Blog posts

The future of the NHS GP Quality and Outcomes Framework in England

My new editorial in the BMJ discusses the GP Quality and Outcomes Framework (QOF). My conclusion is that QOF in England requires selective reform rather than wholesale abolition. While QOF initially improved recorded quality of care through financial incentives,  these gains are not always sustained long-term and may not reflect true clinical improvements.

Policymakers should be encouraged to retain the most effective elements — particularly those related to early detection and management of long-term conditions — while removing less useful or overly bureaucratic aspects. Going forward, QOF should be integrated into a broader strategy that supports sustainable quality improvement, continuity of care, and minimised administrative burden, using developments in information technology to support better outcomes and reduce health inequalities.

Majeed A, Molokhia M. Impact of pay for performance in primary care. BMJ 2025; 389 :r1171 doi:10.1136/bmj.r1171

Why we need a new funding model for NHS general practice In England

A properly weighted and adequately resourced funding model for general practices n England is essential if we are to reduce health inequalities and ensure high-quality primary care for all. The announcement of a review of the Carr-Hill Formula is therefore very welcome and long overdue.

The current NHS funding formula for general practice in England has not kept pace with changing population needs and does not sufficiently account for levels of deprivation or the complexity of care required in more disadvantaged communities. We know that general practices in deprived areas face higher levels of multimorbidity, greater social complexity, and significantly greater demand. Yet NHS funding for primary care has not adequately reflected these realities.

It is also essential that any changes to the Carr-Hill Formula are accompanied by an overall increase in funding for NHS general practice in England. Simply redistributing a fixed pot of funding risks creating new pressures in other areas that have funding taken away from them, and further destabilising primary care services that are already stretched. We need to increase overall investment in general practice so that patients in deprived communities receive the care they need without compromising provision elsewhere.

Assisted Dying: Serious Practical Questions Remain Unanswered

MPs who voted in support of assisted dying — and indeed many doctors and other healthcare professionals who support such measures — may not have fully considered the profound practical challenges this would present for the NHS and for medical education and training.

Implementing an NHS-based assisted dying service would be a vast and complex undertaking. At present, the NHS is neither prepared nor equipped to deliver such a service in a safe, equitable, and ethical way. There is no public funding allocated for assisted dying. As Secretary of State Wes Streeting has rightly pointed out, any future funding would inevitably have to come at the expense of other health services that are already under considerable strain.

Beyond funding, the educational and professional implications for the medical workforce have barely been addressed. There has been no clear plan for how assisted dying would be integrated into undergraduate medical education or postgraduate clinical training — nor how issues of conscientious objection, professional standards, and clinical governance would be handled in practice. Integrating assisted dying into undergraduate education and postgraduate training would require new frameworks, ethical guidelines, and practical training modules. Developing these educational and training programmes would take years and require significant investment, with no clear plans for this currently in place.

The complexity of implementation—financially, educationally, and ethically—suggests that any move toward assisted dying would require far more planning than current discussions reflect. Without addressing these fundamental questions, any move toward legalising assisted dying risks creating more problems than it solves. Policymakers, healthcare leaders, doctors, other healthcare professionals and the public deserve a much fuller and more honest debate about what such a profound change would truly require.

Balancing Free Speech and Institutional Responsibility in England’s Universities

The Office for Students (the independent regulator of higher education in England) has suggested that students should be prepared to be “shocked and offended” at university as part of the educational process. This policy seeks to promote freedom of expression and open debate within academic settings. However, implementing such an approach poses significant challenges for both university staff and students. Institutions must not only consider the legal boundaries surrounding freedom of expression in the UK but also manage the practical and ethical complexities involved in fostering an environment that encourages robust discussion while protecting the rights and well-being of all members of the university community.

The first challenge for universities is that the UK does not allow full freedom of expression. There are many laws that limit what people in the UK can say, and these are often different from limits on freedom of expression in other countries. For example, the USA generally has fewer restrictions on freedom of expression than the UK.

UK laws aim to balance freedom of expression with other societal interests, such as public safety, national security, and the protection of individual rights. Some of the relevant laws include:

1. Public Order Act 1986

2. Communications Act 2003

3. Malicious Communications Act 1988

4. Defamation Act 2013

5. Counter-Terrorism and Border Security Act 2019

6. Online Safety Act 2023

7. Obscene Publications Act 1959

8. Equality Act 2010

Universities will have to consider whether the views that their staff and students express are in breach of any of these laws. Incorrect interpretation of the law by universities may expose them, and the staff or students expressing potentially illegal views, to legal action.

