diabetes and diabetic eye disease in particular, not only in India but worldwide, and to reduce the costs of diabetic eye screening in the NHS. We are thankful for this amazing chance to make a difference.” The project lead is Professor Sobha Sivaprasad from Moorfield’s Hospital in London.
A recent article in the journal BJGP Open provides advice on the management of transgender patients in primary care. With referrals to gender identity clinics rising rapidly, general practitioners (GPs) and primary care physicians are more likely to meet patients who are transgender (whose gender identity, or internal sense of gender, does not match their gender assigned at birth) or diagnosed with gender dysphoria (the severe psychological distress that is experienced by an individual as a result of the conflict between their gender identity and gender assigned at birth).1 Teaching on transgender medicine is lacking in both undergraduate and postgraduate curricula, leading to a perceived lack of expertise in this area. Furthermore, General Medical Council (GMC) guidelines on the GP’s role in prescribing are vague, resulting in some controversy. As waiting times for appointments at specialist clinics are often at least 18 months, GPs and primary care physicians will increasingly be involved in the initiation of the transition process: this is the process by which an individual changes their phenotypic appearance of gender to match their gender identity through medications and/or surgery.
Some of the actions advised:
- Ensure the patient’s electronic record is updated with the correct pronoun and patient’s desired name.
- Outline potential treatment options to include psychological therapy, speech and language therapy, hormones, and surgery.
- Discuss with the patient a direct referral to a specialist gender identity clinic, advising that wait times are often lengthy.
- Explain that initiating medications is usually done by the specialist gender identity team or under their advice, then discuss medication side-effects and risks.
- If the individual is distressed or experiencing mental ill health, discuss a referral to the community mental health team.
- If the patient is self-medicating, consider specialist advice from an endocrinologist.
- Discuss smoking cessation if the patient is a smoker, or weight loss if they are overweight.
- Provide the individual with advice on websites or support groups for transgender people.
The full article can be read in BJGP Open.
A paper published in the journal BMC Family Practice discusses the management of polypharmacy (the concurrent use of multiple medications by one individual). Because of ageing populations, the growth in the number of people with multi-morbidity and greater compliance with disease-specific guidelines, polypharmacy is becoming increasingly common.
Although the correct drug treatment in patients with complex medical problems can improve clinical outcomes, quality of life and life expectancy, polypharmacy is also associated with an increased risk of adverse drug events, some severe enough to result in hospital admission and even death. Hence, having systems in place to ensure that medications are started only when there is a suitable indication, ensuring patients are fully aware of the benefits and complications that may arise from their treatment, and reviewing patients regularly to ensure their medication regime remains appropriate, are essential.
The development and rapid uptake of electronic patient records – particularly in primary care settings where the majority of prescribing takes place – makes monitoring of patients more straightforward than in the past; and allows identification of sub-groups of patients at particularly high risk of adverse drug events and complications. It also facilitates ‘deprescribing’ the process by which medications are reviewed and stopped if not clinically beneficial.
In recent years, we have also seen the development of smartphone ‘apps’ to improve communication between patients and healthcare professionals, improve people’s understanding of their conditions and their treatment, and maintain a record of changes made to patient’s medication. In the longer term, developments such as the introduction of artificial intelligence and clinical decision support systems also have the potential to improve prescribing and minimise the risks from polypharmacy. Finally, there is considerable scope to improve the quality of prescribing and reduce risks from poly-pharmacy using non-medical groups such as pharmacists, specialist nurses and physician assistants.
On the 29 March 2017, the Prime Minister of the UK Theresa May formally notified the European Union (EU) Council President, Donald Tusk, of the UK’s intention to leave the EU. Theresa May’s letter to Donald Tusk triggered a two-year process during which the UK will have to negotiate both the terms of its exit from EU and the arrangements that will replace those we have had for over 40 years with the other member states of the EU. The consequences of the United Kingdom’s departure from the EU (commonly referred to as ‘Brexit’) will be wide-ranging and will affect all areas of UK’s society, including the National Health Service (NHS).
For the NHS, Brexit comes at a time when it faces many other major challenges. These include severe financial pressures, rising workload, increased waiting times for both primary care and specialist services, and shortages of health professionals in many key areas (such as in general practice and in emergency departments), and rising rates of obesity and type 2 diabetes. The NHS also faces challenges from societal changes, such as population growth; and an aging population, which is leading to an increase in the number of older people with complex medical problems. Hence, Brexit has come at a difficult time for the NHS and will add further to the many issues the NHS needs to address in the next few years.
The most immediate challenges from Brexit will come in areas such as the recruitment and retention of doctors and other health professionals; and in negotiating new arrangements for accessing healthcare both for EU nationals living in or visiting the UK; and for UK nationals living in or visiting the EU. There are also numerous EU laws that affect the NHS and public health in the UK. For now, these EU laws will be incorporated into UK law via the ‘Great Repeal Bill’, which will end the primacy of EU law in the UK. Over time, parliament will decide which parts of EU law to keep, change or remove from UK law, a process that will take many years.
Further complications in dealing with Brexit arise from the devolved nature of the NHS in the UK, which means that the UK does not have a single NHS but rather, it has different versions in each of the four nations of the UK. Some issues arising from Brexit that will affect the NHS will be dealt with by the UK Parliament (such as freedom of movement); and some issues (such as how health services are organised) will be dealt with by the devolved administrations in Wales, Scotland and Northern Ireland.
For many decades, the NHS has faced shortages in its clinical workforce and has relied heavily on overseas trained doctors, nurses and other health professionals to fill these gaps. This reliance on overseas-trained staff will not end in the foreseeable future. For example, although the Secretary of State for Health, Jeremy Hunt, has announced that the government will support the creation of an additional 1,500 medical student places in England’s medical schools, it will be over 10 years before these students complete their medical degrees and their subsequent post-graduate medical training. Hence, these additional doctors will not address the immediate needs of the NHS and we will continue to rely on the nationals of other countries to staff the NHS for many years to come.
Furthermore, although the UK has been able to recruit health professionals from other countries in the past, we may find that this will become more difficult in the future. The changes in the political environment in the UK, for example increased antagonism towards immigration, may discourage health professionals from other countries from moving to the UK; as will the fall in the value of pound against currencies such as the Euro, which makes the UK less attractive to work in financially.
Like our own NHS, health systems in other countries in the EU and elsewhere in the world also face their own challenges; and other countries will be keen to retain their health professionals to help address the health needs of their own populations. There is a global shortage of health professionals and they will be in demand in many countries. The UK may therefore find itself a less attractive destination for health professionals in the future. Moreover, as we saw with the junior doctor contract dispute in England, when the NHS tries to impose unpopular employment policies on its staff, this can lead to an exodus of health professionals out of the NHS. We may therefore find other countries trying to recruit health professionals from the UK to address their own staffing needs, thereby further exacerbating staff shortages in the NHS.
The recruitment of overseas-trained staff by the NHS has been facilitated by EU legislation on the mutual recognition of the training of health professionals. This means that health professionals trained in one EU country can work in another EU country without undergoing a period of additional training. Moving forwards, it is unclear that this cross-EU recognition of training will continue in the UK. There are some in the UK who see clinical training here as superior to that in other EU countries and view Brexit as an opportunity to implement tougher employment checks on EU trained health professionals. This too may discourage health professionals from elsewhere in the world moving to the UK. We will therefore need to take urgent action to ensure that the NHS can continue to recruit sufficient professional staff to meet the health needs of our population.
The UK government will also have to address the issue of access to healthcare, both for EU nationals living in or visiting the UK and UK nationals living in or visiting other EU countries. Currently, all these individuals are entitled to either free or low cost healthcare. It is unclear what will happen to these arrangements for accessing healthcare in the future, until further progress is made in our negotiations with the EU. Access to healthcare is particularly important for the elderly, retired UK nationals living overseas, in countries such as Spain, who will have a high need for health care. Furthermore, as the NHS has never been very effective in reclaiming the fees owed to it by overseas visitors to the UK, the UK may find itself substantially worse off financially when new arrangements for cross-national funding healthcare are put in place.
There are also many other areas that affect the NHS that will need to be addressed. These include, for example, our involvement in future Europe-wide public health initiatives. These cover many areas including food regulations, road safety, air pollution, tobacco control, and chemical hazards; and are important when dealing with cross-national issues that do not stop at a country’s boundaries (e.g. air pollution). Although such initiatives have had important positive effects on health in the UK, there is strong resistance from some pro-Brexit politicians about participating in such programmes, as they often view them as unnecessary interference in the UK’s internal affairs. There are also risks to health-related research and development in our universities, the pharmaceutical industry, and the wider life sciences sector. This will include the ability of UK researchers to lead multi-national EU-funded research programmes, which is another area that is at risk post-Brexit.