Beyond legal constraints, universities face additional challenges in enforcing internal policies. As responsible employers, universities will have policies to address issues such as bullying, harassment, and discrimination — particularly in relation to protected characteristics such as sex, ethnicity, and disability. Failing to protect individuals or groups could result in internal complaints, referrals to external bodies such as the Office for Students, and potentially legal action. The dividing line between what is legal and illegal may not be clarified until tested in court. For example, how does allowing students to be “shocked and offended” align or conflict with the legal duty to prevent harassment?

The government has not provided clear evidence that a major problem exists regarding staff and students being unable to express their views freely within UK universities. What we may see instead is an increase in complaints and legal challenges, which could consume significant institutional time and resources. Although the aims of the Office for Students may be well-intentioned, the practical challenges of implementing this policy are considerable. Universities must carefully navigate complex legal frameworks and their own institutional responsibilities to ensure both freedom of expression and protection from harm.

Without clearer guidance and stronger evidence of a significant underlying problem, there is a risk that universities will expend considerable time and resources responding to legal uncertainties and complaints. A more constructive and collaborative approach — one that supports universities in fostering open debate while upholding legal and ethical standards — may ultimately prove more effective in promoting freedom of expression within higher education.

Abolishing NHS England will make only modest savings

Abolishing NHS England and reducing Integrated Care Board (ICB) staffing by 50% may appear substantial, but the projected savings – around £500 million annually if fully achieved – would represent only a modest increase (approximately 0.25%) in annual NHS funding in England, given the NHS England budget is approaching £200 billion per year. Evidence from past NHS reforms (like the 2012 Health and Social Care Act) shows mixed results; some efficiency gains but often offset by new layers of complexity elsewhere in NHS structures.

Without parallel initiatives to streamline administrative processes, improve efficiency, and enhance clinical productivity, such structural changes to NHS England and ICBs alone will not significantly improve frontline clinical care or health outcomes. Administrative costs, while important to minimise, make up a relatively small proportion of the overall NHS budget. Genuine productivity gains will therefore require systematic reforms aimed at reducing unnecessary bureaucracy and optimising workforce deployment, alongside strategically investing in information technology and process improvements.

Reference

Majeed A. Abolishing NHS England will make only modest savings. BMJ 2025; 389 :r788 doi:10.1136/bmj.r788

Digital Kiosks in Emergency Departments: Can They Enhance Efficiency and Patient Care?

Emergency departments (EDs) are often the first point of contact for patients requiring urgent medical attention. With increasing patient volumes and limited resources, EDs face challenges in maintaining efficiency and ensuring timely care. A recent systematic review published in the Journal of Medical Internet Research by our research group explores the role of digital check-in and triage kiosks in addressing these challenges.

Key Findings from the Systematic Review

The review analysed five studies conducted between 2019 and 2022 across Canada, the United States, and the United Kingdom, encompassing a total of 47,778 patients and 310,249 ED visits. These studies varied in design, including cross-sectional analyses, pilot studies, retrospective analyses, and randomised controlled trials,

  1. Efficiency Improvements
    Digital kiosks have been associated with reduced patient wait times and improved patient flow within EDs. By streamlining the check-in and triage processes, these kiosks can expedite patient assessment and allocation to appropriate care pathways.
  2. Patient Safety and Accuracy
    The studies reviewed indicated that digital kiosks can accurately capture patient information and symptoms, aiding in effective triage decisions. However, the accuracy is contingent upon the design of the kiosk interface and the algorithms used for symptom assessment.
  3. Patient Satisfaction
    Patient responses to digital kiosks were generally positive, with many appreciating the privacy and autonomy provided during the check-in process. Nonetheless, some patients expressed a preference for human interaction, highlighting the need for a balanced approach.

Considerations for Implementation

While digital kiosks offer promising benefits, their successful integration into ED workflows requires careful planning:

  • Accessibility: Ensuring that kiosks are user-friendly for patients of all ages, languages, and technological proficiencies is crucial.
  • Integration with Existing Systems: Kiosks should seamlessly integrate with electronic health records and other hospital information systems to maintain continuity of care.
  • Staff Training: ED staff should be trained to assist patients with kiosk use and to interpret the data collected effectively.
  • Continuous Evaluation: Ongoing assessment of kiosk performance and patient outcomes is necessary to identify areas for improvement.