At a time when the NHS is already facing major problems, Brexit will impose a further layer of complexity on the challenges the NHS must address in the next few years. Thus far, the negotiations with the EU over Brexit have been dominated by issues such as the size of the financial settlement the UK will have to make when it leaves the EU. However, it is very clear that Brexit will have wide-ranging impacts on the NHS and it therefore essential that the NHS engages with government to ameliorate these risks and ensure they are dealt with before the we leave the EU. This will include gaining support for the continued recruitment of health professionals from elsewhere in the world; addressing issues around access to healthcare; and the continued participation in EU-wide public health and research programmes that benefit the health of the UK population.
This blog was first published in Public Sector Focus in March/April 2017.
In an article published in the British Medical Journal, I discuss the implications of the current shortage of NHS general practitioners. Ensuring that countries have sufficient primary care doctors is a key challenge for health planners globally because of the important role that primary care plays in supporting cost-effective health systems that promote equity in health outcomes. For example, the USA is predicted to need 7,800 to 32,000 additional primary care physicians by 2025. We also know that the National Health Service (NHS) in the United Kingdom is short of general practitioners. What we do not know is the size of the shortage; and how many additional general practitioners the NHS needs to provide comprehensive primary care services.
In its plan for general practice published in 2016, NHS England set a target of 5,000 additional general practitioners by 2020. However, no data was presented to show that this was a sufficient number to meet the needs of primary care in England. Research presented at the Royal College of General Practitioners 2016 Annual Conference concluded that NHS England had substantially under-estimated the current shortage of general practitioners and how many new general practitioners would be needed to address future health needs in primary care. According to this analysis, in 2016 the NHS in England was already around 6,500 general practitioners below the ideal number, rising to 12,100 short by 2020. Given that recruitment to general practice training schemes in England remains below target, shortages of general practitioners will continue in the foreseeable future. What can the NHS do to provide comprehensive primary care services in this era of permanent shortages of general practitioners?
One key issue in workforce planning is the lack of accurate and timely data on workload in primary care; and the lack of accurate information on the number of general practitioners working in the NHS. The NHS does not routinely collect or publish information of the workload of general practices (in stark contrast to hospital activity, where workload statistics are published regularly). Information on the number of general practitioners working in the NHS is also limited and does not fully take into account what proportion of their time general practitioners spend on direct clinical care as opposed to time spent on administrative tasks; or time spent in management roles either inside or outside their general practices. Improving the statistics of the number of general practitioners working in the NHS and their workload would be a useful start. However, it will not by itself address the shortage of general practitioners. That requires more radical solutions than the NHS is currently considering.
The most important step will be to link primary care funding to workload through the implementation of workload-based funding for general practices. Since the NHS was established in 1948, capitation-based payments have been the core method of finding NHS general practice. However, capitation increasingly looks like a 20th century model of funding and one that is not fit for the 20th century. With activity-based funding, general practices would be paid for the work that they do. Any new work would only taken on by general practices if the funding for the work met the full costs of providing the service. Activity-based funding would also allow more rational decisions to be made about the transfer of work from secondary care to general practice; rather than the current situation in which work is often transferred from hospitals to general practices because there is little or no additional cost for the NHS in doing this.
One disadvantage for the NHS of activity-based finding is that this would be considerably more costly than the current method of funding. The government would then have a stark choice: fund NHS general practice entirely from taxation; part-fund it from taxation and allow general practices to charge patients to make up the difference; or scale back the services that general practices offer to fit in with the public funding that was available. All these options are problematic but this an issue on which the government urgently needs to take a decision as the current situation not tenable.
The NHS can also examine the use of non-medical practitioners and to what extent work done by general practitioners can be carried out by groups such as nurses, physician assistants, healthcare assistants, pharmacists and physiotherapists. For example, programmes that allow patients to see physiotherapists directly without requiring a referral from a general practitioner can help reduce demands on general practices and provide an alternative, cost-effective care pathway for patients with musculoskeletal problems. The NHS also needs to make more services fully accessible by patients without requiring a referral from a general practitioner – for example, exercise and weight reduction programmes, antenatal services, podiatry, termination of pregnancy services, and services for drugs and alcohol misuse.