Conclusion

Digital check-in and triage kiosks present a valuable tool for enhancing efficiency and patient care in emergency departments. While they are not a panacea, when thoughtfully implemented, they can alleviate some of the pressures faced by EDs and contribute to improved patient experiences.

For a more detailed exploration of this topic, refer to our full article in the Journal of Medical Internet Research: Safety and Efficacy of Digital Check-in and Triage Kiosks in Emergency Departments: Systematic Review.

Barriers to Dementia Care Services in Europe: Key Insights and Ways Forward

Dementia, including Alzheimer’s disease, is a significant public health challenge in Europe, with nearly 14 million people currently affected. Despite available healthcare and social care services, utilisation of these services by people living with dementia remains suboptimal due to various barriers. Our recent systematic review published in BMC Geriatrics provides critical insights into these challenges, highlighting barriers across informational, organisational, cultural, stigma-related, financial, and logistical domains.

Informational and Educational Barriers

A lack of awareness and insufficient knowledge among caregivers and healthcare professionals stands out as a key barrier. Inadequate dissemination of dementia-related information contributes to difficulties in planning and accessing appropriate care. Enhancing educational resources and improving health literacy among caregivers and healthcare workers are essential for overcoming these challenges.

Organisational Barriers

Fragmented services and poor coordination among healthcare providers frequently hinder effective dementia care. Issues such as inconsistent care strategies, unclear roles, and insufficient resources exacerbate the difficulties faced by families and professionals alike. The Covid-19 pandemic has further intensified these problems, highlighting the urgency for integrated, person-centred care systems.

Cultural and Stigma-related Challenges

Societal stigma and cultural misunderstandings significantly impact dementia care, deterring individuals from seeking necessary help. Cultural sensitivity, improved community education, and targeted interventions can mitigate stigma-related issues, promoting better acceptance and utilization of dementia services.

Financial and Logistical Challenges

The economic burden of dementia care often strains family resources, compounded by complex administrative procedures and insufficient public funding. Additionally, logistical issues, including long waiting lists, transportation problems, and limited service availability, particularly in rural areas, create further barriers.

Policy Recommendations

To address these challenges, tailored, context-specific policies and integrated care pathways are necessary. European initiatives, such as Alzheimer Europe’s Strategic Plan and the Glasgow Declaration, underline the importance of inclusive strategies and active involvement of people with dementia in policy-making processes.

By addressing these identified barriers through coordinated actions, Europe can improve access to dementia care, enhancing the quality of life for individuals living with dementia and also for their caregivers.

The Covid-19 pandemic five years on

As we reach the fifth anniversary of the onset of the Covid-19 pandemic, this moment provides an opportunity for reflection on the many challenges faced by healthcare workers like me during the early days of the pandemic. At that time, the SARS-CoV-2 virus was a largely unknown entity. Clinical guidelines were still under development and personal protective equipment (PPE) was scarce. For those on the NHS frontline, the experience was marked by a mix of anxiety, urgency, and dedication to the patients we were trained to serve.

Unfamiliar Territory 

In the initial stages, Covid-19 was a “novel” infection. There was a scarcity of data on the illness, and the disease was manifesting in ways that were not entirely well understood. As primary care physicians, we were suddenly thrust into the realm of the unknown, treating patients with undifferentiated respiratory illnesses that did not yet have well-defined and evidence-based treatment protocols.

The Personal Risk Factor 

One of the most daunting aspects of those early days was the awareness of personal risk. It became apparent that healthcare workers were at a significantly higher risk of contracting the disease through their exposure to infected individuals. One thing struck me and others very profoundly was the pattern among the first NHS staff who died due to Covid-19. Many of them were like me: male, over 50, and from ethnic minority groups. This resemblance was not just a statistical observation; it was a stark reminder of my own clinical vulnerability and that of many of my colleagues.

Ethical Duty vs. Personal Safety 

Yet, despite these risks, we had patients to treat. Faced with an ethical duty to provide care, healthcare workers had to weigh this against the risks to their own health. It was an emotionally and ethically complex position to be in. While the fear and anxiety were real, they had to be balanced against our professional obligations to our patients and the NHS. It was a test of not just our medical skills but also our commitment to the Hippocratic Oath.

The Importance of Resilience 

The job had to be done, and so we donned our PPE, took the necessary precautions, and went to work. This resilience is a testament to the dedication of healthcare workers globally who stood firm in their commitment despite the many unknowns in early 2020. The role of healthcare providers in those critical moments was instrumental in broadening our understanding of the virus, which subsequently guided future public health responses, medical treatments and vaccination.

Ongoing Challenges 

The situation has evolved and we now know much more about Covid-19. We now also have vaccines that reduce the risk of serious illness, hospitalisation and death. Yet the lessons of those early days continue to resonate. Healthcare providers still face risks, both physical and emotional, particularly as new variants of the SARS-CoV-2 virus emerge. The Covid-19 story is not over, particularly for those people who suffer recurrent infections or with Long Covid but the experiences of the past provide a foundation upon which we build our ongoing responses.

The broader implications of healthcare workers’ experiences during the Covid-19 pandemic extend far beyond individual resilience and sacrifice. These experiences have exposed critical vulnerabilities in global health systems, highlighting the urgent need for better preparedness, clearer communication strategies and equitable access to protective resources. Furthermore, the pandemic underscored profound health inequalities, notably the increased risks faced by poorer people, ethnic minority groups and the elderly. Recognising these inequalities provides an impetus for policy makers and healthcare leaders to implement structural changes, fostering a more robust, responsive, and inclusive approach to future public health emergencies.

Conclusions 

As we navigate the ongoing challenges posed by Covid-19, reflecting on where we began and the progress we have made since early 2020 is essential. The evidence presented in the Covid-19 Inquiry serves as a timely reminder of healthcare workers’ immense bravery, resilience, and sacrifice globally. While anxiety was palpable, commitment to patient care remained unwavering. Looking ahead, it’s vital we learn from these experiences, investing in preparedness, communication, and systems that protect both patients and those who care for them, ensuring we’re better equipped for future health crises.

Medical Journals Should Use the Term “Public Health and Social Measures”

The COVID-19 pandemic brought many terms into the spotlight, one of which was “non-pharmaceutical interventions” (NPIs). Used widely in academic papers, public health guidelines, and media reports, NPIs became a catch-all phrase for measures like contact tracing, quarantine, and hand hygiene; essentially anything that wasn’t a drug or vaccine. However, BMJ Editor Kamran Abbasi and I argue in our editorial it is time to end the use of this term in favour of “public health and social measures.” Here’s why this shift matters.

The Problem with Defining by Negation

The term “non-pharmaceutical interventions” defines these strategies by what they aren’t rather than what they are. This framing is inherently limiting. Imagine calling surgery a “non-drug intervention”—it sounds absurd because surgery stands on its own as a complex, evidence-based practice. Similarly, public health measures like sanitation or hand hygiene aren’t just stopgaps until a drug or vaccine becomes available. They are powerful tools with scientific grounding, often critical in the early stages of a health crisis and remain valuable even after pharmaceutical options emerge. By labelling them as “non-pharmaceutical,” we risk undervaluing their role and complexity.

A Misleading Hierarchy

The NPI label also subtly suggests that these interventions are second-rate compared to drugs or vaccines. This perception can lead to serious consequences: underfunding, limited evaluation and a reluctance to fully integrate them into health strategies. Yet, history shows that measures like clean water systems or contact tracing can have major impacts of public health; sometimes more effective than any medication. The implied inferiority of NPIs feeds into a biomedical bias, prioritising technological fixes over holistic approaches that address behaviour, culture, and social determinants like poverty or housing.

Missing the Social Dimension

Another flaw in the term “non-pharmaceutical” is its failure to reflect the social and behavioural core of these measures. Hand-washing campaigns do not succeed through science alone. They depend on people’s willingness to adapt, shaped by trust, norms, and socioeconomic context. Calling them “non-pharmaceutical” strips away this human element, reducing them to technical fixes rather than collective efforts. This oversight can widen health inequities, as solutions that ignore social factors often fall short for vulnerable populations.