Another action that can be taken to improve the supply of general practitioners is reducing the administrative burden on them. This requires a detailed review of all non-clinical tasks undertaken by general practitioners with the aim of removing as many as possible to free up more time for clinical work. An increasing administrative burden on physicians is a global phenomenon and something that increases stress among doctors. Hence, reducing the administrative burden on general practitioners, as well as releasing time that can be spent on clinical tasks, can also improve their morale and reduce their stress levels.
The NHS also needs to encourage doctors to return to clinical practice after career breaks. This is particularly important for women doctors who may have had career breaks for family reasons. Doctors are expensive to train and for the NHS not to have implemented effective initiatives to encourage their return to clinical work after career breaks is a waste of the public investment in their training. Other sectors – such as universities – have active programmes to encourage women to support women in returning to work and the NHS can learn from them. Key barriers to return to work include the very high indemnity payments that doctors now have to pay (particularly for out-of-hours work) and the poor child care support offered by the NHS to doctors with families. Finally, given that shortages of general practitioners will continue in the foreseeable future, they should be treated by the NHS as a scarce resource and be deployed in a manner that makes full use of their skills and training; with caps on the amount of work they are expected to carry out. In parallel, measures must be taken to remove barriers to recruitment and retention, while we put the systems in place to measure, track, and ultimately fix this threat to the sustainability of the health service.
1. Dall T, Chakrabarti R, Iacobucci W, Hansari A, West T. The Complexities of Physician Supply and Demand: Projections from 2015 to 2030. Association of American Medical Colleges. Washington, DC, USA, 2017.
2. Majeed A. Primary care: a fading jewel in the NHS crown. London Journal of Primary Care; 2015: 7: 89-91. http://www.tandfonline.com/doi/full/10.1080/17571472.2015.1082343.
3. Department of Health. General Practice Forward View. https://www.england.nhs.uk/gp/gpfv/
4. Hayhoe B, Majeed A, Hamlyn M, Sinha M. Primary care workforce crisis: how many more GPs do we need? RCGP Annual Conference, Harrogate, 2016.
5. King’s Fund. Understanding the pressures in general practice. London, 2016. http://www.kingsfund.org.uk/publications/pressures-in-general-practice
6. Rhys G, Beerstecher HJ, Morgan CL. Primary care capitation payments in the UK. An observational study. BMC Health Serv Res. 2010;10:156.
7. Iacobucci G. GPs urge BMA to explore copayments for some services. BMJ 2017;357:j2503.
8. Salisbury C, Montgomery AA, Hollinghurst S, Hopper C, Bishop A, Franchini A, Kaur S, Coast J, Hall J, Grove S, Foster NE. Effectiveness of PhysioDirect telephone assessment and advice services for patients with musculoskeletal problems: pragmatic randomised controlled trial. BMJ. 2013 Jan 29;346:f43.
9. Greenfield G, Foley K, Majeed A. Rethinking primary care’s gatekeeper role. BMJ: British Medical Journal (Online). 2016 Sep 23;354.
10. Erickson SM, Rockwern B, Koltov M, McLean RM, for the Medical Practice and Quality Committee of the American College of Physicians. Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians. Ann Intern Med. 2017;166:659-661. doi: 10.7326/M16-2697
As a doctor with many years experience of working in the NHS, I am aware of the impact that mental health problems can have on people’s health, well-being and quality of life, as well as on their family and friends. Mental health problems are also important for employers, and result in considerable financial costs in lost production and in staff absences from the work-place due to ill-health. However, even though mental health problems are very common, many people find it difficult to talk about them.
Encouraging a supportive environment in the workplace that reduces the risk of mental health problems developing – and in supporting staff to seek help when mental health problems do arise – is very important for employers. It improves employees’ health and well-being, and creates a more productive and pleasant working environment.
As a Mental Health Champion for the School of Public Health at Imperial College London, I see my role as supporting my departmental colleagues to achieve these objectives and ensure that mental health issues in the workplace are given the prominence they deserve. I want college staff to feel they can discuss any mental health problems they are experiencing in an open and constructive manner, and not feel pressurised to keep their mental health problems hidden from their colleagues.