Clarity for the Public

Communication is critical in a health crisis, and “non-pharmaceutical interventions” may not mean much to the average person. It is jargon that obscures rather than enlightens. In contrast, “public health and social measures” is straightforward. It signals that these actions protect communities and require shared effort. When people understand what is at stake and why it matters, they are more likely to follow the advice they have been given.

A Call for Change

We propose “public health and social measures” as a term that captures the full scope of these interventions; their diversity, their evidence base and their reliance on social dynamics. It aligns with the World Health Organization’s recommendations and encourages a broader view of health, one that integrates biology with environment and society. The BMJ is aiming to lead by example, committing to this terminology across its content. We urge other journals, reviewers, and health professionals to follow this example.

Why It Matters Now

As we face ongoing and future health challenges – such as pandemics, climate-related crises or an increase in chronic diseases – this shift is not just semantic. It is about ensuring these measures get the research, funding and respect they deserve. By reframing them as “public health and social measures,” we elevate their status, improve public understanding, and foster interdisciplinary solutions that address public health challenges effectively.

Missed Appointments: An Opportunity to Address Patient Safety

Our recent article in the Journal of Patient Safety discusses the topic of missed appointments in healthcare. Missed appointments are often seen as an administrative inconvenience in healthcare; wasting appointments that could have gone to other patients. However, missed appointments are also a critical patient safety concern that can delay necessary interventions, worsen health outcomes, and erode trust between patients and clinicians. Instead of viewing them as patient noncompliance, we must shift our perspective to understand the underlying barriers that prevent people from attending their scheduled appointments.

Understanding the Root Causes of Missed Appointments

Patients miss appointments for a variety of reasons, many of which are outside their control. Socioeconomic challenges, work obligations, caregiving responsibilities, mental health issues, transportation difficulties, and previous negative experiences with the healthcare system all contribute to non-attendance. Disadvantaged populations – such as poorer individuals, ethnic minorities, the elderly and rural communities – face even greater hurdles in accessing healthcare. When these challenges are ignored, healthcare systems risk isolating the very patients who need support the most.

The Consequences of Missed Appointments

The impact of missed appointments extends beyond inconvenience. They disrupt continuity of care, leading to delayed diagnoses and potentially preventable complications. Patients with chronic diseases, such as diabetes, hypertension, or mental health conditions, face particularly severe consequences when they miss follow-ups. Additionally, when healthcare providers interpret missed appointments as a lack of commitment, punitive measures – such as discharging patients from services – can further alienate vulnerable individuals and create barriers to essential care.

Beyond direct clinical risks, there is also the issue of trust. Patients who feel unheard, rushed, or judged during healthcare interactions may disengage from the system altogether, leading to long-term avoidance of care. This breakdown in trust is a significant patient safety issue, as it discourages individuals from seeking timely medical attention.

A Patient-Centred Approach to Reducing Missed Appointments

Addressing missed appointments requires a fundamental shift in approach. Instead of punitive policies, healthcare providers should focus on identifying and removing barriers to attendance. Some key strategies include:

  • Understanding Social Determinants of Health: Recognising that financial constraints, transportation issues, and job inflexibility impact appointment attendance. Partnering with community organisations to provide support services – such as transportation assistance or mobile health clinics – can help overcome these barriers.
  • Creating a Compassionate Healthcare Environment: Patients are more likely to attend appointments when they feel valued and respected. Clinicians should take time to listen, address concerns, and ensure that healthcare settings are welcoming and inclusive.
  • Flexible Scheduling Options: Evening and weekend appointments can accommodate patients with demanding work schedules or caregiving responsibilities.
  • Leveraging Technology: Telemedicine offers an alternative for patients who struggle to attend in-person visits. AI-driven predictive analytics can also help identify individuals at high risk of missing appointments, allowing for targeted interventions such as personalized reminders or proactive outreach.

Turning Missed Appointments into Opportunities for Improvement

Rather than viewing missed appointments solely as a problem to be fixed, healthcare systems should treat them as a diagnostic tool—an indicator of broader systemic issues. By shifting the focus to patient safety and proactive intervention, healthcare providers can transform these challenges into opportunities to improve engagement, build trust, and ensure that every patient receives the care they need when they need it. A patient-centred, safety-focused approach to missed appointments benefits everyone. It leads to better health outcomes, strengthens patient-provider relationships, and ultimately creates a more equitable and accessible healthcare system for all.